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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

Table of Contents 1 of 210 PREFACE INTRODUCTION POLICIES P 1.10 P 2.07 P 4.03 P 6.03 P 9.05 P 10.06 P 11.03 P 12.03 P 13.02 P 14.04 P 16.05 P 17.02 P 23.00 S 1.02 S 2.00 S 3.01 S 4.00 S 5.05 S 7.02 S 8.00 S 9.00 S 10.00 S 11.00 S 12.00 Determination of Hospital Destination Policy Medical Standards During Patient Transfer Policy Helicopter Utilization Policy Report Format Policy Vascular Access Policy Refusal of Service Policy Infection Control Policy On-Scene AED Coordination Policy Multiple Encounter Incident Policy Medical Intervention Policy Scope of Practice Policy Medical Values Statement Policy Central On-Line Medical Control Policy KCFD Request of MAST Ambulance Policy KCFD/MAST Rehabilitation Policy Procedures for Do Not Resuscitate Requests Policy Person Exceeding the EMS System's Capability Policy DOA Policy Ambulance Diversion Guidelines Policy Safe Place for Newborns Act of 2002 Policy Suspected Abuse/Neglect Policy Medical Research in KCMO EMS Policy Patient Contact Policy Equipment Brought In Policy 4 5 6 11 13 15 17 18 23 24 25 26 29 31 33 35 37 38 39 40 43 48 49 50 51 52 53 54 56 58 59 60

DISPATCH RELATED POLICIES DP 1.01 Emergency Medical DispatchTM Policy DP 2.02 Ambulance Transport Requests From Health Care Facilities Policy DP 3.00 Notification of OMD Policy DP 4.00 EMS CAD Data Policy P 19.00 911 Dispatch Policy to Hospitals with Emergency Departments Policy P 20.00 Physician Certification Statements (PCS) Policy

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

Table of Contents 2 of 210 MEDICAL COMBINED ADULT/PEDIATRIC AB 2.03 General Medical Protocol AB 4.02 Allergic Reaction (Anaphylaxis) Protocol AB 5.01 Shock Protocol AB 6.04 Behavioral/Psychiatric Disorders Protocol AB 7.05 Altered Mental Status Protocol AB 8.03 Hyperthermia Protocol AB 9.02 Hypothermia Protocol AB 10.04 Poisoning Protocol AB 11.05 Seizure Protocol AB 12.01 Syncope Protocol AB 13.08 Respiratory Distress Protocol AB 14.04 Cardiac Dysrhythmia Protocol AB 17.07 Cardiac Arrest Protocol AB 18.02 Child birth/Neonatal Resuscitation Protocol AB 19.02 Ophthalmologic Emergencies Protocol S 6.02 Treatment of Nerve Agent and Organophosphate Pesticide Casualties Protocol TRAUMA COMBINED ADULT/PEDIATRIC ABT 1.06 General Trauma Protocol ABT 3.04 Burns Protocol ABT 8.00 Spinal Restriction/Omission of Spinal Restriction Protocol ADULT PROTOCOLS A 6.09 Chest Pain Protocol A 7.03 Stroke/CVA Protocol A 8.01 Prehospital Termination of Resuscitation Protocol PROCEDURES C 1.05 Oral Endotracheal Intubation Procedure C 2.05 CO2 Detector (EZ CAP II) Procedure C 3.05 Nasotracheal Intubation Procedure C 4.01 Needle Thoracostomy Procedure C 5.02 Needle Cricothyroidotomy with Transtracheal Jet Insufflation Procedure C 6.01 Intraosseous (Intramedullary) Cannulation Procedure C 7.01 Transcutaneous Cardiac Pacing Procedure C 19.02 Pulse Oximetry Procedure C 20.00 Nasogastric/Orogastric Tube Insertion Procedure C 22.03 Confirmation of Endotracheal Tube Placement Procedure C 23.00 Esophageal Detector Device (EDD) Procedure Version 1.6 effective 7/1/2008

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

Table of Contents 3 of 210 C 24.01 C 25.02 C 26.00 C 27.00 C 28.00 C 29.01 SC 1.00 SC 2.00 SC 3.00 SC 4.00 SC 5.00 SC 6.00 SC 7.00 SC 8.00 AB 15.05 AB 16.02 DRUGS D 1.02 D 2.01 D 3.02 D 5.01 D 8.01 D 9.01 D 11.01 D 12.00 D 13.00 D 14.00 D 15.01 D 16.00 D 18.00 D 19.00 D 20.00 D 22.01 D 23.00 D 24.00 D 25.00 D 26.01 D 27.00 12-Lead ECG Monitoring (Zoll E-Series) Procedure End Tidal CO2 Monitoring (Zoll E-Series - Capnostat) Procedure Rapid Bedside Glucose Determination Procedure Intranasal Drug Administration Procedure Non-Invasive BP Monitoring (Zoll E-Series) Procedure Continuous Positive Airway Pressure (CPAP) Procedure Manual C-Spine Immobilization Procedure Log Roll Procedure Rigid Long Spine Board Immobilization Procedure Standing Rigid Long Spine Board Immobilization Procedure Spinal Immobilization Using the Rigid Short Immobilization Device Procedure Spinal Immobilization Using Rapid Extrication Procedure Stifneck Cervical Collar Application Procedure HeadBed II Cervical Immobilization Device Application Procedure Analgesic Medication Administration Procedure Procedural Sedation Procedure Naloxone HCl (Narcan) Glucose (Dextrose) Oxygen (O2) Diazepam (Valium) Diphenhydramine (Benadryl) Albuterol (Proventil) Adenosine (Adenocard) Epinephrine Atropine Lidocaine Nitroglycerin Furosemide (Lasix) Calcium Chloride Dopamine Sodium Bicarbonate Midazolam (Versed) Aspirin Atrovent (Ipratroprium Bromide) Neosynephrine (Phenylephrine) Morphine Sulfate Glucagon 150 153 157 158 159 161 163 165 168 170 172 175 179 182 184 186 188 189 190 191 192 193 194 196 197 198 199 200 201 202 203 204 205 206 207 208 210

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

Preface 4 of 210 The policies, protocols, procedures and drugs described in this document are applicable to the Kansas City, Missouri Emergency Medical Services (EMS) System. This System includes the Kansas City, Missouri Fire Department (KCFD), the Metropolitan Ambulance Services Trust (MAST) and the Kansas City International Airport Police Emergency Medical Technician Program (KCI EMT). The document represents the hard work of multiple individuals and agencies including: KCFD, MAST, KCI EMT Program, the Emergency Physicians Advisory Board (EPAB), the Protocol and Clinical Upgrade Subcommittees of EPAB, the Office of the EMS Medical Director and the Emergency Medical Services Coordinating Committee of Kansas City, Missouri. It is a "living document" and is frequently updated. We would like to thank the above agencies for their tireless work on this document and most especially we would like to thank the individual paramedics, system status controllers, EMTs, first responders and other individuals who continuously provide excellent emergency medical care under frequently difficult and sometimes dangerous circumstances to the Citizens of Kansas City, Missouri and it's visitors. Joseph Salomone, MD EMS Medical Director Kansas City, Missouri Theodore M. Barnett, MD Chairman EPAB

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

Introduction 5 of 210 The Scope of Practice Policy (P 16.05) delineates the specific skills that each level of City priviledged out-of-hospital practitioner (Emergency Responder, EMT, and Paramedic) can accomplish within the KCMO EMS System. Furthermore, each protocol specifies what skills are appropriate for each level of priviledged practitioner. Items written in "normal" type are appropriate for all levels or personnel. Items written in "bold" are to be accomplished only by paramedic level personnel. Items that are in "bold" and prefaced with "(orders)" are to be accomplished only by paramedics after approval by on-line medical control.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 1.10 Determination of Hospital Destination Policy 6 of 210

BACKGROUND: N/A POLICY: I. General Routing A. For all life threatening emergencies, transport the patient to the nearest appropriate hospital. 1. When the hospital is "closed to ambulances", no patient will be taken to that hospital. Patients will be transported to the nearest "open" hospital emergency department or trauma center as indicated. 2. The following situations are exceptions to "A.1:" a) Patients who are in cardiac arrest may still be taken to the closest appropriate hospital, unless it is "out of service." b) Medical patients who are "unstable" may still be taken to the closest appropriate hospital, unless it is "out of service." c) "Unstable" is defined as: (1) Unable to establish or maintain an airway (2) Unable to ventilate (3) Unremitting shock (4) As determined by medical control B. For all non-life threatening emergencies, transport the patient to the hospital of the patient's choice. 1. When the patient is unable to make such a judgment, the choice of an appropriate party acting on behalf of the patient will be followed. 2. When no person is available to act for the patient, transport to the nearest appropriate "open" hospital. 3. When the chosen hospital is "closed to ambulance," transport the patient to an appropriate "open" hospital of the patient's second choice. C. MAST ambulances should not transport more than one patient in the same ambulance unless the patients have established a previous relationship, such as family or friends and are being transported to the same destination hospital. D. Patients with isolated mental health problems may be taken directly to Western Missouri Mental Health if they request. 1. This does not include drug or alcohol intoxicated patients or patients with any other active medical problem. E. See attached table for a list of facilities and services provided.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 1.10 Determination of Hospital Destination Policy 7 of 210 II. Trauma Routing A. Any trauma patient with any of the following criteria should be routed to a Level I/II Trauma Center even if it is not the nearest hospital. 1. Physiologic Criteria a) Shock (1) BP less than 90 systolic (adults) (2) Capillary refill > 3 seconds b) Respiratory distress (1) RR > 29 or < 10 (adults) (2) Decreased or absent breath sounds (3) Accessory muscle use c) Altered mental status (1) Glasgow Coma Scale or less than 14 (2) AVPU scale P or U 2. Mechanism of Injury a) Occupant ejection b) Fall from height > 20 feet c) Pedestrian/bicycle/motorcycle hit at speed > 20 mph d) Death of same car occupant e) Prolonged extrication > 20 minutes 3. Anatomic a) Penetrating injury to head, chest, abdomen, neck, groin or extremities proximal to elbow or knee b) Airway burns c) 20% second degree burns and/or 5% third degree burns d) Flail chest e) Two or more proximal long bone fractures f) Pelvic fracture g) Paralysis h) Amputation proximal to wrist or ankle i) Open and/or depressed skull fracture B. For any trauma patients with the following criteria, contact medical control and consider transport to a Level I/II Trauma Center even if it is not the nearest hospital. 1. Age < 5 or > 55 2. Pregnancy 3. Patient with bleeding disorder or patient on anticoagulants 4. Patient with any known serious medical disorder C. Patients who are less than 16 years old and who meet the physiologic (pediatric), mechanism of injury or anatomic criteria should be routed to a Missouri state designated pediatric trauma center.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 1.10 Determination of Hospital Destination Policy 8 of 210 D. Traumatic cardiopulmonary arrest patients should be taken to the nearest Level I/II Trauma Center, unless it is "out of service." E. When there is more than one adult trauma patient, attempt to evenly distribute patients. If this is not feasible, contact central medical control at Truman Medical Center ­ Hospital Hill for routing assistance. F. When more than one patient less than 16 years old meets physiologic or anatomic criteria per the trauma routing protocol, contact central medical control at Children's Mercy Hospital for routing assistance. III. Hospital Diversion Routing A. Definitions 1. Diversion ­ The rerouting of an ambulance(s) from the intended receiving facility to an alternate receiving facility due to a temporary lack of critical resources in the intended receiving facility. 2. Diversion Categories: a) Open ­ The hospital ED is open to all ambulance traffic. b) Trauma Diversion ­ Level I or Level II trauma centers may close to ambulances carrying patients who meet trauma routing criteria. c) Closed to Ambulances ­ The ED is functioning but cannot accept ambulance patients. d) Open to Trauma ­ The ED can only accept ambulance patients meeting trauma routing criteria. e) Out of Service ­ The emergency department has suffered structural damage, loss of power, an exposure threat or other conditions that precludes the admission and care of any new patients. f) Forced Open ­ The emergency department has been forced open due to multiple closures in a catchment area. B. Hospital Diversion Procedure 1. The Kansas City, Missouri EMS System uses a web-based, real time, computerized diversions system called the "EMSystem." Each hospital follows the procedures in the "EMSystem Protocols and Policies" Manual when going on and off diversion status. 2. If the EMSystem is down for any reason, the hospital shall fax the MAST Dispatch center to go on and off diversion status. 3. "Call by call" diversion status is not recognized in the system.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 1.10 Determination of Hospital Destination Policy 9 of 210 4. Enroute diversions should be a rare event a) This may occur when a hospital is "closed to ambulances" without the knowledge of the EMS crew. b) Diversions enroute may only occur by an order given by medical control. c) Contact medical control at Truman Medical Center ­ Hospital Hill for orders. 5. A Level I/II trauma center on "trauma diversion" will continue to receive trauma patients that do not meet trauma routing criteria. DOCUMENTATION REQUIREMENTS: N/A NOTES: I. Hospital Transfers: A. When the receiving hospital is closed, interfacility transfers that have been arranged between two hospitals for the direct admission of patients to inpatient beds will be followed. B. If the inpatient bed is not available at the receiving hospital upon ambulance arrival to that receiving hospital, then the patient will be delivered to the hospital emergency department and the ambulance will be released for further calls. II. Patients under Arrest: A. Hospital destination for patients who are under arrest by law enforcement 1. Patients under arrest with a life-threatening emergency will be transported to the closest appropriate hospital as directed by this policy. 2. Patients under arrest and considered to have a non-life threatening emergency have no freedom of movement, or right to designate medical treatment. The patient will be transported to the hospital designated by the arresting officer.

III. Patients refusing transport to any other facility Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 1.10 Determination of Hospital Destination Policy 10 of 210 A. Patient care and safety should be the central consideration in all diversion decisions. If a patient demands transport to a hospital that is on diversion, and if the patient is refusing transport if they will not be taken to their hospital of choice because of the diversion status, then transport to the patient's hospital of choice: 1. Contact the receiving hospital "for information" and inform them that you are bringing the patient per this protocol. 2. Do not ask permission of the hospital. 3. This should be an informed decision on the patient's part. The medic should explain that since the hospital is "closed to ambulances" it means that this may delay and/or otherwise impede the patient's care. 4. Obtain the patient's signature on the "refusal of diversion" form. (Document if the patient refuses to sign.) IV. General parent-child considerations A. In general, if the parent is supportive, most children should be transported with a parent, unless accompaniment interferes with the care of the child. B. Children usually respond best to open and honest dialogue. C. In situations of major trauma or cardiopulmonary arrest, it is usually better to have the parent not ride in the ambulance

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 2.07 Medical Standards During Patient Transfer Policy 11 of 210 BACKGROUND: N/A POLICY: I. Medication Administration A. During the transfer of patients between health care facilities paramedics may be required to monitor the intravenous infusion of medications, or administer medications not approved by the EMS Medical Director for use in the prehospital setting (nonstandard medications.) B. Policy 1. The MAST paramedic may monitor and administer nonstandard medications prescribed by the patient's transferring physician with online medical control guidance during the patient transfer as needed. Medications requiring continuous infusion will be administered via a mechanical infusion pump: a) Understanding of a mechanical infusion pump is the paramedic's responsibility (i.e. if the paramedic does not understand, then the paramedic should not leave the facility until it has been explained.) b) If the paramedic is asked to manipulate more drugs or devices than the paramedics thinks is appropriate, then the paramedic should notify the appropriate personnel at the transferring hospital. If the problem cannot be solved, then the paramedic should contact a supervisor. 2. The administration of any nonstandard medications shall be recorded on the patient care report (PCR) noting the transferring physician's name, medical control contacted, and dosage and route of administration of medication. II. Respiratory Support A. Paramedics may be asked to transfer patients who are receiving positive pressure ventilatory support. Overall responsibility for the patient rests with the paramedic. A second medically trained person is preferred to help to attend to the airway and provide ventilatory support. B. Policy 1. MAST paramedic should not transport the positive pressure ventilated patient without a second medically trained person to assist if in the paramedic's judgment additional help is needed to help attend to the airway and provide ventilatory support. 2. If the paramedic is asked to do so, the paramedic should inform the appropriate personnel at the transferring hospital of the MAST Policy. If the problem cannot be solved, then the paramedic should contact a supervisor. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 2.07 Medical Standards During Patient Transfer Policy 12 of 210 3. If a patient is on oxygen of any source or has any respiratory symptoms, then an appropriately sized bag-valve-mask must always accompany the patient. 4. If a patient is found to be on Positive End Expiratory Pressure (PEEP) at the transferring facility, then a bag-valve-mask with an attached PEEP valve and a person knowledgeable in its use will accompany the patient in transfer. 5. The level of response (lights and siren or not) from the sending hospital to the receiving hospital can be specified by the transferring physician. If no level is specified, then paramedic judgment will determine the level of ambulance response. 6. If a patient is determined to be critical by the paramedic, at least an information call should be made to the receiving hospital to request a standby elevator. If a critical patient is not going to a critical area, the paramedic may request an evaluation by the ED prior to proceeding to the non-critical area. III. MAST transports patients from hospitals to psychiatric facilities A. The patient cannot legally refuse treatment and transport once a physician has determined that the patient is, or may be, suicidal. This MUST be documented on the PCR B. The patient must be transported to the psychiatric facility regardless of the patient's demands to refuse transport. C. Verbal, physical, or chemical restraint may be appropriate; contact law enforcement personnel for assistance as needed DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 4.03 Helicopter Utilization Policy 13 of 210 BACKGROUND: Dispatching of air ambulances within the City of Kansas City, Missouri, will be done through the MAST Communications Center. POLICY: I. Indications A. Use of air ambulance transport is the judgment of the on-scene paramedic B. Factors to consider include 1. Optimum speed of response and transport a) Be aware of helicopter spin up time, response time, load time and transport time 2. Impaired ground accessibility a) Location b) Traffic volume c) Condition of roads or streets 3. Shortage of conventional ground transport units and need for rapid transport 4. Rapid transport of medical personnel and supplies 5. Distribution among area hospitals to avoid overloading the nearest emergency facility a) In a multiple casualty incident, the air unit should transport to the furthest appropriate facility from the scene 6. Need for multiple response of ground vehicles, usually in outlying areas II. Procedures A. It is within the authority of the SSCs to dispatch air ambulances as additional units B. When MAST Communications receives a request for air ambulance service from other entities prior to the arrival of a MAST unit, air ambulances may be ordered depending on location of MAST units and number of patients. C. MAST Communications will advise responding MAST unit and other ground units that an air ambulance has been ordered. D. It is the responsibility of the on-scene paramedic to: 1. Triage patients and consider the mode of transportation and destination of all patients. 2. Immediately notify the ranking fire and law enforcement on-scene personnel that an air ambulance is enroute. 3. Confirm a suitable landing zone (LZ) for air ambulance. a) This is primarily a fire and police responsibility depending on jurisdiction. b) In Kansas City, Missouri, the Kansas City Fire Department will coordinate the LZ. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 4.03 Helicopter Utilization Policy 14 of 210 E. The air ambulance pilot has final authority if an LZ is acceptable. 1. If another LZ is requested/suggested by the pilot, it must be provided. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 6.03 Report Format Policy 15 of 210 BACKGROUND: The reason for contact should be stated clearly at the beginning of the transmission. POLICY: I. The three accepted reasons for contact are: A. "FOR ORDERS" 1. Requests for orders 2. Refusals 3. Consultations with the base station physician in unusual circumstances B. "FOR INFORMATION WITH CRITICAL/TRAUMA PATIENT" 1. Patients meeting trauma routing criteria 2. Patients in cardiac arrest 3. Patients with airway compromise 4. Patients with other serious physiologic derangements per paramedic discretion C. "FOR INFORMATION" 1. This is a courtesy to the hospital and does not include patients in the above groups II. Ambulance Identification A. Vehicle identification (i.e., MAST Unit 125) B. Paramedic name C. Estimated time or arrival (ETA) III. Patient Report A. Patient's age and sex B. Basic problem or chief complaint C. Brief relevant history; include past medical history, medications, and allergies only if relevant D. Vital signs (pulse, blood pressure, respirations, cardiac monitor pattern if appropriate) E. General appearance include level of consciousness F. Pertinent physical findings G. Care in progress (i.e., airway, splints, backboard, collar, oxygen, etc.) H. Request specific orders following the appropriate protocols IV. Special Notes A. Be as concise and accurate as possible. Radio reports should not take more than one minute per patient B. Significant objective findings (i.e., critical vital signs) may take precedence over history and need to be reported first C. Patient's name may be broadcast if it will further patient care; patient name may be broadcast at hospital request Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 6.03 Report Format Policy 16 of 210 D. Radio report is a paramedic function except under extreme conditions. Unstable patients may necessitate an EMT giving a radio report. E. Any request for drug orders will include dose and route. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 9.05 Vascular Access Policy 17 of 210 BACKGROUND: N/A POLICY: I. Intent A. Standardize vascular access B. Insure patient safety by decreasing the likelihood of inappropriate administration of fluid or drug II. Policy A. Vascular access can be achieved using either: 1. Saline lock (used only on patients who have stable vital signs and do not require volume replacement). 2. IV of LR for administration of fluids or medications 3. IO (only in critically ill pediatric patients) B. Type/amount of fluid determined by appropriate protocol C. Lactated Ringers (LR) ­ used if fluid administration is/may be necessary 1. Age 12 - Maxi-drip administration set and 1000 ml bag 2. Age < 12 - Maxi-drip and 500 ml bag (not 1000 ml bag) D. IO ­ Failed IV attempts for approximately 1.5 minutes (or very low likelihood of IV success given clinical situation) E. Continuing drug infusion therapy (i.e., drug added to IV fluid to give at constant controlled infusion rate.) Use a mini-drip administration set. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 10.06 Refusal of Service Policy 18 of 210 BACKGROUND: The purpose of this policy is to assist EMS personnel with clear rules for managing situations in which the patient or the patient's representative declines or refuses care or transportation by EMS. POLICY: I. A "patient" is any person who is ill or injured or in need of treatment by medical personnel. This includes any person that has activated the EMS system or for whom the EMS system has been activated for, including emergency and non-emergency calls for service, or any person that presents themselves to EMS personnel with a medically related complaint such that it could be reasonably inferred that the person is seeking or in need of medical attention. Appropriate paperwork will be completed, including a patient care report. II. "No patient" is defined as A. No patient found on EMS arrival after adequate investigation B. Bogus (false) call C. After adequate investigation it is reasonably certain that the person or persons on scene did not request an ambulance 1. Deny any physical complaints 2. Person or persons on scene do not appear to have obvious injuries or illness 3. The person or persons on scene are capable of making competent decisions regarding refusal of care III. A "No Patient" PCR must include documentation of the elements listed above. IV. Assessment A. A patient must meet certain criteria prior to being allowed to refuse care. In order to be considered competent the patient must be able to provide the following information. If the patient is able to answer the following questions, the patient will be allowed to refuse medical treatment without contacting medical control with exceptions listed in IV.B. below. 1. His/Her own name 2. Where he/she is 3. What day of the week it is OR what month and year it is 4. The circumstances surrounding the request for EMS B. There are specific categories of patients that are inherently difficult. The following is a guideline to assist in making the best decision for the patient 1. Diabetic patients unconscious at the scene a) If the patient receives ALS care, including the administration of glucose or glucagon b) The patient becomes alert after the administration of glucose or glucagon c) After becoming alert, defined in IV.A., the patient wishes to refuse care and transport Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 10.06 Refusal of Service Policy 19 of 210 d) Patients should optimally be able to eat a meal prior to leaving the scene and have a responsible party able to observe the patient for > 1 hour. 2. Suicidal/Threatening a) Once a patient activates the 911 system and expresses a threat to themselves an EMS response cannot be cancelled b) A patient cannot refuse medical treatment and transport if there is reason to believe that the patient is at risk of self-inflicted physical harm as evidenced by, but not limited to threats or attempts to commit suicide or to inflict physical harm on themselves. c) Patients do not have to verbalize suicidal intent to be at risk of harm to themselves. If a patient's actions, behavior or verbal comments are consistent with and could reasonably be assumed to be an act of suicidal intention, or risk of self harm, the patient cannot refuse medical treatment and transport. d) A patient cannot refuse medical treatment and transport if there is reason to believe that the patient is at risk of physical harm as evidenced by, but not limited to a result of abuse or neglect, or due to the patient's or the patient's caretaker's impairment in his/her capacity to make decisions with respect to the need for treatment. e) If the patient refuses medical treatment and transport, (1) Law enforcement should be contacted for assistance (2) If the patient is not placed in protective custody, base station contact will be made to determine the patients disposition. (3) If base station physician contact is required; the base station physician will be apprised of the patient's condition including the history, vital signs, level of consciousness, and mental status including all reasons that the patient is determined to be at risk of physical harm to themselves. From this information, the base station physician will determine transport and treatment. (4) If the base station physician determines that the patient is at risk of physical harm and should be transported, but the patient continues to refuse, reasonable restraint (to assure the patient and allied health personnel safety) may be utilized to transport the patient to the hospital.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 10.06 Refusal of Service Policy 20 of 210 (5) Assistance from the appropriate law enforcement agency should be sought for those patients exceeding the capabilities of the transporting unit. (6) The appropriate law enforcement agency should be advised that a KCMO licensed base station physician has determined that the patient is at risk of physical harm to themselves and has ordered the patient to be transported for evaluation. (7) All actions taken to restrain the patient as well as the base station physician's orders to restrain must be documented on the Missouri State Run Report form. f) Law enforcement should not transport the patient who has ingested medications or has physical injuries. g) If law enforcement does transport the patient, the patient refusal must be signed by the highest ranking law enforcement agent. 3. Incompetent Adult patients (Mentally Retarded, Mentally Ill, Alzheimer's, OBS, etc.) a) If the patient's guardian is on scene with a Durable Power of Attorney, the patient may not refuse treatment or transport for himself. b) If the guardian is not oriented, as defined in IV.A., Medical Control must be contacted. c) If the patient's guardian cannot prove Durable Power of Attorney, Medical Control must be contacted. d) If the patient's guardian is not present, Medical Control should be contacted to approve transport. If the patient's condition is urgent, the patient will be transported by standing order prior to guardian contact or base station approval. 4. Emancipated Minor Patient a) Emancipation is defined as a minor (17 years or less) who is living apart from their legal guardian and who is not financially supported by their guardians. These patients shall be handled as adults. (1) person enlisted or commissioned in the U. S. Armed Forces (2) person legally declared an adult by the courts 5. Minor patient - Guardian present (Minor = 17 years of age or younger) a) If guardian is oriented, as defined in IV.A., all patient care must be decided by the guardian. If the patient is a refusal, the guardian will be given the instructions and sign the refusal of care form. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 10.06 Refusal of Service Policy 21 of 210 b) If abuse of the patient is suspected, law enforcement will be notified. 6. Minor patient - Guardian not present (Minor = 17 years of age or younger) a) This patient must be transported or a competent adult (18 years of age or older), defined by IV.A., must be on scene and take responsibility en loco parentis for the patient and sign the refusal of care form. b) Law enforcement may take these patients into protective custody pending parental notification and response to the scene. In these instances the law enforcement officer should sign the patient refusal form. 7. Intoxicated patients a) Intoxicated patients may have serious underlying medical conditions. These patients should be properly assessed to include a blood glucose reading. b) If the patient is competent, as defined by IV.A., and is turned over to Law Enforcement the patient must sign a refusal of care form along with the highest ranking police officer as a witness. c) If the patient is competent, as defined by IV.A., but is in such condition that a reasonable person would consider them not capable of being able to adequately care for themselves, the patient should be transported. If the patient continues to refuse then contact medical control for guidance on medical treatment and transport. DOCUMENTATION REQUIREMENTS: I. Have the patient sign the refusal of care form. II. If the patient refuses to sign, document the refusal on the Patient Care Report and, if possible have a witness (preferably someone related to the patient) sign the refusal form. III. Advise the patient and family that you will return and transport if requested to do so. IV. Explain the potential risks of refusing care to the patient. If appropriate, recommend that the patient seek further medical care as soon as possible. V. Document all recommendations given to the patient. Additionally, document the base station physician's recommendations to uphold the patient's decision to refuse service. VI. These patients should receive an instruction sheet copy. Specific instructions should be given as appropriate. Have the patient sign the instruction sheet as documentation that the sheet was given.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 10.06 Refusal of Service Policy 22 of 210 NOTES: I. The obligations under EMTALA apply in the following situations: (1) A request for emergency services is made. This request can come from the patient, someone accompanying the patient, a law enforcement officer bringing someone to the ED for a blood alcohol level measurement, or someone walking into the ED requesting a blood pressure check. (2) A reasonably prudent layperson would conclude, based on the person's appearance or behavior that the person is in need of emergency treatment. Applying this condition obligates all hospital staff to recognize when a visitor, another employee, or anyone on the hospital campus, is in need of medical assistance, i.e., needs a medical screening examination. II. An emergency medical condition is a medical condition that manifests as acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could place the individual's health at risk.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 11.03 Infection Control Policy 23 of 210 BACKGROUND: N/A POLICY: I. The infection control procedures will be followed as directed by the MAST Health and Safety Manual and any other applicable mandated standards, rules or regulations II. Special Considerations A. Severe Acute Respiratory Syndrome (SARS) 1. Patients presenting with complaints of cough, shortness or breath, or current pneumonia should be screened with the following: a) History of fever or confirmed fever (> 38 C, > 100.4 F) b) Pulse oximetry (< 94% RA) c) Travel history to areas considered high risk by CDC within the last 10 days OR close contact with a person with the above history and criteria within the last 10 days d) If the patient meets above criteria then: (1) Place surgical mask on patient if patient can tolerate (2) All personnel in close contact should wear N95 mask and appropriate eye protection in addition to standard precautions 2. Protective eye wear, N95 mask and gloves should be considered for all situations in which close contact with persons with severe respiratory distress where the above history and findings are not immediately available. 3. Transportation of patients with known SARS should follow standard airborne particulate exposure precautions and appropriate post transport vehicle cleaning. 4. Receiving facility should be notified prior to arrival of a patient that may require respiratory isolation. The terminology "SARS" should not be used. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 12.03 On-Scene AED Coordination Policy 24 of 210 BACKGROUND: N/A POLICY: I. EMT-First Responder (EMT-FR) has medical authority over public access defibrillator (PAD) personnel at scenes until arrival of the transporting EMTParamedic (EMT-P). II. Transporting EMT-Paramedic has medical authority at scenes. III. On arrival, the EMT-P or EMT-FR should receive a verbal report from the EMT-FR or PAD site personnel to include: A. Age B. Witnessed or un-witnessed arrest C. Approximate time from collapse D. Initiation of CPR prior to EMT-FR arrival E. Initial rhythm (shockable vs. non-shockable) F. Number of shocks delivered G. Response to treatment IV. If the EMT-FR arrives first on scene with a PAD program AED being used, the EMTFR has the following options: A. If the PAD personnel are proceeding with a shock, the EMT-FR should wait until the shock is complete. B. Have the PAD personnel remove the AED and the EMT-FR applies the EMTFR AED and follows the appropriate protocol. V. When the EMT-P arrives on the scene and has assumed care of the patient, he will proceed as directed by current system advanced life support protocols. VI. The EMT-P will follow these procedures: A. If the EMT-FR or PAD AED is proceeding with a shock, the EMT-P will wait until this is complete B. After completion of the shock from the AED, the EMT-P or his designee will immediately switch to the Zoll monitor, keeping interruptions to CPR at a minimum VII. The EMT-P should consider the shocks delivered by any AED as part of the dysrhythmia algorithm. For example, if the patient remains in V-fib after shock by the AED, the EMT-P should enter the treatment sequence at the point where the shock has been delivered and establish IV access, give epinephrine and intubate. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 13.02 Multiple Encounter Incident Policy 25 of 210 BACKGROUND: N/A POLICY: I. A minimum of two persons per incident is necessary to utilize this policy. Persons meeting the following criteria may be considered to be listed on a multiple encounter incident refusal form: A. No complaints/symptoms at present B. No acute findings on exam at present C. Radial pulse and respirations are within normal range D. The patient expresses a desire to not be transported E. There are no communication problems with the patient F. There has been no use of drugs or alcohol within the past 8 hours G. The mechanism does not include any criteria that would require trauma center preferential routing H. An individual patient care report (PCR) must be completed on any patient who reports any of the following symptoms including pre-existing conditions (even if now resolved): 1. Respiratory symptoms (cough, dyspnea) 2. Weakness, tingling in extremities 3. Alteration of consciousness 4. Chest pain 5. Neck or back pain I. An individual PCR will be completed for each person (patient) in the same vehicle involved in a motor vehicle crash (MVC) if either of the following have occurred: 1. There is significant intrusion into the passenger compartment 2. There are patients in the same vehicle that meet trauma routing criteria J. For minors, there must be some adult person acting in loco parentis for that minor K. If there are any questions about whether this policy can apply to a specific incident, contact medical control L. A PCR will be completed for each multiple encounter incident and the Multiple Encounter Incident Form (MEIF) will be attached to the PCR. M. This policy applies to school bus motor vehicle crashes. Base station contact is not necessary when utilizing this policy for school bus motor vehicle crashes when someone is acting in loco parentis for the minors. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 14.04 Medical Intervention Policy 26 of 210 BACKGROUND: Kansas City, MO EMS Ordinance, Section 34-374 states (a) "the senior EMS provider in charge shall have authority for patient management, including medical management of the patient at the scene of an emergency." The senior EMS provider is operating under the authority of the EMS Medical Director or his designee. The EMS Ordinance, Section 34-374 further states "if a licensed physician appears on the scene and desires to assume direction and control of patient care, the physician shall execute a form which declares the physician has assumed responsibility for patient care." Two scenarios are common: I. Personal Physician A. Individual is the personal physician of the patient and has previously established a doctor-patient relationship with the patient B. Most commonly occurs when the patient is still in the doctor's office C. May also include a "team physician" II. Intervener Physician A. Physician does not have a prior formal doctor-patient relationship with the patient B. Most commonly occurs when the doctor happens on scene prior to, concurrent with or after EMS arrival The highest priority is the provision of effective and efficient care and transport of the patient. This policy describes the relationship between the patient, the EMS system, and the physician in these scenarios. POLICY: I. Personal Physician: A. If the patient's personal physician is present and desires to continue care, the prehospital provider should defer to the orders of the personal physician as within the paramedics scope of practice B. Regardless of a physician executing a physician intervention form; EMS personnel retain the authority to establish medical direction with on-line medical control and assume medical authority of the patient if they believe the care rendered by the personal physician is not the standard of care. EMS personnel will not comply with orders that exceed their scope of practice or are inconsistent with the standard of care. C. The medical direction of EMS personnel shall revert to protocols and/or online medical control at any time the personal physician is no longer in attendance. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 14.04 Medical Intervention Policy 27 of 210 II. Intervener Physician On Scene: A. If an individual identifies themselves as a physician on scene and expresses intent to assume medical care for a patient, EMS personnel will briefly discuss the situation with the physician. B. EMS personnel will ask for proof of licensure to practice medicine in the State of Missouri. The only acceptable evidence of licensure are 1. State of Missouri medical license card 2. KCMO Base Station Physician certification card C. If the physician cannot provide this proof of licensure, the paramedic will not transfer medical authority. D. If after establishing proof of licensure listed in II.B.2; EMS personnel will provide the physician with a "medical intervention form" for review. E. If after reading the document and any further discussion, the physician wishes to take over medical care of the patient the paramedic will perform the following 1. Contact with on-line medical control is mandatory to determine whether to relinquish responsibility to the intervener physician. 2. If on-line medical control relinquishes responsibility to the intervener physician, then: a) The intervener physician must sign the "medical intervention form." b) The intervener physician must accompany the patient to the hospital, sign the MAST Patient Care Report, and give a report to the receiving hospital physician. 3. If a patient explicitly requests that the intervener physician not provide care then the paramedic maintains medical authority of the patient. 4. If patient care has progressed to time for transport, the paramedic will decline the offer of assistance and transport. 5. Contact with the on-line medical control is not necessary if the intervener physician is a BSP and can demonstrate proof of certification as a BSP in the KCMO EMS System. F. At no time shall patient care be compromised for on-line medical control contact to relinquish responsibility to the intervener physician. G. The on-scene paramedic will continue to have ultimate authority for the patient. If the paramedic feels at any time that the intervening physician is either not providing the standard of care or is interfering with the furtherance of patient care, the paramedic will terminate the medical intervention relationship and assume care of the patient per KCMO EMS protocols. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 14.04 Medical Intervention Policy 28 of 210

Medical Intervention Form

Be advised that these EMT/Paramedics are operating under the authority of Missouri State Statues and Kansas City, Missouri City EMS Ordinance. Once under the care of the EMS System, the patient has a physician responsible for his/her care. No physician or other person will interfere or direct patient care without consultation and relinquishing authority by a KCMO certified base station physician. Thank you, Kansas City EMS Medical Director 2400 Troost, Suite 4200 Kansas City, Missouri 64108 816.513.6262 If you (physician) choose to take responsibility for patient care: I. You must produce evidence to practice medicine in the State of Missouri by providing either; A. A valid State of Missouri license to practice medicine, OR B. A valid KCMO Base Station Physician card II. You will assume responsibility for patient care at the scene and during transport to the hospital III. You must accompany the patient to the hospital IV. You must sign the MAST patient care report V. You must give a report to the receiving emergency department personnel on arrival VI. You assume all liability for patient care rendered while the patient is in your control I have read the above and accept responsibility/liability for the care of this patient. _____________________________ Run Number _____________________________ Date _____________________________ Paramedic Witness ______________________________ Physician (Print Name) ______________________________ Physician Signature _____________________________ State of Missouri License Number Or KCMO BSP License Number

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 16.05 Scope of Practice Policy 29 of 210 BACKGROUND: N/A POLICY: I. "Paramedic" means city licensed Paramedic-Driver or Paramedic-Attendant, on duty with MAST, a licensed paramedic operating in a mutual aid capacity, or employed by the Office of the EMS Medical Director. "EMT" means city licensed EMT-Driver, on-duty with MAST or city licensed KCFD EMT-First Responder, on duty with KCFD. "First Responder" means city licensed KCFD First Responder, on duty with KCFD. II. Paramedics are authorized to perform the following skills within the KCMO EMS System: A. All patient care activities authorized by the EMS Medical Director protocols. B. The senior paramedic on the responding ambulance is in charge of all patient care activities relating to that call unless specifically relieved of those duties by another provider on scene due to incident command or physician intervention per the physician intervention policy. III. EMTs are authorized to perform the following skills within the KCMO EMS System: A. All patient care activities authorized by the EMS Medical Director protocols, EXCEPT the following: 1. Invasive airway procedures such as endotracheal intubation or transtracheal jet insufflation. 2. Invasive circulatory procedures such as intravenous cannulation, intraosseous cannulation, and regulating intravenous infusions. 3. Administration of medications except as noted below: a) Oxygen b) Oral Glucose c) Patient's own medications where EMS may assist patient d) MARK I Kits are permitted to be administered for "self-aid" 4. Needle decompression of the chest. 5. Defibrillation or cardioversion using a manual defibrillator. 6. Interpretation of electrocardiographs. 7. External cardiac pacing. B. When performing patient care activities, EMTs are expected to follow the EMS Medical Director protocols until the arrival of the paramedic (paramedic then assumes responsibilities for patient care activities) or designation of the medical operations officer under incident command, except in cases where: 1. Following the direction of the paramedic would present a danger to the patient or public OR

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 16.05 Scope of Practice Policy 30 of 210 2. There are multiple patients on the scene such that the paramedic and EMT are taking care of separate patients, in which case the EMT on the responding ambulance should take responsibility for individual patient care IV. First Responders are authorized to perform the following skills within the KCMO EMS System: A. All patient care activities authorized by the EMS Medical Director protocols, EXCEPT for the following: 1. Invasive airway procedures such as endotracheal intubation or transtracheal jet insufflation. 2. Invasive circulatory procedures such as intravenous cannulation, intraosseous cannulation, and regulating intravenous infusions. 3. Administration of medications except as noted below: a) Oxygen is permitted to be administered by First Responders. b) MARK I Kits are permitted to be administered for "self-aid". 4. Needle decompression of the chest. 5. Defibrillation or cardioversion using a manual defibrillator. 6. Interpretation of electrocardiographs. 7. External cardiac pacing. B. When performing patient care activities, First Responders are expected to follow the EMS Medical Director protocols until the arrival of the paramedic (paramedic then assumes responsibilities over patient care activities) or designation of a medical operations officer under incident command, except in cases where: 1. Following the direction of the paramedic would present a danger to the patient or public OR 2. There are multiple patients on the scene such that the paramedic and First Responder are taking care of separate patients, in which case the First Responder should take responsibility for individual patient care. DOCUMENTATION REQUIREMENTS: N/A NOTES: I. Some manual monitor/defibrillators have an "automatic external defibrillator" (AED) mode. EMTs may operate the AED function of a manual monitor/defibrillator. II. EMTs may obtain a blood sample for, and perform, a rapid bedside glucose test as allowed by the State of Missouri and as delineated in the KCMO EMS System Protocols. If the blood sample is obtained by the EMT, then the blood sample will be obtained with a lancet or similar device.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 17.02 Medical Values Statement Policy 31 of 210 BACKGROUND: N/A POLICY: I. The following is a list of the recognized values for use in meeting the customer's medical needs within the KCMO EMS system. This list of values will be used to evaluate clinical care that falls outside of the established protocols. A. Safety: In order to protect the crew, the patient, or the public from a danger on the scene, established treatment modalities may need to be modified. B. Follow the ABC's: Generally, the care of the patient should be in accordance with the following priorities: 1. Airway Maintenance: Beginning with the simple, non-invasive techniques, and working to the more invasive. 2. Assurance of adequate ventilation and oxygenation: Any patient in significant distress should receive as high a concentration of oxygen as is practical to deliver. If any doubt exists as to the adequacy of ventilation, then the patient should receive positive pressure ventilation with the maximum available concentration of oxygen. 3. Assurance of adequate circulation: Through CPR and/or the appropriate treatment of bleeding and shock. C. Use Medical Control: When in doubt, call medical control. D. Primum Non Nocere (First Do No Harm): 1. A medication or invasive treatment should only be used if both the treatment is indicated, and there exists no contraindication to that treatment. On-line medical control should be used prior to any invasive treatment unless that treatment is authorized as a standing order. 2. Potentially unstable patients may be stressed by exertion, as a general rule, exertion should be minimized. (Potentially unstable includes, but is not limited to, patients with chest pain, dyspnea, or altered mental status.) E. Default to Transport: The preference is to transport the patient to an emergency department or a hospital with inpatient capabilities. If any doubt exists as to the legal or medical competence of the patient to refuse care, online medical control should be contacted. F. Customer Service: The human needs of the customer must be met including physical (medical and non-medical), and psychological (including the needs of reassurance and comfort). In all cases, be PROFESSIONAL, POLITE, and attentive to those needs. G. Clear Documentation: All patient encounters must be documented clearly and accurately.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 17.02 Medical Values Statement Policy 32 of 210 H. Render Timely Care: The clinical needs of the patient must be met in a timely fashion. This generally includes initiating treatment prior to moving the patient to the ambulance. Exceptions include major trauma, crew/patient safety, and other circumstances as determined by the senior paramedic. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 23.00 Central On-Line Medical Control Policy 33 of 210 BACKGROUND: I. The Kansas City, Missouri Emergency Medical Service System has utilized Base Station Certified Physicians (BSP) to provide on-line medical control for more than two decades. On-line medical control provides "real time" consultation to field medics in cases mandated by protocol and in any case which, in the paramedic's judgment, requires physician input. Historically, over 125 certified BSPs operating out of 10 or more hospitals have provided that on-line medical control. II. By this Policy, the system will transition to a "centralized" medical control system. Advantages of centralized medical control include: A. Enhanced consistency of orders; B. Eliminates the burden of radio medical control from busy practitioners; C. Allows continued oversight by the Office of the EMS Medical Director; D. Potentially allows for better data collection concerning medical control contacts; E. Should allow easy transition to a less traditional medical control model, utilizing paramedics for some orders. POLICY: I. All radio medical control contacts fall into one of three types (as per P 6.03 Report Format Policy): A. "For orders" 1. Calls in which protocol mandates an order from a BSP 2. Calls in which the paramedic believes physician input is necessary 3. These calls require contact with a BSP B. "For information with a critical / trauma patient" 1. Call notifying the receiving hospital of a critical or potentially critical patient arrival, including: calls meeting trauma routing criteria; patients in cardiac arrest; patient with significant airway compromise; other patients with serious physiological derangement 2. These calls are simply notification to the receiving hospital that a patient with these criteria are arriving, BSP contact is not necessary C. "For information" 1. All other calls fall into this category 2. These calls are simply notification to the receiving hospital that a patient is arriving, BSP contact is not necessary II. MAST units will contact a Base Station Certified Physician at one of the centralized on-line medical control hospitals for all "for orders" calls A. The following are central on-line medical control hospitals 1. Truman Medical Center Hospital Hill (TMC-HH) ­ all adult patients 2. Children's Mercy Hospital (CMH) ­ all pediatric patients Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 23.00 Central On-Line Medical Control Policy 34 of 210 B. Paramedic responsibilities: 1. Call the appropriate central on-line medical control hospital for all "for orders" calls 2. Give a concise radio report as per Report Format Policy 3. Received and carry out orders 4. Call the receiving hospital and give a concise report C. Central on-line medical control hospital responsibilities 1. Answer "for orders" radio calls within 30 seconds 2. Have at least one BSP on duty at all times 3. Obtain and maintain BSP certification on all full time emergency physician staff III. MAST units will contact the receiving hospital directly for all "for information on a critical / trauma patient" and all "for information" calls IV. If the MAST unit can not contact the central medical control hospital by radio, for any reason, it will contact the MAST Dispatch Center for help and/or further instructions. The Dispatch Center will facilitate contact with the central medical control hospital, whenever possible, via an appropriate recorded line. DOCUMENTATION REQUIREMENTS: N/A I. The paramedic will fill out the "medication/treatment authorization" section to include the appropriate "check-box" as well as the "on-line" physician and "medical facility" II. The BSP should fill out any "log-book" type instrument that may be developed in the future to track on-line medical control contacts NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 1.02 KCFD Request of MAST Ambulance Policy 35 of 210 BACKGROUND: N/A POLICY: I. "STAND-BY AMBULANCE" A. Automatic request with two alarm fire or at the discretion of the KCFD incident commander B. Ambulance is dedicated to the particular event C. The unit paramedic and/or the supervisor will make contact with the Incident Commander or his/her designated liaison for instructions D. Stand-by ambulance can be used to establish or assist in a triage/treatment sector for a multi-casualty incident E. Only under extraordinary circumstances, such as patients meeting trauma routing criteria, should a stand-by ambulance transport ­ additional units are requested for transport F. Caring for patients and patient destination are the responsibility of the senior paramedic on scene II. "TREAT AND TRANSPORT AMBULANCE" A. Usually requested when there is a single patient on scene needing medical attention and the KCFD incident commander does not require a "stand-by ambulance." The ambulance's priority is patient treatment and transportation. B. If upon scene arrival, there is no immediate patient to transport, the unit will make contact with the KCFD incident commander or his/her designated liaison for instructions C. The KCFD Incident Commander may convert a "treat and transport ambulance" to a "stand-by ambulance" as needed D. If another "treat and transport ambulance" is needed at a later time, the KCFD Incident Commander or his/her designated liaison will request another ambulance E. If upon scene arrival the requested "treat and transport ambulance" identifies multiple patients, the ambulance crew will convert to a "stand-by ambulance," make contact with the KCFD incident commander and establish a triage/treatment sector F. Caring for patients and patient destination are the responsibility of the senior paramedic on scene III. "REHABILITATION SECTOR AMBULANCE" A. Ambulance requested by KCFD when the Incident Commander or his/her designated liaison decides that a rehabilitation sector is necessary B. Ambulance is solely dedicated to the rehabilitation sector and the crew will be following the KCFD/MAST Rehabilitation Protocol S 2.00 C. A rehabilitation sector ambulance is separate from the "Stand-by" or "Treat and Transport" Ambulance Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 1.02 KCFD Request of MAST Ambulance Policy 36 of 210 D. A separate "stand-by" or "treat and transport" ambulance may be on scene E. If a patient is identified in the rehab sector, that patient becomes either a part of the triage and treatment sector or will be transported by an additional requested ambulance F. Patients will require a Patient Care Report (PCR), whether or not the patient is transported G. If the patient refuses transport following treatment, a refusal will be completed as per the refusal of care policy H. Caring for patients and patient destination are the responsibility of the senior paramedic on scene DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 2.00 KCFD/MAST Rehabilitation Policy 37 of 210 BACKGROUND: This protocol is designed to be incorporated with the Kansas City Missouri Fire Department Emergency Incident Rehabilitation S.O.P. POLICY: The mechanism for establishing a rehab sector for KCFD shall be as follows: I. The Incident commander or his designee may request a rehab sector be established as per the S.O.P. II. A MAST rehab sector ambulance (NOT Stand-by or Treat and Transport) will be requested by the I.C. according to EMS system protocol S 1.02. III. Upon arrival, the MAST rehab sector ambulance shall establish a rehabilitation sector in an area designated by the I.C. or the designated KCFD rehab sector officer. IV. Upon establishment of this sector, fire companies will be rotated into the sector for rehabilitation assessments. The assigned ambulance crew will utilize KCFD rehab incident rehabilitation reports to document the requested information. KCFD will provide thermometers to be used in this sector. Rest periods shall not be less than 10 minutes. The sector members are to be evaluated in a preventative manner. If a person exhibits signs or symptoms of heat illness, then defer to step 7. V. The heart rate should be measured for 30 seconds as early as possible in the rest period. If a member's heart rate exceeds 110 beats per minute, take an oral temperature. If the member's temperature exceeds 100.6° F, the evaluating ALS EMS person will notify the rehab sector officer to hold the effected member for further evaluation. If it is below 100.6° F, but the heart rate remains above 110 beats per minute, increase rehabilitation time until the heart rate is below 110. If the heart rate is less than 110 beats per minute with a temperature less than 100.6° F, then the chance of heat illness is diminished. VI. If a rehab sector member is identified as needing further time in the rehab sector, the sector officer should be notified and he will order further rehab time for that person. VII. If a rehab sector member is identified as having a medical, traumatic or heat illness problem, that member becomes a patient and becomes a part of the triage and treatment sector of the "stand-by ambulance" or treated and transported by the "treat and transport" ambulance. As a patient, this person requires a Missouri Ambulance Reporting Form, whether or not the person is transported. VIII. Upon termination of the Rehab sector, all KCFD rehab incident reports will be turned over to the Incident Commander or the Rehab sector officer. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 3.01 Procedures for Do Not Resuscitate Requests Policy 38 of 210 BACKGROUND: N/A POLICY: I. Do Not Resuscitate (DNR) requests are orders by a patient's physician to refrain from initiating cardiopulmonary resuscitative measures in the event of a cardiac or respiratory arrest. DNR Requests are compatible with maximal therapeutic care and the patient may receive vigorous support (e.g. intravenous lines, drugs) up until the point of respiratory or cardiac arrest. II. The Emergency Medical Services (EMS) provider will honor the DNR Request Form when properly executed and presented. Guidelines for acceptance of DNR orders include: A. If any doubt exists about the validity of the DNR Request Form, or if alternately worded directives to limit medical care are presented, or if the intent of the patient or the appropriate surrogate is unclear, resuscitation must be initiated and medical control should be contacted. B. The DNR Request Form must be signed and dated by the patient or the appropriate surrogate and the witness and the patient's physician. C. The revocation provision must remain unsigned in order for this DNR Request Form to remain in effect. D. No cardiac monitoring is necessary. No medical control contact is necessary. E. If this DNR Request Form is presented after BLS or ALS resuscitative procedures (including the AED) have begun, all resuscitative efforts shall cease. F. The EMS provider shall assist appropriate agencies in documenting the existence of the DNR Request Form. G. The DNR Form shall remain at the facility/home. Under circumstances in which the patient is being transported, a copy of the form will accompany the patient to the hospital. H. If the patient expires during transport, the paramedic must contact medical control for routing instructions. DOCUMENTATION REQUIRMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 4.00 Person Exceeding the EMS System's Capability Policy 39 of 210 BACKGROUND: N/A POLICY: When it is perceived by the responding Kansas City, Missouri EMS agencies that a person has exceeded the extrication limits of the agencies (even acting in concert) as a result of but not limited to the patient's size and weight, then the individual case will be referred to an interagency task force for review and recommendations to the Office of the EMS Medical Director. The EMS Medical Director will make the final decision as to whether the patient has exceeded the system's capabilities and can no longer be transported. This policy applies only to the transport of the person. When a request for service is made to the MAST Communications Center, an ambulance will be dispatched to the person. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 5.05 DOA Policy 40 of 210 BACKGROUND: N/A POLICY: I. Trauma - MAST: A. If there is any doubt the arrest state is traumatic or any question concerning any sign of life at the scene, then resuscitation should be initiated and medical control contacted. B. Patients may be pronounced DOA if the following criteria are met: 1. A patient with obviously fatal traumatic injuries, and 2. Patient has no audible heart sounds AND has not been observed at the scene to possess any sign of life (verbal or motor response, respiratory effort, or palpable pulse) C. The absence of any sign of life at the scene, the absence of audible heart sounds, and circumstances preventing resuscitation should be documented on the ambulance run report in those patients pronounced DOA. II. Medical - MAST: A. A patient in cardiopulmonary arrest due to medical causes may be pronounced DOA if the following criteria are met: 1. Asystole is confirmed in three leads OR has no audible heart sounds AND 2. Clearly has one of the following signs present: a) Rigor mortis b) Dependent lividity B. Generalized tissue decomposition is not compatible with life and the patient can be pronounced DOA without cardiac monitor application. C. Resuscitation should be initiated if there is any question as to whether one of these signs is present. D. Those patients pronounced DOA should have rigor mortis or dependent lividity and asystole or the absence of heart sounds documented on the ambulance run report. E. If electrodes are placed to confirm asystole in three leads, clothing should not be moved if at all possible. Electrodes should be placed on exposed parts of skin that are free of blood splatter (e.g. back of hands, on the ankles).

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 5.05 DOA Policy 41 of 210 III. Trauma - KCFD: A. If the patient is not decapitated, resuscitation should be initiated. IV. Medical - KCFD: A. A patient in cardiopulmonary arrest due to medical causes may be pronounced DOA if the following criteria are met: 1. The AED has advised not to shock AND 2. Patient has no audible heart sounds AND 3. Patient has rigor mortis present. B. Generalized tissue decomposition is not compatible with life and the patient can be pronounced DOA without AED application. C. Resuscitation should be initiated if there is any question as to whether one of these signs is present. DOCUMENTATION REQUIREMENTS: I. MAST (Medical): 1. Rigor or lividity present 2. No heart tones or asystole on the monitor, whichever method is used 3. Any tissue decomposition 4. No scene access due to environment or law enforcement 5. EKG rhythm if asystole is used to confirm II. MAST (Trauma): 1. Mechanism of injury 2. Patient exam/surroundings 3. Specific documentation of sustained injury 4. No heart tones 5. No scene access due to environment or law enforcement III. KCFD (Medical): 1. Rigor mortis 2. No heart tones 3. AED advises not to shock

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 5.05 DOA Policy 42 of 210 NOTES: I. Trauma patients who present pulseless from obvious trauma on arrival of MAST or Fire have a less than 1% chance of survival. Resuscitation, transportation and treatment of traumatic cardiac arrest should be a rare exception, i.e., the patient took their last breath in your presence. II. If unable to begin CPR in a reasonable period of time due to patient accessibility or location, (i.e. drowning requiring water rescue, trench cave-ins, auto wrecks with lengthy extrication, etc.) contact medical control and notify them of patient's condition and circumstances that prohibit resuscitation and ask them to pronounce them DOA. III. This protocol is applicable to pediatric patients. If the fire department/first responder is presented with a non-breathing child or infant with rigor mortis and no heart tones, the AED patches may be placed anterior/posterior. IV. Police are in charge at a crime scene. They have the right to deny EMS providers access to the patient/crime scene. Police procedural instructions define obvious signs of death as "lack of vital signs plus either rigor mortis, lividity or a combination of both". V. Rigor mortis and/or asystole are not reliable signs of death in hypothermia. If hypothermia is a consideration, resuscitation should be initiated. VI. It is not the policy of MAST or KCFD to move or transport patients who have been pronounced dead. Do NOT move them to the ambulance. VII. The pronouncing agency must remain on scene with the body until released by the appropriate law enforcement agency or coroner.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 7.02 Ambulance Diversion Guidelines Policy 43 of 210 BACKGROUND: I. The Kansas City Metropolitan Healthcare Council and MARCER have revised, and the EMS Medical Director has endorsed, updated regional diversion guidelines entitled "Organization and Management for Hospitals and EMS Agencies: a Community Plan for Diversion." The "Policy," "Definitions," "Procedures," and "Regional Catchment Areas" portions are reproduced here. The Policy of the Kansas City, Missouri EMS System is as follows, in so far as the guidelines do not conflict with any other City regulation or policy. POLICY: I. If all hospitals within a predefined catchment area are closed, they will be "forced open" and the patient will be taken to the closest appropriate hospital within the catchment area, with the exception of hospitals that are out of service. A. If all hospitals in a catchment area are forced open, ambulances transporting patients to the now "open" hospitals will be distributed in a fashion to equalize as much as possible the number of patients. B. If all hospitals in a catchment area are forced open, ambulances stationed in and/or normally transporting to hospitals in other catchment areas, will make every effort to not transport patients to hospital that were forced open. C. If a trauma center is in a catchment area in which all hospitals forced open, it does not mean that the trauma center is open for trauma. That decision is made by the individual trauma center. II. When the receiving hospital is closed, interfacility transfers of direct admission patients arranged between two hospitals will be followed. If the inpatient bed is not available at the receiving hospital upon ambulance arrival to the receiving hospital, the patient will be delivered to the hospital emergency department and the ambulance will go back in service. III. MARCER and the Metropolitan Healthcare Council have jointly developed a process to track hospital diversions, to monitor trends, to monitor compliance with protocols and to produce appropriate reports for routine review. IV. The decision to divert should be based on the immediate capabilities and capacities of the emergency department and institution to care for patients. (An exception is trauma diversion, in which availability of an operating room or appropriate surgeon may limit the ability to function as a trauma center.) V. Patients who are in cardiac arrest will be taken to the closest appropriate hospital, unless the hospital is "out of service." Patients who are "unstable" may still be taken to the closest appropriate hospital, unless it is "out of service" or on "trauma diversion" (for "unstable" trauma patients only).

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 7.02 Ambulance Diversion Guidelines Policy 44 of 210 VI. The patient shall be informed when the hospital of his or her choice is on diversion and that, in such cases, resources normally utilized for treatment may not be available. Based upon local EMS agency policies, if a patient demands transport to a hospital that is on diversion, and if the patient is refusing transport because their hospital of choice is on diversion status, then the medic may take the patient to the hospital of the patient's choice. EMS agencies shall follow their local policies regarding appropriate documentation of such patient requests. VII. Level I or Level II trauma centers may close to ambulances carrying patients who meet trauma routing criteria. VIII. No facility can divert patients on the basis of ability to pay. IX. Hospitals going on a divert status must do so prior to being notified of an ambulance's impending arrival (i.e. there should be no "diversions in route"). During a multi-casualty incident (MCI) the EMS agency may distribute patients to multiple facilities in order to optimize utilization of resources. This should not be interpreted as a "diversion en route". X. Each hospital should develop its own internal policy regarding ambulance diversion. XI. Diversion notifications should be made to all EMS providers, hospitals and EMCCs (EMSystem Coordination Centers) through the EMSystem. (If there is a local problem with the EMSystem, the appropriate EMCC can be contacted by phone or FAX and enter the notification into the EMSystem.) XII. If all hospitals within a predefined catchment area are closed, then "all are open" and the patient will be taken to the closest appropriate hospital within the catchment area (with the exception of hospitals that are out of service). A. If all hospitals in a catchment area are "closed to ambulances" and therefore all are "open," then ambulances transporting patients to the now "open" hospitals will be distributed in a fashion so to equalize as much as possible the number of patients going to those now "open" hospitals. B. If all hospitals in a catchment area are "closed to ambulances" and therefore all are "open," ambulances stationed in and/or normally transporting to hospitals in other catchment areas, will make every effort (within the bounds of this policy and their own EMSystem policy) to not transport patients to hospitals that are "open" only because all hospitals in their catchment area are closed. C. If a trauma center is in a catchment area in which all hospitals are now "open" only because all have "closed," it does not automatically mean that the trauma center is open for trauma. (There are specific criteria that must be met in order to be designated a trauma center.) That decision is made by the involved trauma center.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 7.02 Ambulance Diversion Guidelines Policy 45 of 210 XIII. The Kansas City community plan for ambulance diversion makes a clear distinction between emergency transport of patients who require emergency care and individual hospital policies regarding the transportation and receiving of patients for direct admission to the hospital. Specific examples include patients who require hospital admission from a primary care physician's office, recently discharged surgical patients, or patient transport from a nursing home to a hospital for non-life threatening conditions. Hospitals whose emergency departments become overwhelmed and are "closed to ambulances" may continue to accept such patients by ambulance for direct admission to the hospital. Since direct admission policy and procedures may vary from one hospital to another, EMS agencies and hospitals are encouraged to work closely together to coordinate direct admissions to avoid additional congestion in the ED. XIV. MARCER and the Metropolitan Healthcare Council have jointly developed a process to track hospital diversions, to monitor trends, to monitor compliance with protocols and to produce appropriate reports for routine review. XV. DEFINITIONS A. Diversion ­ The rerouting of an ambulance(s) from the intended receiving facility to an alternate receiving facility due to a temporary lack of critical resources in the intended receiving facility. B. Diversion Categories: 1. Open ­ The hospital ED is open to all ambulance traffic. 2. Trauma Diversion ­ Level I or Level II trauma centers may close to ambulances carrying patients who meet trauma routing criteria. 3. Open to Trauma Only ­ Level I or Level II trauma center may accept patients that meet KCMO EMS trauma routing criteria. 4. Closed to Ambulances ­ The emergency department is functioning but cannot accept ambulance patients due to a temporary resource limitation. 5. Out of Service ­ The emergency department has suffered structural damage, loss of power, an exposure threat or other conditions that precludes the admission and care of any new patients. C. Catchment Area ­ Three or more hospitals that are related by multiple factors such as ground travel time, capabilities and traffic flow may be considered to be a working group for diversion purposes. A hospital may be part of more than one group. These catchment hospitals are to be defined and reviewed yearly by MARCER. Attachment A contains a list of participating hospitals and their respective catchment designations.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 7.02 Ambulance Diversion Guidelines Policy 46 of 210 D. Unstable 1. Unable to establish or maintain an airway 2. Unable to ventilate 3. Unremitting shock 4. As otherwise defined in appropriate EMS agency protocols, (including as determined with medical control contact) XVI. PROCEDURES A. The decision to initiate or terminate a diversion status rests with the individual hospital according to their written policies. B. Criteria to determine the necessity of implementing the hospital diversion plan include: ED bed saturation; number of patients in the ED waiting area, as well as patient waiting times; number of ambulance patients waiting or en route; acuity of patients waiting to be admitted; and ED staffing capabilities. C. The diversion is initiated or terminated using the EMSystem according to the EMSystem Protocols and Policies. D. For participating Missouri hospitals in the Kansas City region, the EMSystem will automatically notify the Missouri Department of Health and Senior Services (DHSS) upon commencement of diversion status via an electronic mail message. In the event the EMSystem is not operational at the commencement time of diversion, participating Missouri hospitals will send DHSS a fax notification or, by other electronic means, report the commencement of diversion. E. The appropriate EMCC and/or EMS dispatch center assures that ambulance crews in the field are informed of hospital diversion status on a "real-time" basis through their own written policies, protocols or standard operating procedures. F. The ambulance crews in the field use all appropriate information to make the destination determination. In some systems this may also include on-line contact with a medical control physician. G. If all but one hospital in a catchment area is "closed to ambulances," the appropriate EMCC will contact the hospitals involved in that catchment area via the EMSystem, inform them of that fact and request an update of their diversion status. H. If all hospitals in a catchment area are "closed to ambulances," the appropriate EMCC will contact the hospitals in that catchment area via the EMSystem, inform them of that fact and request an update of their diversion status. If, within 10 minutes of this contact, none of the hospitals in the catchment area have changed their status to either "open" or "trauma diversion" then the EMCC will change all of the hospitals in the catchment area to "open."

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 7.02 Ambulance Diversion Guidelines Policy 47 of 210 I. Within eight (8) hours of termination of the diversion, participating Missouri hospitals in the Kansas City region will report the following information to the Missouri DHSS via the EMSystem or by other electronic means: 1. Diversion start time 2. Name of individual who made the decision to implement the diversion status 3. Reason for the diversion status 4. Time the diversion was terminated 5. Name of the individual who made the decision to terminate the diversion status XVII. REGIONAL CATCHMENT AREAS FOR HOSPITAL DIVERSION ­ See MARCER For Details DOCUMENTATION REQUIREMENTS: N/A NOTES: I. Children's Mercy Hospital ­ As the only pediatric hospital, it is not included in any catchment area. II. Veteran's Administration Hospital ­ Not included in any catchment area. III. Bates County Memorial Hospital (Butler, Missouri), Cass Medical Center (Harrisonville, Missouri), Cushing Memorial Hospital (Leavenworth, Kansas), Excelsior Springs Medical Center (Excelsior Springs, Missouri), Lafayette Regional Health Center (Lexington, Missouri) and Saint John Hospital (Leavenworth, Kansas) -- not included in any catchment area due to geographic distance to the metropolitan region.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 8.00 Safe Place For Newborns Act of 2002 Policy 48 of 210 BACKGROUND: This act allows a parent or a person acting on the parent's behalf to relinquish the custody of a child less than 30 days old to hospital, EMS, Fire or Police personnel. If the delivery of the child is to any place other than a hospital, the person taking custody must arrange for the immediate transportation of the child to the hospital. POLICY: I. If the physical custody of the child is relinquished to KCFD personnel: A. Treat the child according to appropriate protocols B. Contact the KCFD Dispatch Center and request an ambulance for transport of the child to the closest appropriate hospital C. Document the details of the call on the KCFD EMS Report II. If the physical custody of the child is relinquished to MAST personnel: A. Treat the child according to the appropriate protocols B. Deliver the child to the closest appropriate hospital. (Generally, Children's Mercy Hospital would be considered to be the most appropriate hospital.) C. Document the details of the call on the PCR DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 9.00 Suspected Abuse/Neglect Policy 49 of 210 BACKGROUND: N/A POLICY: I. Definition - Includes physical, emotional, or sexual abuse as well as physical or emotional neglect. II. Duty to Report A. State law requires that suspected child abuse or neglect be reported to the Missouri Department of Health and Senior Services. Any paramedic, EMT or first responder having reasonable cause to suspect that a child (any person less than 18 years of age) has been or may be abused or neglected must report or cause a report to be made to the Division of Family Services. Notification should be done by telephoning 1-800-392-3738 or 1-573-751-3448. B. State law requires that suspected elder abuse or neglect be reported to the Missouri Department of Health and Senior Services. Any paramedic, EMT or first responder having reasonable cause to suspect that a person sixty years of age or older (or a handicapped person between the ages of 18 and 59) has been or may be abused or neglected must report or cause a report to be made to the Department of Health and Senior Services. Notification should be done by telephoning 1-800-392-0210 or 1-800-392-0272. III. Assessment/Treatment/Notification A. Provide necessary medical care as related by the appropriate medical or trauma protocol. B. Although a preliminary assessment of abuse or neglect is made in the field, the final determination is made upon review of the incident by appropriate personnel. Accusations of abuse or neglect should not be made in the field. C. If the provider's preliminary assessment is that abuse or neglect may have occurred, the provider should relay this assessment to appropriate personnel as patient care is transferred. (i.e. KCFD personnel should notify the MAST paramedic and the MAST paramedic should notify the receiving physician.) D. Report or cause a report to be made as noted under "Duty to Report." DOCUMENTATION REQUIREMENTS: I. Documentation A. The KCFD EMS Report (Narrative Section) or the PCR shall include: 1. Facts upon which the abuse or neglect is suspected. (Emotional or accusatory conclusions are improper.) 2. Identity of persons who were notified 3. That the applicable agency was notified and by whom. NOTES: N/A Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 10.00 Medical Research in KCMO EMS Policy 50 of 210 BACKGROUND: I. Emergency Medical Services is a unique form of medicine II. There are numerous clinical and quality of care issues that can only be studied using a research format III. The EMS system should hold itself to the same patient safeguards and ethical conduct set forth under various governing bodies. POLICY: IV. Any research that is proposed to be conducted in the Kansas City Missouri Emergency Medical Services System, including, but not limited to the Kansas City Missouri Fire Department and the Metropolitan Ambulance Services Trust shall meet the following guidelines. V. Approval of the concept, plan and protocol by the Office of the EMS Medical Director VI. Research plan and protocol must be approved by an Institutional Review Board (IRB) of a certified research institution as determined by the EMS Medical Director VII. Any research approved for the Kansas City Missouri Emergency Medical Services System will include oversight and participation from the Office of the EMS Medical Director VIII. Any costs for conducting research will be borne by the investigator IX. Investigators proposing research for the Kansas City Missouri Emergency Medical Services System will disclose to the Office of the EMS Medical Director any financial or other relationships with companies or organizations that may influence their proposed research. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 11.00 Patient Contact Policy 51 of 210 BACKGROUND: I. To measure a complete sequence of events while delivering prehospital care, times to patient contact are essential. II. Times to patient contact allows the system to analyze delays from time of first responder/ALS on scene to patient's side and possibly provide solutions to improving access to patients once on scene POLICY: I. KCFD emergency responders and ALS providers will verbally confirm "patient contact" with their respective dispatch centers when they arrive at the patient's side to begin patient care. II. KCFD and MAST dispatch centers will accurately record in their respective Computer Aided Dispatch programs the "patient contact" time III. Quality Assurance/Dispatch Center Directors will compile compliance with this policy in aggregate and by medic/EMT or Fire Company and report monthly to the EMS Medical Director/EPAB DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

S 12.00 Equipment Brought In Policy 52 of 210 BACKGROUND: I. The purpose of this policy is to assist EMS personnel for what equipment needs to be brought to the patient by the EMS crew. POLICY: I. Any call of an emergency nature should be considered to have potential for serious medical conditions until proven otherwise. II. The optimal amount and type of equipment brought into the scene is dependent on multiple factors including but not limited to the type of call, the location of the call, ingress and egress capabilities, and the operating environment. III. It is incumbent upon the EMS crew to be aware of all problems that could reasonably be foreseen at the scene. IV. Ultimately the EMS crew must decide which equipment to take to the patient on each call and must take responsibility for the consequences if the crew fails to recognize problems that could have reasonably been foreseen. EMS crews will be held accountable for bad outcomes that arise due to a poor decision process. V. EMS crews should not be complacent with bringing in less equipment on lower priority calls; even the lowest priority call can have potential for emergency medical attention. VI. At a minimum, an EMS crew should bring in the appropriate amount of equipment to provide medical treatment for any condition which could reasonably be foreseen. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 1.01 Emergency Medical Dispatch Policy 53 of 210 BACKGROUND: I. The Emergency Medical Dispatch TM Protocol developed by Medical Priority Consultants has historically been the protocol that MAST System Status Controllers have followed when receiving calls and prioritizing EMS System responses. II. The Protocol includes a standardized call interrogation process that determines a "nature code" and/or a "response determinant". Each individual EMS System uses this information to make a System specific decision on what resources to send and how fast (response configuration). POLICY: I. MAST System Status Controllers will follow the Emergency Medical Dispatch TM Protocols when prioritizing all emergency and selected non-emergency calls. II. The initial step in call prioritization is the determination of a "nature code" or a specific "response determinant." Each nature code and each response determinant must have an EMS System response configuration assigned to it. Response configurations include: A. Code 1 ­ Life Threatening Emergency with a red lights and sirens (RLS) response by MAST with a response time compliance criteria of 9 minutes or less on not less than 90% of responses. KCFD Emergency Responders are also sent with a RLS response. B. Code 2 ­ Non-Life Threatening Emergency with a RLS response by MAST with a response time compliance criteria of 11 minutes or less on not less than 90% of responses. KCFD Emergency Responders are also sent with a RLS response in select Code 2 calls (Code 2 with Fire). C. Code 3 ­ Non-Life Threatening Emergency with a non ­ RLS response by MAST with a response time compliance criteria of 20 minutes or less on not less than 90% of responses. D. Code 4 ­ Unscheduled Non-Emergency Transport with a non-RLS response by MAST with a response time compliance criteria of 60 minutes or less on not less than 90% of responses. E. Other "Codes" exist for Scheduled Transports. III. Contact the Office of the EMS Medical Director for a complete listing that references the possible nature codes, response determinants, and their respective response configurations. Calls prioritized by SSCs will be dispatched with these response configurations as per protocol. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 2.02 Ambulance Transport Requests From Health Care Facilities Policy 54 of 210 BACKGROUND: N/A POLICY: I. Ambulance Transport Request Received from Hospital Emergency Department A. If received via an emergency line (911 or regional number) then the SSC will use the EMDTM Protocol and prioritize the call per the Protocol. B. If received via a non-emergency line then the SSC will prioritize the call as follows: 1. ED to home or nursing home ­ Code 4 2. ED to ED a) Code 4 if routine transfer b) Code 3 if (1) Cardiac patient being transferred for emergency catheterization (2) Any patient being transferred for emergency surgery (3) Stroke patient being transferred for emergency intervention (cath lab) (4) Physiologically unstable patient being transferred to a higher standard of care c) Code 2 if requested by ED II. Ambulance Transport Request Received from Nursing Home (or other Non-Hospital Health Care Facility) A. If received via an emergency line (911 or regional number) then the SSC will use the EMDTM Protocol and prioritize the call per the Protocol. B. If received via a non-emergency line then the SSC will prioritize the call as follows: 1. If the patient has a priority complaint then the SSC will use the EMDTM Protocol and prioritize the call per the Protocol. 2. If the patient has a non-priority complaint then the SSC will use "Card 33 Transfer / Interfacility / Palliative Care" Protocol. After following the Protocol, if the patient still has no priority complaint, the SSC may prioritize the call as a Code 4. 3. Requests for ambulance transport that do not involve priority or nonpriority complaints do not mandate use of the EMDTM Protocol. These types of calls include (but are not limited to): a) Transport to or from scheduled appointments (i.e., doctors appointment, dialysis, etc.) b) Transport to or from scheduled diagnostic testing (i.e., CT or MRI scans) c) Transport to or from procedures (i.e., radiation therapy, feeding tube replacement, splint replacement, wound care, etc.) Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 2.02 Ambulance Transport Requests From Health Care Facilities Policy 55 of 210 d) If a new priority complaint is discovered during questioning, then the SSC will default to the EMDTM Protocol DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 3.00 Notification of Office of the EMS Medical Director Policy 56 of 210 BACKGROUND: The Office of the EMS Medical Director serves as the day to day oversight body for all EMS activities in Kansas City, Missouri. Timely notification of the Office of the EMS Medical Director allows for the EMS Medical Director and his designee to determine when and if there should be a scene response or other action in response to an incident. POLICY: I. The MAST Communication Center will immediately notify the Office of the EMS Medical Director for the following types of incidents: A. Four or more units responding emergency to the same call B. Mass casualty incidents, involving, but not limited to: 1. nuclear, biological or chemical exposures 2. collapsed buildings 3. aircraft accidents 4. train derailments C. Significant job related injuries to MAST, KCFD, KCPD personnel, City officials D. Requests by MAST or KCFD supervisor/management personnel E. EMS region is forced open per diversion policy F. Trauma Centers forced open due to multiple closures per diversion policy II. Office of the EMS Medical Director will designate at least one Assistant to the EMS Medical Director to be on call at all times. This duty will be alternated between the Assistants as determined by the EMS Medical Director and his designees. The on call Assistant will contact the communication center and determine if a response is indicated and will notify the EMS Medical Director as necessary. III. Procedure A. SSCs will activate pagers using the automatic paging system. The on call Assistant will contact the Communication Center to acknowledge the page, determine if a response is necessary, and will be responsible to make the decision to notify the EMS Medical Director. B. At SSC discretion, the EMS Medical Director and/or the Assistants to the EMS Medical Director can be contacted directly. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 3.00 Notification of Office of the EMS Medical Director Policy 57 of 210 EMS Medical Director: Joseph Salomone, MD Email: [email protected] Blackberry: 816.291.0932 Mobile: 816.682.9432 Assistants to the EMS Medical Director: Daniel Lindholm, NREMT-P Email: [email protected] Blackberry: 816.225.0824 HD Pager: 816.717.7829 James McElroy, NREMT-P Email: [email protected] Blackberry: 816.719.0654 Randall Bennett, NREMT-P Email: [email protected] Blackberry: 816.335.5375 Mobile: 816.260.8357

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

DP 4.00 EMS CAD Data Policy 58 of 210 BACKGROUND: The oversight and daily supervision of the system is the responsibility of the EMS Medical Director. One of the primary component measures of the clinical and operational efficiency of the EMS system is response times. Since response times are critical to the measurement of the performance of MAST itself, it is vital that the data integrity of the CAD system be preserved. POLICY: I. All CAD data will be secured, and at no times will edits, revisions, alterations, corrections or adjustments to the initially recorded CAD data times be allowed. All exception reports, changes and corrections will be noted using an agreed upon auditing system, and justifications for any discrepancies in the recorded CAD times will be noted and reviewed by the EMS Medical Director and/or his designee. The actual CAD times will not be altered or amended in any way. II. Unaltered copies of the CAD database will be transmitted periodically to the Office of the EMS Medical Director and interval periodic reviews of the CAD times will be audited for inaccuracies or edits. III. The EMS Medical Director and/or his designee will produce the monthly response time reports and these reports will be reviewed and discussed by MAST staff, and adjusted final response times determined based on these reviews. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 19.00 911 Dispatch to Hospitals with Emergency Departments Policy 59 of 210 BACKGROUND: The system has experienced incidences in which 911 calls are made for ambulance response to hospital emergency department waiting rooms, hospital lobbies, and other areas of the hospitals. These calls are made by persons who are either awaiting medical care by these facilities or have been evaluated and dismissed, yet want transportation to another hospital. This has the potential to create negative situations for the persons calling, the hospitals, and the EMS service. As a result, the following policy has been developed for this situation: POLICY: I. If a call is made from an area within a hospital with an emergency department by a person who is not an employee or staff member of that hospital, then the MAST communications center will call the emergency department physician of that facility to report this request. II. The emergency department physician or his/her designee will confirm the request and an ambulance will be immediately dispatched to the hospital, OR A. The emergency department physician or his/her designee will deny the request and an ambulance will NOT be dispatched to the hospital, OR B. The emergency department physician or his/her designee will neither confirm nor deny the request, but will recontact the MAST communications center within 10 minutes to confirm or deny the request. An ambulance will NOT be immediately dispatched to the hospital. III. If the emergency department physician or his/her designee has neither confirmed nor denied the request for an ambulance by recontacting the MAST communications center, an ambulance will be dispatched to the hospital after 10 minutes from the call to the emergency department by the MAST communications center. IV. If any question exists as to whether the facility is a hospital with an emergency department or whether the request is made by an employee or staff member, then an ambulance will be immediately dispatched in the usual fashion. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

P 20.00 Physician Certification Statements (PCS) Policy 60 of 210 BACKGROUND: This policy is designed to address the proper execution of Physician Certification Statements (PCS) in the non-emergency setting and to allow MAST to receive a completed PCS before dispatching a non-emergency transport ambulance. In addition, this policy is designed to encourage healthcare facilities to utilize the most appropriate transportation method for their customers. This policy addresses non-emergency transportation requests from hospitals, nursing facilities, outpatient clinics, and physician offices. A PCS is required, pursuant to 42.C.F.R. 410.40(d)(2) and (3), by the Health Care Financing Administration (HCFA) on all non-emergency ambulance transports. POLICY: I. This policy pertains to non-emergency transportation requests. II. All requests for non-emergency transportation will be handled in the MAST system by either a MAST ambulance. III. Upon receipt of a non-emergency transport request from a hospital, nursing facility, outpatient clinic or physician office, the calling party will be asked to supply to MAST dispatch, by fax, a properly executed PCS prior to scheduling an ambulance transport. (THE AMBULANCE WILL NOT BE SCHEDULED PRIOR TO RECEIPT OF THE PCS.) The SSC (system status controller) shall fax a blank PCS to the calling facility if one is not readily available at the calling facility. IV. If the facility does not have fax capabilities, and the calling party states a completed PCS is available verifying medical necessity (indicating "no" on question 4), the SSC will schedule ambulance transportation and advise the transporting crew to pickup the PCS on their arrival. V. If the sending facility is unwilling to complete and/or fax a PCS, or the faxed PCS indicates "yes" on question 4 (indicating the patient can be safely transported by wheelchair van), the SSC shall inform the caller that an ambulance will not be sent and the SSC will direct the calling party to the appropriate agency for transportation. VI. Contraindications A. Any residential request for non-emergency transportation. B. Any emergency request for transportation. DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 2.03 General Medical Protocol 61 of 210 The purpose of this protocol is to outline the general approach to the patient with a medical illness. Scene Size-Up: · Assure that the scene is safe for yourself, other rescuers and the patient. It may be appropriate to withdraw from the scene in some situations until a safe environment can be obtained. Or it may be appropriate to rapidly extricate the patient from a dangerous situation. · Identify the number of patients and other resources that may be needed · Initiate the Incident Management System if appropriate · Call for law enforcement and/or first responder assistance if needed · Call for more EMS units if needed · Begin triage if appropriate · Identify yourself and seek permission to examine and treat the patient Body Substance Isolation: · Apply universal precautions / body substance isolation as appropriate Primary Survey · Search for immediate life threats by assessing the "ABCs" (airway, breathing or circulation problems) and treating the problems as they are found Assessment: A - 1 Assess airway: Note patient's ability to speak, and any evidence of actual or potential airway obstruction including vomitus, bleeding, dentures, loose teeth or foreign bodies A - 2 Assess breathing: Note patient's ability to speak, rate, depth and quality of ventilations, abnormal noises/stridor, retractions, accessory muscle use, nasal flaring, or cyanosis A - 3 Assess circulation: Note pulses, level of consciousness, skin abnormalities (color, temperature, capillary refill, moisture) A - 4 Assess neurologic function (disability): Note level of consciousness, Glasgow Coma Scale or AVPU Scale, movement of each extremity

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 2.03 General Medical Protocol 62 of 210 Intervention: I - 1 Secure Airway · BLS Maneuvers · Jaw thrust, head tilt - chin lift · Oral or nasal airway · Suction · ALS Maneuvers · Oral endotracheal intubation · Nasal endotracheal intubation · Needle cricothyroidotomy I - 2 Administer oxygen · Nasal cannula at 2 - 5 liters per minute oxygen flow · Non-rebreather mask at 15 liters per minute oxygen flow I - 3 Assist ventilation as required · Bag-valve-mask ventilation · Bag to endotracheal tube ventilation I - 4 Assist circulation as required · If no pulse: o Initiate CPR and search for a "shockable rhythm" as indicated o Follow DOA or DNR protocol if indicated · If major bleeding is present, control with direct pressure Notes: · Generally, abnormalities found in the primary survey are addressed with appropriate interventions at the time of discovery · It may be appropriate to move directly from the primary survey to another protocol (i.e. cardiac arrest, respiratory distress, shock) · Bag-valve-mask ventilation is indicated prior to attempts at endotracheal intubation Secondary Survey · A systematic history and physical examination, focused on the patient's complaints, searching for problems that may not be immediately life or limb threatening, but that may become so if not addressed appropriately

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 2.03 General Medical Protocol 63 of 210 Assessment: A - 1 Obtain chief complaint A - 2 Obtain "SAMPLE" history · Symptoms (including pertinent positives and negatives) · Allergies · Medications · Past medical history · Last meal · Events/Environment leading to this episode A - 3 Obtain vital signs which include pulse, MANUAL systolic and diastolic blood pressures, respiratory rate, and determine pain score (Palpated systolic blood pressure is not sufficient except under extreme conditions.) A - 4 Perform focused physical examination (this evaluation is dependent on the above history as well as findings from the primary survey and may be more or less detailed depending on the situation) A - 5 Consider application of cardiac monitor (paramedic interpret) A - 6 Consider application of pulse oximeter A - 7 Consider application of NIBP cuff A - 8 Consider obtaining 12 Lead EKG (paramedic interpret) A - 9 Consider obtaining rapid beside glucose determination A - 10 Assessment summation: Consider information gathered in primary and secondary survey, determine an impression of the patient's primary problem and proceed to the appropriate treatment protocol A - 11 Obtain repeat vital signs prior to transfer of care to receiving facility or whenever there is an observed change in the patients status Interventions: I - 1 Secure airway (see primary survey) I - 2 Administer oxygen and assist ventilation as required (see primary survey) I - 3 Consider establishing IV access I ­ 4a Consider administering drug therapies (if indicated) · Right patient? · Right drug? · Right dose? · Right route? · Right time? · Right reason? · Right documentation? · Allergies?

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 2.03 General Medical Protocol 64 of 210 I ­ 4b When the paramedic is being assisted by another medical professional with administering drug therapies extreme caution must be made to insure proper delivery · The paramedic must read back to the assisting medical professional the above "Rights of Medication Administration" I ­ 5 Consider other therapeutic modalities (if indicated) I ­ 6 Transport while monitoring vital signs and patient condition · Red lights and sirens transport to the hospital may be indicated if the patient is physiological unstable: o Unable to establish or maintain an airway o Unable to ventilate o Unremitting shock o As otherwise defined in appropriate protocols (including as determined with medical control contact) · Patient destination as determined by appropriate protocol · Medical control contact as determined by appropriate protocol Documentation: · Document all assessments, vital signs, monitor findings, and interventions

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 4.02 Allergic Reaction (Anaphylaxis) Protocol 65 of 210 Allergic reactions can be mild to life threatening. Potential routes for exposure to antigens can be through inhalation, physical contact, ingestion, or injection. Assessment: A - 1 Complete vital signs A - 2 Obtain brief history with particular attention to known allergies and any recent exposure A - 3 Assess cardiac, respiratory and neurologic systems. Note condition of the skin (i.e. hives, swelling or redness) A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter Interventions: I - 1 Secure airway I - 2 Administer oxygen and assist ventilation as required I - 3 Establish IV access I - 4 Transport immediately while monitoring vital signs Mild Anaphylaxis Alert and appropriate, normotensive, may have wheezing with good air exchange and no cyanosis; may have hives Interventions: I - 1 If wheezing, administer Albuterol 2.5 mg (3 ml unit dose of 0.083% solution) via inhalation using hand held nebulizer or an aerosol mask. Albuterol may be repeated if patient continues to be in respiratory distress. I - 2 (ORDERS) Consider the administration of Epinephrine 1:1,000, 0.01 ml/kg (up to 0.3 ml) SQ. This may be repeated X 2 with base station physician approval. I - 3 (ORDERS) Consider the administration of Diphenhydramine (Benadryl) 1 mg/kg (maximum 50 mg) IM

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 4.02 Allergic Reaction (Anaphylaxis) Protocol 66 of 210

Anaphylaxis with Respiratory Distress Respiratory distress including wheezing with poor air exchange, without signs of shock Interventions: I - 1 Administer Epinephrine 1:1000, 0.01 ml/kg (up to 0.3 ml) SQ I - 2 (ORDERS) Epinephrine may be repeated with base station physician approval I - 3 Administer Albuterol 2.5 mg (3 ml unit dose of 0.083% solution) via inhalation using hand held nebulizer or an aerosol mask. If patient continues to be in respiratory distress Albuterol may be repeated I - 4 Administer Diphenhydramine (Benadryl) 1 mg/kg (maximum 50 mg) IV Anaphylactic Shock Hypotension, delayed capillary refill, altered mental status, with or without respiratory distress Interventions: I - 1 Place in supine position with legs elevated (unless this position increases respiratory distress) I - 2 Start IV or IO of LR and infuse 20 ml/kg bolus up to maximum of 1000 ml, consider repeat if needed to maintain blood pressure I - 3 Administer Epinephrine 1:10,000, 0.1 ml/kg (maximum of 3 ml) IV or IO, slow titration. If unable to secure a line, inject Epinephrine 1:1,000 solution 0.01 ml/kg (max 0.3 ml) into venous plexus at the base of the tongue I-4 If wheezing, administer Albuterol 2.5 mg (3 ml unit dose of 0.083% solution) via inhalation using hand held nebulizer or an aerosol mask. Albuterol may be repeated if patient continues to be in respiratory distress. I - 5 Administer Diphenhydramine (Benadryl) 1 mg/kg (maximum 50 mg) IV or IO Notes: · 1:1,000 concentration: 0.01 ml/kg = 0.01 mg/kg · 1:10,000 concentration: 0.1 ml/kg = 0.01 mg/kg · If anaphylactic shock is suspected and the patient has an anaphylactic kit available, the EMT may proceed to assist the patient with the administration of the auto-injected epinephrine

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 5.01 Shock Protocol 67 of 210 Shock is characterized by inadequate tissue perfusion leading to decreased tissue oxygenation and eventual cell death and is the end result of several different conditions. Shock can be divided into 4 categories: hypovolemic shock (blood or fluid loss), cardiogenic shock, distributive shock (neurogenic or spinal, septic, anaphylactic) and obstructive shock (pulmonary embolism, tension pneumothorax, cardiac tamponade). Typical signs of shock include altered mental status, cool, clammy skin, poor capillary refill, tachycardia and hypotension. Assessment: A - 1 Complete vital signs A - 2 Obtain a brief history including onset, duration, possible etiologies, and past history of similar occurrences, noting any history of fever, blood loss, fluid loss, allergic exposure or trauma A - 3 Assess cardiac, respiratory and neurologic systems. Note the condition of the skin (i.e. color, temperature, and capillary refill). The blood pressure is one of the least sensitive and late signs of shock A - 4 If anaphylactic shock is suspected, proceed to the allergic reaction (anaphylaxis) protocol A - 5 If shock is secondary to a cardiac dysrhythmia, proceed to the cardiac dysrhythmia protocol A - 6 Apply cardiac monitor (paramedic interpret) A - 7 Apply pulse oximeter Interventions: I-1 I-2 I-3 I-4 I-5 Secure airway Administer oxygen and assist ventilation as required Control any obvious hemorrhage Place in supine position with the legs elevated (unless this position increases respiratory distress) Establish IV access Cardiogenic Shock I-1 Infuse 10 ml/kg LR (maximum 250 ml) and assess the response to the bolus by reassessing the breath sounds and the work of breathing, the mental status, capillary refill, pulse rate and quality, and BP (ORDERS) A 10-20 ml/kg bolus may be repeated (ORDERS) If the patient has had an adequate volume resuscitation and remains in shock, administer Dopamine 10-20 micrograms/kg/min IV or IO

I-2 I-3

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 5.01 Shock Protocol 68 of 210 Any Other Type Of Shock Suspected I-1 Infuse 20 ml/kg LR (maximum 1000 ml) and assess the response to the bolus by reassessing the breath sounds and the work of breathing, the mental status, capillary refill, pulse rate and quality, and BP This may be repeated one time to a total of 40 ml/kg LR (maximum 2000 ml) without base physician approval. The response to the second bolus should be reassessed as previously described (ORDERS) If the patient remains in shock following a 40 ml/kg (maximum 2000 ml) bolus, subsequent 20 ml/kg (1000 ml) boluses may be given with base station physician approval. Responses to the additional boluses should be reassessed as previously described (ORDERS) If the patient has had an adequate volume resuscitation and remains in shock, consider administration of Dopamine 10-20 micrograms/kg/min IV or IO Transport immediately while monitoring vital signs frequently

I-2

I-3

I-4 I-5 Notes: · · · ·

Shock is generally not a result of head injuries and other causes should be considered Dopamine is usually contraindicated in shock secondary to hypovolemia Hypoglycemia should be considered in any patient presenting with shock. A rapid bedside glucose test may be necessary to rule out this etiology If anaphylactic shock is suspected and the patient has an anaphylactic kit available, the EMT may proceed to assist the patient with the administration of the auto-injected epinephrine

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 6.04 Behavioral/Psychiatric Disorder Protocol 69 of 210 Assessment: A - 1 Complete vital signs A - 2 Obtain brief history noting any bizarre or abrupt changes in behavior, suicidal ideation, possible alcohol or drug ingestion, and significant past medical history (i.e., diabetes, previous psychiatric disturbances) A - 3 Briefly evaluate cardiac, respiratory and neurologic system including mental status Probable Psychiatric Problem Only Interventions: I - 1 Attempt to establish rapport with patient I - 2 If patient is dangerous to himself or others, have police assist in transport. Restrain if absolutely necessary I - 3 If suicidal, do not leave patient alone and, if possible, remove any dangerous objects (i.e., guns, knives, pills, etc.) I - 4 If emergency treatment is unnecessary, do as little as possible except to reassure while transporting. Consider your own safety and limitations If Agitated Assessment: A - 1 As above A - 2 As soon as possible, apply cardiac monitor (paramedic interpret) A - 3 As soon as possible, apply pulse oximeter A - 4 As soon as possible do a rapid bedside glucose determination Interventions: I - 1 Consider your own safety and limitations I - 2 If patient is dangerous to himself or to others, have police assist in transport. Restrain if absolutely necessary I - 3 Treat as "lethargic" section if safe and able I - 4 Consider chemical restraint if the patient is violent/agitated and there is fear for patient, and/or emergency providers' life or limb and if the patient is greater than 12 years old A. Chemical restraint is a decision that relies on paramedic judgment. Most violent/agitated patients can be handled with verbal or physical restraint alone B. (ORDERS) If there is any doubt about the need for chemical restraint, then contact medical control prior to administration C. Administer Midazolam (Versed) 0.1 mg/kg (maximum 10 mg) IM only I - 5 Consider the possibility of aspiration when deciding on physical restraint positioning I - 6 As soon as possible, administer oxygen Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 6.04 Behavioral/Psychiatric Disorder Protocol 70 of 210 I-7 Notes: · · Midazolam does not replace physical restraint of the patient. Proceed to appropriate protocol for further treatment (i.e., altered mental status). Probable Dystonic Reaction Assessment: A ­ 1 Complete vital signs A ­ 2 Obtain brief history noting any bizarre or abrupt changes in behavior, possible alcohol or drug ingestion, and significant past medical history (i.e., diabetes, previous psychiatric disturbances), and any new medications, particularly psychiatric or antiemetic agents, time of last dose and any known allergic or previous dystonic reactions A ­ 3 Briefly evaluate cardiac, respiratory and neurologic system including mental status Interventions: I­1 I­2 I­3 I­4 I­5 Notes: · Dystonic reactions are generally characterized by any or all of the following o Oculogyric crisis (deviation of eyes in all directions), Buccolingual crisis (forced spasm of the face, jaw, tongue and pharynx muscles), Protrusion of tongue, Trismus, Forced jaw opening, Difficulty in speaking, Facial grimacing, Torticollis (usually associated with oculogyric and buccolingual crisis), Opisthotonic crisis, Lordosis or scoliosis, Tortipelvic crisis (typically involves hip, pelvis, and abdominal wall muscles, causes difficulty with ambulation) Mental status is unaffected Vital signs are usually normal Remaining physical examination findings are normal Administer oxygen and assist ventilations as needed Establish IV access Consider diphenhydramine, 50 ­ 100 mg IM or IV (ORDERS) May repeat dose once with base station physician approval Transport in position of comfort Transport while monitoring vital signs frequently

· · ·

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 7.05 Altered Mental Status Protocol 71 of 210 Assessment: A - 1 Complete vital signs A - 2 Obtain brief history at scene with particular attention to onset and progression of present state. If this information is unobtainable, at least establish when patient was last seen alert and/or appropriate A - 3 Briefly assess cardiac, pulmonary, and neurologic systems. Note any signs of trauma. Check for pill bottles or syringes and bring with patient A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter A - 6 Do a rapid bedside glucose determination Interventions: I-1 I-2 I-3 I-4 Secure airway Administer oxygen and assist ventilation as required Establish IV access If hypoglycemic (< 60), administer Glucose. A. Oral Glucose: If the patient is awake and has an intact gag reflex B. Intravenous Glucose: i. For patients < 25 kg (< 8 years) 2-4 ml/kg D25W IV to a maximum of 50 ml ii. For patients > 25 kg (>8 years) 50 ml D50W IV If unable to establish IV after 3 attempts, administer Glucagon A. For patients < 25 Kg (< 8 years) 0.5 mg IM or SC B. For patients > 25 kg (>8 years) 1.0 mg IM or SQ Administer Naloxone 0.1 mg/kg IV, IN, IM, IO, ET, or SQ (maximum 2.0 mg) Transport while monitoring vital signs frequently

I-5

I-6 I-7 Notes: ·

If a rapid bedside glucose determination is not available and if the patient is a known diabetic and is confused, yet is awake and has an intact gag reflex, then consider the administration of oral glucose for possible hypoglycemia.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 8.03 Hyperthermia Protocol 72 of 210 Hyperthermia may be the result of environmental heat loads, infections, drug ingestions, or chronic diseases. Elevations in body temperature may induce seizures in children. Hyperthermia from an environmental heat load requires exogenous cooling. Hyperthermia with an altered mental status is a true emergency regardless of the etiology. Assessment: A - 1 Complete vital signs A - 2 Obtain brief history noting length of illness and treatment given. If suspected environmental etiology note the type and length of exposure (i.e. exercise related) A - 3 Briefly assess cardiac, respiratory, and neurologic systems. Note condition of skin (moist or dry) A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter Hyperthermia With Altered Mental Status Assessment: A - 1 As above A - 2 Do a rapid bedside glucose determination Interventions: I-1 I-2 I-3 I-4 I-5 I-6 Secure airway Administer oxygen and assist ventilation as required Establish IV access Remove patient's clothing and consider cooling by sponging the patient with room temperature water and if possible, fan the patient to achieve evaporation. Avoid inducing shivering in the patient Proceed to appropriate protocol for further treatment Transport while monitoring vital signs. Cool while enroute. Do not let cooling in the field delay transport

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 8.03 Hyperthermia Protocol 73 of 210 Hyperthermia Without Altered Mental Status Interventions: I-1 I-2 I-3 I-4 Secure the airway and administer oxygen as needed Loosen clothing, remove any heavy clothing, and do not cover with blankets Consider establishing IV access Consider cooling the patient by sponging with room temperature water. Avoid inducing shivering

Notes: · If shock is present, treat as the shock and/or general medical protocols

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 9.02 Hypothermia Protocol 74 of 210 Children in general and neonates in particular are more susceptible to hypothermia than adults in similar circumstances. Assessment: A - 1 Complete vital signs. Severe hypothermia may mimic death A - 2 Obtain brief history noting length of exposure and pertinent medical history (i.e., drug ingestion, diabetes) A - 3 Briefly assess cardiac, respiratory and neurologic systems. Note condition of skin for evidence of local injury (i.e., frostbite) A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter Hypothermia Assessment: A - 1 As above A - 2 Do a rapid bedside glucose determination Interventions: I-1 I-2 I-3 I-4 I-5 I-6 I-7 Handle the patient as gently as possible. Avoid any unnecessary manipulation Secure airway with as little manipulation as possible since stimulation of the airway may precipitate ventricular fibrillation in the hypothermic patient Administer oxygen and assist ventilation as required Establish IV access Remove any wet clothing and wrap the patient in blankets. Proceed to appropriate protocol for further treatment Transport while monitoring vital signs Local Injury (Frostbite) Interventions: I-1 I-2 I-3 I-4 I-5 Handle injured part very gently. Protect from pressure, trauma, or friction but leave uncovered Do not allow limb to thaw if there is a chance that refreezing will occur before evacuation and transport is complete Maintain core temperature with blankets Transport while monitoring vital signs In general, active rewarming should be done at the hospital, not in the field

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 10.04 Poisoning Protocol 75 of 210 Assessment: A - 1 Complete vital signs A - 2 Obtain a brief history. Bring any containers, package inserts, etc. of suspected ingestion. Small amounts of ingested alcohol may cause unconsciousness and/or hypoglycemia in a child A - 3 Assess cardiac, respiratory and neurologic systems A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter A - 6 Do a rapid bedside glucose determination Patient With Decreased Level Of Consciousness Interventions: I-1 I-2 I-3 I-4 I-7 Secure airway Administer oxygen and ventilation as required Establish IV access Proceed to appropriate protocol for further treatment Transport in lateral decubitus position while monitoring vital signs

Alert Patient With Oral Ingestion Interventions: I-1 I-2 I-3 I-4 Secure airway Administer oxygen and ventilation as required Save spontaneous emesis Transport while monitoring vital signs

Notes: · (ORDERS) For Tricyclic Antidepressant (TCA) overdoses with wide complex tachycardias, administer Sodium Bicarbonate 1 mEq/kg IV · (ORDERS) For Calcium Channel Blocker overdoses with hypotension, administer Calcium Chloride 10% solution 0.2 ml/kg IV (maximum single dose of 10 ml) · Proceed to appropriate protocol for further treatment

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 11.05 Seizure Protocol 76 of 210 Assessment: A-1 A-2 · · · · A-3 A-4 A-5 A-6 Complete vital signs; Seizures may be a sign of hypoxia or cardiac arrest Obtain a brief history including Exact description of the incident from observers History of medication use Presence/absence of alcohol or substance abuse Recent illness or trauma Assess cardiac, respiratory and neurologic systems, note any seizure activity Apply cardiac monitor (paramedic interpret) Apply pulse oximeter Perform rapid bedside glucose determination Single Seizure With Typical Postictal Phase. Interventions: I-1 I-2 I-3 I-4 I-5 Secure airway Administer oxygen and assist ventilation as required Suction as needed Transport in lateral decubitus position while monitoring vital signs Consider establishing IV access Repetitive Seizures Interventions: I-1 I-2 I-3 I-4 I-5 I-6 Secure airway Administer oxygen and assist ventilation as required Establish IV access Administer glucose as needed per "Altered Mental Status Protocol" Administer glucagon as needed per "Altered Mental Status Protocol" In actively seizing patients, consider the following anticonvulsants A. For PEDIATRIC PATIENTS 1. No IV established a) Administer midazolam 0.2mg/Kg via intranasal atomizer (see dosing card) b) Do not delay treatment of seizure to establish IV1-3 2. IV established a) Administer diazepam 0.1-0.2 mg/kg SIVP over 1 minute. The first dose should not exceed 5 mg b) (ORDERS) May be repeated every 3-5 minutes at half dose Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

AB 11.05 Seizure Protocol 77 of 210 B. For ADULT PATIENTS 1. No IV established a) Administer midazolam 0.3 mg/kg via intranasal atomizer OR diazepam 5 mg rectally. May repeat dose once. 2. IV established a) Administer diazepam 5 mg SIVP over 1 minute. May repeat dose once b) (ORDERS) Additional doses of Valium may be repeated every three to five minutes until cessation of seizure activity Evaluate for RESPIRATORY DEPRESSION when administering either diazepam or midazolam If hyperthermic, loosen clothing and do not cover with blankets Transport while monitoring vital signs

I-7 I­8 I­9 Notes:

1. Fisgin T, G. Y., Tezic T, Senbil N, Zorlu P, Okuyaz C, Akgun D., Effects of intranasal midazolam and rectal diazepam on acute convulsions in children: prospective randomized study. J Child Neurol 2002, 17, (2), 123-6. 2. Lahat E, G. M., Barr J, Bistritzer T, Berkovitch M, comparison of intranasal midazolam with intravenous diazepam for treating febrile seizures in children: Prospective randomized study. British Medical Journal 2000, 321, 83-86. 3. Mahmoudian T, Z. M., Comparison of intranasal midazolam with intravenous diazepam for treating acute seizures in children. Epilepsy Behav 2004, 5, (2), 253-5. 4. Proceed to appropriate protocol for further treatment.

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AB 12.01 Syncope Protocol 78 of 210 Syncope is often vasovagal or a simple faint. However, other causes to be considered are cardiac (especially in older individuals), neurologic (seizures, strokes) and occult blood loss (ectopic pregnancy, occult GI bleeding). History and physical exam are critical in determining the more serious causes. Assessment: A - 1 Complete vital signs A - 2 Obtain brief history including onset, duration, warning symptoms (e.g. light headiness, dizziness, nausea), presence of seizure activity, and precipitating factors (e.g. sudden change of position) A - 3 Assess cardiac, respiratory and neurologic systems A - 4 Apply cardiac monitor (paramedic interpret) A - 5 Apply pulse oximeter A - 6 Consider a rapid bedside glucose determination Stable Vital Signs And Normal Level Of Consciousness Interventions: I-1 I-2 I-3 I-4 Secure airway Administer oxygen and assist ventilation as required Establish IV access Transport while monitoring vital signs Unstable Vital Signs Or Altered Level Of Consciousness Interventions: I-1 I-2 I-3 I-4 I-5 Secure airway Administer oxygen and assist ventilation as required Establish IV access Transport while monitoring vital signs Proceed to appropriate protocol for further treatment (e.g. altered mental status, shock)

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AB 13.08 Respiratory Distress Protocol 79 of 210 Respiratory distress can be divided into processes involving the upper or lower airway. Examples of upper airway problems include: foreign body obstruction, epiglottitis, croup, and trauma. Diseases which cause lower airway obstruction include: asthma, COPD, congestive heart failure with pulmonary edema, bronchiolitis, pneumonia, bronchopulmonary dysplasia (BPD), and pneumothorax. If unable to differentiate the cause of respiratory distress: Open and maintain the airway, administer oxygen, insure adequate ventilation, transport rapidly and contact medical control. Assessment: A - 1 Complete vital signs A - 2 Obtain brief history including onset, potential aspiration of small objects or food, fever or cough, chest pain, past history of prior respiratory or cardiac problems (i.e. asthma, COPD, heart failure), or in infants, a history of prematurity A - 3 Assess adequacy of airway and ventilation to include (when appropriate): vocalization, vigor of cough/cry, rate and depth of respirations, breath sounds, and evidence of distress such as accessory muscle use, stridor, cyanosis, and nasal flaring A - 4 Assess cardiac and neurologic systems A - 5 Apply cardiac monitor (paramedic interpret) A - 6 Apply pulse oximeter A - 7 Consider performing a 12 Lead EKG (paramedic interpret) Interventions: I-1 I-2 I-3 I-4 I-5 Secure airway Administer oxygen and assist ventilations as required Consider applying CPAP device Establish IV access (consider) Transport in position of comfort while monitoring vital signs

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AB 13.08 Respiratory Distress Protocol 80 of 210

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AB 13.08 Respiratory Distress Protocol 81 of 210

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AB 13.08 Respiratory Distress Protocol 82 of 210 Emphysema or Bronchitis Interventions: I - 1 Administer Albuterol/ Ipratropium (Atrovent) mixture [2.5 mg Albuterol (3 ml unit dose - 0.083% solution) and 0.5 mg Ipratropium (2.5 ml unit dose 0.02% solution)] via inhalation using a hand held nebulizer. Nebulization is achieved using 6-8L/min flow of oxygen. An aerosol mask nebulizer may be used for those unable to hold a hand held device in the mouth I - 2 Repeat Albuterol treatment (without Ipratropium) as necessary I - 3 Consider applying CPAP device Asthma Interventions: I - 1 For mild cases, administer Albuterol 2.5 mg (3 ml unit dose - 0.083% solution) via inhalation using a hand held nebulizer. Nebulization is achieved using 6-8L/min flow of oxygen. An aerosol mask nebulizer may be used for those unable to hold a hand held device in the mouth. I - 2 For moderate to severe cases, administer Albuterol/Ipratropium mixture [2.5 mg Albuterol (3 ml unit dose - 0.083% solution) and 0.5 mg Ipratropium (2.5 ml unit dose - 0.02% solution)] via inhalation using hand held nebulizer. I - 3 Repeat Albuterol treatment (without Ipratropium) as necessary I - 4 Administer Epinephrine A. If patient is 40 years old and if the patient is in severe respiratory distress administer Epinephrine 1:1000, 0.01 ml/kg (up to 0.3 ml) subcutaneously B. (ORDERS) Repeat as necessary X 2 I - 5 Consider applying CPAP device Notes:

· Albuterol and Ipratropium for dual administration may be separately packaged and mixed by the paramedic, or may be premixed The impression of mild asthma is based on paramedic judgment. Generally, the patient with a mild asthma attack would have wheezing, but be able to complete full sentences and be in no respiratory distress.

·

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AB 13.08 Respiratory Distress Protocol 83 of 210 Congestive Heart Failure with Pulmonary Edema (Adults Only) Interventions: I - 1 Administer NTG 0.4mg tablet sublingual (if systolic blood pressure is above 100 mm Hg and heart rate > 50 and < 140) I - 2 Repeat NTG tablets q 5 minutes until respiratory distress is relieved or systolic blood pressure drops < 100 mm Hg (or may consider 1" NTG ointment if unable to tolerate p.o. medication) I - 3 (ORDERS) Administer furosemide (Lasix), 0.25 - 1.0 mg/kg slow IV push (or consider matching the usual PO daily dose, IV) I - 4 (ORDERS) If the respiratory distress continues after 3 NTG tabs and if systolic blood pressure is above 100 mm Hg and heart rate > 50 and < 140 then administer morphine sulfate slow IV push in 2mg increments until respiratory distress is relieved or total of 10mg has been given I - 5 Consider applying CPAP device Tension Pneumothorax Tension pneumothorax is a clinical diagnosis which should be considered when the following signs/symptoms are present: 1) Progressing severe respiratory distress* 2) Progressing shock* 3) Decreased or absent breath sounds on the involved side* 4) Jugular venous distension 5) Tympany to percussion on the involved side 6) Tracheal deviation away from the involved side Interventions: I - 1 Perform needle decompression A. If signs (*) 1, 2 and 3 are present, then this procedure may be accomplished without online medical control contact B. (ORDERS) If signs (*) 1, 2, and 3 are not present, then online medical control must be contacted prior to performance I - 2 If shock persists, refer to the shock protocol

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AB 14.04 Cardiac Dysrhythmia Protocol 84 of 210 Assessment: A - 1 Complete vital signs A - 2 Obtain brief history of current symptoms, especially any chest pain or shortness of breath A - 3 Obtain a past history of any cardiac disease or conditions to include congenital disease, previous dysrhythmias, coronary artery disease and its complications, heart failure, heart murmurs, and medications A - 4 Assess the cardiac, respiratory, and neurologic systems. Particularly note any signs of poor perfusion such as altered level of consciousness, cool clammy skin, or hypotension. A - 5 Determine stability A. Unstable: Presence of dysrhythmia with any one of the following: i. Altered mental status ii. Clinical signs of shock iii. Severe shortness of breath/pulmonary edema iv. Severe chest pain (consistent with ischemia) v. Cyanotic on 100% oxygen with adequate ventilations B. Stable: i. Presence of dysrhythmia and absence of above signs or symptoms ii. If uncertain about the patient's stability, contact medical control A - 6 Apply cardiac monitor (paramedic interpret) A - 7 Apply pulse oximeter A - 8 If stable, perform 12 Lead EKG (paramedic interpret) Interventions: I-1 I-2 I-3 I-4 I-5 I-6 Treat the patient, not the rhythm strip Secure airway Administer oxygen and assist ventilation as required Establish IV access. Consider IO in severely obtunded child. Transport while monitoring vital signs and cardiac rhythm frequently Proceed according to specific dysrhythmia section.

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AB 14.04 Cardiac Dysrhythmia Protocol 85 of 210 Tachydysrhythmia A. Regular Rhythm Narrow Complex Tachycardia (Probable PSVT) Heart rate > 150 bpm in Adults or > 220 bpm in Pediatrics. If the cardiac rate is less than the designated criteria rate, consider other etiologies and contact a BSP to discuss etiology and treatment Stable Intervention: I-1 I-2 I-3 I-4 I-5 Treat as "General Treatment." Perform Valsalva maneuver (do not do carotid massage or eyeball pressure) Transport while monitoring vital signs and cardiac rhythm frequently (ORDERS) Administer Adenosine 0.1 mg/kg (max 6 mg) IV for first dose (ORDERS) Administer Adenosine 0.2 mg/kg (max 12 mg) IV for second dose Unstable Intervention: I-1 I-2 I-3 I-4 Treat as "General Treatment." If unable to obtain immediate IV access, go to cardioversion Adults only, administer 10 ml/kg (max 250 ml) IV bolus LR Administer Adenosine 0.1 mg/kg (max 6 mg) IV for first dose. A second dose of Adenosine 0.2 mg/kg (max 12 mg) IV may be given after 1 minute if the first dose is ineffective. Perform synchronized cardioversion: A. If rectilinear biphasic waveform defibrillator: (120 J maximum) i . 1st attempt: 0.5 Joules/kg ii. 2nd attempt: 1 Joules/kg (150 J maximum) iii. 3rd attempt: 2 Joules/kg (200 J maximum) th iv. 4 attempt: 3 - 4 Joules/ kg (200 J maximum) B. If monophasic waveform defibrillator: (100 joules maximum) i. 1st attempt: 0.5 Joules/kg (200 joules maximum) ii. 2nd attempt: 1 Joules/kg iii. 3rd attempt: 2 joules/kg (300 joules maximum) iv. 4th attempt: 3-4 joules/kg (360 joules maximum) Administer sedation if cardioversion planned and patient awake Transport while monitoring vital signs and cardiac rhythm frequently

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I-6 I-7

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AB 14.04 Cardiac Dysrhythmia Protocol 86 of 210 B. Wide Complex Tachycardia (Probable VT) Heart rate > 150 bpm. If the cardiac rate is less than the designated criteria rate, consider other etiologies and contact a BSP to discuss etiology and treatment Intervention: I-1 If no pulse, treat as V-fib

Stable Intervention: I-1 I-2 I-3 Treat as "General Treatment." Administer Lidocaine 1-1.5 mg/kg SIVP bolus and 20-50 microgram/kg/min (2-4 mg/min max) drip and begin transport If unsuccessful, repeat Lidocaine 0.5-1.0 mg/kg SIVP every five to ten minutes until wide complex tachycardia resolves or until maximum dose of 3 mg/kg Unstable Intervention: I-1 I-2 Treat as "General Treatment." Perform synchronized cardioversion: A. If rectilinear biphasic waveform defibrillator: i . 1st attempt: 0.5 Joules/kg (120 J maximum) nd (150 J maximum) ii. 2 attempt: 1 Joules/kg iii. 3rd attempt: 2 Joules/kg (200 J maximum) iv. 4th attempt: 3 - 4 Joules/ kg (200 J maximum) B. If monophasic waveform defibrillator: (100 joules maximum) i. 1st attempt: 0.5 Joules/kg nd ii. 2 attempt: 1 Joules/kg (200 joules maximum) (300 joules maximum) iii. 3rd attempt: 2 joules/kg th iv. 4 attempt: 3-4 joules/kg (360 joules maximum) Administer sedation if synchronized cardioversion is planned and patient awake Administer Lidocaine 1-1.5 mg/kg SIVP bolus and 20-50 micrograms/kg/min (2-4 mg/min max) IV drip followed by cardioversion as described above If cardioversion unsuccessful or recurrent, repeat Lidocaine 0.5-1.0 mg/kg SIVP every five to ten minutes until wide complex tachycardia resolves or until maximum dose of 3 mg/kg Version 1.6 effective 7/1/2008

I-3 I-4 I-5

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AB 14.04 Cardiac Dysrhythmia Protocol 87 of 210 I-6 I-7 Transport while monitoring vital signs and cardiac rhythm frequently If cardiac arrest occurs, proceed to the appropriate protocol

Notes: · If delays in synchronization occur and clinical conditions are critical, go to immediate unsynchronized shocks

Bradydysrhythmia Stable Adults And Children Interventions: I-1 I-2 Treat as "General Treatment" Transport while monitoring vital signs and cardiac rhythm frequently

Unstable Adults And Children 8 Years And Older Interventions: I-1 I-2 I-3 I-4 I-5 Treat as "General Treatment" Administer Atropine 1 mg SIVP Apply an external pacer (ORDERS) Administer Atropine 0.5 mg to 1 mg SIVP every 3-5 minutes to a maximum of 3 mg Transport while monitoring vital signs and cardiac rhythm frequently Unstable Children < 8 Years Interventions: I-1 I-2 Treat as "General Treatment" Do compressions if, despite adequate oxygenation and ventilation: A. HR < 80 beats/minute in infants B. HR < 60 beats/minute in child Administer Epinephrine 0.1 ml/kg (1:10,000) IV or IO; or 0.1 ml/kg (1:1000) ET This may be repeated every 3-5 minutes to desired rate effect Transport while monitoring vital signs and cardiac rhythm frequently Administer Atropine 0.02 mg/kg IV, IO, ET. This may be repeated one time after 3-5 minutes (Atropine minimum dose 0.1 mg) Apply an external pacer Version 1.6 effective 7/1/2008

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AB 14.04 Cardiac Dysrhythmia Protocol 88 of 210 Premature Ventricular Contractions Stable Intervention: I-1 Treat as "General Treatment"

Unstable criteria + Premature Ventricular Contractions greater than 6/minute or couplets. Interventions: I-1 I-2 I-3 I-4 Treat as "General treatment" Transport while monitoring vital signs and cardiac rhythm frequently (ORDERS) Administer Lidocaine 1 mg/kg SIVP bolus and begin a 20-50 microgram/kg/min (2-4 mg/min max) drip (ORDERS) If PVCs continue, repeat Lidocaine 0.5-1.0 mg/kg SIVP every 510 minutes until the PVCs resolve or until a maximum dose of 3 mg/kg

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AB 17.07 Cardiac Arrest Protocol 89 of 210 Assessment & Interventions: Per General Medical Protocol, Adult and Pediatric Cardiopulmonary Arrest Algorithms and AED Algorithm on the following pages Notes: · · · Treat the patient, not the monitor Protocols for cardiac arrest presume that the condition continually persists, the patient remains in cardiac arrest, and CPR is always performed Two-person BVM ventilation should be performed in preference to one-person BVM ventilation o Rescuers should be aware not to over ventilate while performing BVM o Over ventilation produces gastric distention and increases intrathoracic pressure o Over ventilation impedes blood flow during chest compressions CPR is paramount o Discontinuation of chest compressions should be kept to a minimum: CPR should not be withheld for IV insertions or IV drug administrations Intubation should be completed efficiently and without prolonged delay When the KCFD and MAST arrive at the scene simultaneously, the ALS monitor/defibrillator should be used for defibrillation. This: o Decreases the time to interpret the rhythm and the time to shock o Decreases the delays in resuming CPR After arrival of ALS, the AED should not be used as the primary device for defibrillation unless there is a malfunction of the ALS monitor/defibrillator o If the AED is already in the analysis or shock mode, it should be allowed to complete analysis or deliver the shock before being switched to the ALS monitor/defibrillator Adequate chest compressions and defibrillation are more important and take precedence over initiating an IV line or injecting medications In children (< 8 y/o), when IV/IO is established, perform rapid bedside glucose determination Lidocaine, Epinephrine, Atropine and Naloxone can be administered via ET tube Bolus medication should be administered rapid IV or IO push at the port site closest to the patient. After each IV medication administration, give a bolus of LR (3-5 ml in a child and 20-30 ml in an adult) and elevate the extremity. This should improve drug delivery

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· · · ·

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AB 17.07 Cardiac Arrest Protocol 90 of 210 · For patients in cardiac arrest suspected of being hyperkalemic (i.e., renal failure patient, patient in dialysis unit), consider administration of the following prior to the first dose of Epinephrine: o Calcium Chloride 10% solution 0.2 ml/kg IV push (maximum single dose of 10 ml) o Sodium Bicarbonate 1 mEq/kg IV push o Give the Calcium chloride and Sodium Bicarbonate at different sites or flush with at least 10 ml of IV fluid in between each drug administered to prevent drug precipitation If problems arise (i.e., scene unsafe, inability to intubate or start IV, etc.) it is valid to continue good CPR and proceed to the nearest appropriate hospital Contact medical control per report format procedure EMTs are authorized to defibrillate using only the automatic external defibrillators (AED) or using manual defibrillators when in the "AED" mode

· · ·

Documentation Requirements for MAST: 1. 2. 3. 4. 5. If CPR was being performed on arrival and by whom (KCFD, bystander, other) Whether the cardiac arrest was witnessed or not Estimated "down time" Any AED usage, by whom, and number of shocks if any If AED was initial defibrillator on scene, that monitor/defibrillator was switched to ALS monitor 6. Initial EKG rhythm including paramedic interpretation* 7. Any return of spontaneous circulation (ROSC)* 8. Intubation* (see intubation documentation policy) 9. IV or IO start* 10. Medications and times of administration* 11. Code summary must be included with PCR

*Required time stamp using Zoll monitor event markers Documentation Requirements for KCFD: 1. 2. 3. 4. 5. 6. 7. 8. Age Sex If CPR was being performed on arrival and by whom (KCPD, bystander, other) Whether the cardiac arrest was witnessed or not Estimated "down time" (approximate, if known; if unknown, state unknown) Any AED usage, by whom, and number of shocks if any Care turned over to MAST/ALS provider Assisted in care during transport Version 1.6 effective 7/1/2008

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AB 17.07 Cardiac Arrest Protocol 91 of 210

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AB 17.07 Cardiac Arrest Protocol 92 of 210

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AB 17.07 Cardiac Arrest Protocol 93 of 210

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AB 18.02 Childbirth/Neonatal Resuscitation Protocol 94 of 210 Assessment: A ­ 1 Complete vital signs A ­ 2 Obtain brief history noting due date, history of multiple births, onset of labor, timing of contractions, history of ruptured membranes including fluid color (i.e. meconium), or history of previous perinatal complications A ­ 3 Assess cardiac, respiratory and neurologic systems as well as the abdomen. As appropriate, assess for crowning, abnormal presentation or significant vaginal bleeding Delivery Not Imminent Assessment: A ­ 1 Monitor contractions including strength and frequency Interventions: I­1 I­2 I­3 I­4 I­5 Secure airway Administer oxygen and assist ventilation as required Transport in position of comfort as soon as possible while monitoring vital signs. If the patient is hypotensive, place in left lateral decubitus position Notify the receiving hospital of impending arrival Be prepared to stop transport to deliver infant if indicated Delivery Imminent Interventions: I­1 I­2 I­3 I­4 I­5 I­6 Secure airway Administer oxygen and assist ventilation as required Establish IV access (if time allows) Use sterile technique if possible If abnormal part (arm or foot) presents, contact Medical Control immediately for routing instructions If umbilical cord is prolapsed, contact Medical Control immediately for routing instructions and initiate transport. Enroute, do the following: A. Elevate mother's hips B. With a sterile, gloved hand, gently push the baby up the vaginal canal several inches and maintain this position during transport If normal presentation and crowning, control the delivery of the head, but do not attempt to delay or restrain the delivery in any fashion Version 1.6 effective 7/1/2008

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AB 18.02 Childbirth/Neonatal Resuscitation Protocol 95 of 210 I­8 I­9 I ­ 10 I ­ 11 I ­ 12 I ­ 13 I ­ 14 Reduce nuchal cord as necessary. If unable to reduce, clamp the cord in two places and cut the cord between the two clamps Suction the mouth and then the nose with a bulb syringe after the head is delivered. (Suction the mouth first, if the nose is suctioned first the neonate may gasp and aspirate the contents of the mouth) Deliver the anterior shoulder followed by the posterior shoulder Keep the infant level with the perineum; dry with a towel; wrap in a blanket Clamp the cord in two places. Leave about 8 ­ 10 inches between the abdominal wall and the first clamp. Cut the cord between the two clamps If the mother or neonate is unstable, then consider requesting a second Code 2 unit as time warrants. If the mother develops profuse hemorrhage or shock, then follow the shock protocol (i.e. fluid boluses). If the mother is hypotensive in the supine position, transport in the left lateral decubitus position. Request first responders, if not already present, for extra manpower if indicated Transport while monitoring vital signs. Do not wait for placental delivery. If the placenta delivers spontaneously, bring to the hospital If vaginal bleeding occurs after placental delivery, externally massage the uterus (fundus). Follow the shock protocol and administer IV fluids as indicated If not already notified, contact Medical Control and notify about impending arrival/delivery Neonatal Resuscitation Assessment: A ­ 1 Assess airway, breathing and circulation. [The need for resuscitation can be guided by heart rate, respiratory rate and effort and tone and color. Do not be overly concerned about exact APGAR calculation. See NOTE at the end of this protocol] A ­ 2 Look for meconium staining of amniotic fluid Interventions: Resuscitation of the neonate rarely requires advanced life support. It should proceed in a stepwise fashion with continuing reassessment to avoid overly aggressive interventions I­1 I­2 I­3 Keep the neonate warm and dry. IT IS VERY IMPORTANT TO DRY THE NEONATE. HYPOTHERMIA FROM BEING WET CAN STRESS THE NEONATE SEVERLY Position the neonate on his/her back in a slight trendelenburg position with the head in a neutral position If the neonate is depressed and the amniotic fluid is stained with meconium: Version 1.6 effective 7/1/2008

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AB 18.02 Childbirth/Neonatal Resuscitation Protocol 96 of 210 A. Immediately intubate the neonate B. Apply suction with the meconium adaptor directly to the ET tube. Repeat intubation with a new ET tube, suction in the mouth and then the nose prior to reintubation, and repeat suction until clear. If the neonate deteriorates, stop suctioning and move on to resuscitation Suction the mouth and then the nose with the bulb syringe or a suction device (low suction) A. Suction the mouth first (if the nose is suctioned first the neonate may gasp and aspirate the contents of the mouth) B. Do not suction for more than 10 seconds at a time. Apply suction only while removing the catheter C. Suctioning can cause reflex bradycardia If no meconium is present: A. Initially administer oxygen by face mask B. Keep neonate warm and dry. If necessary, tactile stimulation may be used to stimulate adequate breathing. Drying, suctioning, flicking the soles of the feet and gently rubbing the neonate's back are approve methods C. If necessary, insert an oral airway and ventilate with a bag valve mask and high flow oxygen at 20 ­ 30/minute. It may be necessary to disable the popoff valve of the BVM for the initial ventilations. Take care not to over inflate the lungs D. If evidence of respiratory distress despite adequate warming, drying, stimulation and oxygen treatment, intubate the trachea and gently ventilate using BVM and high flow oxygen If the heart rate of the neonate is less than 80 beats/minute, begin chest compression at the midsternum at 100 ­ 120/minute Contact Medical Control immediately for routing instructions Administer epinephrine via the ET tube (0.01 mg/kg = 0.1 cc/kg of 1/10,000)

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I­5

I­6 I­7 I­8

Notes: · APGAR Scoring System Clinical Signs A ­ Appearance P ­ Pulse G ­ Grimace A ­ Activity R ­ Respiratory Effort 0 Points Blue, Pale Absent No Response Limp Absent 1 Point Pink Body Blue Extremities < 100 Grimaces Some Extremity Flexion Slow, Irregular 2 Points Completely Pink > 100 Cries Active Motion Good Strong Cry

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AB 19.02 Ophthalmologic Emergencies Protocol 97 of 210 Assessment: A ­ 1 Complete vital signs. Assess and treat the ABCs and other life threatening emergencies. Do not allow an ophthalmologic problem to distract you from a life threatening emergency A ­ 2 Obtain a brief history with particular attention to any possible chemical exposure or trauma. Determine if the patient complains of a loss or change in vision, eye pain, eye redness, etc. A ­ 3 Do a brief examination without actually touching the eyes. Document the presence of gross abnormalities including: foreign bodies, pupil irregularity, pupil reactivity, hyphema (blood behind the cornea), subconjunctival hemorrhage, red or pink discoloration to the eye, discharge, lacerations, ptosis (drooping eyelid), etc. A ­ 4 If possible, determine gross visual acuity. Ability to read print, count fingers, or determine light from dark are important findings. Determine this for each eye independently Chemical Exposures Interventions: I­1 I­2 I­3 The first priority, in all cases, is IMMEDIATE, thorough and continuous irrigation with water, NS, or LR until emergency department personnel assume care. Tap water, bottled water, IV fluids, etc. can provide this Attempt to identify the offending substance causing the injury and bring in any containers Transport while continuously irrigating the effected eye(s) Eye Trauma With The Possibility Of A Ruptured Globe Interventions: I­1 I­2 I­3 I­4 The first priority is to prevent further injury. Use a cup to protect the eye. Tape the cup onto bony prominences about the orbit and do not apply any pressure to the eyeball (globe). Gauze is not needed under the cup If an object remains impaled in the eye, do not remove it. Use gauze and/or a cup to stabilize the object. Do not put pressure on the globe Minimize intraocular pressure by elevating the head of the bed, if possible. Try to have the patient avoid coughing, sneezing, straining, or blowing nose Transport while monitoring vital signs

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S 6.02 Treatment of Nerve Agent and Organophosphate Pesticide Casualties Protocol

98 of 210 The use of the "MARK I" kit for treatment of suspected nerve agent poisoning is indicated only if: A. Appropriate signs and symptoms of nerve agent poisoning are present (as described in detail in this protocol). B. The use of the antidotes does not delay transfer of the patient to an appropriate casualty collection point or hospital. C. The use of the MARK I kit is not well described in the pediatric population. Do not use for pediatric patients unless directed by medical control. General Information: Nerve agents are the most toxic of the known chemical agents. In the liquid or vapor form they can cause death within minutes after exposure, generally due to respiratory arrest. Under temperate conditions nerve agents are liquids. When dispersed some become a vapor hazard. Nerve agents inhibit cholinesterase, an enzyme that breaks down acetylcholine. In the presence of a nerve agent, acetylcholine accumulates and stimulates affected organs as described: A. Eye - miosis (pinpoint pupils), eye pain, dim and/or blurred vision, conjunctival injection B. Nose - rhinorrhea (runny nose) C. Airways - bronchoconstriction, bronchorrhea (increased secretions), tightness in the chest, severe respiratory distress, apnea (breathing stopped) D. GI tract - nausea, vomiting, diarrhea E. Glands - sweating, tearing F. Muscles - fasciculations, twitching, fatigue, weakness, flaccid paralysis G. CNS - loss of consciousness, seizure activity, apnea H. Heart - slow, normal or fast rate, high or normal BP Assessment: I. As per General Medical Protocol II. Special attention to signs and symptoms described above.

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S 6.02 Treatment of Nerve Agent and Organophosphate Pesticide Casualties Protocol

99 of 210 Interventions: I. Decontamination ­ As determined by Incident Commander II. Supportive treatment per "General Medical Protocol" III. Apply cardiac monitor (paramedic level only) IV. Perform IV access V. Administer antidotes as outlined below A. "MARK I" Kit 1. Atropine (2 mg autoinjector) a) Blocks some of the effects of acetylcholine b) Dries secretions and relieves bronchospasm 2. 2 PAM (600 mg autoinjector) a) Reactivates cholinesterase allowing acetylcholine to be destroyed b) Mainly improves motor strength 3. Diazepam (paramedic level only) a) 5 ­ 10 mg IV b) Stops seizure activity VI. Specific Treatment: A. Vapor Exposure (Mild) (Triage-Green) 1. Clinical a) Miosis b) Dim vision c) Headache d) Severe rhinorrhea e) Time of onset - seconds to minutes after exposure 2. Treatment a) Self - one atropine from the MARK I kit (Note: You are now a patient, notify supervisor, and seek care.) b) Patient ­ one atropine from the MARK I kit. Observation and reevaluation as scenario allows.

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Joseph Salomone, MD EMS Medical Director

S 6.02 Treatment of Nerve Agent and Organophosphate Pesticide Casualties Protocol

100 of 210 B. Vapor Exposure (Moderate) (Triage-Yellow) 1. Clinical: all of the above, plus: a) Shortness of air b) Vomiting c) Diarrhea d) Time of onset - seconds to minutes after exposure 2. Treatment a) Self ­ one MARK I kit then 1 atropine auto injector every 5-10 minutes (max of 3) or until signs and symptoms decrease (Note: You are now a patient, notify supervisor, and seek care.) b) Patient - one MARK I kit then 1 atropine auto injector every 510 minutes (max of 3) or until signs and symptoms decrease. Observation and reevaluation as scenario allows. C. Vapor Exposure (Severe) (Triage-Red) 1. Clinical: all of the above, plus: a) Severe breathing difficulty or breathing stopped b) Generalized muscle twitching, weakness or paralysis c) Convulsions d) Loss of consciousness e) Loss of bowel or bladder control f) Time of onset: seconds to minutes after exposure 2. Treatment a) Self ­ none (provider will be unable to help himself) b) Patient ­ three MARK I kits immediately. Continue atropine 1 mg IV every 5-10 minutes until signs and symptoms decrease. (Note: It may take more than 20 mg of atropine to get desired effect. Atropine given IV prior to MARK I kits may cause Vfib in the hypoxic patient). Give diazepam to control seizures as per seizure protocol. Support airway as per protocol. (Note: Intubation before the 3 MARK I kits may be ineffective due to increased airway resistance.)

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Joseph Salomone, MD EMS Medical Director

S 6.02 Treatment of Nerve Agent and Organophosphate Pesticide Casualties Protocol

101 of 210 D. Liquid Exposure (Mild) (Triage-Yellow) 1. Clinical a) Muscle twitching at site of exposure b) Sweating at site of exposure c) Nausea or vomiting d) Time of onset: 10 minutes to 18 hours after exposure 2. Treatment: a) Self - one MARK I kit every 5-10 minutes (max of 3 kits) or until signs and symptoms decrease. (Note: You are now a patient, notify supervisor, and seek care.) b) Patient ­ one MARK I kit every 5-10 minutes (max of 3 kits) or until signs and symptoms decrease. Observation and reevaluation as scenario allows. E. Liquid Exposure (Severe) (Triage-Red) 1. Clinical a) Same symptoms as severe vapor exposure b) Time of onset: minutes to an hour after exposure 2. Treatment: Same as for severe vapor exposure 3. Reassess 10 minutes after medication administration and consider readministration of atropine if indicated. Documentation Requirements: N/A Notes: I. Runny nose, bronchoconstriction, increased secretions, chest tightness, respiratory distress and/or difficulty bag valve mask ventilating the patient, vomiting and/or diarrhea are all possible symptoms that may be improved by repeated atropine administration. II. Readministration of the 2 PAM autoinjector in the field is not warranted unless directed by medical control. III. Antidote administration will be documented on the appropriate triage tag or prehospital care report. The used auto injectors will be attached to the patient. IV. Early notification to the receiving hospital is imperative as it takes at least 20 minutes to assemble and set up their DECON team. References: Sidell, Frederick R. MD, William C. Patrick, III, Thomas R. Dashiell, Jane's Chem-Bio Handbook, Virginia: 1999 Sidell, Frederick R. MD, "Medical Aspects of Chemical Biological Warfare: Vol. 1, Chapter 5 Nerve Agents, Brigadier General Russ Zajtchuk MC, U.S. Army, Washington, DC: Office of the Surgeon General, 1997 Version 1.6 effective 7/1/2008

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Joseph Salomone, MD EMS Medical Director

ABT 1.06 General Trauma Protocol 102 of 210 The purpose of this protocol is to outline the general approach to the patient with a traumatic injury. Scene Size-Up: · Assure that the scene is safe for you, other rescuers and the patient. It may be appropriate to withdraw from the scene in some situations until a safe environment can be obtained. Or it may be appropriate to rapidly extricate the patient from a dangerous situation. · Identify the number of patients and other resources that may be needed · Initiate the Incident Management System if appropriate · Call for law enforcement and/or first responder assistance if needed · Call for more EMS units if needed · Begin triage if appropriate · Identify yourself and seek permission to examine and treat the patient Body Substance Isolation: · Apply universal precautions / body substance isolation as appropriate Primary Survey · Search for immediate life threats by assessing the patient using C-A-B process (circulation survey and controlling external hemorrhage, airway, and breathing) and treating the problems as they are found Assessment: A - 1 Survey for any active external hemorrhage A - 2 Assess airway with simultaneous cervical spine stabilization: Note patient's ability to speak, and any evidence of actual or potential airway obstruction including vomitus, bleeding, dentures, loose teeth or foreign bodies A - 3 Assess breathing: Note patient's ability to speak, rate, depth and quality of ventilations, abnormal noises/stridor, retractions, accessory muscle use, nasal flaring, or cyanosis A - 4 Assess circulation: Note pulses, level of consciousness, skin abnormalities (color, temperature, capillary refill, moisture) A - 5 Assess neurologic function (disability): Note level of consciousness, Glasgow Coma Scale or AVPU Scale, movement of each extremity

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ABT 1.06 General Trauma Protocol 103 of 210 Intervention: I-1 If major bleeding is present, control with sterile dressing and direct pressure. In the rare instance when direct pressure fails to control bleeding and the patient may exsanguinate, apply tourniquet(s) if in appropriate location or consider application of approved hemostatic dressing(s): Consider application of approved tourniquet(s) to control extremity hemorrhage per Application of Tourniquet Protocol Consider application of approved hemostatic dressing(s) to wounds in area(s) or that could not be controlled by placement of tourniquet per Use of Hemostatic Dressings Protocol Secure Airway (While stabilizing the cervical spine with manual in-line restriction. Do not apply traction) BLS Maneuvers · Jaw thrust, (head tilt - chin lift only if no concern about cervical spine injury) · Oral or nasal airway · Suction · Assist ventilations with 100% oxygen and BVM if indicated by respiratory rate/effort ALS Maneuvers · Oral endotracheal intubation o Orotracheal intubation may be attempted if unable to adequately ventilate the patient with BVM because of severe facial trauma or excessive blood or secretions. Maintain in-line cervical spine stabilization during attempts o Transport of the unstable trauma patient should not be delayed by attempts at intubation unless the patient cannot be adequately ventilated with BVM · Nasal endotracheal intubation · Needle cricothyroidotomy Administer oxygen Nasal cannula at 2-5 liters per minute oxygen flow Non-rebreather mask at 15 liters per minute oxygen flow Goal is to maintain SAO2 at greater than 97% Assist ventilation as required Bag-valve-mask ventilation Bag to endotracheal tube ventilation

· · I-2 ·

·

I-3 · · · I-4 · ·

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ABT 1.06 General Trauma Protocol 104 of 210 I-5 · Assist circulation as required If no pulse: o Follow DOA protocol if applicable o A cardiopulmonary arrest secondary to trauma cannot be adequately resuscitated in the field and must reach definitive care without delay for any chance of survival o Initiate CPR if indicated Transport of the unstable patient should not be delayed to initiate IV therapy. Begin IV in route to the hospital. Initiate one or two large bore IVs with LR Administer fluids as per the shock protocol Spinal restriction as indicated Maintain body temperature with blankets

· · I-6 I-7 Notes: · · ·

Generally, abnormalities found in the primary survey are addressed with appropriate interventions at the time of discovery It may be appropriate to move directly from the primary survey to another protocol (i.e. cardiac arrest, respiratory distress, shock) Bag-valve-mask ventilation is indicated prior to attempts at endotracheal intubation

Secondary Survey · A systematic history and physical examination, focused on the patient's complaints, searching for problems that may not be immediately life or limb threatening, but that may become so if not addressed appropriately Assessment: A-1 A-2 · · · · · · A-3 Obtain chief complaint Obtain "SAMPLE" history Symptoms (including pertinent positives and negatives) Allergies Medications Past medical history Last meal Events/Environment leading to this episode Obtain vital signs which include pulse, MANUAL systolic and diastolic blood pressures, respiratory rate, and determine pain score (Palpated systolic blood pressure is not sufficient except under extreme conditions.)

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Joseph Salomone, MD EMS Medical Director

ABT 1.06 General Trauma Protocol 105 of 210 A - 4 Perform focused physical examination (this evaluation is dependent on the above history as well as findings from the primary survey and may be more or less detailed depending on the situation) A - 5 Consider application of cardiac monitor (paramedic interpret) A - 6 Consider application of pulse oximeter A - 7 Consider application of NIBP cuff A - 8 Consider obtaining rapid beside glucose determination A - 9 Assessment summation: Consider information gathered in primary and secondary survey, determine an impression of the patient's primary problem and proceed to the appropriate treatment protocol A - 10 Obtain repeat set of vital signs prior to transfer of care to receiving facility or whenever there is an observed change in the patients status. Interventions: Secure airway (see primary survey) Administer oxygen and assist ventilation as required (see primary survey) Consider establishing IV access enroute to hospital unless unable to transport immediately I ­ 4a Consider administering drug therapies (if indicated) · Right patient? · Right drug? · Right dose? · Right route? · Right time? · Right reason? · Right documentation? · Allergies? I ­ 4b When the paramedic is being assisted by another medical professional with administering drug therapies extreme caution must be made to insure proper delivery · The paramedic must read back to the assisting medical professional the above "Rights of Medication Administration" I ­ 5 Consider other therapeutic modalities (if indicated) I ­ 6 Transport while monitoring vital signs and patient condition · Patient destination as determined by appropriate protocol · Medical control contact as determined by appropriate protocol I-1 I-2 I-3

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Joseph Salomone, MD EMS Medical Director

ABT 1.06 General Trauma Protocol 106 of 210 Documentation: · Document all assessments, vital signs, monitor findings, and interventions

Considerations for Specific Body Areas Head Trauma Assessment: A - 1 As per primary and secondary survey A - 2 Obtain brief history noting mechanism of injury, use of safety devices and level of consciousness A - 3 The neurologic exam should include assessing the level of consciousness Glasgow Coma Scale/AVPU Scale), pupil size and reactivity, and presence of posturing or paralysis A - 4 Be alert for associated injuries. Assume that cervical spine injury is present in all patients with significant head trauma Interventions: I-1 I-2 As per primary and secondary survey If intubation is indicated, administer lidocaine, 1 mg/kg prior to intubation to help control intracranial pressure (prehospital intubation is not a priority if airway can be adequately maintained with basic maneuvers) and administration of midazolam (Versed) 2.5mg IV if systolic blood pressure greater than 100mmHg for sedation. Administer IV fluids to maintain systolic blood pressure >120mmHg en route to hospital for severe head injuries with GCS of less than 9, otherwise titrate IV LR to maintain systolic blood pressure => 90mmHg. Transport as above

I-3 I-4

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ABT 1.06 General Trauma Protocol 107 of 210 Chest Trauma Assessment: A - 1 As per primary and secondary survey A - 2 The chest/abdominal exam should include specifically assessing for open wounds, flail segments, tracheal deviation, unequal breath sounds, subcutaneous emphysema and adequacy of ventilation Interventions: I­1 I­2 I­3 I­4 I­5 I­6 I­7 Note: · With penetrating chest injury, consider the potential for remote injury Abdominal Trauma Interventions: I­1 I­2 I­3 I­4 I­5 As per primary and secondary survey If evisceration is present, cover the exposed viscera with sterile saline soaked pads. Do not attempt to replace the exposed viscera into the abdominal cavity If a pelvic fracture is suspected, place the patient on a long spine board For penetrating chest/abdominal trauma, administer IV LR fluids to keep systolic blood pressure => 90mmHg Transport as above As per primary and secondary survey A flail chest with respiratory distress is best treated with positive pressure ventilation Cover an open chest wound with non-porous material secured on three sides to act as a "flap" Tension pneumothorax can occur with or without a penetrating chest injury. If suspected, treat per the needle thoracostomy procedure For penetrating chest/abdominal trauma, administer IV LR fluids to keep systolic blood pressure => 90mmHg Monitor cardiac rhythm and treat dysrhythmias per the appropriate protocol Transport as above

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Joseph Salomone, MD EMS Medical Director

ABT 1.06 General Trauma Protocol 108 of 210 Spinal Trauma Interventions: I­1 I­2 I­3 · As per primary and secondary survey Using manual in-line stabilization, apply appropriately sized cervical collar Spinal restriction: In the unstable patient, transport should not be delayed by the application of a short spine board prior to extrication. Appropriate rapid extrication techniques using appropriate collar and long spine board with manual spinal immobilization should be used In the stable patient, complete spinal immobilization as indicated by mechanism of injury, using appropriate collar, short spine board, and long spine board as indicated per the spinal immobilization procedural protocols In a pregnant female, if the uterus is palpable above the umbilicus, then roll the long spine board 10º to 15º to the left to prevent compression of the vena cava and hypotension. If unable to roll the long spine board, the uterus should be gently, manually displaced to the left with the palm of your hand Have suction immediately available, as there is always a risk of aspiration while immobilized on a spine board If spinal shock occurs: Elevate foot of long spine board (Trendelenburg) Administer 20 ml/kg (maximum 1000 ml) bolus initially and assess the response to the bolus by reassessing breath sounds, the mental status, capillary refill, pulse rate and quality and blood pressure This may be repeated one time to a total of 40 ml/kg (maximum 2000 ml) without base station physician approval. The response to the second bolus should be reassessed as above (ORDERS) Consider dopamine 10- 20 micrograms/kg/minute IV or IO in patients with adequate volume resuscitation (40 ml/kg or 2000 ml maximum) and who remain in shock Transport as above Extremity Trauma Assessment: A ­ 1 As per primary and secondary survey A ­ 2 Assess the injured extremity noting neurovascular adequacy (color, temperature, deformity, open wounds, and distal sensation and movement)

· ·

I­4 I­5 · · · · I­6

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ABT 1.06 General Trauma Protocol 109 of 210 Interventions: I­1 I­2 · · As per primary and secondary survey Fractures, dislocations and sprains Apply the appropriate splint Splinting principles o Splint the joint above and below suspected fractures o Splint the bone above and below suspected joint injuries o Splint in the position found. Severely angulated fractures may be straightened by gentle continuous traction if necessary for immobilization, extrication, or if significant neurovascular compromise is present o Recheck neurovascular status immediately after splinting and then periodically o If bone fragments retract into the wound with immobilization techniques, then notify the receiving physician on hospital arrival o If an open wound is noted in the fractured extremity, then notify the receiving physician on hospital arrival Apply sterile saline moistened dressing to all open wounds Chemical cold packs may be applied after splinting Amputations Apply pressure with sterile gauze pads and elevate to control external bleeding. In the rare instance when direct pressure fails to control bleeding and the patient may exsanguinate, apply tourniquet(s) if in appropriate location or consider application of approved hemostatic dressing(s) The amputated part should be rinsed with sterile saline, wrapped in a dry dressing, placed in a water tight container (i.e. plastic bag or cup), and placed on a chemical cold pack to be kept cool during transport Amputated parts should never be: soaked or placed in water or saline; placed directly on ice or ice packs; cooled with dry ice Partial amputations should be dressed and splinted in alignment with the extremity. Avoid torsion As time is of the greatest importance to assure viability of the amputated pare, transport should proceed as promptly as possible Penetrating extremity wounds Apply pressure with sterile gauze pads and elevate to control external bleeding. In the rare instance when direct pressure fails to control bleeding and the patient may exsanguinate, apply tourniquet(s) if in appropriate location or consider application of approved hemostatic dressing(s) Splint extremity Transport as above

· · I­3 ·

· · · · I­4 ·

· I­5

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ABT 1.06 General Trauma Protocol 110 of 210 Documentation Requirements: Document all: 1. Assessments 2. Vital signs 3. ECG findings 4. Interventions Notes: · Adult/Pediatric Glasgow Coma Scale

Eyes Opening 1 Year and Older 4 3 2 1 spontaneously to verbal command to pain no response Birth - 1 Year spontaneously to shout to pain no response Best Motor Response > 1 Year 6 5 4 3 2 1 obeys localizes pain flexion withdrawal flexion abnormal (decorticate) extension (decerebrate) no response < 1 Year localizes pain flexion withdrawal flexion abnormal (decorticate) extension (decerebrate) no response Best Verbal Response > 5 Years 5 4 3 2 1 ____ Total 3-15 oriented and converses disoriented and converses inappropriate words incomprehensible sounds no response 2-5 Years appropriate words and phrases inappropriate words cries, screams grunts no response 0-23 months cries appropriately smiles, coos cries inappropriate crying, screaming grunts no response

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ABT 3.04 Burns Protocol 111 of 210 Assessment: A - 1 As per general trauma protocol. A - 2 Obtain brief history including the following: Thermal injury How did the burn occur? Type of burn contact? What was the duration of exposure? Did the burn occur in a closed space? Was gasoline or other fuel involved? Electrical injury What type (AC, DC, RF)? Duration of contact? Estimated voltage? Associated trauma? Chemical injury What was the agent? Duration of contact? What decon measure used? Scald injury What was the liquid? What was the temperature of the liquid (ask someone to check water heater temp) Was the patient wearing clothes, how quickly were they removed? Was the burned area cooled? A - 3 Assess cardiac, respiratory, and neurologic systems particularly noting · any singed nasal hair · oral burns · hoarseness · carbonaceous sputum A - 4 Assess the Percentage Total Body Surface Area (%TBSA), noting depth and extent A. The patient's palm represents about 1% of their total body surface area B. The rule of nines applies only to adults. Burn diagrams may be used for children C. Use superficial partial thickness, deep partial thickness, and full thickness to describe burn thickness A - 5 Be alert for associated injuries A - 6 Apply cardiac monitor (paramedic interpret) A - 7 Apply pulse oximeter A - 8 Prevent hypothermia regardless of the burn size

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ABT 3.04 Burns Protocol 112 of 210 Interventions: I-1 I-2 I-3 As per general trauma protocol Administer high flow humidified oxygen via non-rebreathing mask if there is any suspicion of smoke inhalation, toxic gas exposure, or carbon monoxide poisoning If 20% partial thickness or 5% full thickness burn: A. Establish IV access B. Infuse LR at the following rates 1. 0 - 15 years old 20cc/kg (max of 500ml) 2. > 15 years old 500cc/hr C. Assess the response, including breath sounds, mental status, capillary refill, pulse rate and quality, and BP. If evidence of shock, treat per shock protocol (including fluid resuscitation) Gently wrap burned areas in dry burn sheets. Attempt to leave unbroken blisters intact A. If the burn involves the face and total extent of burn is 10% of total body surface area, you may cool the burned area by moistening the dressing with saline B. If the burn is 10% of total body surface area and does not involve the face, then use "Burn Free" from the burn pack C. If the burn is > 10% of total body surface area, then apply dry sterile dressings or wrap in dry burn sheets. No attempt should be made to cool large burn areas (>10%) D. (ORDERS) If the patient has no airway or respiratory compromise and has none of the contraindications, administer Morphine per the Analgesic Medication protocol Remove rings, bracelets and other constricting items For a chemical burn, remove contaminated clothing and irrigate areas with copious amounts of water. If dry/powdered chemical, brush off prior to any irrigation. Bring the container and/or substance identification to the hospital Transport as soon as possible while monitoring vital signs

I­4 I-5

I-6 I-7 I-8 Notes: · · ·

Never apply ice directly to a burned surface % TBSA estimations are unreliable in high voltage electrical burns Extreme caution must be exercised when cooling burn areas or infusing even moderate volumes of UV fluids which may make the patient hypothermic

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ABT 8.00 Spinal Restriction/Omission of Spinal Restriction Protocol 113 of 210

Assessment ­ Per General Trauma Protocol Treatment ­ Is there reason to suspect that a spinal injury may have occurred? Yes No Go to the appropriate protocol Immobilize the patient's spine using the appropriate spinal restriction technique for the situation. Some patients may meet criteria for omission of spinal restriction. (i.e. clinical spinal "clearance" in the field). See below for details. Notes: I. Any doubt or concern about the need for spinal restriction should prompt providers to fully restrict motion of the patient's spine. I. Children who resist spinal restriction should be immobilized as fully as possible without fighting, wrestling, or manipulating their spine. This may result in limited or even no restriction. If the pediatric patient is not fully restricted, the reason(s) why should be documented in the narrative of the run ticket. In some cases, the parent(s) may be able to convince the child to allow spinal restriction. Omission of Spinal Restriction Background: Recent studies have shown that spinal restriction can be safely omitted in a select group of patients who meet certain clinical criteria, even though they have a mechanism of injury known to cause spinal injury. Omitting spinal restriction in appropriate patients: improves patient comfort; may allow better ventilation; speeds treatment and transport; simplifies evaluation; and reduces cost to the patient and the system. Indications: I. The patient must meet the criteria diagramed in the "Omission of Spinal Restriction Algorithm". II. Applicable only to patients between the ages of 12 and 65. III. Applicable only to patients who are (or who have been) ambulatory at the scene after an accident or injury. Contraindications: I. The patient does not meet the criteria diagramed in the "Omission of Spinal Restriction Algorithm". II. Not applicable to patient less than or equal to 12 years old or greater than or equal to 65 years old. III. Not applicable to patients who are not (or have not been) ambulatory at the scene after an accident or injury. IV. Not applicable to patients who are already in spinal restriction by first responders (or are in the process of being placed in spinal restriction). Note: Omission of spinal restriction is a paramedic level skill.

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ABT 8.00 Spinal Restriction/Omission of Spinal Restriction Protocol 114 of 210

Omission of Spinal Restriction Algorithm

Yes No

Mechanism?

Yes

Abnormal mental status

No

Communication problem?

No

Yes

Drugs/ETOH?

No

Yes

Distracting injuries?

No

Yes

Restrict spine

Neurological complaints?

No

Yes

Spinal pain or midline tenderness?

No

Yes

Pain with ROM?

No

Yes

No spinal restriction

Explanation of Steps of Algorithm: Mechanism ­ is there a mechanism present that could cause a spinal injury? Examples include, but are not limited to: long fall; motor vehicle crash; assault. Abnormal Mental Status ­ is the patient's mental status abnormal? The patient should be alert, "oriented X 3", with a GCS of 15 and cooperative. Communication Problem ­ is there a communication barrier with the patient? Examples include, but are not limited to: does not speak a common language with the provider; mental deficiency. Evidence of Intoxication ­ is there evidence that the patient is under the influence of drugs or alcohol? Examples include, but are not limited to: history of intake, physical evidence of intake, slurred speech, nystagmus, odor, etc.

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ABT 8.00 Spinal Restriction/Omission of Spinal Restriction Protocol 115 of 210

Distracting Injuries ­ is there an injury (or situation) that could distract the patient's attention away from symptoms caused by a spinal injury? Examples include, but are not limited to: long bone fractures; pelvic fractures; severe pain from any injury; "mental distress" from the event; etc. Neurologic Complaints · Does the patient have any motor or sensory symptoms? ­ examples include, but are not limited to: complaints of numbness, tingling, "lightening like" pain, or weakness. · Does the patient have any motor or sensory signs on exam? ­ an adequate examination includes: o Motor Function o Upper Extremities o Finger Abduction/Adduction o Grip o Finger/Hand Extension o Lower Extremities o Toe/Foot Plantar Flexion o Toe/Foot Dorsal Flexion o Sensory ­ Light Touch to face, arms/hands and legs/feet. Spinal Pain or MidlineTenderness · Does the patient have any spinal pain? ­ examples include, but are not limited to: complaints of midline neck or upper, mid or lower back pain soreness, stiffness, aches, etc. · Does the patient have any tenderness to palpation over the spine? ­ this includes not just pain, but soreness, stiffness, aches, etc. Pain with Range of Motion ­ Does the patient have any pain with range of motion of the spine? The range of motion is unassisted by the provider and the complaint may not be pain but includes soreness, stiffness, aches, etc. Note: Any doubt or concern about the need for spinal restriction should prompt providers to fully restrict motion of the patient's spine. Documentation: The paramedic responsible for determining that spinal restriction can be omitted should fill out an "Omission of Spinal Restriction" Checksheet and turn it in with the appropriate PCR.

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ABT 8.00 Spinal Restriction/Omission of Spinal Restriction Protocol 116 of 210 Omission of Spinal Restriction Algorithm Check Sheet Run #_______________ Patient Name___________________ Date_________ YES Abnormal mental status? Communication problem? Drugs/ETOH? Distracting injuries?

(long bone/pelvic fracture, severe pain, etc.)

NO

Motor or sensory symptoms?

(weakness, numbness or tingling, or "shooting" pains in any extremity)

Weak finger abduction or adduction? Weak grip? Weak finger or hand extension? Weak toe or foot plantar flexion? Weak toe or foot dorsal flexion? Abnormal light touch sensation to face, arms, hands, legs or feet? Spinal pain or tenderness on palpation? Pain with ROM?

If "Yes" to any, then spinal restriction CANNOT be omitted. Paramedic #__________ Paramedic Signature____________________________________

(Turn in check sheet with run ticket.)

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Joseph Salomone, MD EMS Medical Director

A 6.09 Chest Pain Protocol 117 of 210 Chest pain may be caused by a variety of problems including, but not limited to Acute Coronary Syndrome (ACS), pulmonary embolism, pneumonia and chest wall pain. ACS includes myocardial infarction, stable and unstable angina. The impression of ACS is rarely definitive in the prehospital setting. If clinical features favor ACS, treat, and document, as such including: Assessment: A ­ 1 Assess ABC's A ­ 2 Obtain a complete set of vital signs A ­ 3 Obtain a brief history characterizing pain and associated symptoms A ­ 4 Note past history including medications and allergies A ­ 5 Assess cardiac, respiratory and neurologic systems A ­ 6 Have AED / defibrillator present A ­ 7 If patient arrests, proceed to appropriate protocol A ­ 8 Apply cardiac monitor (paramedic interpret) A ­ 9 Apply pulse oximeter A ­ 10 Perform 12-lead ECG unless chest pain is clearly not cardiac (i.e., local chest trauma, etc.) (paramedic interpret) A ­ 11 Factors favoring Acute Coronary Syndrome (ACS) include: 1. Central chest pain or pressure 2. Radiation to arm, shoulder, neck or jaw 3. Shortness of breath 4. Nausea and/or vomiting 5. Diaphoresis 6. Prior angina or MI A ­ 12 Patient history factors favoring cardiac disease: 1. Prior MI 2. HTN 3. Diabetes 4. Family history of cardiac disease 5. Smoking 6. High cholesterol level 7. Age

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 6.09 Chest Pain Protocol 118 of 210 Interventions: I ­ 1 Secure airway I ­ 2 Administer oxygen and assist ventilation as required I ­ 3 If ACS is suspected: 1. Administer two baby ASA (chew / swallow) 2. Establish IV access 3. Administer NTG 0.4mg tablet sublingual a. Systolic blood pressure > 100 mmHg and heart rate > 50 and < 140 4. Repeat NTG tablets q 5 minutes until pain relieved or systolic blood pressure < 100 mmHg a. May consider 1 inch of NTG ointment if unable to tolerate p.o. medication 5. If the chest pain continues after 3 NTG tablets and if systolic blood pressure > 100 mmHg and heart rate > 50 and < 140 a. Administer morphine sulfate slow IV push in 2mg increments until pain relieved or a total of 10mg has been given* I ­ 4 Monitor vital signs and cardiac rhythm frequently I ­ 5 Treat arrhythmias per protocol and physician order I ­ 6 Transport patient as soon as possible Documentation Requirements: Patients with CP that is clearly not cardiac in origin may not require the following documentation elements. All others, including suspected ACS require the following. 1. Time of chest pain onset 2. Signs and symptoms (see assessment of CP) 3. Medications (if possible) 4. Previous medical history (if possible) to include: a. HTN b. Past MI c. Diabetes d. Bleeding disorders 5. 12-lead ECG acquisition and paramedic interpretation 6. Oxygen use (if indicated) 7. Oxygen saturation monitor readings 8. Continuous EKG monitoring and paramedic interpretation 9. IV access* 10. ASA, NTG, morphine sulfate administration* 11. Glucose monitor reading (if appropriate) 12. Destination hospital contact regarding evidence of myocardial infarction *Requires time stamp using Zoll monitor event markers Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 6.09 Chest Pain Protocol 119 of 210 Notes: · · Be alert for atypical presentations of ACS, especially in women and the elderly Contact destination hospital immediately if evidence of Myocardial Infarction: o "Evidence of myocardial infarction" is defined as: ST elevation of 1mm in two or more contiguous leads The 12SLTM interpretation reports "acute" or "possible acute" myocardial infarction. Transmit 12-lead ECG to destination hospital as soon as possible. A 12-lead ECG should be repeated and interpreted if cardiac rhythm or patient symptoms change In patients who take NTG on a regular basis, NTG may be administered prior to gaining IV access The patient may have taken NTG tablets prior to arrival. Morphine sulfate administration is indicated if pain persists after 3 tablets, assuming the NTG is working properly, i.e., burning tongue, headache, etc. If systolic blood pressure drops below 100 mmHg or heart rate is < 50 bpm or > 140 bpm, cease NTG administration / wipe off ointment and cease morphine sulfate administration

· · · · ·

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 7.03 Stroke/CVA Protocol 120 of 210 Assessment: A ­ 1 Obtain a complete set of vital signs A ­ 2 Obtain a brief history at scene with particular attention to exact time of onset and progression of symptoms · If time of onset is unknown (i.e., patient awoke with symptoms) then note last time patient was "normal" A ­ 3 Other specific medical history elements of importance include: · Medications (especially anticoagulants or antihypertensives) · History of hypertension · MI, prior CVA, known bleeding problems and/or cardiac dysrhythmias A ­ 4 Briefly assess cardiac, pulmonary and neurologic systems A ­ 5 Administer the Cincinnati Prehospital Stroke Scale (CPSS): · Facial droop: Have patient show teeth or smile: o Normal ­ both sides of the face move equally well o Abnormal ­ one side of the face does not move as well as the other · Arm drift: Patient closes eyes and holds both arms out: o Normal ­ both arms move the same or both arms do not move o Abnormal ­ one arm does not move or one arm drifts down compared to the other · Speech: Have the patient say "everything's up to date in Kansas City": o Normal ­ patient uses correct words with no slurring o Abnormal ­ patient slurs words, uses inappropriate words or is unable to speak Any abnormal finding on the CPSS is "positive" for a possible stroke A ­ 6 Assess cardiac rhythm (paramedic interpret) A ­ 7 Assess oxygen saturation level A ­ 8 Assess blood glucose level

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 7.03 Stroke/CVA Protocol 121 of 210 Interventions: I ­ 1 Secure airway I ­ 2 Administer oxygen and assist ventilation as required I ­ 3 Establish IV access I ­ 4 Consider administration of glucose / glucagon as per "Altered Mental Status Protocol" if indicated I ­ 5 If seizure occurs, treat per seizure protocol I ­ 6 Transport in the lateral decubitus ("rescue") position unless suspicion of cervical spine injury I ­ 7 Transport while frequently assessing vital signs I ­ 8 If the time of onset is less than 3 hours and one or more of the CPSS criteria are abnormal: · Medical control should be contacted with transport to an appropriate hospital expedited. This may include accomplishing many of the listed treatments enroute to the hospital Documentation Requirements: 1. Time of onset or last time patient was "normal" 2. Medications 3. Previous medical history (see assessment) 4. CPSS score 5. Oxygen administration 6. Oxygen saturation readings 7. EKG monitoring and paramedic interpretation 8. Glucose readings BSP contact if needed Notes: · Hypertension is commonly present in the stroke patient. Treatment is somewhat controversial but most agree that it is inappropriate in the prehospital setting

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 8.01 Prehospital Termination of Resuscitation Protocol 122 of 210 Introduction: Numerous studies have demonstrated that a certain population of cardiac arrest patients will not survive to hospital discharge if they fail prehospital therapy. Patients that meet the below criteria will be eligible for termination of resuscitation efforts in the field and do not require transport to an Emergency Department. If there is any doubt as to whether to transport or not, it is generally safer to transport per the existing cardiac arrest protocol Indications: A. Primary Cardiac Arrest B. Age >= 18 years old C. ECG Criteria 1. Either Asystole or PEA as presenting rhythm 2. Asystole must be the terminal rhythm D. ETT intubation E. IV access or IO F. > 20 minutes of appropriate therapy Contraindications: A. Non-primary Cardiac Arrest (cause of arrest possibly attributed to other pathology) Including but not limited to the following: 1. Hypothermia 2. Drug Overdose (possible acute overdose) 3. Primary Respiratory Arrest (i.e., status asthmaticus, etc.) 4. Carbon Monoxide Poisoning 5. Traumatic Arrest 6. Drowning B. Ventricular Fibrillation or Ventricular Tachycardia at any time during resuscitation C. Any Return of Spontaneous Circulation (ROSC) i.e., pulse during resuscitation D. Any neurologic activity E. Family desires transport (either voiced or perceived) F. Other (unstable scene, disagreement among family members, etc.) G. Any AED discharged prior to arrival H. EMS responder witnessed cardiac arrest

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 8.01 Prehospital Termination of Resuscitation Protocol 123 of 210 Technique: A. Follow appropriate cardiac arrest protocol to include 1. Successful intubation 2. Successful IV drug administration 3. Minimum of 20 minutes of appropriate therapy B. If the patient fits inclusion criteria and does not fit any exclusion criteria, and the above procedures have been accomplished, the paramedic may initiate the termination of resuscitation procedure C. The following is specific for Termination of Resuscitation in the Field 1. Paramedic must have clear communication with base station physician on a Med Channel (no phone line orders for termination) 2. Base Station Physician and Paramedic must both agree on termination of resuscitation 3. Base Station Physician name must be recorded 4. MAST Communications Center will notify appropriate law enforcement 5. MAST Communications Center will notify appropriate medical examiners office Documentation: A. Field Termination Data sheet must be filled out completely B. Age C. Sex D. Race E. Any CPR on arrival and by whom (KCFD vs. bystander vs. other) F. Any AED activity and by whom G. Presenting EKG rhythm with paramedic interpretation* H. Intubation (see policy) I. IV* J. 20 minutes of resuscitation time K. Primary cardiac event L. Terminal rhythm including paramedic interpretation (should by Asystole)* M. Family acceptance N. Time of termination* O. Code summary* P. Base Station Physician name *Required time stamp using Zoll monitor event markers

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

A 8.01 Prehospital Termination of Resuscitation Protocol 124 of 210

Termination of Resuscitation Data Sheet Date _____/_____/_____ Medic #_______________________

All categories must be checked off

Run #___________________

1. Primary Cardiac Arrest (No other cause for arrest, i.e. trauma, etc) 2. No obvious signs of Trauma 3. Normal Temperature 4. Age >18 years old 5. Initial Rhythm A. PEA B. Asystole 6. Terminal rhythm Asystole 7. Endotracheal Intubation 8. IV drug administration 9. > 20 Minutes of Resuscitation 10. Base Station Physician _________________________Med Channel______ 11. Time of Termination (military time)___________ 12. Document drugs given

Drug Given Time

13. Please place this form with all accompanying ECG strips. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 1.05 Oral Endotracheal Intubation Procedure 125 of 210 INDICATIONS: · · This procedure is for paramedics only Endotracheal intubation is the most effective means of: o Delivering high concentrations of oxygen o Ventilation o Airway control (allows suctioning, prevents aspiration, route of drug administration)

CONTRAINDICATIONS: N/A PRECAUTIONS: 1. Endotracheal intubation is not the initial step in the treatment of a respiratory arrest. Adequate oxygenation and ventilation should be accomplished first using BLS techniques (i.e., BMV with 100% oxygen) 2. Endotracheal intubation may be safely accomplished in the patient with suspected cervical spine injuries as long as the head and neck are immobilized by an assistant using "in-line stabilization" 3. Transport of the unstable trauma patient should not be delayed by attempts at intubation unless the patient cannot be adequately ventilated with BMV 4. Do not use the teeth as a fulcrum 5. Have suction ready since regurgitation is common TECHNIQUE: 1. Gather and test appropriate equipment prior to starting (while ventilation is continuing), including testing the cuff, inserting the stylette, and having suction present and on 2. Place the patient in the "sniffing position" (except if cervical spinal injury is suspected ­ see above) 3. An assistant should perform Sellick's maneuver (cricoid pressure) to avoid regurgitation. This maneuver should be performed gently to avoid C-spine movement. It cannot stop active vomiting and if the patient starts to vomit, pressure should be released to avoid esophageal injury 4. The laryngoscope blade is inserted and used to lift the tongue and epiglottis up. Do not use the teeth as a fulcrum, the blade is not a "lever" 5. Guide the endotracheal tube between the vocal cords under direct visualization 6. The endotracheal tube should be advanced until the cuff is 2-3 cm beyond the cords (adults) 7. Confirm endotracheal tube placement (see confirmation procedure)

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 1.05 Oral Endotracheal Intubation Procedure 126 of 210 8. After endotracheal tube placement is confirmed, the tube should be secured. Do not remove your hand from the tube until it has been secured. Reconfirm placement after securing tube 9. Confirmation of Endotracheal Tube Placement: See the "Confirmation of Endotracheal Tube Placement" procedure 10. Securing Endotracheal Tube Placement: If there is time enough to intubate the patient in the prehospital setting then there is enough time to secure the endotracheal tube. Probably the most common reason given when an esophageal intubation is discovered is that "the tube moved." The following procedure should be used on all patients undergoing endotracheal intubation to minimize tube movement 1. Secure the endotracheal tube: a. Appropriate commercial securing device b. Umbilical tape tie-in c. Regular tape 2. Secure the head from movement with cervical collar 3. Create a "buffer" between endotracheal tube and BVM with blue corrugated tubing COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: N/A NOTES: 1. An intubation attempt should not take more than 15-20 seconds to complete 2. If intubation is still unsuccessful after three attempts then another operator may attempt or alternate means of airway control should be considered (i.e., two person BMV, needle cricothyroidotomy) as applicable 3. Do not use a cuffed endotracheal tube less that 6 mm is size 4. "When in doubt, take it out" and assure oxygenation and ventilation 5. If an initial attempt at intubation results in esophageal intubation, the endotracheal tube may be left in the esophagus to provide a landmark for another attempt if this does not impede BMV

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 2.05 CO2 Detector (EZ Cap II) Procedure 127 of 210 INTRODUCTION: 1. CO2 is a product of cellular metabolism 2. Exhaled air has a high pCO2, inspired air has essentially no CO2 3. End-tidal CO2 monitors measure pCO2 of inspired and expired air by color indicator 4. Color varies between expiration and inspiration as CO2 levels rise and fall 5. In cardiac arrest patients, CO2 may not be carried to the lungs because of poor perfusion. Therefore, the expired pCO2 may be very low INDICATIONS: 1. To assist in initial verification of endotracheal tube placement 2. The end-tidal CO2 detector is an adjunct used to help confirm correct endotracheal tube placement and to help monitor tube placement. It does not replace clinical evaluation CONTRAINDICATIONS: 1. Mouth to endotracheal tube ventilation 2. Patients less than 15 kg (30 lbs) in weight TECHNIQUE: Initial Verification of Endotracheal Tube Placement: 1. 2. 3. 4. 5. Remove from package immediately prior to using device If initial color indicator is not the same or darker than the "area" then do not use Insert endotracheal tube, inflate cuff (if applicable), attach device Ventilate patient with six breaths of moderate tidal volume Compare color indicator to color chart on the end tidal CO2 monitor on full end expiration

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 2.05 CO2 Detector (EZ Cap II) Procedure 128 of 210

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Joseph Salomone, MD EMS Medical Director

C 2.05 CO2 Detector (EZ Cap II) Procedure 129 of 210

Continuing Verification of Endotracheal Tube Placement: 1. If color changes to an A or B range after an initial C range then either: a. The endotracheal tube has become dislodged from the trachea Or b. The patient has deteriorated and now has poor pulmonary perfusion 2. If color changes to an A range after an initial B range then either: a. The endotracheal tube has become dislodged from the trachea Or b. The patient has deteriorated and now has poor pulmonary perfusion 3. If either of the two above scenarios occurs, use the EDD and clinical means to confirm proper placement and/or change in perfusion status Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 2.05 CO2 Detector (EZ Cap II) Procedure 130 of 210 COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: N/A NOTES: · Interpreting results before 6 full breaths can lead to false positive results o Gastric distention with air prior to intubation may introduce CO2 levels high enough into the stomach to give a false positive reading when the endotracheal tube is actually in the esophagus The CO2 detector should not be used to detect right main stem bronchus intubations, use your clinical assessment to confirm correct placement Reflux of gastric contents, mucus, edema fluid or tracheal epinephrine into the CO2 detector can yield persistent yellow or white discoloration that does not vary with the respiratory cycle. Discard if this happens

· ·

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 3.05 Nasotracheal Intubation Procedure 131 of 210 INDICATIONS: 1. This procedure is for paramedics only 2. General-Endotracheal intubation is the most definitive means of: a. Delivering high concentrations of oxygen b. Ventilation c. Airway control (allows suctioning, prevents aspiration, route of drug administration). 3. The nasal route of endotracheal intubation is preferred when direct laryngoscopy is difficult or impossible due to: a. Inability to open the patient's mouth b. Intact gag reflex. c. Patient awake d. Oral anatomic abnormality - including lower facial trauma 4. Other advantages include: a. Better fixation of endotracheal tube b. Fewer oral secretions c. Better long term patient tolerance d. Can be done with the patient sitting CONTRAINDICATIONS: 1. Respiratory arrest - the patient must be breathing to guide endotracheal tube placement 2. Pediatric patients 3. Coagulopathy/anticoagulant therapy 4. Major mid-face trauma (risk of intra-cranial endotracheal tube placement) RELATIVE CONTRAINDICATIONS: Open skull fractures and gunshot wounds to the head (the fracture or the missile may disrupt the base of the skull allowing intracranial placement of the endotracheal tube). Nasotracheal intubation in this setting can only be attempted after online medical control. Do not delay transport of the trauma patient for medical control .

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 3.05 Nasotracheal Intubation Procedure 132 of 210 PRECAUTIONS: 1. Nasotracheal intubation is not the initial step in the treatment of a patient with respiratory compromise. Adequate oxygenation and ventilation should be accomplished first using BLS techniques (i.e. bag-valve-mask with 100% O2). 2. Transport of the unstable trauma patient should not be delayed by attempts at nasotracheal intubation unless the patient cannot be adequately ventilated with BVM. 3. Have suction ready since regurgitation/epistaxis is common. TECHNIQUE: 1. Nasal mucosa is constricted with 0.5% phenylephrine (Neo-Synephrine) spray. 2. Gather and test appropriate equipment prior to starting. This should include testing the cuff, turning suction on and assuring the ET adapter is firmly seated on the endotracheal tube. 3. Unless contraindicated, place head in the sniffing position with the face midline. 4. A 7mm endotracheal tube is lubricated with 2% lidocaine jelly and is inserted along the floor of the nasal cavity (the right nare is used - if unobstructed - to avoid trauma to Kesselbach's plexus; keep the endotracheal tube close to the floor to avoid damage to the turbinates). 5. Breath sounds are monitored through the endotracheal tube, and it is gently advanced. A decrease in resistance indicates passage into the nasopharynx. 6. The endotracheal tube is advanced into the hypopharynx while monitoring breath sounds. As long as breath sounds are heard, retropharyngeal placement is unlikely. 7. Advance the endotracheal tube into the trachea during an inspiratory effort. Never force the endotracheal tube. The patient will frequently cough during this maneuver. Vocalization should cease. 8. Confirm endotracheal tube placement. 9. After endotracheal tube placement is confirmed, the tube should be secured. Do not remove your hand from the tube until it has been secured! Reconfirm tube placement after securing tube. If the endotracheal tube does not pass into the trachea it may have five possible mislocations: a. Esophagus b. Left pyriform sinus c. Right pyriform sinus d. Vallecula e. Above cords but unable to pass. 10. If not contraindicated, endotracheal tube or head movement may be attempted to appropriately relocate endotracheal tube.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 3.05 Nasotracheal Intubation Procedure 133 of 210 11. Confirmation of Endotracheal Tube Placement: See the "Confirmation of Endotracheal Tube Placement" procedure 12. Securing Endotracheal Tube Placement: If there is time enough to intubate the patient in the prehospital setting then there is time enough to secure the endotracheal tube. Probably the most common reason given when an esophageal intubation is discovered is that "the endotracheal tube moved". a. The following are acceptable methods: i. Umbilical tape tie-in ii. Regular tape b. Confirm endotracheal tube placement after each patient movement. COMPLICATIONS: 1. 2. 3. 4. 5. 6. Unrecognized esophageal intubation with resultant hypoxic brain injury Severe epistaxis (nosebleed) Turbinate avulsion Mucosal perforation with retropharyngeal passage Vomiting/aspiration Sinusitis/otitis media/bacteremia

DOCUMENTATION REQUIREMENTS: See confirmation procedure NOTES: I. The endotracheal tube may be advanced a maximum of three times in attempting to pass it into the trachea. More attempts will increase the likelihood of trauma and are unlikely to be successful II. The endotracheal tube should not be removed from the nares between passes III. An intubation attempt should not take more than 30-45 seconds to complete IV. "When in doubt, take it out" and assure oxygenation and ventilation

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 4.01 Needle Thoracostomy Procedure 134 of 210 INDICATIONS: I. Tension pneumothorax is a clinical diagnosis which should be considered when the following signs/symptoms are present: A. Progressing severe respiratory distress* B. Progressing shock* C. Decreased or absent breath sounds on the involved side* D. Jugular venous distention E. Tympany to percussion on the involved side F. Tracheal deviation away from the involved side II. *Signs 1,2, and 3 must be present or approval from a base station physician should be obtained prior to performing the procedure. III. Tension pneumothorax is most common in the patient with: A. Chest trauma B. The intubated patient with high airway pressures causing rupture of bronchioles or alveoli CONTRAINDICATIONS: N/A PRECAUTIONS: N/A TECHNIQUE: I. Locate the second intercostal space in the mid clavicular line on the involved side of the chest. II. Cleanse with betadine or alcohol as time permits. III. Insert a 14 gauge "over the needle" catheter (Use 18 gauge if < 2 months age) through the open end of a glove finger tip, puncture, and advance needle to hub of catheter to establish the flutter valve mechanism. IV. Insert the needle/catheter with attached flutter valve into the chest just over the top of the third rib. V. As you enter the pleural space air and/or blood will escape. VI. Advance the catheter and remove the needle. VII. Secure in place. VIII. The catheter has a tendency to kink. If reaccumulation of air in the pleural space is occurring, proceed with repeat needle thoracostomy.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 4.01 Needle Thoracostomy Procedure 135 of 210 COMPLICATIONS: I. Creation of pneumothorax II. Damage to lung or viscera III. Bleeding (intercostal vessels are below each rib, therefore always go above the rib) IV. Infection DOCUMENTATION REQUIREMENTS: I. Indications for procedure II. Technique used III. Response to intervention NOTES: N/A

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 5.02 Needle Cricothyroidotomy With Transtracheal Jet Insufflation Procedure 136 of 210 INDICATIONS: Inability to manage the airway by any other less invasive means. CONTRAINDICATIONS: This is not a prophylactic measure (i.e. the patient must actually need airway immediately). PRECAUTIONS: I. Patients cannot breathe through a TTJI catheter. Any respiratory effort must be assisted. II. Due to inadequate ventilation, CO2 retention and acidosis will occur with this method. III. Neck swelling may obscure landmarks. TECHNIQUE: I. Locate the cricothyroid membrane between the thyroid and cricoid cartilages. II. Cleanse with betadine or alcohol as time permits. III. Gently insert a transtracheal catheter (adults 13 gauge, children 14 gauge) with a 10 ml syringe attached into the lower half of the cricothyroid membrane in a caudal direction. The catheter is curved and should progress at a 45 degree angle. Apply a slight negative pressure on the syringe plunger. IV. As you enter the trachea, air will fill the syringe. V. Advance the catheter as you withdraw the needle and recheck for air flow with the syringe to reconfirm intratracheal placement. VI. Secure catheter with the attachments provided in the kit. VII. Attach the transtracheal high pressure tubing and jet insufflation device to the secured transtracheal catheter and an oxygen source at 50 psi. VIII. Intermittently insufflate by depressing the trigger device with a cycle of approximately one second on and 3-4 seconds off. COMPLICATIONS: I. Placement at wrong level (with cord/laryngeal damage) A. Bleeding B. Massive subcutaneous and/or mediastinal emphysema C. Esophageal injury D. Tension pneumothorax E. Infection DOCUMENTATION REQUIREMENTS: I. Indications for procedure II. Procedure for placement including time of placement III. Response to intervention Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 6.01 Intraosseous (Intramedullary) Cannulation Procedure 137 of 210 INDICATIONS: I. Emergent need for vascular access II. Failed IV attempts for approximately 1.5 minutes (or very low likelihood of IV success given clinical situation) III. Cardiac arrest or severe shock CONTRAINDICATIONS: I. Do not place in a fractured bone (infusion will leak out of fracture). II. This is an emergency invasive procedure and should not be done for a "prophylactic" or TKO line. PRECAUTIONS: Watch carefully for swelling at the insertion site or soft tissue opposite the insertion site as the needle may not have penetrated bone or may have gone through both cortices. TECHNIQUE: I. Cleanse the selected site with betadine or alcohol. A. Site 1: anterior medial aspect of proximal tibia one to two finger breadths below the tibial tuberosity with needle inserted slightly away from joint space. B. Site 2: distal tibia at the junction of the medial malleolus and shaft of the tibia with needle inserted slightly away from joint space. II. After setting needle guard for desired depth, insert bone marrow aspiration needle into tibia using firm pressure and drilling motion, keeping needle perpendicular to bone. A. 18 gauge needle - under six months B. 15 gauge needle - over six months III. Sudden decreased resistance indicates entry into marrow cavity. Needle should feel secure in bone. IV. Remove stylet and attempt to aspirate blood/marrow from needle. Failure to aspirate does not necessary indicate a failed placement. V. Secure in place. COMPLICATIONS: I. Extravasation of fluids II. Compartment syndrome III. Infection IV. Marrow/growth plate damage V. Fat embolism VI. Fracture Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

C 6.01 Intraosseous (Intramedullary) Cannulation Procedure 138 of 210

DOCUMENTATION REQUIREMENTS: I. Indications for procedure II. Description of procedure III. Response to intervention NOTES: I. Only one attempt in given bone since infusion would leak out site of first attempt. If attempt unsuccessful, leave the needle in place. II. All MAST medications and solutions can be infused via IO line. Fluids may have to be pressure infused to obtain an adequate flow rate. III. If unsuccessful at starting the IO with an 18 gauge needle as a result of the needle bending, then consider using a 15 gauge needle. IV. The marrow aspirate can be used for a rapid bedside glucose determination.

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Office of the EMS Medical Director Emergency Medical Services

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Joseph Salomone, MD EMS Medical Director

C 7.01 Transcutaneous Cardiac Pacing Procedure 139 of 210 INDICATIONS: I. Unstable bradycardia as defined by any of the following: A. Altered mental status B. Clinical signs of shock C. Severe shortness of breath/pulmonary edema. D. Severe chest pain (consistent with ischemia) E. Cyanotic on 100% oxygen with adequate ventilation II. Bradycardic/asystolic cardiac arrest A. The outcome of prolonged bradycardic/asystolic cardiac arrest is dismal even with pacing. Indiscriminate pacing of this rhythm is unwarranted. B. Pacing of bradycardic/asystole of short duration, especially post countershock bradycardic/asystole is more likely to be useful. CONTRAINDICATIONS: Prophylactic pacing - the pacer electrodes may be placed in the stable bradycardic patient but should not be used unless the patient deteriorates. PRECAUTIONS: Transcutaneous pacing is not the initial step in treatment of either unstable bradycardia or bradycardic/asystolic cardiac arrest. Appropriate BLS and ALS maneuvers, as mandated by protocol, should be carried out first. TECHNIQUE: I. Connect ECG electrodes to patient in standard positions (pacer will not operate without ECG monitor intact). II. Clean & dry chest. Remove excess hair if necessary to obtain electrode to skin contact. III. Connect pacing electrodes to matching pacing cable. IV. Peel off protective covering and attach electrodes to patient's chest as described: A. anterior - posterior (Preferred due to better capture rates and will not interfere with defibrillation.) 1. Place negative electrode on left anterior chest halfway between the xiphoid process and left nipple, with the upper edge of the electrode below the nipple line. 2. Place positive electrode on left posterior chest beneath the scapula and lateral to the spine. B. anterior ­ anterior 1. Place negative electrode on left chest midaxillary over fourth interspace. 2. Place positive electrode on right chest, subclavicular area. V. Push "pacer" button. VI. If no intrinsic beats then skip this step. Insure that each QRS complex is being sensed. If not, then adjust the QRS size and change between leads I, II, III to get the best size.

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C 7.01 Transcutaneous Cardiac Pacing Procedure 140 of 210 Select pacing rate A. Adults and children 12 years, begin at 70 bpm. B. Children 1 year and < 12 years, begin at 90 bpm. C. Infants < 1 year, begin at 100 bpm. VIII. Activate pacer by pushing start/stop button. (Light will flash and spike will be seen on rhythm strip.) IX. Increase current by 20 mA increments until electrical capture occurs. X. Determine that mechanical capture has occurred. If so, consider using tape to secure electrodes to the patches to prevent displacement. XI. To terminate pacing push start/stop button. COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: I. Two copies of the code summary. A. one copy to be cut and pasted onto "critical care flow sheet" B. one copy to EMS Medical Director II. Completed "critical care flow sheet" (in addition to run ticket). III. Documentation of indications for and response to pacing (including mechanical capture). NOTES: I. Patient discomfort A. Pacing may be painful to the awake patient. B. Sedation may be useful (Simple reassurance may also be useful.) II. Electrical capture A. Usually evidenced by wide QRS. B. In some patients capture is less obvious and only manifested by minor changes in QRS configuration. III. Mechanical capture A. Manifested by signs of improving cardiac output (i.e. increased level of consciousness or BP). B. Do not confuse skeletal muscle contractions for carotid or femoral pulses. IV. CPR may be safely accomplished during this procedure. V. Defibrillation/cardioversion may be done without removing pacing electrodes. Charging the defibrillator automatically turns off the pacer. When restarted the pacer comes on to its "default" settings of 40 bpm and 0 mA. VI. To obtain adequate tissue perfusion, rates may need to be higher than the initial settings. VII. If pacing is not successful, consider further ALS interventions as indicated. VII.

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C 19.02 Pulse Oximetry Procedure 141 of 210 The pulse oximeter is a cutaneous monitor used as an adjunct in the assessment of respiratory status. The device also assists in evaluating improvement or deterioration during treatment. This device is never used to withhold O2 to a patient who needs it. Any patient who would currently receive O2 per system protocol, or who appears to clinically need it, should continue to be given oxygen. INDICATIONS: I. The following is a partial list of situations where pulse oximetry may be used: A. Only for use in perfusing patient B. Respiratory Disorders. (e.g. Asthma, COPD, respiratory distress, airway obstruction or injury) C. Cardiovascular Disorders. (e.g. CHF, chest pain, dysrhythmia) D. Altered Mental Status. (e.g. Coma, Overdose, CVA, Seizures) E. Trauma II. The pulse oximeter must be used prior to and after intubation or assisted ventilation of the perfusing patient III. The pulse oximeter must be used prior to and after administering sedative agents CONTRAINDICATIONS: I. Non-perfusing rhythm PRECAUTIONS: I. Pulse oximetry values may be inaccurate in a variety of situations A. Inaccurate readings can be seen with patient movement, the presence of nail polish, vasoconstriction, decreased peripheral perfusion, hypotension, hypothermia, abnormal hemoglobins, hypovolemia, carbon monoxide poisoning, smoke inhalation, and methemoglobinemia B. Prehospital personnel should correlate the SaO2 reading with the clinical status of the patient II. Sickle cell anemia (readings are generally falsely low secondary to the abnormal hemoglobin molecule.)

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C 19.02 Pulse Oximetry Procedure 142 of 210 TECHNIQUE: I. Check vital signs II. Turn on the Zoll E-Series monitor III. Ensure that the pulse oximetry probe cable is connected to the monitor. IV. Select appropriate site. Avoid placing the probe on areas distal to orthopedic injuries or distal to a blood pressure cuff V. Place probe on the patient VI. Read the pulse rate, O2 saturation, and document findings at least every 10 minutes and with any change in therapy or clinical condition VII. Oxygen will be applied or increased according to the clinical setting. Although normal SaO2 levels are > 95%, SaO2 levels above 90% are generally acceptable in almost any adult patient. Pediatric patients in respiratory distress should be placed on supplemental oxygen regardless of the oxygen saturation reading A. For patient's not on home O2 therapy, oxygen should be applied via nasal cannula or mask per system protocol B. Patients currently on chronic home O2 therapy should have an initial SaO2 reading done. Oxygen may be increased until SaO2 levels of 90%-92% are obtained. COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: N/A NOTES: Reference: Zoll E-Series Pulse Oximetry (SpO2) Insert, September 2006

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C 20.00 Nasogastric/Orogastric Tube Insertion Procedure 143 of 210 Nasogastric/Orogastric intubation is indicated for decompression of a distended stomach caused by aggressive positive-pressure ventilation. It should always be preceded by intubation of the trachea with an endotracheal tube, in order to protect the airway from possible aspiration. INDICATIONS: Cardiopulmonary arrest with gastric distension compromising ventilation efforts. CONTRAINDICATIONS: I. Conscious patient II. Non-intubated patient III. The nasogastric tube should not be used in those patients with midface trauma. If the cribriform plate has been fractured, the tube could be placed in the patient's brain. PRECAUTIONS: I. Despite careful technique, the Levine tube may become lodged in the trachea. It is imperative that ET and Levine tube placement be monitored continuously. II. Incorrect NG insertion technique may cause trauma and bleeding from the nasal turbinates. If placed incorrectly, pull back gently on the Levine tube and advance again. III. The tube may coil up in the posterior pharynx. Visualize the patient's oropharynx. If a coil of the Levine tube is visualized, pull back gently until the tip of the tube is visible in the posterior pharynx, then advance the tube again. IV. The Levine tube is not to be used for medication or fluid administration TECHNIQUE: I. Nasogastric Route (Adults Only) A. Lubricate the tip and the first few inches of a number 16 Levine tube generously with water-soluble lubricant. B. Pass the tube GENTLY along the floor of the nasal passage. C. As the tube begins to enter the oropharynx, you will feel a lessening of resistance of the tube. Advance the tip of the tube into the stomach. The appropriate length to insert is approximately equal to the distance between the nose and the umbilicus. D. Verify correct placement by connecting an irrigating syringe, pushing 20 ml of air into the Levine tube, and auscultating over the stomach for the sound of gurgling E. Connect the Levine tube to portable or on-board suction (low) to provide continuous decompression. Version 1.6 effective 7/1/2008

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C 20.00 Nasogastric/Orogastric Tube Insertion Procedure 144 of 210 II. Orogastric Route (Children and Adults) A. Using a laryngoscope and proper size blade, visualize the trachea and insure the ET tube is properly placed. B. Visualize the esophagus immediately posterior to the trachea. Quickly advance the lubricated Levine tube (number 16 french for adults, number 12 french for children) through the mouth into the esophagus. C. Advance the tip of the tube into the stomach. The appropriate length to insert is approximately equal to the distance between the mouth and the umbilicus. D. Verify correct placement by connecting an irrigating syringe, pushing 20 ml of air into the Levine tube, and auscultating over the stomach for the sound of gurgling. E. Connect the Levine tube to portable or on-board suction (low) to provide continuous decompression. COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

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C 22.03 Confirmation of Endotracheal Tube Placement Procedure 145 of 210 INDICATIONS: All endotracheal intubations must have objective confirmation of correct placement CONTRAINDICATIONS: N/A PRECAUTIONS: No one clinical sign is an absolute indicator of proper endotracheal tube placement TECHNIQUE: I. Clinical Signs of Placement: A. Direct visualization B. Equal breath sounds (high in mid-axillary line); if breath sounds are decreased on left, consider right mainstem intubation, pull endotracheal tube back and recheck breath sounds C. No gastric sounds with ventilation D. Cuff inflation palpated in supra-sternal notch E. Chest wall movement F. "Fogging" of endotracheal tube G. Airflow felt through endotracheal tube H. Compliance of bag with ventilation I. Observation of pink membranes and "non-deterioration" J. Gastric contents in endotracheal tube imply in esophagus K. Vocalization implies in esophagus L. Palpation of endotracheal tube passing the cords via Sellick's maneuver II. Placement Confirmation Using the CO2 Detector / Monitor: See CO2 Detector / Monitor Procedures III. Placement Confirmation Using the Esophageal Detector Device (EDD): See the Esophageal Detector Device Procedure

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C 22.03 Confirmation of Endotracheal Tube Placement Procedure 146 of 210

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C 22.03 Confirmation of Endotracheal Tube Placement Procedure 147 of 210 COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: I. Time of intubation* II. Type of intubation III. Size of endotracheal tube IV. Presence and quality of breath sounds V. Absence of air movement in the epigastric area VI. Application of EZ Cap II ET CO2 detector and color change VII. Method used to secure ET tube VIII. Application of Zoll E-Series Capnostat End Tidal CO2 detector and results IX. Confirmation of placement after patient moves X. Any complications XI. Completion of Intubation Data sheet NOTES: I. Head movement has been shown to dislodge correctly placed and secured endotracheal tubes. Secure the head with a c-collar and head block device to restrict movement. II. Blue corrugated tubing should be used as an intermediary between the BVM and the endotracheal tube to provide a "cushion" and decrease inadvertent dislodgement with accidental and sudden movements. III. Endotracheal tube placement should be confirmed after each patient movement. IV. When removing the patient from the unit, disconnect the BVM from the endotracheal tube until the patient is out and the wheels are lowered. V. None of the clinical signs are absolute; there are documented cases of unrecognized esophageal intubation using each of these techniques. VI. "When in doubt, take it out" and assure oxygenation and ventilation. VII. If an initial attempt at intubation results in esophageal intubation, the endotracheal tube may be left in the esophagus to provide a landmark for another attempt if this does not impede BVM ventilation.

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C 23.00 Esophageal Detector Device (EDD) Procedure 148 of 210 INTRODUCTION: The EDD is a syringe used to aspirate air from the endotracheal tube. If the endotracheal tube is properly placed in the trachea, the rigid trachea remains patent, allowing free aspiration of air into the syringe barrel. If the endotracheal tube is placed in the esophagus, the soft, unsupported walls will collapse around the endotracheal tube and air can not be aspirated (i.e. the syringe plunger will not retract). INDICATIONS: I. To assist in initial verification of endotracheal tube placement. II. The EDD is an adjunct used to help confirm correct endotracheal tube placement. It does not replace clinical evaluation. III. See "Confirmation of Endotracheal Tube Placement" Procedure and "End Tidal CO2 Monitor" Procedure for specific indications. CONTRAINDICATIONS: I. Patients less than 5 years old or less than 20 kg (44 lbs). II. Pregnant patients. PRECAUTIONS: I. The following may lead to equivocal or misleading results, therefore, clinical evaluation, including direct laryngoscopy, are recommended in these situations: A. Endotracheal tube obstruction (i.e. kinking, secretions) B. Pulmonary edema C. Morbid obesity D. Mainstem bronchus intubation E. Bronchospastic or obstructive lung disease II. Pharyngeal intubation may yield results mimicking intra-tracheal intubation. III. Use caution if aggressive ventilation is performed, especially if through the endotracheal tube, prior to EDD use. (This could cause intra-esophageal air build up which could allow free aspiration of air, mimicking intra-tracheal placement.)

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C 23.00 Esophageal Detector Device (EDD) Procedure 149 of 210 TECHNIQUE: I. Perform "leak test": Place gloved thumb over the EDD adapter and retract syringe plunger. Discard if air leak is detected. II. Insert endotracheal tube and use end tidal CO2 monitor as appropriate. III. Connect EDD to endotracheal tube. IV. Retract the syringe plunger over 2­3 seconds. A. If air returns and fills the syringe completely: The endotracheal tube is likely in the trachea. Confirm clinically and secure the tube. B. If air does not fill the syringe immediately or vomitus returns or resistance to retraction occurs: The endotracheal tube is likely in the esophagus. Remove endotracheal tube and ensure adequate oxygenation and ventilation COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: N/A NOTES: N/A

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C 24.01 12-Lead ECG Monitoring (Zoll E-Series) Procedure 150 of 210 INTRODUCTION: The principle purpose of obtaining a 12-lead ECG in the prehospital setting is to identify patients having an acute ST-elevation myocardial infarction and to relay this information to the receiving hospitals allowing them to appropriately prepare for patient arrival. This has been shown to decrease "door to drug" and "door to invasive intervention" time, both of which improve patient survival. INDICATIONS: I. A prehospital 12-lead ECG should specifically be considered during the assessment of patients being treated as per the following protocols: A. Suspected myocardial infarction. 1. Chest Pain. 2. Respiratory Distress (possible congestive heart failure / pulmonary edema). B. Dysrhythmia diagnosis. 1. Cardiac Dysrhythmia (may be particularly helpful in pediatric patients). CONTRAINDICATIONS: Do not delay the treatment and / or transport of unstable patients to obtain a 12-lead EKG. PRECAUTIONS: I. Do not prolong scene time to obtain 12-lead ECG (should take less than 5 minutes). II. A normal (or nonspecific) 12-lead ECG does not rule out myocardial infarction or ischemia, therefore do not base prehospital treatment on the results of the ECG. III. If a patient on whom you have obtained a 12-lead ECG is refusing transport you should strongly consider contacting medical control for advice.

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C 24.01 12-Lead ECG Monitoring (Zoll E-Series) Procedure 151 of 210 TECHNIQUE: I. The patient should be in the supine position. If the patient cannot tolerate that position, place them in the semi-reclining or sitting position. II. Prep the skin and shave hair as needed. III. Apply electrodes as described:

Limb Leads: Right arm (RA) ­ Right wrist Right leg (RL) ­ Right ankle Left arm (LA) ­ Left wrist Left leg (LL) ­ Left ankle Precordial (Chest) Leads: V1 ­ 4th intercostal space to the right of the sternum V2 ­ 4th intercostal space to the left of the sternum V3 ­ Directly between leads V 2 and V 4 V4 ­ 5th intercostal space at midclavicular line V5 ­ Level with V4 at left anterior axillary line V6 ­ Level with V5 at left midaxillary line

1. Do not use nipples as reference points as locations vary widely. 2. If the patient has pendulous breasts, place electrodes under breasts. B. Attach 12-lead cable to electrodes and machine ­ avoid patient, cable or vehicle movement and 60 cycle interference. C. Enter appropriate patient information. 1. Age and Sex (both necessary for accurate 12SLTM interpretation). 2. First 3 letters of patients last name (for identification purposes). D. Obtain 12-lead EKG. 1. 12-Lead Acquisition ­ the E-Series unit begins pre-acquisition of 12lead data when you attach the electrodes to the patient, as follows: a) Attach electrodes to the patient lead wires. b) Attach lead wires and electrodes to the patient. c) Attach the V-lead cable to the 12-lead ECG cable. (when vleads are not in use, ensure the v-leads protective cap is plugged into the v-lead connector) d) Attach the 12-lead cable to the ECG connector at the back of the E-Series product. Arrange the 12-lead cable such that it is neat and not dangling or looped, and assure that it is not pulling on individual electrodes. e) Turn the selector switch to MONITOR mode. f) If PADS or PADDLES are selected, select Lead I. (you must select leads to obtain a 12-lead printout) g) If the unit is configured to print 12-lead 4 X 3 reports, press RECORDER button for 3 seconds to initiate 12-lead printout. The unit begins printout of the 12-lead report. This reports consists of 10 seconds of 12-lead ECG data printed in four staggered 2.5 second segments.

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C 24.01 12-Lead ECG Monitoring (Zoll E-Series) Procedure 152 of 210 (1) Note: If the v-leads are not in use, pressing and holding the RECORDER button for 3 seconds, causes a 2 X 3 report to be printed. This report consists of 5 seconds of ECG data printed in two staggered 2.5 second segments (leads I, II, and III, and leads aVR, aVL, and aVF). E. If the 12-lead ECG shows evidence of an acute myocardial infarction, then contact the destination emergency department as early in the call as possible to allow them the time to prepare appropriately for the patient. Review 12SL analysis for confirmation. 1. "Evidence of myocardial infarction" is defined as: a) ST segment elevation of 1mm in two contiguous leads b) The 12SLTM interpretation reports "acute" or "possible acute" myocardial infarction. F. Transmission of 12-lead ECG 1. After acquisition, open Zoll Data Relay on tablet 2. Bluetooth connect to download 12-lead to tablet 3. Select desired destinations from list 4. Transmit ECG data COMPLICATIONS: Delay in treatment or transport to obtain a 12-lead ECG may result in patient deterioration. DOCUMENTATION REQUIREMENTS: I. Print 1 copy of the 12-lead ECG for the receiving facility. If transmission of ECG was unsuccessful, print a copy for submission with the run ticket. II. Run ticket documentation should include the 12SLTM interpretation as well as the paramedic interpretation. Paramedic interpretation should include the heart rate and rhythm as well as the presence or absence of evidence of myocardial infarction. NOTES: N/A Reference: Zoll E-Series 12-Lead Monitoring insert, September 2006

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C 25.02 End Tidal CO2 Monitoring (Zoll E-Series - CAPNOSTAT) Procedure 153 of 210 INTRODUCTION: I. CO2 is a product of cellular metabolism that is removed from the body by ventilation, thus end-tidal air has a high pCO2. Inspired air has essentially no CO2. The CO2 monitor is a device which measures the pCO2 of expired air and displays a numerical value of measured end-tidal CO2. The unit can display a capnogram that demonstrates the change in the pCO2 during inspiration and expiration by a waveform on a monitor and will calculate and display respiratory rate based on the measured time interval between detection peaks of the CO2 waveform. II. In the cardiac arrest patient, CO2 may not be carried to the lungs because of poor perfusion. Therefore, the expired pCO2 may be very low. INDICATIONS: The Zoll E-Series EtCO2 option is indicated for the continuous noninvasive monitoring of end tidal carbon dioxide (EtCO2) and respiration rate in intubated patients. The E-Series EtCO2 option with Respironics Novametrix technology supports two methods for continuous measurement of end tidal carbon dioxide and respiration rate. The method used will be the CAPNOSTAT 5 Mainstream CO2 Sensor attached to an airway adapter that connects to an endotracheal tube, mask or disposable mouthpiece. The E-Series EtCO2 option is designed to monitor adult, pediatric, and neonatal patients. The CO2 monitor is an adjunct used to help confirm correct endotracheal tube placement and to help monitor tube placement. It does not replace clinical evaluation. CONTRAINDICATIONS: I. Mouth to endotracheal tube ventilation II. Patients less than 15 kg (30 lbs) in weight PRECAUTIONS: I. Always ensure the integrity of the patient breathing circuit after insertion of the airway adapter by verifying proper ventilation by auscultation and by verifying a proper CO2 waveform (capnogram) on the monitor display. II. Failure to recognize deterioration in patient status with changes in EtCO2 levels or loss of capnogram

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C 25.02 End Tidal CO2 Monitoring (Zoll E-Series - CAPNOSTAT) Procedure 154 of 210 TECHNIQUE: I. Initial Verification of Endotracheal Tube Placement: A. Turn on the monitor and ensure that the CAPNOSTAT Sensor is plugged into the monitor. B. Attach CAPNOSTAT Sensor to the adapter and ensure adaptor is placed between endotracheal tube and BVM or ventilator. C. After the monitor stops displaying WARM UP in the upper right corner of the display, note the EtCO2 level indicated in the upper left corner of the display. Press the "Wave 2" soft key under the display once to display the capnograph waveform and observe for the changes in waveform during patient ventilation. D. Continually monitor indicator and waveform which changes with ventilation, throughout transport. E. Patients who do not require intubation but do require the use of nebulizer, the detector may be connected to the nebulizer and the same procedure followed to monitor EtCO2 and to observe waveform capnography. II. Continuing Verification of Endotracheal Tube Placement: A. If the EtCO2 monitor changes to very low or no indicated EtCO2 and/or loss of capnogram, then either: 1. The endotracheal tube has become dislodged from the trachea. OR 2. The patient has deteriorated and now has poor pulmonary perfusion. OR 3. There is a problem with the sampling circuit of the device. B. First ensure that the CAPNOSTAT CO2 detector is correctly plugged into the Zoll monitor and that the cable is intact, that the detection device is placed properly and attached to the airway adapter, and the airway adapter is properly placed in the airway circuit. If the above condition persists, use the EDD and/or clinical means to confirm proper placement and change in perfusion status.

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C 25.02 End Tidal CO2 Monitoring (Zoll E-Series - CAPNOSTAT) Procedure 155 of 210

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C 25.02 End Tidal CO2 Monitoring (Zoll E-Series - CAPNOSTAT) Procedure 156 of 210

COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: See Confirmation of Endotracheal Tube Placement NOTES: I. Not effective for detecting right mainstem or pharyngeal intubation. II. If there is no EtCO2 level detected and no capnogram, then recheck equipment and/or use other means to verify placement. Reference: Zoll E-Series End Tidal Carbon Dioxide (EtCO2) Insert, September 2006

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C 26.00 Rapid Bedside Glucose Determination Procedure 157 of 210 INDICATIONS: I. Any suspected alteration in glucose level that might impact patient assessment or treatment. This could include patients with: A. Altered Mental Status B. Behavioral or Psychiatric Disorders C. Hyper or Hypothermia D. Ingestions or Overdose E. Seizures F. Pediatric Cardiac Arrest CONTRAINDICATIONS: N/A PRECAUTIONS: I. Airway, breathing and circulation should be assessed and treated in the initial evaluation of every patient and obtaining a rapid bedside glucose determination should not interfere with this evaluation and treatment. II. If problems arise with the device, obtaining a rapid bedside glucose determination should not delay the administration of glucose, if indicated. TECHNIQUE: Refer to the manufacturer's instructions for specific directions on the utilization of each model of glucometer in use. (See Attachment) COMPLICATIONS: I. Pain, infection or bleeding at site of lancet (or IV) stick. II. Delay in administration of glucose. DOCUMENTATION REQUIREMENTS: I. Include the following (minimum): A. The blood glucose level obtained B. Complications NOTES: N/A

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C 27.00 Intranasal Drug Administration Procedure 158 of 210 INDICATIONS: A. B. C. D. Emergent need for medication administration No IV has been established Pediatric seizures (Midazolam) Altered mental status suspected narcotic overdose (Naloxone)

CONTRAINDICATIONS: A. B. C. D. Excessive nasal discharge Bleeding from nares Mucosal destruction Current patient use of nasal vasoconstrictors (Neosynephrine)

PRECAUTIONS: N/A TECHNIQUE: A. B. C. D. Draw up proper dosage (see appropriate protocol) Expel air from syringe Attach the MAD device via luer lock Briskly compress the syringe plunger into nares

COMPLICATIONS: A. Gently pushing the plunger will not result in atomization B. Fluid may escape from nares C. Not 100% effective DOCUMENTATION REQUIREMENTS: A. B. C. D. Indications for procedure Description of procedure Dosage used Response to intervention

NOTES: · Does not replace standard therapy (i.e., IV, O2 and monitoring)

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C 28.00 Non-Invasive Blood Pressure Monitoring (Zoll E-Series) Procedure 159 of 210 INDICATIONS: The ZOLL E SeriesTM NIBP option is indicated for the non-invasive measurement of arterial blood pressure for resting patients during treatment and transport. The NIBP option is designed to measure blood pressure for adult and pediatric patients. The NonInvasive Blood Pressure (NIBP) option on the E SeriesTM unit allows you to take a single blood pressure measurement, STAT measurements (automatically repeated measurements over a 5 minute period), or automatic measurements at repeating preselected intervals. The blood pressure information (including the patient's systolic, diastolic and mean blood pressure values) is shown on the E Series monitor in the NIBP display area (in the upper left-hand corner). CONTRAINDICATIONS: The ZOLL E Series NIBP option is not indicated for use on neonatal patients or infants whose upper arm circumference is less than 17 cm. PRECAUTIONS: NIBP should not be utilized without first obtaining or confirming the systolic and diastolic blood pressure with a manual sphygmomanometer, and a manual confirmation should be obtained whenever there is a change of 30 mmHg or greater. TECHNIQUE: To take safe and accurate blood pressure measurements using the E-Series NIBP option, you must perform the following steps: I. Select the proper size cuff A. The NIBP option comes with a cuff that inflates to cut off the patient's blood flow and then deflates slowly to allow the blood flow to resume gradually. To take accurate measurements, you must use the proper sized cuff. Bladder length should be at least 80 percent of the limb circumference, while the cuff width should be equal to 40 percent of the limb circumference. Select the appropriate size cuff for the patient from the following table: Limb Circumference 31 to 40 cm (12.20 to 15.75 in.) 23 to 33 cm (9.06 to 12.99 in.) 17 to 25 cm (6.69 to 9.84 in.) Cuff Large Adult Adult Long Small Adult

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C 28.00 Non-Invasive Blood Pressure Monitoring (Zoll E-Series) Procedure 160 of 210 II. Ensure the hose is connected to the E Series unit and to the cuff. III. Apply the cuff to the patient. Confirm appropriate size with cuff indicator. ( Index arrow on cuff falls within range markings on cuff) IV. Press blue NIBP softkey on lower right side of display to start NIBP measurement. (The default initial inflation pressure is 180 mmHg.) V. Note indication that measurement is being obtained in upper left corner of display. Patient must remain still for accurate reading to be obtained. VI. Read result and note measurement. If systolic blood pressure is greater than 180 mmHg, the cuff will re-inflate and attempt repeated measurement. COMPLICATIONS: I. II. III. Failure to recognize unstable or deteriorating patient. Delay in treatment or transport waiting for measurement. Injury to limb from cuff over inflation.

DOCUMENTATION REQUIREMENTS: Time of NIBP measurement, results and cuff size. NOTES: Reference: Zoll E series Non-invasive Blood Pressure Insert, September 2006

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C 29.01 Continuous Positive Airway Pressure (CPAP) Procedure 161 of 210 INTRODUCTION: Continuous Positive Airway Pressure (CPAP) is a method for delivery of ventilatory support that maintains positive airway pressure throughout the breathing cycle. CPAP has been shown to rapidly improve vital signs, gas exchange, reduce the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from asthma, COPD, pulmonary edema, CHF, and pneumonia. INDICATIONS: I. Any patient who is in respiratory distress with signs and symptoms consistent with asthma, COPD, pulmonary edema, CHF, or pneumonia and who is: a. Awake and able to follow commands b. Is over 12 years old and is able to fit the CPAP mask c. Has the ability to maintain an open airway II. Patients must exhibit at least two of the following: a. A respiratory rate greater than 25 breaths per minute b. SPO2 of less than 94% at any time c. Use of accessory muscles during inspirations CONTRAINDICATIONS: I. II. III. IV. V. Patient is in respiratory arrest/apneic Patient is suspected of having a pneumothorax Patient has suffered trauma to the chest Patient has a tracheostomy Patient is actively vomiting or has upper GI bleeding

PRECAUTIONS: N/A

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C 29.01 Continuous Positive Airway Pressure (CPAP) Procedure 162 of 210 TECHNIQUE (Placement of device): I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. XIII. XIV. XV. EXPLAIN THE PROCEDURE TO THE PATIENT! Ensure adequate oxygen supply to ventilation device, and set flow rate to 15 lpm Place the patient on continuous pulse oximetry Place the patient on cardiac monitor and obtain complete vital signs. Use NIBP whenever possible for continuous blood pressure evaluation Place the delivery device over the mouth and nose Secure the mask with provided straps or other provided devices Begin using at 5 cm H2O on PEEP valve (on face mask) and oxygen blender set at maximum FIO2 of 95% (on end of oxygen supply tubing) Check for air leaks Monitor and document the patient's response to treatment. It is very important to provide encouragement and support as the patient adjusts to mask and PEEP Check and document vital signs every 5 minutes If no response within 3-5 minutes, may increase PEEP to 10 cm H2O maximum Administer appropriate medications as otherwise indicated (NTG paste, Albuterol / Atrovent through side port of mask) Continue to coach patient to keep mask in place and readjust device/mask as needed If respiratory status deteriorates, remove device and consider intermittent positive pressure ventilation via BVM and/or endotracheal intubation If systolic blood pressure falls to below 100 mm/Hg, titrate PEEP back to 5 cm H2O or consider using alternative therapy

TECHNIQUE (Removal of device): I. CPAP therapy needs to be continuous and should not be removed unless the patient can not tolerate the mask or experiences respiratory arrest or begins to vomit II. Intermittent positive pressure ventilation with a BVM and/or endotracheal intubation should be considered if the patient is removed from CPAP therapy DOCUMENTATION REQUIREMENTS: N/A NOTES: I. Do not remove CPAP until hospital therapy is ready to be placed on patient II. Watch patient for gastric distention, which can result in vomiting III. Procedure may be performed on patient with Do Not Resuscitate Order IV. Due to changes in preload and afterload of the heart during CPAP therapy, a complete set of vital signs must be obtained every 5 minutes. Consider placing NIBP cuff to monitor blood pressure V. Advise destination hospital that you are using CPAP on the patient and ask them to be prepared to continue therapy if possible Version 1.6 effective 7/1/2008

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SC 1.00 Manual C-Spine Immobilization Procedure 163 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury that movement of the C-spine would exacerbate C. Invasive airway maneuvers if the patient requires spinal immobilization, even if the patient is fully immobilized. II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head should be immobilized in the position found. III. Precautions A. Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. B. In multiple casualty incidents, triage must be used to determine care and immobilization. IV. Procedure A. From behind the patient 1. From behind the patient, place the hands over the patient's ears without moving the head. 2. Place the thumbs against the posterior aspect of the skull. 3. Place the little fingers just under the angle of the mandible. 4. Spread the remaining fingers on the flat lateral planes of the head and increase the strength of the grasp. 5. If the head is not in a neutral in-line position, slowly move it until it is. 6. Bring your arms in and rest them against the seat, headrest, or your torso for support. B. From the side of the patient 1. Stand at the side of the patient. Pass your arm over the patient's shoulder and cup the back of his head with your hand. Be careful not the move the head. 2. Between where the upper molars insert in the maxilla and the inferior margin of the zygomatic arch, and indentation is formed. By placing Version 1.6 effective 7/1/2008

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SC 1.00 Manual C-Spine Immobilization Procedure 164 of 210 the thumb and first finger of your other hand on each cheek respectively just inferior to the zygomatic arch, they will be in this indentation. Its exact location can easily be ascertained by feel and, it provides a secure place to grasp the face so that movement can be eliminated. 3. Tighten the anterior and posterior pressure of the hands. 4. If the head is not in a neutral in-line position, move it until it is. Brace your elbows on your torso for support. C. From in front of the patient 1. Stand directly in front of the patient. Place your hands on the sides of the head. 2. Place the little fingers at the posterior aspect of the skull. 3. Place one thumb in the indentation that can be felt just inferior to the zygomatic arch on each cheek. Spread the remaining fingers on the flat lateral planes of the head and increase the strength of the grasp. 4. If the head is not in a neutral in-line position, move it until it is. 5. Bring your arms in and brace your elbows against your torso for support. 6. This method can also be used when kneeling alongside the thorax of a supine patient and facing toward the head. D. Supine patient 1. Except that the fingers point in a caudad direction instead of a cephalad direction, hand placement for a supine patient from a position kneeling above the head is the same as when immobilizing a sitting patient from the front. 2. The little fingers are placed at the posterior aspect of the skull. A thumb is placed in the indentation that can be felt just inferior to the zygomatic arch, on each cheek. The other fingers are spread across the flat lateral planes of the head, facing the patient's feet. V. Notes ­ This procedure is largely borrowed WITH PERMISSION from the Prehospital Trauma Life Support Textbook, second edition. VI. Complications ­ Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. VII. Documentation A. Neurologic status before and after the procedure. B. At the time the procedure was done.

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SC 2.00 Log Roll Procedure 165 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury that movement of the C-spine would exacerbate C. Supine, prone, and lateral position of the patient II. Precautions ­ Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. III. Procedure A. Supine patient 1. While the EMT at the patient's head (EMT #1) maintains neutral inline immobilization, a cervical collar is applied and a rigid long spine board is placed alongside the patient. 2. EMT #2 kneels at the patient's mid thorax and EMT #3 kneels next to him at the patient's knees. The arms are straightened and placed palmin next to the torso while EMT #3 brings the legs together into neutral alignment. 3. EMT #2 extends the patient's arms, locking the elbows, and grasps the far side of the patient at the shoulder and the wrist. EMT #3 grasps the hip and tightly grasps both pants cuffs at the ankles. (If the patient is wearing shorts or a skirt or if the pants have been cut off, a cravat around the ankles will provide a similar hold around the lower legs.) 4. With the arms locked firmly at the patient's sides, the patient is rolled slowly onto his/her side until he/she is perpendicular to the ground. The EMT at the thorax controls most of the weight and therefore sets the pace. The EMT at the head signals the maneuver and watches the thorax turn and maintains neutral in-line support of the head, rotating it exactly with the torso and being careful to avoid any flexion or hyperextension. EMT #3, at the legs, assists with the rotation of the torso with his/her hand at the patient's hip. He/she rotates the legs, moving in line with the torso at all times. a) As well as rotary alignment, the EMT at the legs must also maintain lateral and anterior/posterior alignment. To maintain lateral alignment, the ankles must be kept elevated. 5. The board is positioned next to the patient by a helper. Whether the board is placed flat on the ground or is held at a 30-40 degree angle, or is placed flat against the patient's upturned back, is solely a matter of individual preference.

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SC 2.00 Log Roll Procedure 166 of 210 6. The patient is then rolled back onto the board in the same manner. If the board was angled or upright, the patient and the board are then lowered to the ground together. 7. While keeping the patient in neutral alignment, adjust the patient's position so that he/she is centered on the board and a proper space exists between the top of the patient's head and the head end of the board. B. Prone or lateral patient 1. When the patient presents in a semi-prone or prone position, a method similar to that for a supine patient is used. It incorporates the same initial alignment of the patient's limbs, the same positioning of EMTs and hand placement, and the same responsibilities for maintaining alignment. 2. The EMT at the head positions his/her arms in anticipation of the full rotation that will occur. A cervical collar can only be safely applied once the patient is in an in-line position and supine on the rigid long spine board, not before. 3. The patient is rolled away from the direction in which his/her face initially points. This determines on which side of the patient the EMTs place themselves. The head is rotated less than the torso, so that by the time the patient is on his/her side (perpendicular to the ground), the head and the torso have come into proper alignment. EMT #3 must keep the pelvis and legs in alignment with the torso throughout the entire procedure. 4. Two options exist in placing the rigid long spine board. Either it can initially be placed on the ground 4 to 5 inches from the patient's side with the EMTs kneeling on it or, once the patient has been rolled onto his/her side, it can be inserted (on its side) longitudinally between the patient's back and the 2 EMTs at the patient's side. 5. In either case the two EMTs support the body, while continuing to hold the patient steady, and shuffle backwards one at a time to provide space to continue rotating the patient. 6. Rotation of the patient is continued in the same direction as before, and the patient (or the patient and the board) are rolled until on the ground and supine. Neutral alignment is maintained throughout. 7. A cervical collar is applied and the patient's position on the board is adjusted as needed. IV. Notes A. This procedure is largely borrowed with permission from the Prehospital Trauma Life Support Textbook, second edition. V. Complications ­ Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. Version 1.6 effective 7/1/2008

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SC 2.00 Log Roll Procedure 167 of 210 VI. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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SC 3.00 Rigid Long Spine Board Immobilization Procedure 168 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury C. Critical trauma patients to use as a "full body splint" for rapid splinting of potential injuries that taking time for individual splinting would be detrimental to the patient. II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. C. If the patient's spine is chronically deformed to the point where the long board would cause injury, alternative immobilization techniques should be used. III. Precautions ­ Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. IV. Procedure A. Adult 1. Move the head to a neutral in-line position (unless contraindicated) and provide manual immobilization. Apply a cervical collar as appropriate. 2. Using an acceptable method, position the patient on the rigid long spine board. 3. Immobilize the upper torso to the board so that it cannot move up, down, or laterally. To do this, use an "X" strapping over the shoulders. 4. Immobilize the lower torso (pelvis to the board so that it cannot move up, down, or laterally. To do this, use a straight strap across the iliac crests or groin loops. 5. Readjust the torso straps as needed. 6. Secure the legs to the board with straps proximal and distal to the knees. The feet should then be secured to the board using another strap in a figure eight pattern. 7. Pad under the head as needed. Version 1.6 effective 7/1/2008

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SC 3.00 Rigid Long Spine Board Immobilization Procedure 169 of 210 8. Immobilize the head using a cervical immobilization device. 9. Place the patient's extended arms palm-in along his sides and secure them. B. Pediatric 1. Two major adjustments in the previous method are necessary when immobilizing a small child to a rigid long spine board. a) Due to the relatively large size of the child's head, padding is needed under the torso to elevate it and maintain the spine in neutral alignment. The padding must extend from the lumbar area to the top of the shoulders, and to the right and left edges of board. A folded blanket usually works well. b) Small children are usually narrower than an adult-sized rigid long spine board. Blanket rolls can be placed between the child's sides and the sides of the board to prevent lateral movement. Pediatric immobilization devices take these differences into account, and are preferable. V. Notes ­ This procedure is largely borrowed with permission from the Prehospital Trauma Life Support Textbook, second edition. VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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SC 4.00 Standing Rigid Long Spine Board Immobilization Procedure 170 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury C. Standing position of the patient II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. C. If the patient's spine is chronically deformed to the point where the long board would cause injury, alternative immobilization techniques should be used. III. Precautions ­ Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. IV. Procedure A. Manual methods-Unstable patient 1. Apply manual immobilization from behind the patient. 2. Insert the rigid long spine board behind the patient from the side. The EMT providing in-line immobilization keeps it pressed against the patient with his hip and leg. 3. One EMT at each side inserts his hand nearest the patient under the patient's armpit and grasps the nearest hand-hold on the board above the armpit. 4. Next, each EMT grasps a hand-hold near the top of the board with his free hand. 5. Another rescuer or spectator places his foot or hands at the bottom of the board so that it cannot move. The EMTs lower the board partway to the ground, stopping about halfway down. 6. The EMT holding the head must rotate his hands without losing immobilization. The EMTs at the sides may have to reposition their arms so that they will clear those of the EMT at the head when the board is fully lowered. 7. Lower the board to the ground. The EMT at the head must go from a standing to kneeling position to avoid moving the head out of line. Version 1.6 effective 7/1/2008

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SC 4.00 Standing Rigid Long Spine Board Immobilization Procedure 171 of 210 8. Apply a cervical collar and immobilize the patient to the board. B. Mechanical method-Stable patient 1. The rapid method for immobilizing a standing patient described above provides protection of the spine. However, if the patient is stable, mechanical immobilization of the torso, neck, and head prior to lowering provides more positive immobilization and is safer, affording less chance of movement. If time is not a key factor, it is the method of choice and should be used. The stability of the patient and security of the scene should be the determining factor and not the individual EMT's preference. a) Once manual in-line immobilization has been obtained from behind the patient, a cervical collar is applied and the long board is inserted behind the patient from the side. b) Immobilize the upper and lower torso to the board using the appropriate procedure. Rapidly re-evaluate and adjust the torso straps. c) Pad behind the head as needed, and maintain manual immobilization. Do not tie or immobilize the legs of a standing patient. d) Have the patient hold his hands in front of him. With one EMT at each side of the board, lower the board to the ground. Do this in two distinct steps, stopping halfway down to adjust your hands. e) Once on the ground, complete the immobilization and apply a cervical immobilization device. V. Notes ­ This procedure is largely borrowed with permission from the Prehospital Trauma Life Support Textbook, second edition. VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. C. This procedure is frequently disconcerting to patients. To alleviate this sensation, it is helpful to slightly lean the head of the board backwards instead of keeping the board purely vertical. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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SC 5.00 Spinal Immobilization Using the Rigid Short Immobilization Device Procedure 172 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury C. Sitting position of the patient D. When the scene and the patient's condition are stable and time is not an overriding concern. E. When a special rescue situation involving substantial lifting or technical rescue hoisting exists, and significant movement or carrying of the patient is involved before it is practical to complete the supine immobilization to a rigid long spine board. II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. C. If the patient's spine is chronically deformed to the point where the rigid short immobilization device would cause injury, alternative immobilization techniques should be used. D. When time is an overriding primary concern 1. When the scene is unsafe and clear danger to the EMT and patient exists, necessitating rapid removal to a safe location 2. When the patient's condition is so unstable that he needs immediate intervention which can only be provided in a supine position and/or out of the vehicle, or when his condition requires immediate transport to the hospital without delay 3. When the patient blocks the EMT's access to other more seriously injured patients in the vehicle. 4. In such patients, rapid extrication should be used. III. Precautions A. Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. IV. Procedure Version 1.6 effective 7/1/2008

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SC 5.00 Spinal Immobilization Using the Rigid Short Immobilization Device Procedure 173 of 210 A. Application of the Rigid Short Immobilization Device. 1. Apply manual immobilization from behind the patient. Apply a cervical collar. 2. Remove the rigid short immobilization device from the carrying case and set the head roll and forehead/chin restraints aside. 3. Position an EMT on each side of the patient. Place the back side of the rigid short immobilization device (with the restraints and receivers) away from the patient and slide it behind the patient's back. Use care to minimize patient movement. 4. Center the rigid short immobilization device along the patient's spine and position the top of the chest flaps just below the patient's armpits. 5. Pull the leg restraints from behind the patient and lay them aside. 6. Release the chest restraints from the hook and loop holders. Wrap the chest flaps around the patient. Fasten the middle chest restraint and then the bottom chest restraint. 7. Use the lift handles to raise the rigid short immobilization device until the tops of the chest flaps press firmly under the patient's armpits. Tighten the middle and bottom chest restraints to secure it in place. 8. Insert one of the long groin loop straps above the knee and, with a back-and-forth motion, work it under the thigh and buttock until it is in a straight line in the intergluteal fold from back to front. Position it in the crotch on one side of the genitalia. Bring the strap up the inner thigh, over the pelvis, and fasten it to the buckle on the same side of the vest so that the strap has formed a loop over one side of the pelvis. Repeat this procedure with the other strap. a) Fastening and adjusting only one side at a time prevents unwanted movement of the patient. b) Do not use leg restraints when the patient has suffered a femur fracture or groin injury. 9. Fill any gap between the rigid short immobilization device and the patient's head with the head roll or other suitable padding. 10. Wrap the head flaps around the patient's head and secure the head flaps in place with the forehead/chin restraints. Use of a chin restraint is optional. 11. Fasten and tighten the top chest restraint. Make sure all restraints are secure. Carefully turn, lift, or tilt the patient for extrication. Manual immobilization of the head may now be released. B. Transition to a rigid long spine board 1. If possible, the ambulance cot with a rigid long spine board on it should be brought to the opening of the car door. The board should be placed under or at least next to the patient's buttock, so that one end is securely supported on the car seat and the other end is on the Version 1.6 effective 7/1/2008

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SC 5.00 Spinal Immobilization Using the Rigid Short Immobilization Device Procedure 174 of 210 ambulance cot. If a cot is not available, the rigid long spine board can be held by others while the patient and device are lifted out of the seat as a unit and placed on the rigid long spine board. Rotate the patient and device in place and elevate the legs, lowering the patient and the device onto the rigid long spine board. Then slide the patient and device along the board until properly positioned. Lower the legs onto the board. If the groin straps have been placed over the pelvis correctly, they will only need to be loosened in obese or extremely muscular patients. Position the rigid long spine board on the ambulance cot. Securely fasten the patient to the rigid long spine board as per procedure. There is no need to use a cervical immobilization device unless the device has shifted. Immobilize the legs to the board. Secure the rigid long spine board and patient to the ambulance cot.

2.

3. 4. 5. 6.

V. Notes A. This procedure is largely borrowed with permission from the Prehospital Trauma Life Support Textbook, second edition. B. This procedure is also borrowed from the rigid short immobilization device manufacturer's recommendations. C. To adapt the rigid short immobilization device for pediatric use, place blankets or towels on the patient's chest before securing the chest restraints. D. The rigid short immobilization device does not interfere with or limit the use of anti-shock trousers. E. To leave a pregnant patient's abdomen exposed, fold two sections of each chest flap inward. Position and tighten the chest restraints carefully. F. To provide more chest exposure, fold two sections of each chest flap inward. Unfasten the top and middle chest restraints to perform defibrillation. VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

SC 6.00 Spinal Immobilization Using Rapid Extrication Procedure 175 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury C. Sitting position of the patient D. When time is an overriding primary concern 1. When the scene is unsafe and clear danger to the EMT and patient exists, necessitating rapid removal to a safe location 2. When the patient's condition is so unstable that he needs immediate intervention which can only be provided in a supine position and/or out of the vehicle, or when his condition requires immediate transport to the hospital without delay 3. When the patient blocks the EMT's access to other more seriously injured patients in the vehicle II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. C. When the scene and the patient's condition are stable and time is not an overriding concern; in which case the rigid short immobilization device should be used. D. When a special rescue situation involving substantial lifting or technical rescue hoisting exists, and significant movement or carrying of the patient is involved before it is practical to complete the supine immobilization to a rigid long spine board; in which case the rigid short immobilization device should be used. III. Precautions A. Most methods of immobilization require three operators to perform them properly and to ensure the maintenance of manual immobilization throughout. When only two operators are available, one should maintain manual immobilization, and the other should apply the device. When first responders or others are enlisted to help, care must be taken to assign them tasks that do not require previous training, or are the least sensitive, and to furnish them with precise directions. B. Rapid extrication should be selected only when time is a factor, and not on the basis of personal preference.

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Office of the EMS Medical Director Emergency Medical Services

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Joseph Salomone, MD EMS Medical Director

SC 6.00 Spinal Immobilization Using Rapid Extrication Procedure 176 of 210 IV. Procedure A. EMT #1 gets behind the patient and brings the head into a neutral in-line position and provides manual immobilization. If this cannot be done from behind the patient, this will have to be done from the side. EMT #2 is positioned in the open doorway, and supports the patient's mid-thorax. EMT #1 and #2 bring the patient to an upright sitting position. B. A rapid assessment is performed and a cervical collar is applied. C. While the patient is being assessed, the long board is placed near the door. If the open door presents an obstacle to the EMTs working outside the car in the doorway, the door can be manually forced back-springing the hinges as far as possible. D. While EMT #1 maintains manual immobilization of the head and EMT #2 supports the mid-thorax, EMT #3 works from the passenger's seat to free the patient's legs from the pedals and prepares to move them. E. At EMT #2's command, he and EMT #3 begin to rotate the patient until his back faces the open doorway and his feet are brought up onto the passenger's seat. This usually takes three or four short moves. EMT #1 follows the rotation maintaining the neutral in-line positioning of the patient's head throughout. The rotation is coordinated with good voice commands by EMT #2, and is done in short moves which quickly follow each other. F. In many vehicles, EMT #1 will not be able to extend his arms far enough to complete the rotation from his original position. Either EMT #3 from the passenger's seat, or another EMT from outside the driver's door, will have to provide manual stabilization of the head when EMT #1 cannot complete the rotation. If EMT #3 does this, EMT #1 can get out of the car and re-position himself in the driver's doorway and re-take the manual immobilization. G. The rotation is completed when the patient's back is squarely facing the open doorway and his feet are on the passenger's seat. The rigid long spine board is now inserted on the car seat at the patient's buttock, and EMT #2 and the EMT holding the patient's head lower him onto the long board. Other EMTs, other responders, or bystanders are recruited to hold the board firmly in place. H. Once the patient's torso is down on the board, EMT #2 places his hands in the patient's armpits and EMT #3 positions himself to move the patient's legs and hips, and all prepare to slide the patient up the backboard. I. With the EMT at the head setting the pace, the patient is slid in 6-12 inch increments up the board until his hips are fully on the board. The EMT at the legs will have to move across the side of the car on the seat. Do not attempt to move the patient all the way in one step. Moving in increments, teamwork, and good communication are each necessary in order to move the patient as a unit without compressing or distracting the spine. J. When the patient's hips are on the board, EMT #3 (at the feet) can exit the car and come to the driver's door to assist in further moving the patient onto the Version 1.6 effective 7/1/2008

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Joseph Salomone, MD EMS Medical Director

SC 6.00 Spinal Immobilization Using Rapid Extrication Procedure 177 of 210 rigid long spine board. Frequently EMT #2 takes over responsibility for the hips and legs at this point, and EMT #3 takes over control of the upper torso. If additional EMTs are available, time can be saved by having one of them assume this position. With the EMT at the head now giving the orders, the patient is slid in 6-12 inch increments up the board until he is fully positioned on it. K. Once the patient is properly positioned on the rigid long spine board, and with the EMT at the head giving the commands, the patient and the board are lifted and moved away from the car. L. The patient is then secured to the rigid long spine board per procedure. V. Notes A. This procedure is largely borrowed with permission from the Prehospital Trauma Life Support Textbook, second edition. B. In the previous steps, exact roles and positioning of each of the three EMT's has been indicated. This only represents one sample, as very few field extrications are ideal. As long as the manual immobilization of the head is maintained without interruption and the spine is maintained in-line without unwanted movement, any positioning of the EMTs that works can be used. However, care should be taken to avoid numerous position changes and hand position take-overs, as they invite a lapse in immobilization. C. The rapid extrication technique can effectively provide manual in-line immobilization of the head, neck, and torso throughout the patient's removal from the vehicle. Three points are key: 1. At all times one EMT must immobilize the head, another must rotate and immobilize the torso, and a third must move and control the legs. 2. Second, in-line immobilization of the head and torso will be nearly impossible to maintain as the EMTs attempt to move the patient in one continuous motion. It is important to limit each movement, stopping to reposition and prepare for the next step. Undue speed will actually cause delay and may result in movement of the spine. 3. It has already been noted that many acceptable variations exist, and each is "right" as long as it follows the general principles for this maneuver. It is also important to note that each victim (body size) and each vehicle (design and body size) require some variation from others. 4. When a patient is found lying on the seat or floor of a car, or on the ceiling of an overturned car, a modified version of the rapid extrication technique can be used to provide manual immobilization while moving and sliding him directly onto the rigid long spine board. 5. Rapid extrication should be selected only when time is a factor, and not on the basis of personal preference.

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Joseph Salomone, MD EMS Medical Director

SC 6.00 Spinal Immobilization Using Rapid Extrication Procedure 178 of 210 VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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Joseph Salomone, MD EMS Medical Director

SC 7.00 Stifneck Cervical Collar Application Procedure 179 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. III. Precautions A. Do not rely on the cervical collar by itself to adequately immobilize a patient's cervical spine. Collars are tools to aid in immobilization. No collar by itself provides sufficient immobilization. B. Do not use an improperly sized collar. Too large a collar may hyperextend a patient's cervical spine; too small a collar may not provide appropriate stability. Special sizes of Stifneck collars are available for children and other individuals with small frames. IV. Procedure A. Sizing the collar 1. Proper sizing is critical for good patient care. Too short a collar may not provide enough support, while too tall a collar may hyperextend a patient. Use the tallest collar that does not hyperextend. The key dimension on a patient is the distance between an imaginary line drawn across the top of the shoulders, where the collar will sit, and the bottom plane of the patient's chin. 2. The key dimension on the collar is the distance between the sizing post (black fastener) and the lower edge of the rigid encircling band (not the foam padding). The importance of proper sizing is emphasized on each stifneck collar by a sticker pointing out the sizing post. 3. When the patient is being held in a neutral position, use your fingers to visually measure the distance from the shoulder to the chin (key dimension). 4. Then use your fingers to select the size of stifneck collar that most closely matches the key dimension of the patient. B. Assembly and Pre-forming 1. The collar is assembled by moving the black fastener (sizing post) at the end of the chin piece up the inside wall of the collar and then

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SC 7.00 Stifneck Cervical Collar Application Procedure 180 of 210 pushing the black fastener all the way into the small hole. Press firmly. 2. Flex the collar sharply inward until you can touch the hook section of the Velcro to the inner wall of the collar. This will pre-form the collar into a cylinder to simplify application. C. Application to the patient who is sitting or standing 1. With the patient's head held in neutral alignment, position the chin piece by sliding the collar up the chest wall. Be sure that the chin is well supported by the chin piece and that the chin extends far enough onto the chin piece to at least cover the central fastener. Difficulty in positioning the chin piece may indicate the need for a shorter collar. 2. Bring the rear of the collar around, and attach the Velcro. Re-check the position of the patient's head and collar for proper alignment. Make sure that the patient's chin at least covers the central fastener in the chin piece. If it doesn't, tighten the collar until proper support is obtained. Select the next smaller size if you think further tightening of the collar may cause the patient to become further extended. D. Application to the supine patient 1. If the patient is supine, begin by sliding the back portion of the collar behind the patient's neck. Be sure to fold the loop Velcro inward on top of the foam padding to prevent it from collecting debris that could limit its gripping ability. Once the loop Velcro is visible, turn all of your attention to positioning the chin piece and attaching the Velcro as previously described. 2. An alternative is to start by positioning the chin piece and then sliding the back portion of the collar behind the patient's neck. E. Final adjustment 1. Once positioned, hold the collar in place by using the trach hole. You can avoid torquing the neck by using the trach hole as an anchor point while pulling and attaching the loop Velcro so that it mates with, and is parallel to, the hook Velcro. 2. Be sure to maintain neutral alignment throughout this procedure. V. Notes A. This procedure is largely borrowed from the manufacturer's instructions for use. B. The most important steps of application are proper sizing and proper positioning of the chin piece.

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SC 7.00 Stifneck Cervical Collar Application Procedure 181 of 210 VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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Joseph Salomone, MD EMS Medical Director

SC 8.00 HeadBed II Cervical Immobilization Device Application Procedure 182 of 210 I. Indications A. Suspected C-Spine injury B. Suspected spinal injury C. To be used after the patient is fully immobilized on a rigid long spine board. II. Contraindications A. If careful movement of the head and neck into a neutral in-line position results in: 1. Neck muscle spasm 2. Increased pain 3. The commencement or increase of a neurological deficit such as numbness, tingling, or loss of motor ability 4. Compromise of the airway or ventilation B. In such patients, the patient's head will have to be immobilized in the position found. III. Precautions A. Manual immobilization of the head must be maintained until application is complete. B. Application pressure, surface condition, and temperature can affect the bond strength of the adhesive. The HeadBed is effective only when firmly attached to the rigid long spine board. If the HeadBed does not firmly attach to the rigid long spine board, alternative means of immobilization should be used. IV. Procedure A. Unfasten one end of the loop strap and center the HeadBed under the patient's head with the ears directly above the graphic ears on the HeadBed. Pad as necessary to maintain neutral alignment. B. Wrap the side panels up to contact the head just at the top of the ears. While maintaining neutral alignment, the rescuer holding the head repositions his fingers to hold both the head and the side panels. C. Apply the loop strap across the forehead above the eyebrows so that the side panels are held snugly to the patient's head. Press the strap firmly onto the hook fastener on both sides. D. Pull out both red tabs simultaneously to expose the adhesive on the underside of the device. Press firmly over the white areas to anchor the HeadBed to the rigid long spine board, then check that it is well adhered. E. Attach one end of the dual adhesive strap to the underside of the rigid long spine board. Be sure that the forehead is dry, and then position the strap so that it adheres to both the eyebrows and the loop strap. F. Secure the strap to the opposite side of the rigid long spine board, sticking any excess under the board. With the strap in place, application is complete and manual immobilization of the head may be released. G. Pull out the red tab at the occipital area to expose the occipital tab.

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Joseph Salomone, MD EMS Medical Director

SC 8.00 HeadBed II Cervical Immobilization Device Application Procedure 183 of 210 V. Notes A. This procedure is largely borrowed from the manufacturer's instructions for use. B. To avoid tangling the strap, peel the liner off as you go rather than all at once. C. Apply the straps snugly, but not so tightly as to cause patient discomfort. D. In wet conditions, a piece of tape placed directly over the dual adhesive strap and completely encircling the board may be appropriate. VI. Complications A. Moving a patient's head into the neutral position may rarely cause neurological complications. See Contraindications for this procedure. B. Immobilizing a patient on a rigid long spine board may rarely cause increased pain or possibly injury. If the patient complains of increased pain, careful evaluation should be done to see whether an alternative means of immobilization should be used. VII. Documentation A. Neurologic status before and after the procedure. B. Document the time the procedure was done.

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Joseph Salomone, MD EMS Medical Director

AB 15.05 Analgesic Medication Administration Procedure 184 of 210 INDICATIONS: I. The relief of moderate to severe acute pain in trauma patients with: A. Extremity injuries B. Shoulder / hip injury C. Burns without airway or respiratory compromise CONTRAINDICATIONS: I. Trauma A. Head injury B. Suspected spine injury (meets criteria for immobilization per spinal immobilization algorithm) C. Thoraco-abdominal trauma D. Meets trauma routing criteria (exception is burns without airway or respiratory compromise) II. Medical A. Respiratory distress or compromise (Asthma or COPD) B. Cardiac dysrhythmia present C. Altered mental status D. Undiagnosed acute abdominal conditions E. Pregnancy III. Drugs A. Drug / alcohol intoxication B. Sensitivity / allergy to opiates IV. Hypotension and suspected shock V. Age < 12 months PRECAUTIONS: N/A TECHNIQUE: I ­ 1 Follow appropriate protocol including: a. Complete vital signs b. Determine pain score c. Obtain brief history d. Assess cardiac, respiratory and neurologic systems I ­ 2 Establish that the patient meets the above indications. The patient's injuries must be treated prior to the administration of any pain medication I ­ 3 Apply cardiac monitor (paramedic interpret) I ­ 4 Apply pulse oximeter I ­ 5 Establish IV access Version 1.6 effective 7/1/2008

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AB 15.05 Analgesic Medication Administration Procedure 185 of 210 I ­ 6 If the patient maintains a. Systolic blood pressure above 100 mmHg AND b. Pulse rate > 50 and < 140 then consider: 1. Morphine sulfate 2 mg slow IV push q 5 minutes until pain is relieved or 10 mg has been given. For pediatric patients consider 0.05 mg/kg (maximum 2 mg). 2. (ORDERS) May repeat once with base station physician approval I ­ 7 Monitor vital signs and cardiac rhythm I ­ 8 Transport patient as indicated by primary condition, closely monitoring vital signs, respiratory effort, and level of consciousness I ­ 9 Naloxone (Narcan) may be used to reverse respiratory depression and hypotensive effects as needed and should be readily available COMPLICATIONS: N/A DOCUMENTATION REQUIREMENTS: I. II. III. IV. V. VI. VII. VIII. IX. X. XI. XII. Absence of contraindications IV* Oxygen administration Oxygen saturation levels EKG monitoring including paramedic interpretation* Drug, dose and timing of administration* Complete set of vital signs pre & post drug administration Neurovascular status of injured extremity, including reexamination if manipulated Pain scale using 0-10 scale, pre & post drug administration Base Station Physician authorizing administration Any complications Controlled substance sheet completed (green sheet)

*Required time stamp using Zoll monitor event markers NOTES: N/A

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Joseph Salomone, MD EMS Medical Director

AB 16.02 Procedural Sedation Procedure 186 of 210 INDICATIONS: Sedation for patients undergoing painful procedures (i.e., cardioversion) CONTRAINDICATIONS: I. Any known allergy to benzodiazepines II. Whether the patient is too unstable to delay the procedure for administration of analgesia III. The criteria for instability warranting emergent cardioversion (altered mental status, clinical signs of shock, severe respiratory distress, severe chest pain, cyanosis) are, in and of themselves, relative contraindications to the administration of midazolam A. When considering administering sedation prior to cardioversion, the risks and benefits of sedation must be weighed. (i.e., pain relief and amnesia for the event versus worsening of hypotension and/or respiratory depression) PRECAUTIONS: N/A TECHNIQUE: I ­ 1 Secure airway I ­ 2 Administer oxygen and assist ventilation as required I ­ 3 Apply cardiac monitor (paramedic interpret) I ­ 4 Apply pulse oximeter I ­ 5 Establish IV access I ­ 6 Administer Midazolam (Versed) 0.05 mg/kg slow IV push (maximum initial dose of 2.0 mg) a. Observe respirations, oxygen saturation and blood pressure i. If patient's oxygen saturation falls, administer additional oxygen and assist ventilations with appropriate airway adjuncts as needed ii. If the patient's blood pressure drops significantly, refer to the shock protocol b. (ORDERS) If sedation is inadequate after 2 minutes, contact medical control for additional dose i. If the procedure is to correct a life-threatening condition, do not wait 2 minutes before completing the procedure COMPLICATIONS: N/A

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AB 16.02 Procedural Sedation Procedure 187 of 210 DOCUMENTATION REQUIREMENTS: I. II. III. IV. V. VI. VII. VIII. IX. X. XI. Absence of contraindications Drug, dose and timing of administration* Effect on patient Any complications IV start* Oxygen administration Oxygen saturation readings EKG monitoring* Complete set of vital signs pre & post sedation Any BSP approving use Controlled substance sheet (green sheet) completion

*Required time stamp using Zoll monitor event markers NOTES: N/A

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D 1.02 Naloxone HCl (Narcan) 188 of 210 I. Pharmacology and Actions: A. Naloxone is a narcotic antagonist which blocks narcotic effects by occupying, without activating, narcotic receptor sites. The duration of action is 20 to 60 minutes. II. Indications: A. Used for the reversal of narcotic effects, especially respiratory depression, due to overdose of narcotic drugs by any route. B. Used diagnostically in coma of unknown etiology to rule out (or reverse) narcotic depression. III. Contraindications: N/A IV. Precautions: A. AIRWAY AND VENTILATION ALWAYS TAKE PRIORITY OVER AN IV AND NALOXONE. B. In appropriate clinical situations (i.e. a known or suspected narcotics abuser) it may be advisable to restrain the patient prior to administering Naloxone. C. In patients who are physically dependent on narcotics, withdrawal symptoms may be precipitated. V. Administration: A. For specific doses refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), intraosseous (IO), endotrachael (ET), subcutaneous (SQ), or intramuscular (IM) or intranasal (IN). VI. Special Considerations: A. The duration of action of Naloxone is shorter than many narcotics and so the patient must be monitored closely for return of CNS or respiratory depression. Patients who receive this drug must be transported. B. Very large doses may be needed to reverse some narcotics (i.e. propoxypheneDarvon; pentazocine-Talwin).

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Joseph Salomone, MD EMS Medical Director

D 2.01 Glucose (Dextrose) 189 of 210 I. Pharmacology and Actions: A. Glucose is the major metabolic substrate for energy metabolism. Although all tissues need glucose, the brain is particularly sensitive to low glucose levels. Glucose specifically reverses hypoglycemia. II. Indications: A. Confirmed hypoglycemia with a rapid bedside glucose test. B. Suspected hypoglycemia as manifested by altered mental status (including apparent drug or alcohol use, seizure or post ictal state) or coma. C. See IV B III. Contraindications: N/A IV. Precautions: A. Extravasation of glucose will cause skin necrosis. The IV should be secure and the free return of blood should be checked once or twice during administration. If extravasation does occur, immediately stop administration. Notify the ED staff upon arrival of possible glucose extravasation. B. High glucose levels have been associated with worsened neurologic outcomes of patients with stroke, cardiac arrest and low perfusion states. When these states exist, it is preferable to only administer glucose after hypoglycemia has been documented by a rapid bedside glucose test. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV) and intraosseous (IO). C. PALS recommends in cardiac arrest or low perfusion states, the D25W should be administered over 10 minutes. VI. Special Considerations: A. Consider oral glucose if mental status permits its use. B. One bolus should raise the blood sugar by 100-200 mg%.

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Joseph Salomone, MD EMS Medical Director

D 3.02 Oxygen (O2) 190 of 210 I. Pharmacology and Actions: A. Oxygen is necessary for normal cellular energy production. Tissue hypoxia leads to cellular damage and death. Supplemental oxygen should raise blood oxygen levels and should improve tissue hypoxia. B. In normal individuals, breathing is regulated by changes in blood carbon dioxide levels. There must be a large decrease in blood oxygen to stimulate breathing. II. Indications: A. Suspected hypoxemia or respiratory distress of any kind. B. Acute chest pain. C. Shock. D. Major Trauma. E. All acutely ill patients III. Contraindications: N/A IV. Precautions: A. Supplemental oxygen does nothing for ventilation. Insure adequate ventilation. B. A small percent of patients with COPD breathe because they are hypoxic. Supplemental oxygen may depress ventilation in these patients. Therefore, the COPD patient should generally be given low doses of oxygen. However, adequate oxygen therapy should not be withheld due to this concern. Hypoventilation can be avoided by coaching the patient or actively ventilating with BVM or per ET tube. C. Whenever practical, humidified oxygen should be provided (e.g. asthmatics and infants). Non-humidified oxygen promotes heat loss via the airway, thickens secretions, and is drying to the mucous membranes. V. Administration: A. For specific flow rates and routes, refer to the applicable protocol. B. Acceptable routes of administration include nasal cannula, mask, bag-valve device, and nebulization devices. VI. Special Considerations: A. Restlessness may be a sign of hypoxia. B. Oxygen toxicity is not a concern in the field. C. Some patients tolerate one modality (i.e. mask or nasal cannula) better than another. Use your best judgment. D. Nasal cannulas also work on "mouth breathers".

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D 5.01 Diazepam (Valium) 191 of 210 I. Pharmacology and Actions: A. Diazepam acts as a sedative, anticonvulsant, muscle relaxant and an amnesic agent. II. Indications: A. Repetitive seizures B. Any single seizure lasting greater than 15 minutes. C. Any single seizure associated with respiratory depression. D. For sedation/amnesia in association with cardioversion in the awake patient. III. Contraindications: N/A IV. Precautions: A. Respiratory depression and/or hypotension are potential complications. B. The patient's blood pressure, pulse, and respirations should be closely monitored. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), and rectal (PR). VI. Special Considerations: A. IM administration is not appropriate due to erratic absorption. B. Do not mix with other agents. Turn off IV flow and administer through IV port closest to patient's vein.

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D 8.01 Diphenhydramine (Benadryl) 192 of 210 I. Pharmacology and Actions: A. Diphenhydramine is an antihistamine which competitively blocks H-1 histamine receptors. Histamine can cause bronchoconstriction, vasodilation and capillary leak. It also has some anticholinergic (atropine-like) effects as well as direct CNS depressant effects. II. Indications: A. Anaphylaxis 1. Mild anaphylaxis 2. Anaphylaxis with respiratory distress 3. Anaphylactic shock B. Dystonic reaction III. Contraindications: N/A IV. Precautions: A. In anaphylaxis, oxygen, epinephrine, fluids, and albuterol should be utilized prior to administration of diphenhydramine. B. Diphenhydramine causes sedation. C. Due to anticholinergic effects, use with caution in patients with glaucoma, prostatism, or peptic ulcer disease. D. Hypotension or hypertension may occur after IV use. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), intraosseous (IO), and intramuscular (IM). VI. Special Considerations: N/A

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D 9.01 Albuterol (Proventil) 193 of 210 I. Pharmacology and Actions: A. Albuterol is a relatively selective Beta-2 agonist which increases intracellular cyclic AMP causing reduced myoplasmic Ca++ and therefore smooth muscle relaxation and bronchodilation. Albuterol also has some Beta-1 agonist activity which can increase myocardial contractility, irritability (arrhythmogenic), and rate. II. Indications: A. Bronchospasm due to any etiology including: asthma, COPD, allergic reactions, and pulmonary infections. III. Contraindications: N/A IV. Precautions: A. Do not neglect more basic maneuvers such as O2, appropriate airway control (including intubation), and appropriate ventilation (including BVM). B. Use with caution (i.e. close monitoring of vital signs, patient condition, and EKG monitor) in patients with coronary artery disease, dysrhythmias, hypertension, prior recent beta adrenergic drug use, monamine oxidase inhibitor use, or tricyclic antidepressant use. C. Albuterol may lower the serum potassium level. D. Albuterol may exacerbate congestive heart failure. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include nebulizer and metered dose inhaler (MDI). VI. Special Considerations: A. Tremors, nervousness, nausea, vomiting and cardiac irritability may be manifest and may warrant termination of treatment.

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2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 11.01 Adenosine (Adenocard) 194 of 210 I. Pharmacology and Actions: A. Adenosine is an endogenous nucleoside present in all cells of the body. Cardiac effects of adenosine include: slowing conduction through AV node, and coronary and peripheral vasodilation. The half life is less than 10 seconds due to cellular uptake and metabolism. II. Indications: A. Regular rhythm narrow complex tachycardia > 150 BPM in adults or > 220 BPM in pediatrics. If the cardiac rate is less than the designated criteria rate, consider other etiologies and contact a base station physician to discuss etiology and treatment. 1. Unstable patient - the standard treatment is emergent cardioversion. Adenosine may be indicated while setting up to sedate and cardiovert the patient. 2. Stable patient - only supportive care is necessary for the asymptomatic patient. Many patients have symptoms and yet are not truly unstable. Adenosine may be indicated in this subset of patients with base station approval. B. Wide complex tachycardia > 150 BPM in which the etiology is uncertain and IV lidocaine trials are ineffective. III. Contraindications: A. Patients with an allergy to adenosine IV. Precautions: A. May produce transient first, second or third degree AV blocks or asystole. B. May cause bronchospasm in asthma patients. C. Effects are antagonized by methylxanthines (caffeine, theophylline). D. Effects are potentiated by dipyridamole (Persantine) and carbamazepine (Tegretol). V. Administration: A. Establish an IV as close to the core as is practical (e.g. antecubital vein). Administer by rapid IV bolus at injection port closest to patient and follow by a saline flush. B. For specific doses, refer to the applicable protocol. C. Only acceptable route of administration is intravenous (IV). VI. Special Considerations: A. Is not effective in: 1. sinus tachycardia 2. Atrial fibrillation Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 11.01 Adenosine (Adenocard) 195 of 210 3. atrial flutter 4. ventricular tachycardia B. Frequent, transient side effects include: 1. facial flushing 2. dyspnea 3. chest pressure 4. nausea 5. headache 6. light headedness.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 12.00 Epinephrine 196 of 210 I. Pharmacology and Actions: A. Epinephrine is a natural catecholamine that acts to stimulate sympathetic (i.e., fight or flight) activity. Accordingly this exhibits an increase in blood pressure, coronary blood flow, cardiac electrical activity, heart rate, strength of contraction and broncho-dilatation. Epinephrine also makes ventricular fibrillation more susceptible to defibrillation. II. Indications: A. Used in cardiac arrest protocol for ventricular fibrillation, pulseless ventricular tachycardia, asystole, bradycardia, and pulseless electrical activity. B. Used to treat severe bronchospasm or laryngospasm as seen in asthma and anaphylaxis. III. Contraindications: N/A IV. Precautions: A. Epinephrine should be used with caution in patients with suspected myocardial ischemia, history of coronary artery disease, or age greater than 50. B. In patients greater than 50 years of age, the role of epinephrine in asthma is controversial. C. In patients taking digitalis, epinephrine may exacerbate ventricular ectopy. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include subcutaneous (SQ), intravenous (IV), intraosseous (IO), and endotracheal (ET). The sublingual venous plexus may be utilized as a site in anaphylactic shock. VI. Special Considerations: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 13.00 Atropine 197 of 210 I. Pharmacology and Actions: A. Atropine is vagolytic and therefore increases heart rate and electrical conduction within the heart. II. Indications: A. Used in cardiac resuscitation of symptomatic bradycardia and asystole. III. Contraindications: N/A IV. Precautions: A. Atropine may induce tachycardia; therefore, it should be used with caution in patients with coronary artery disease or ongoing myocardial ischemia. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), intraosseous (IO), and endotracheal (ET). VI. Special Considerations: A. Ventricular fibrillation has occurred after IV administration of atropine. B. Excessive doses of atropine may cause delirium, ataxia, blurred vision, tachycardia or coma. C. Atropine may be useful in the treatment of organophosphate poisoning.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 14.00 Lidocaine 198 of 210 I. Pharmacology and Actions: A. Lidocaine functions to decrease the amount of electrical activity in the heart and increase the heart's threshold for ventricular fibrillation. II. Indications: A. Used in cardiac resuscitation after delivering a full set of countershocks and epinephrine for ventricular fibrillation, and pulseless ventricular tachycardia. B. Used in cardiac resuscitation of wide complex tachycardia and for suppression of ventricular ectopy. III. Contraindications: N/A IV. Precautions: A. Large doses of lidocaine may induce heart block and alter heart conduction. B. Excessive doses of lidocaine can cause neurologic changes (seizures, mental status changes), myocardial depression and circulatory collapse. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), intraosseous (IO), and endotracheal (ET). VI. Special Considerations: A. If the patient is successfully converted from ventricular fibrillation or ventricular tachycardia to a perfusing rhythm, a lidocaine bolus followed by a drip should be administered.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 15.01 Nitroglycerin 199 of 210 I. Pharmacology and Actions: A. Nitroglycerin functions to dilate smooth muscle within arteries and veins. Consequently, this decreases the work of the heart, increases blood supply to cardiac tissue and lowers blood pressure. II. Indications: A. Used to treat chest pain of cardiac origin B. Used to treat congestive heart failure with pulmonary edema. III. Contraindications: A. VIAGRA TM has been shown to potentiate the hypotensive effects of nitrates. B. The administration of an organic nitrate within 24 hours of taking VIAGRA TM is contraindicated. IV. Precautions: A. Because of nitroglycerin's tendency to lower blood pressure, it should be given with caution. Vitals signs are to be monitored. B. Patients should expect a headache after taking a nitroglycerin. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include sublingual (SL) for tablets, and cutaneous for the 2% ointment. VI. Special Considerations: A. Patients being treated with nitroglycerin should be on a monitor and have an IV in place. B. Sublingual nitroglycerin should produce a "fizzing" effect when placed under the tongue. If the "fizzing" is not present, the nitroglycerin may not be effective.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 16.00 Furosemide (Lasix) 200 of 210 I. Pharmacology and Actions: A. Furosemide is a diuretic that functions to increase the production of urine thereby decreasing the amount of fluid in the cardiovascular system. II. Indications: A. Used for the emergency treatment of acute pulmonary edema. III. Contraindications: N/A IV. Precautions: A. Dehydration and hypotension can result from the high doses of furosemide. B. Furosemide is a sulfonamide derivative and should be used with caution in patients with sulfa allergies. C. Rapid administration of furosemide can cause permanent hearing loss. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration per protocol is only intravenous (IV). VI. Special Considerations: A. In patients with renal insufficiency or failure, furosemide may not produce any noticeable increased urine output, but may be useful through its vasodilatory effect. B. In patients who use furosemide chronically, very large doses may be required to obtain the desired effect.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 18.00 Calcium Chloride 201 of 210 I. Pharmacology and Actions: A. Calcium increases myocardial contractile function. B. Calcium has a myocardial cellular membrane stabilizing effect with hyperkalemia. II. Indications: A. Known or suspected hyperkalemia B. Known or suspected hypocalcemia C. As an antidote for toxicity from calcium channel blocker overdose III. Contraindications: N/A IV. Precautions: A. Use with caution in patients receiving digitalis (digoxin) because of the increased ventricular irritability associated with digitalis toxicity. B. Calcium chloride will precipitate when mixed with sodium bicarbonate. C. Extravasation of calcium chloride can result in tissue necrosis. D. Calcium chloride is not routinely used as a first line cardiac arrest drug. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), and intraosseous (IO). VI. Special Considerations: A. Calcium chloride may be useful in the treatment of calcium channel blocker overdoses.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 19.00 Dopamine 202 of 210 I. Pharmacology and Actions: A. Dopamine is a precursor of norepinephrine that stimulates dopaminergic, beta 1 adrenergic, and alpha adrenergic receptors in a dose dependent fashion. B. There is a substantial variability to drug effect, so titrate to hemodynamic effect desired. II. Indications: A. Consider for the treatment of shock after adequate volume resuscitation has been performed. III. Contraindications: N/A IV. Precautions: A. Extravasation of dopamine may produces tissue necrosis. B. Relative contraindications of dopamine are pulmonary congestion and increased vascular resistance. C. Dopamine should never mix with sodium bicarbonate because it is inactivated in the alkaline pH. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), and intraosseous (IO). VI. Special Considerations: A. Low dose (1 to 5 mcg/kg/min) stimulates dopaminergic receptors to produce cerebral, renal and mesenteric vasodilatation. B. Medium dose (5 to 15 mcg/kg/min) stimulates beta 1 receptors greater than alpha or dopaminergic receptors to enhance cardiac output with only modest increases in systemic vascular resistance. C. High dose (greater than 15 mcg/kg/min) stimulates alpha receptors greater than beta 1 or dopaminergic receptors to produce renal, mesenteric, peripheral arterial and venous vasoconstriction

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 20.00 Sodium Bicarbonate 203 of 210 I. Pharmacology and Actions: A. Sodium bicarbonate serves as a buffer for acidosis. B. H+ + HCO3- = H2CO3 = H2O + CO2 II. Indications: A. Known or suspected hyperkalemia B. Known or suspected tricyclic antidepressant overdose C. Considered during CPR only after adequate ventilation and chest compressions are insured. The patient should be intubated and there should exist a continued cardiac arrest interval during which defibrillations, epinephrine, and lidocaine have been utilized. III. Contraindications: N/A IV. Precautions: A. Administration of sodium bicarbonate rapidly generates carbon dioxide which can result in tissue and cerebrospinal fluid acidosis. B. Sodium bicarbonate is not recommended for routine use in cardiac arrest patients. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include intravenous (IV), and intraosseous (IO). VI. Special Considerations: A. Sodium bicarbonate may be useful in the treatment of tricyclic antidepressant overdose. B. Adequate ventilation is a major buffering agent and is essential prior to the administration of sodium bicarbonate.

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 22.01 Midazolam (Versed) 204 of 210 I. Pharmacology and Actions: A. Midazolam is a water soluble, short acting sedative with muscle relaxing and amnesic properties similar to diazepam (Valium). B. Its relatively short duration of action makes it the drug of choice for sedation when prolonged effects are not needed or wanted. C. Midazolam given intranasally (IN) has been shown to be safe and effective for the management of acute seizures in pediatric patients II. Indications: A. Intranasal administration in seizure patients with no IV established B. Sedation and amnesia prior to performing painful procedures, e.g. cardioversion. C. Chemical restraint. III. Contraindications: N/A IV. Precautions: A. Respiratory depression and/or hypotension are potential complications. B. The patient's respiratory status should be monitored closely when using midazolam. C. Pulse oximetry is mandatory to monitor the patient's oxygen saturation. D. Cardiac monitoring accompanied by frequent blood pressure checks are mandatory. V. Administration: A. For specific doses, refer to the applicable protocol. B. May be administered IV, IM or intranasal (IN). VI. Special Considerations: A. Airway support equipment and IV fluids must be readied for use prior to the administration of midazolam (with exception of pediatric seizures) in the event that blood pressure and ventilatory support are required

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 23.00 Aspirin 205 of 210 I. Pharmacology and Actions: A. Aspirin has been proven to reduce mortality and re-infarction rates in myocardial infarction by altering platelet function and prolonging bleeding time. This is not an anticoagulant and does not effect the clotting cascade. II. Indications: A. Use in patients with chest pain considered to be of cardiac ischemic origin. III. Contraindications: A. Patients with known allergies to aspirin or nonsteroidal anti-inflammatory drugs. (e.g. ibuprofen, ketoprofen, naprosyn, or relafen) B. Patients with a history of asthma. IV. Precautions: N/A V. Administration: A. For specific doses refer to the applicable protocol. B. Route of administration is oral (PO); chewed or swallowed. VI. Special Considerations: N/A

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 24.00 Ipratroprium Bromide (Atrovent) 206 of 210 I. Pharmacology and Actions: A. Atrovent is chemically related to Atropine, but has minimal systemic absorption in the inhaled form. Atrovent causes bronchodilation without the anticholinergic side effects of Atropine. II. Indications: A. Bronchospasm in patients with emphysema or chronic bronchitis. III. Contraindications: N/A IV. Precautions: A. Do not neglect more basic maneuvers such as oxygen, airway control and proper ventilation. B. Generally considered safe but is controversial in patients with asthma. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include nebulizer only VI. Special Considerations: A. None

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 25.00 Phenylephrine (Neosynephrine) 207 of 210 I. Pharmacology and Actions: A. Phenylephrine is a purely alpha-adrenergic agonist with most of the side effects of epinephrine. However, in the lower concentrations (0.5%), topical administration is rarely associated with severe reactions. II. Indications: A. Vasoconstriction of the nasal mucosa in preparation for nasal intubation. III. Contraindications: N/A IV. Precautions: A. Do not spray repeatedly or excessively. B. A pronounced increase in blood pressure may rarely occur in elderly patients. V. Administration: A. For specific doses, refer to the applicable protocol. B. Acceptable routes of administration include nasal spray only. VI. Special considerations: A. Avoid the eyes as this will result in pupillary dilatation.

Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 26.01 Morphine Sulfate 208 of 210 I. Pharmacology and Actions: A. Acts as an opiate agonist B. Alters the patient's perception of pain and acts as an analgesic by stimulating opiate receptor sites C. Produces venous vasodilation II. Indications: A. The relief of moderate to severe acute pain in some trauma patients with: 1. Extremity injuries 2. Shoulder / Hip injury 3. Burns without airway or respiratory compromise B. As an analgesic in patients with ischemic chest pain C. As an adjunct in the treatment of pulmonary edema III. Contraindications: A. Trauma 1. Head injury 2. Suspected spine injury (meets criteria for immobilization per spinal immobilization algorithm) 3. Thoraco-abdominal trauma 4. Meets trauma routing criteria (exception is burns without airway or respiratory compromise) B. Systems 1. Respiratory distress or compromise (Asthma or COPD) 2. Cardiac dysrhythmia present 3. Altered mental status 4. Undiagnosed acute abdominal conditions 5. Pregnancy C. Drugs 1. Drug/alcohol intoxication 2. Sensitivity/allergy to Morphine D. Hypotension and suspected shock E. Age less than 12 months IV. Precautions: A. This drug causes decreased respiratory drive, and as such should only be given while monitoring pulse oximetry and closely monitoring respiratory status. B. Overdose and side effects can be countered by the administration of naloxone. C. This drug may cause hypotension and direct myocardial depression, monitor vital signs closely. D. Other precautions as listed in other applicable protocols. Version 1.6 effective 7/1/2008

Office of the EMS Medical Director Emergency Medical Services

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Joseph Salomone, MD EMS Medical Director

D 26.01 Morphine Sulfate 209 of 210

V. Administration: A. For specific doses, refer to applicable protocol. B. May be administered IV only. VI. Special Considerations: N/A

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Office of the EMS Medical Director Emergency Medical Services

2400 Troost Avenue, Suite 4200, Kansas City, Missouri 64108 Voice: (816) 513-6262 Fax: (816) 513-6294

Joseph Salomone, MD EMS Medical Director

D 27.01 Glucagon 210 of 210 I. Pharmacology and Actions: A. Glucagon is a hormone secreted by the pancreas. Administration raises blood glucose levels by causing the breakdown of hepatic glycogen stores into glucose. Glucagon also decreases gut motility. Exogenous administration can also stimulate catecholamine release. II. Indications: A. Symptomatic hypoglycemia, confirmed with a rapid bedside glucose test, when IV access is unobtainable. IV access unobtainable means the paramedic is unable to start an IV in less than or equal to 3 attempts or if the paramedic judges IV attempts to be unlikely to be successful due to anatomic or other considerations. (i.e. history of difficult access, morbid obesity, etc.) III. Contraindications: A. Known hypersensitivity to glucagon. B. Known adrenal gland tumor such as pheochromocytoma (due to extreme hypertension from possible catecholamine release). IV. Precautions: A. Glucagon is only effective if there are sufficient stores of glycogen within the liver. B. Supplemental glucose should be given to prevent secondary hypoglycemia as soon as the patient is conscious and able to tolerate oral administration. C. Although side effects are rare, glucagon can cause nausea, and vomiting. V. Administration: A. For specific doses, refer to the applicable protocol. B. The acceptable route of administration is intramuscular (IM). Subcutaneous (SQ) is also safe, but IM injection should have a faster onset of action. VI. Special Considerations: A. Consider oral glucose if mental status permits its use. B. Return to consciousness following the administration of glucagon usually takes from 5 to 20 minutes

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