1. health and fitness
2. disease

2014
Advanced Life Support
ALS Field Treatment Manual
San Joaquin County
EMS Agency
ALS Radio Report Format
Initial MCI Report
1.
2.
3.
4.
5.
6.
7.
8.
Confirm or cancel the MCI
Alert
Location of incident
Name of incident, e.g.
Blackjack Incident
MCI position title, e.g.
Blackjack Medical Group
Supervisor
Incident Type:
a. Trauma
b. Medical
c. Hazmat
Approximate number of
patients
Estimated time triage will be
complete
Second MCI Report
Total number of patients and
their triage categories:
a. Immediate
1) Adult.
2) Pediatric.
b. Delayed.
c. Minor.
Advisory Report to a
Receiving Hospital
Base Hospital Report/ALS
Consultation Report
1. Unit ID.
2. Name and level (EMT or
paramedic) of person
making report.
3. Trauma, MCI, STEMI or
Stroke Alert, if indicated.
4. Transport Code 2 or 3.
5. Patient age, gender,
weight(s).
6. Chief complaint.
7. History of incident.
8. Trauma Triage Criteria met
(if applicable).
9. Pertinent medical history.
10. Pertinent medications.
11. Vital signs to include: blood
pressure, pulse, respirations,
pulse oximetry.
12. Level of Consciousness
13. Treatment provided
14. Patient response to
treatment.
15. Estimated time of arrival to
receiving hospital
1. Unit ID.
2. Name and level (EMT or
paramedic) of person seeking
orders.
3. Request for
consultation/orders needed
(State reason for calling)
4. Trauma, MCI, STEMI or
Stroke Alert, if indicated
5. Transport Code 2 or 3.
6. Patient age, gender, weight.
7. Chief Complaint.
8. History of incident.
9. Trauma Triage Criteria met (if
applicable).
10. Patient Condition (e.g. stable,
improving, worsening).
11. Vital Signs to include: blood
pressure, pulse, respirations,
pulse oximetry and Glasgow
Coma Scale (best eye, motor,
and verbal)
12. Interventions:
a. BLS Treatment rendered
and patient response.
b. ALS Standing Orders
implemented and patient
response.
13. Primary survey (LOC, skin
signs).
14. Secondary Physical Exam.
15. Past medical history/PMD.
16. Medications/allergies.
17. Estimated time of arrival to
receiving hospital.
Note: Patient transport should
begin as soon as any
immediate patient(s) are ready
for transport and destinations
are determined by Control
Facility or standing orders.
Don’t delay transport of
immediate patients waiting for
destinations for all patients
May Receive Prehospital Report:
MICN or Base Physician ONLY!
May Receive Prehospital
Report:
Any Receiving Hospital
Medical Personnel
May Receive Prehospital Report:
MICN or Base Physician ONLY!
_________________________San Joaquin County EMS Agency
San Joaquin County
Emergency Medical Services
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_________________________San Joaquin County EMS Agency
San Joaquin County Emergency Medical Services Agency ALS Field
Manual
Table of Contents
ADULT ADVANCED LIFE SUPPORT TREATMENT POLICIES ...................................................... 1
5700 - ALS TREATMENT POLICIES – INTRODUCTION ................................................................................. 2
5701 - ROUTINE ALS CARE ........................................................................................................................ 4
5702 - ALS ADVANCED AIRWAY MANAGEMENT ....................................................................................... 5
5704 - ALS PATIENT ASSESSMENT – PRIMARY SURVEY ...........................................................................10
5705 - ALS PATIENT ASSESSMENT - SECONDARY SURVEY .......................................................................14
5707 - ALS ADULT PAIN MANAGEMENT...................................................................................................18
5710 - ALS MEDICAL CARDIAC ARREST...................................................................................................20
5710A - ALS MEDICAL CARDIAC ARREST - PIT CREW APPENDIX A ........................................................25
5711 - ALS VENTRICULAR FIBRILLATION/PULSELESS VTACH .................................................................29
5712 - ALS WIDE COMPLEX TACHYCARDIA WITH A PULSE ......................................................................31
5713 - ALS NARROW COMPLEX TACHYCARDIA; AFIB/AFLUTTER ...........................................................32
5714 - ALS NARROW COMPLEX TACHYCARDIA; SVT ..............................................................................33
5715 - ALS ASYSTOLE ..............................................................................................................................35
5716 - ALS PULSELESS ELECTRICAL ACTIVITY (PEA) .............................................................................36
5717 - ALS BRADYCARDIA .......................................................................................................................37
5719 - ALS CHEST PAIN ............................................................................................................................39
5720 - ALS CARDIOGENIC SHOCK.............................................................................................................41
5724 - ALS VENTRICULAR ECTOPY ..........................................................................................................42
5726 - ALS RETURN OF SPONTANEOUS CIRCULATION ..............................................................................43
5727 - ALS THERAPEUTIC HYPOTHERMIA ................................................................................................44
5731 - ALS ALLERGIC REACTION/ANAPHYLAXIS .....................................................................................46
5733 - ALS POISONING/OVERDOSE ...........................................................................................................48
5735 - ALS HEAT ILLNESS ........................................................................................................................51
5736 - ALS HYPOTHERMIA .......................................................................................................................52
5738 - ALS ENVENOMATION .....................................................................................................................53
5751 - ALS ALTERED LEVEL OF CONSCIOUSNESS (ALOC) ......................................................................54
5753 - ALS SEIZURES ................................................................................................................................56
5754 - ALS ACUTE STROKE ......................................................................................................................58
5761 - ALS GYNECOLOGICAL EMERGENCIES ............................................................................................59
5764 - ALS CHILDBIRTH ...........................................................................................................................62
5771 - ALS BRONCHOSPASM ....................................................................................................................65
5772 - ALS ACUTE PULMONARY EDEMA ..................................................................................................66
5774 - ALS AIRWAY OBSTRUCTION ..........................................................................................................67
5782 - ALS BURN CARE ............................................................................................................................68
5783 - ALS ADULT TRAUMA TREATMENT ................................................................................................69
5790 - ALS NERVE AGENT EXPOSURE ......................................................................................................72
PEDIATRIC ADVANCED LIFE SUPPORT TREATMENT POLICIES.............................................77
5800 - PEDIATRIC ROUTINE MEDICAL CARE .............................................................................................78
5810 - PEDIATRIC PULSELESS ARREST: ASYSTOLE/PEA ...........................................................................80
5811 - PEDIATRIC PULSELESS ARREST: VENTRICULAR FIBRILLATION/VENTRICULAR TACHYCARDIA ......81
5812 - PEDIATRIC BRADYCARDIA..............................................................................................................83
5813 - PEDIATRIC TACHYCARDIA WITH PULSES ........................................................................................84
5815 - PEDIATRIC APPARENT LIFE THREATENING EVENT .........................................................................86
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_________________________San Joaquin County EMS Agency
5817 - PEDIATRIC AIRWAY OBSTRUCTION BY FOREIGN BODY ..................................................................87
5819 - PEDIATRIC RESPIRATORY DISTRESS: STRIDOR ...............................................................................88
5820 - PEDIATRIC RESPIRATORY DISTRESS: BRONCHOSPASM ...................................................................89
5824 - PEDIATRIC SHOCK ..........................................................................................................................91
5826 - PEDIATRIC ALLERGIC REACTION ....................................................................................................92
5828 - PEDIATRIC SEIZURE ........................................................................................................................94
5829 - PEDIATRIC ALTERED LEVEL OF CONSCIOUSNESS ...........................................................................95
5830 - PEDIATRIC POISONING/OVERDOSE .................................................................................................97
5837 - PEDIATRIC BURNS ........................................................................................................................100
5839 - PEDIATRIC PAIN MANAGEMENT ...................................................................................................101
5850 - NEONATAL RESUSCITATION .........................................................................................................104
ADVANCED LIFE SUPPORT SKILLS POLICIES AND INTERFACILITY TRANSFER
MEDICATION POLICIES ......................................................................................................................107
2541- PARAMEDIC INFREQUENTLY USED SKILLS ....................................................................................108
2544 – INTRAOSSEOUS CANNULATION – EZ-IO ......................................................................................110
2545 – ENDOTRACHEAL INTUBATION – ADULT PERFORMANCE CRITERIA ..............................................114
2546 – INTRAOSSEOUS CANNULATION - MANUAL ..................................................................................118
2547 – TRANSCUTANEOUS PACING PERFORMANCE CRITERIA .................................................................120
2548 – NEEDLE THORACOSTOMY PERFORMANCE CRITERIA ...................................................................122
2549 – NEEDLE CRICOTHYROTOMY TRANSLARYNGEAL JET VENTILATOR..............................................124
2550 – NASO/OROGASTRIC INTUBATION PERFORMANCE CRITERIA ........................................................126
2551 – 12 LEAD ECG PERFORMANCE CRITERIA .....................................................................................129
2552 – KING AIRWAY PERFORMANCE CRITERIA .....................................................................................131
2553 – ENDOTRACHEAL INTUBATION – PEDIATRIC PERFORMANCE CRITERIA ........................................134
2554 – CONTINUOUS POSITIVE AIRWAY PRESSURE (CPAP) PERFORMANCE CRITERIA ...........................137
2555 – NASOTRACHEAL INTUBATION – ADULT PERFORMANCE CRITERIA ..............................................139
2560 – PARAMEDIC SCOPE OF PRACTICE .................................................................................................145
5952 - MONITORING AN INFUSION WITH POTASSIUM CHLORIDE .............................................................149
5954 - MONITORING AN INFUSION OF HEPARIN .......................................................................................153
5955 - MONITORING AN INTRAVENOUS INFUSION OF NITROGLYCERIN ...................................................157
RELATED POLICIES ..............................................................................................................................163
5001 - AUTHORITY FOR MEDICAL EMERGENCY MANAGEMENT ..............................................................164
5103 - DETERMINATION OF DEATH IN THE FIELD ....................................................................................166
5105 - DO NOT RESUSCITATE ORDERS ....................................................................................................170
5106 - INTERACTION WITH PHYSICIAN OR OTHER HEALTH CARE PROVIDER ON SCENE .........................172
5106A - NOTE TO PHYSICIAN ON INVOLVEMENT WITH EMT-PS .............................................................175
5107 - USE OF RESTRAINTS .....................................................................................................................176
5108 - CARE OF MINORS IN THE FIELD ....................................................................................................180
5110 - ANATOMICAL DONOR CARDS .......................................................................................................183
5115 – CERVICAL SPINE IMMOBILIZATION ..............................................................................................185
5130 - ALS WITHOUT BASE HOSPITAL CONTACT ...................................................................................189
5130A - ALS WITHOUT BASE HOSPITAL CONTACT REPORT .....................................................191
5201 – MEDICAL PATIENT DESTINATION ................................................................................................193
5201A – MEDICAL PATIENT DESTINATION GROUND AMBULANCE ESTIMATE OF DRIVING TIME AND
DISTANCE ................................................................................................................................................199
5210 – MAJOR TRAUMA TRIAGE CRITERIA .............................................................................................202
5215 – TRAUMA PATIENT DESTINATION .................................................................................................205
GROUND AMBULANCE TRANSPORT (TIMES/DISTANCE) ...........................................................................210
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_________________________San Joaquin County EMS Agency
SAN JOAQUIN COUNTY
EMERGENCY MEDICAL SERVICES
Adult Advanced Life Support Treatment Policies
San Joaquin County
Emergency Medical Services
Page 1 of 216
ALS Treatment Policies – Introduction
EMS Policy No. 5700
Approved: January 1, 2010
Supersedes: September 1, 2007
5700 - ALS Treatment Policies – Introduction
INTRODUCTION
I. The Advanced Life Support (ALS) treatment Policies for adults and
pediatrics approved by the Medical Director of the San Joaquin
County EMS Agency directs the delivery of advanced life support
(ALS) by licensed Paramedics accredited to practice in San
Joaquin County. The ALS treatment Policies are the accredited
paramedic’s written orders authorizing the practice of ALS for
specific patient conditions. All prehospital personnel are required
to operate within their respective scope of practice. Accredited
paramedics are expected to have a mastery of the ALS Treatment
Policies, Basic Life Support (BLS) treatment Policies and all other
San Joaquin County EMS Policies governing the delivery of
emergency medical services in the field care setting.
II. The ALS treatment Policies are to be used in concert with sound
medical judgment. Unusual patient presentations make it
impossible to develop a specific policy for every possible patient
presentation. Paramedics should avail themselves of the
opportunity to consult with a mobile intensive care nurse (MICN) or
base hospital physician (BHP) when encountering unusual patient
presentations or potential conflicts in treatment decisions.
III. Base Hospital Physicians may order a deviation from any of the
approved EMS Agency treatment Policies, as long as they remain
within the paramedic scope of practice. These types or orders
may not be relayed by the MICN. Each order from the BHP that
deviates from Policy must be documented on a Base Hospital
Report Form, the prehospital patient care report, and be submitted
to the EMS Agency for review.
IV. In those instances in which EMS Policy allows Paramedics to
perform a procedure or provide medication only upon receipt of a
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ALS Treatment Policies – Introduction
EMS Policy No. 5700
Approved: January 1, 2010
Supersedes: September 1, 2007
Base Hospital Physician order, MICN’s are allowed to relay orders
from the Base Hospital Physician. The paramedic shall document
the Physician’s name on the patient care report.
V. MICNs shall adhere to San Joaquin County EMS Agency Policies
when offering advice, guidance, and direction to ALS and BLS
field personnel.
VI. In order to facilitate the best possible delivery of prehospital
emergency medical care attending paramedics have the right to
speak directly to a Base Hospital Physician during any call.
VII. All prehospital EMS personnel are held to the following patient
care standards:
A. San Joaquin County EMS Agency Policies and Procedures.
B. American Heart Association CPR, AED, and BLS airway
obstruction and ventilation techniques.
C. State of California EMT-P Course Curriculum.
D. OES Region IV Multi-casualty Incident Plan, Field
Operations Manual 1 and 2.
E. S.T.A.R.T. Triage.
F. OSHA and CAL-OSHA standards for infection control.
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Routine ALS Care
EMS Policy No. 5701
Effective: January 1, 2012
Supersedes: February 1, 2007
5701 - Routine ALS Care
DEFINITIONS:
A. Standard Precautions: Application of body substance isolation
precautions including the use of appropriate personal protective
equipment (PPE) shall apply to all patients receiving care,
regardless of their diagnosis or presumed infectious status. Body
substance isolation precautions apply to 1) blood; 2) all bodily
fluids, secretions, and excretions except sweat, regardless of
whether or not they contain visible blood; 3) non intact skin; and 4)
mucous membranes. Standard precautions are designed to
reduce the risk of transmission of microorganisms from both
recognized and unrecognized sources of infection in the
prehospital setting.
POLICY:
I.
Routine ALS Medical Care shall consist of the following:
A. Standard precautions
B. Provision of appropriate BLS care in accordance with
EMS Agency policy
C. ECG monitoring
D. IV access as indicated (may use saline lock when
appropriate)
E. Obtain blood glucose level, as indicated
F. Transport
G. Follow ALS treatment policies as indicated
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ALS Advanced Airway Management
EMS Policy No. 5702
Effective: October 16, 2013
Supersedes: October 1, 2012
5702 - ALS Advanced Airway Management
DEFINITIONS:
A. “Oral Tracheal Intubation (OTI) Attempt” means the introduction of
an Endotracheal Tube Inducer (ETTI) or Endotracheal Tube past
the patient’s teeth.
B. “Difficult Airway” means an airway that has been predicted to be
difficult based on assessment of the patient or upon an attempt to
visualize the cords and the patient has a Cormack-Lehane grade
of three (3) of four (4).
C. “Successful OTI Attempt” means a verified placement and
securing of the endotracheal tube into the patient’s trachea.
D. “Successful OTI Attempt with Complications” means a verified
placement and securing of the endotracheal tube into the patient’s
trachea with any of the following:
1. Failure to perform and document meticulous BLS airway
management skills prior to ALS intervention, as well as
justification for ALS airway.
2. Failure to maintain continuous pulse oximetry and ECG
monitoring, for at least one (1) minute before the attempt and
continuously thereafter.
3. Deviations in vital signs associated with intubation suggestive
of prolonged hypoxia, such as bradycardia or desaturation.
4. Subsequent dislodgement of the endotracheal tube recognized
by the receiving hospital.
5. Subsequent diagnosis of mainstem intubation recognized by
the receiving hospital.
6. Subsequent diagnosis of severe airway complications likely
associated with the prehospital intubation, such as pharyngeal,
esophageal perforation, laryngeal trauma, such as vocal cord
paralysis, or aspiration pneumonia.
POLICY:
I. The approved airway management procedure for the unconscious
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ALS Advanced Airway Management
EMS Policy No. 5702
Effective: October 16, 2013
Supersedes: October 1, 2012
adult patient consists of the following: providing BLS airway
management skills; correctly assessing the need for an advanced
airway; and successfully inserting either an endotracheal tube via
oral tracheal intubation, or a King Airway.
II. Paramedics placing advanced airways shall follow the procedures
specified in EMS Policies No. 2545, 2552, 2553, 2555, and 2556.
III. Oral tracheal intubation in the pediatric patient should only be
performed if unable to ventilate and oxygenate the patient using
two-person Bag/Valve/Mask (BVM) ventilation. In cardiac arrest,
oximetry will not be accurate, so intubation in this case should only
occur if the patient cannot be ventilated by BVM.
IV. Do not delay transport to establish an advanced airway in trauma
patients except in the case of complete airway obstruction, as
evidenced by a complete inability to ventilate the patient using an
Oral Pharyngeal Airway (OPA) and BVM device.
V. If unable to establish an airway due to complete airway obstruction
not relieved using an OPA and BVM maneuvers, begin code three
transport, and consider insertion of a King Airway, or needle
cricothyrotomy (EMS Policy No. 2549) if the King Airway does not
result in successful ventilation.
VI. INDICATIONS FOR INTUBATION:
A. Inability of the patient to protect their airway (coma,
decreased level of consciousness with non-intact gag reflex).
B. Inability to adequately ventilate or oxygenate the patient
using an OPA and BVM device.
C. Cardiac arrest. Adhere to sequence as specified in EMS
Policy No. 5710 ALS Medical Cardiac Arrest.
D. Failing respirations (irregular and shallow), respiratory arrest.
VII. CONFIRMATION OF TUBE PLACEMENT:
A. Paramedics shall ensure that all intubations are confirmed by
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ALS Advanced Airway Management
EMS Policy No. 5702
Effective: October 16, 2013
Supersedes: October 1, 2012
B.
C.
D.
E.
F.
end tidal CO2 device (colorimetric or capnography) and/or
esophageal detection device (EDD) (EDD not used for King
Airway).
Paramedics shall immediately confirm tube placement by
auscultating bilateral lung fields for breath sounds, observe
for chest rise and fall with ventilations, and listen for air flow
into the epigastric area after placement of an endotracheal
tube or King Airway.
Paramedics shall continually monitor capnography readings
on all patients who have an endotracheal tube or King Airway
in place. Monitoring shall commence with transport and shall
continue through to patient transfer at the emergency
department.
Paramedics shall attach a copy of the capnography strip and
document the readings on the patient care record.
Paramedics shall reconfirm ET Tube placement prior to
transferring patient care.
Paramedics shall visualize the pharynx and vocal cords with
the laryngoscope, if there is any doubt as to proper
placement of the endotracheal tube.
VIII. INDICATIONS FOR KING AIRWAY
A. Select King Airway directly upon assessing a CormackLehane grade of 3 or 4,or;
B. Select a King Airway directly in response to other physical or
physiological impediments to the successful insertion of an
endotracheal tube, or;
C. Select a King Airway after two unsuccessful attempts to
insert an endotracheal tube.
IX. APPROVED ADVANCED AIRWAY PROCEDURE:
A. Prepare equipment and position patient with the intent to
provide an airway via either an Endotracheal Tube or via a
King Airway
B. Upon a determination that the patient has a Cormack-Lehane
grade of one (1) or two (2), attempt to insert an endotracheal
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ALS Advanced Airway Management
EMS Policy No. 5702
Effective: October 16, 2013
Supersedes: October 1, 2012
tube as described in EMS Policy No. 2545 – Endotracheal
Intubation – Adult.
1. No more than two (2) attempts per patient with
preoxygenation and continuous oximetry monitoring prior
to each attempt.
2. After two (2) unsuccessful attempts at endotracheal
intubation, insert a King Airway as described in EMS
Policy No. 2552 King Airway.
3. An endotracheal tube inducer (ETTI) shall be used on all
attempts.
4. Each attempt should last no longer than thirty (30)
seconds. If during any attempt patient desaturates below
90%, immediately cease and reventilate to increase
saturation.
5. Ventilate with 100% oxygen for one (1) minute prior to
attempting to intubate, unless transitioning to an
advanced airway per EMS Policy No 5710 ALS Medical
Cardiac Arrest.
6. Monitor pulse oximetry continuously.
C. Upon a determination the patient has a Cormack-Lehan
grade of three (3) or four (4), continue providing BLS
resuscitation, and provide a King Airway as described in EMS
Policy No. 2552 – King Airway.
1. A patient with a Cormack-Lehane grade of three (3) or
four (4) (epiglottis is not or is barely visible) will be
considered to have a difficult airway. The King Airway
shall be utilized on the first attempts for difficult airways in
adult patients.
Cormack and Lehan Classification (Grades) of Difficult
Laryngoscopy
Grade I Most of glottis is seen
Grade II Only posterior portion of glottis can be seen
Grade III Only epiglottis may be seen (none of glottis seen)
Grade IV Neither epiglottis nor glottis can be seen
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ALS Advanced Airway Management
EMS Policy No. 5702
Effective: October 16, 2013
Supersedes: October 1, 2012
2. Only King Airway sizes three (3), four (4), and five (5) are
authorized for use.
3. The King Airway is not authorized for use in adults < 4
feet tall.
Authorized King Airway Sizes
Size Height in Feet
Color
3
4 – 5 Feet
Yellow
4
5 – 6 Feet
Red
5
> 6 Feet
Purple
4. Use a laryngoscope to facilitate placement.
5. Do not exceed manufacture’s recommended pressures.
6. Remove and replace the King Airway if resistance is met
upon initial insertion.
7. After two (2) unsuccessful attempts, place a BLS an
airway and transport code 3 to the closest receiving
hospital.
D. Nasal Intubation: Nasal tracheal intubation may only be
performed with a Base Hospital Physician order. The Base
Hospital Physician’s name shall be documented on the PCR.
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ALS Patient Assessment – Primary Survey
Policy No. 5704
Effective: October 16, 2013
Supersedes: January 1, 2012
5704 - ALS Patient Assessment – Primary Survey
PROCEDURE:
The purpose of the primary survey is to identify and immediately
correct life-threatening problems.
I.
Scene Size Up:
A. Recognize hazards, ensure safety of scene and secure a
safe area for treatment.
B. Apply universal body/substance isolation precautions.
C. Recognize hazards to patient and protect patient from further
injury.
D. Identify the number of patients and initiate ICS/MCI
operations if warranted:
1. Ensure an ALS ambulance response and order
additional resources.
2. Consider/confirm air ambulance response.
3. Initiate S.T.A.R.T. triage, if more than one patient.
E. Observe position of patient(s).
F. Determine mechanism of injury.
G. Plan strategy to protect evidence at potential crime scene.
II.
General Impressions:
A. Check for life threatening conditions.
B. Introduce self to patient.
C. Determine chief complaint or mechanism of injury.
III.
Airway:
A. Ensure open airway
B. Protect spine from unnecessary movement in patients at risk
for spinal injury.
C. Ensuring an adequate airway supersedes spinal
immobilization.
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ALS Patient Assessment – Primary Survey
Policy No. 5704
Effective: October 16, 2013
Supersedes: January 1, 2012
D. Look and listen for evidence of upper airway problems and
potential obstructions:
1. Vomit.
2. Bleeding.
3. Loose or missing teeth.
4. Dentures.
5. Facial Trauma.
E.Utilize any appropriate adjuncts as indicated to maintain
airway.
IV.
Breathing:
A. Look, listen, and feel in order to assess ventilation and
oxygenation.
B. Expose chest, if necessary, and observe for chest wall
movement.
C. Determine approximate rate and depth and assess character
and quality.
D. Reassess mental status.
E. Intervene for inadequate ventilation with:
1. Pocket mask or BVM device.
2. Supplemental oxygen.
F. Assess for other life threatening respiratory problems and
treat as needed.
V.
Circulation:
A. Check for pulse and begin CPR.
B. Defibrillation as necessary.
C. Control life-threatening hemorrhage with direct pressure.
D. Palpate radial pulse.
1. Determine absence or presence.
2. Assess general quality (strong/weak).
3. Identify rate (slow, normal, or fast).
4. Assess regularity (regular/irregular).
E. Obtain baseline blood pressure.
F. Assess skin for signs of hypo-perfusion/SHOCK or hypoxia
(capillary refill, cyanosis, etc.).
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ALS Patient Assessment – Primary Survey
Policy No. 5704
Effective: October 16, 2013
Supersedes: January 1, 2012
G. Reassess mental status for signs of hypoperfusion/SHOCK.
H. Treat hypoperfusion if appropriate.
I. Obtain ECG and continually monitor cardiac rhythm as
appropriate.
VI.
Level of consciousness:
A. Determine need for spinal immobilization, EMS Policy
No.5115 Cervical Spine Immobilization.
1. Determine Glasgow Coma Scale (GCS) Score (see
page 3 for GCS chart).
2. Determine glucose level as needed, EMS Policy N.
5751, ALS Altered Level of Consciousness (ALOC).
VII.
Expose, Examine & Evaluate:
A. In situations with suspected life-threatening mechanism of
injury, complete a Rapid Trauma Assessment.
B. Expose head, trunk and extremities.
C. Head to Toe for DCAP-BTLS
1. Deformity.
2. Contusion/Crepitus.
3. Abrasion.
4. Puncture.
5. Bruising/Bleeding.
6. Tenderness.
7. Laceration.
8. Swelling.
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ALS Patient Assessment – Primary Survey
Policy No. 5704
Effective: October 16, 2013
Supersedes: January 1, 2012
Adult Glasgow Coma Scale:
Eye Opening
Verbal Response
4 = Spontaneous
5 = Oriented
3 = To verbal stimuli
2 = To painful stimuli
4 = Confused
3 = Inappropriate
words
2 = Incomprehensible
sounds
1 = No response
1 = No response
Best Motor
Response
6 = Obeys
commands
5 = Localizes stimuli
4 = Withdrawal from
pain
3 = Abnormal
Flexion
2 = Abnormal
Extension
1 = No response
Note: Always document and report GCS as a breakdown of
scores (i.e. GCS = Eye 3, Verbal 3, Motor 4 for a total score of
10).
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ALS Patient Assessment – Secondary Survey
EMS Policy No. 5705
Effective: September 1, 2007
Supersedes: 510.05
5705 - ALS Patient Assessment - Secondary Survey
PROCEDURE:
I.
The secondary survey is the systematic assessment and
complaint focused, relevant physical examination of the patient.
The secondary survey may be done concurrently with the
patient history and should be performed after the Primary
Survey and the initiation of Routine Medical Care. The purpose
of the secondary survey is to identify problems which, though
not immediately life or limb threatening, could increase patient
morbidity and mortality. Exposure of the patient for
examination may be reduced or modified as indicated due to
environmental factors.
II.
History:
A. A patient’s history should optimally be obtained from the
patient directly. If language, culture, age, disability
barriers or patient condition interferes with obtaining the
history, consult with family members, significant others or
scene bystanders. Check for advanced directives such
as a DNR order, Medic-Alert bracelet and prescription
bottles as appropriate. Be aware of the patient’s
environment and issues such as domestic violence, child
or elder abuse or neglect and report concerns. The
following information should be obtained during the
history:
1. Allergies;
2. Medications;
3. Past medical history relevant to the chief complaint.
4. Have patient prioritize his or her chief complaint if
complaining of multiple problems;
5. Ascertain recent medical history such as hospital
admissions, surgeries, etc;
6. Mechanism of injury if appropriate;
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ALS Patient Assessment – Secondary Survey
EMS Policy No. 5705
Effective: September 1, 2007
Supersedes: 510.05
7. In addition obtain history relevant to specific patient
complaints.
III.
Head and Face:
A. Observe and palpate skull (anterior and posterior) and face
for DCAP-BTLS;
B. Check eyes for equality, responsiveness of pupils,
movement and size of pupils, foreign bodies,
discoloration, contact lenses or prosthetic eyes;
C. Check nose and ears for foreign bodies, fluid or blood;
D. Recheck mouth for potential airway obstructions (swelling,
dentures, bleeding, loose or avulsed teeth, vomit, absent
or present gag reflex) and odors, altered voice or speech
patterns and evidence of dehydration.
IV.
Neck:
A. Observe and palpate for DCAP-BTLS, jugular vein
distension, use of neck muscles for breathing, tracheal
tugging, tracheal shift, stoma and medical information
medallions.
V.
Chest:
A. Observe and palpate for DCAP-BTLS, scars, implanted
devices such as pacemakers and indwelling IV/arterial
catheters, medication patches, chest wall movement,
asymmetry and accessory muscle use in breathing;
B. Have patient take a deep breath if possible and observe and
palpate for signs of discomfort, asymmetry and air leak
from any wound.
C. Assess lung sounds and heart tones as appropriate.
VI.
Abdomen:
A. Observe and palpate for DCAP-BTLS, scars and distention;
B. Palpation should occur in all four quadrants taking special
note of tenderness, masses and rigidity.
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ALS Patient Assessment – Secondary Survey
EMS Policy No. 5705
Effective: September 1, 2007
Supersedes: 510.05
VII.
Pelvis/Genital-Urinary:
A. Generally, a patient’s genital area should not be exposed
and examined unless the assessment of this body region
is required due to the patient’s condition, such as trauma
to the region, active labor or suspected/known bleeding.
When possible have an EMT or paramedic of the same
gender as the patient, perform evaluations of the
pelvis/genital area.
B. Observe and palpate for DCAP-BTLS, asymmetry, sacral
edema and as indicated for other abnormalities;
C. Palpate and gently compress lateral pelvic rims and
symphysis pubis for tenderness, crepitus or instability;
D. Palpate for bilateral femoral masses, if warranted.
VIII. Shoulder and Upper Extremities:
A. Observe and palpate for DCAP-BTLS, asymmetry, skin
color, capillary refill, edema, medical information bracelet,
and equality of distal pulses;
B. Assess sensory and motor function as indicated.
IX.
Lower Extremities:
A. Observe and palpate for DCAP-BTLS, asymmetry, skin
color, capillary refill, edema and equality of distal pulses;
B. Assess sensory and motor function as indicated.
X.
Back:
A. Observe and palpate for DCAP-BTLS, asymmetry and sacral
edema.
XI.
Precautions and Comments:
A. Observation and palpation can be done while gathering a
patient’s history.
B. A systematic approach will enable the rescuer to be rapid
and thorough and not miss subtle findings that may
become life-threatening.
C. Minimize scene times, especially with trauma patients and
pediatrics, by packaging/preparing the patient for
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ALS Patient Assessment – Secondary Survey
EMS Policy No. 5705
Effective: September 1, 2007
Supersedes: 510.05
immediate transport upon ambulance or air ambulance
arrival (spinal immobilization, miller board, pediatric
immobilization device, ensuring rapid ingress/egress for
BLS personnel and equipment.)
D. The Secondary Survey should ONLY be interrupted if the
patient experiences airway, breathing or circulation
deterioration requiring immediate intervention. Complete
the examination before treating the other identified nonlife threatening problems.
E. Reassessment of vital signs and other observations are
necessary, particularly in critical or rapidly changing
patients. Vital signs should be taken approximately every
5 minutes. Changes and trends observed in the field are
essential data to be documented and communicated to
the transport personnel or receiving facility.
F. As stated in the Primary Survey DCAP-BTLS is a mnemonic
that stand for:
1. Deformity;
2. Contusion/Crepitus;
3. Abrasion;
4. Puncture;
5. Bruising/Bleeding;
6. Tenderness;
7. Laceration;
8. Swelling.
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ALS Adult Pain Management
EMS Policy No. 5707
Effective: February 1, 2007
Supersedes: NA
5707 - ALS Adult Pain Management
DEFINITIONS:
A.
Pain: Pain is a significantly unpleasant sensation, occurring in
varying degrees of severity, which results because of injury,
disease, or emotional disorder.
POLICY:
I.
The use of morphine to manage moderate to severe pain is an
advanced life support procedure that is indicated for patients
who are complaining of moderate to severe pain in the
presence of adequate vital signs and level of consciousness.
II.
Morphine may be used to treat stable patients when
extrication, movement, or transport is required and is
anticipated to cause considerable pain to the patient when
there are no known contraindications to administering
analgesia.
III.
Morphine is a potent analgesic and should be used with
caution.
IV.
Procedure:
A. Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No.
5701, Routine ALS Care.
B. Monitor patient closely.
C. Establish IV access (IV NS or NS lock as appropriate).
D. Obtain full set of vital signs.
E. Administer Morphine 2-4mg IV every five minutes as needed
to relieve pain to a maximum dose of 20mg. If unable to
secure IV access, administer Morphine 5-10mg IM, may
repeat one dose in 30 minutes. Document pain scale
before and after medication administration.
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ALS Adult Pain Management
EMS Policy No. 5707
Effective: February 1, 2007
Supersedes: NA
F. Monitor patient and vital signs carefully; ensure patent
airway. Do not administer morphine sulfate for pain if
systolic blood pressure is < 90 or respirations are < 12
without base hospital physician order.
V.
Base Physician Order Requirements:
A. Concomitant administration of midazolam requires a base
hospital physician order.
B. Contact the base hospital physician prior to administering
any pain medication to the following types of patients:
1. Any patient with hypotension, respiratory rate < 12, or
altered mental status
2. Women in labor
VI.
Contraindications:
A. Absolute: Allergy or sensitivity to the medication being
administered.
B. Relative:
1. Nausea/Vomiting
2. Altered level of consciousness
3. Hypotension
4. Suspected drug and/or alcohol intoxication
5. Head injury
6. Pregnancy
7. Multiple systems trauma
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ALS Medical Cardiac Arrest
EMS Policy No. 5710
Effective: October 16, 2013
Supersedes: June 1, 2013
5710 - ALS Medical Cardiac Arrest
PURPOSE:
The purpose of this policy is to provide direction for BLS and ALS
responders for resuscitation of patients who are > 8 years-old in
cardiopulmonary arrest due to asystole, pulseless ventricular
tachycardia, ventricular fibrillation, or pulseless electrical activity
using minimally interrupted cardiac resuscitation (MICR).
DEFINITIONS:
A.
B.
C.
D.
E.
F.
“EMS Agency” means the San Joaquin County Emergency
Medical Services (EMS) Agency.
“MICR” means minimally interrupted cardiac resuscitation that
focuses upon maintaining high quality chest compressions with
both depth and rate.
“MICR Algorithm” means a representation of correct treatment
choices in response to a patient’s cardiac rhythm.
“MICR Round” means the time required to complete 200 – 230
compressions (approx. two minutes), analyze the patient’s
rhythm and provide a shock (if indicated).
“Passive Oxygen Insufflation” (POI) is the method of providing
oxygen to a patient during the first eight (8) minutes of
resuscitation with an oral pharyngeal airway (OPA), high flow
oxygen via non-rebreather mask, and no ventilations.
“Pit Crew” means the configuration of EMS responders and
their defined roles to resuscitate a patient in cardiopulmonary
arrest.
POLICY:
I.
The goal of cardiac resuscitation is to preserve cerebral and
coronary function through meticulous attention to procedure
and achieving return of spontaneous circulation (ROSC).
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ALS Medical Cardiac Arrest
EMS Policy No. 5710
Effective: October 16, 2013
Supersedes: June 1, 2013
A. Focus resuscitative efforts on accomplishing the following in
rank order of importance:
1. Provide high quality chest compressions with minimal
interruption.
2. Apply ECG or AED for analysis and defibrillation.
3. Initiate POI.
4. Provide epinephrine 1mg 1:10,000 via IV/IO each MICR
Round.
B. Use a team approach (“Pit Crew”).
II.
Maintain a chest compression rate of 100 compressions per
minute and alternate chest compression duties between pit
crew team members after each MICR Round. Each MICR
Round consists of between 200 and 230 chest compressions
and will vary based upon AED analysis and shock pattern
limitations.
III.
Initiate an advanced airway after completion of four MICR
Rounds and continue resuscitative efforts based on the
patient’s current cardiac rhythm and applicable treatment
protocols.
IV.
The starting point to measure the beginning of MICR Rounds is
the time that the first EMS personnel on-scene initiates the
MICR procedure (compressions), regardless of whether the first
rounds include establishment of an I.V. or administration of
epinephrine.
V. Contraindications for use of MICR include:
A. Traumatic arrest.
B. Pediatric arrest.
C. Respiratory arrest due to known respiratory problem (e.g.
asthma).
D. Drowning.
E. Obstructed Airway (including partial obstruction due to
vomitus).
F. Patients with a Left Ventricular Assist Device
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ALS Medical Cardiac Arrest
EMS Policy No. 5710
Effective: October 16, 2013
Supersedes: June 1, 2013
PROCEDURE:
I. Obtain patient history and document the following:
A. Estimated down time.
B. Circumstances surrounding arrest:
1. Onset (witnessed or un-witnessed).
2. Preceding symptoms.
3. Bystander CPR.
4. Duration of CPR.
5. Medications.
6. Environmental factors (hypothermia, inhalation, and
asphyxiation).
II. Treatment
A. Follow the MICR Algorithm as described below:
1. First MICR Round: While providing a minimum of 200
chest compressions (two minutes), apply ECG. Use
either AED or manual mode, depending upon which
method minimizes interruption of compressions, and does
not delay administration of an IV/IO and Epinephrine.
Ensure that the airway is secure with an oral pharyngeal
airway (OPA) and institute POI with high flow oxygen nonrebreather mask. If ALS is available start IV/IO and
administer Epinephrine 1 mg (1:10,000) without
interrupting chest compressions.
2. Subsequent MICR Rounds: Following the first MICR
Round (200+ chest compressions and approximately two
minutes), stop compressions to quickly check for a pulse
and for ECG analysis. After analysis and while AED is
charging, immediately perform thirty (30) chest
compressions (less if required by AED limitations) then
provide a single shock.
a) Interruptions for defibrillation must be kept to a
minimum.
(1) Continue chest compressions immediately upon
performing defibrillation.
(2) Do not stop chest compressions to wait for an
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ALS Medical Cardiac Arrest
EMS Policy No. 5710
Effective: October 16, 2013
Supersedes: June 1, 2013
ECG analysis following defibrillation and do not
interrupt chest compressions to perform BLS
airway procedures, start IV/IOs, check pulses, or
administer medications.
b) Rotate chest compression duties between Pit Crew
members every MICR Round.
c) If ALS care is available, administer Epinephrine 1 mg
(1:10,000) once every MICR Round.
3. For return of spontaneous circulation treat the patient in
accordance with EMS Policy No.5726, Return of
Spontaneous Circulation.
B. MICR Algorithm
MICR Algorithm
Administer 1 mg IV/IO
epinephrine without
interrupting CCs.
C. Approach to airway complications for BLS and ALS personnel
1. If BLS personnel determine that vomitus has
compromised the patient’s airway, the BLS crews should
suction the airway prior to applying an AED or POI.
2. If ALS personnel determine that vomitus has
compromised the airway, the ALS crew should suction the
airway and apply either an ETI or King Airway and
transition to treatment described below in section III.
III. Transition to the following treatment after four MICR Rounds (eight
minutes):
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ALS Medical Cardiac Arrest
EMS Policy No. 5710
Effective: October 16, 2013
Supersedes: June 1, 2013
A. Place either a King Airway or an oral tracheal tube and secure
it with a commercial tube restraint. While oral tracheal
intubation will usually interfere with continuous chest
compressions, endeavor to not interrupt compressions for
longer than fifteen (15) seconds.
B. Continue performing high quality, uninterrupted compressions
(> 100/minute).
C. Use waveform capnography from time of tube placement
through the duration of the resuscitation attempt. Both
numerical value (capnometry) and wave morphology MUST
be obtained and documented every five (5) minutes.
D. Once an advanced airway is in place, compressions are given
continuously at a rate of 8-10 ventilations per minute. DO
NOT HYPERVENTILATE.
E. Based upon ECG rhythm analysis, follow the treatment path
specific to Asystole, V-fib and Pulseless VTach, or PEA per
SJCEMSA policies.
IV. Base Hospital Direction and Patient Transport
A. If patient fails to convert to a return of spontaneous circulation
following four MICR Rounds and the appropriate treatment
path specified in SJCEMSA policies has been followed for a
combined total of fifteen (15) minutes, contact the Base
Hospital to discuss discontinuation of resuscitative efforts or
patient transport. If the patient remains in PEA or ventricular
fibrillation prepare patient for transportation. Do not transport
the patient unless ordered to do so by the Base Hospital or
due to scene safety.
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ALS Medical Cardiac Arrest-Pit Crew Appendix A
EMS Policy No. 5710A
Effective: June 1, 2013
Supersedes: None
5710A - ALS Medical Cardiac Arrest - Pit Crew Appendix A
I. Pit Crew Concept
A. The roles and responsibilities detailed below are guidelines.
B. Regardless of the number of responders, Pit Crew members
should focus upon the following critical tasks:
1. Uninterrupted compressions
2. Placement of AED or monitor for rhythm analysis and
shocks as appropriate
3. Placement of an OPA airway and 100% oxygen by
mask (non-rebreather preferred).
C. Pit Crew members take positions according to the diagram
below depending upon crew member availability in order
of the following task priorities:
1. Compression Leader
2. Airway Leader
3. Compression Tech (May be Medication Leader if ALS
EMR crew)
4. Medication Leader (When ALS available)
2
Airway
Leader
1
Compression
Leader
3
Compression Tech
4
Medication Leader
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ALS Medical Cardiac Arrest-Pit Crew Appendix A
EMS Policy No. 5710A
Effective: June 1, 2013
Supersedes: None
II. Pit Crew Procedures
A. If necessary to ensure enough room to conduct cardiac
resuscitation, move patient to an area with a minimum
space of 5’ x 7’.
B. Initiate properly executed chest compressions throughout
duration of pulseless period utilizing a pacing metronome
and assign a timekeeper to track duration of total time
engaged in cardiac resuscitation effort.
1. Compression rate of 100 per minute.
2. Compression depth of 2 ½ inches.
3. Complete recoil.
4. Alternate compressors every MICR Round.
C. Quickly return to chest compressions after appropriate
rhythm checks and while monitor is charging.
1. After rhythm analysis (approximately 5-10 seconds)
and shock is advised, immediately switch
compression technicians and provide 30
compressions (less if required by AED limitations)
prior to giving shock. .
2. Minimize interruptions. Immediately resume chest
compressions after defibrillation attempts.
3. Do not pause to check pulse or analyze rhythm after
defibrillation attempts. Quickly check pulse to
determine return of spontaneous circulation the
moment compressions are halted for AED analysis.
III.
Priorities for Pit Crew Members During MICR Rounds
Priorities by MICR Rounds
Round 1:
Compression Leader:
 Initiate compressions @ rate of 100/min
 ONLY check for pulse if arrest witnessed by an ALS provider
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ALS Medical Cardiac Arrest-Pit Crew Appendix A
EMS Policy No. 5710A
Effective: June 1, 2013
Supersedes: None

21/2” depth compression with full recoil
Airway Leader:
 Place OPA and non-rebreather mask @ 15 lpm
 If ALS available, consider setting up IV
 Run AED
Compression Tech:
 Place ECG/Defib pads
 Turn on monitor (if not AED, consider placing it in AED mode)
 Be available to take over compressions
Medication Leader:
 Initiate IV/IO
 1st dose of Epinephrine
 Check FSBS
Round 2:
Compression Leader:
 Operates AED
Airway Leader:
 Performs compressions (alternating with compression leader if two person
crew)
 Suction patient as needed
Compression Tech:
 Performs compressions
 Assist as needed
Medication Leader:
 2nd dose of Epinephrine
 Consider Narcan
Round 3:
Compression Leader:
 Compressions
Airway Leader:
 Maintain airway
 Run AED
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ALS Medical Cardiac Arrest-Pit Crew Appendix A
EMS Policy No. 5710A
Effective: June 1, 2013
Supersedes: None
Compression Tech:
 Assess quality of compressions
Medication Leader:
 3rd dose of Epinephrine
Round 4:
Compression Leader:
 Prep to transition to post MICR care
Airway Leader:
 Support transition to post MICR care
 Prep equipment for patient movement
 Prep advanced airway adjuncts
Compression Tech:
 Performs compressions
Medication Leader:
 Consider reversible causes (Hs and Ts)
 Provide 4th dose of Epinephrine
Post Round 4:
Compression Leader:
 Perform Compressions
 Support post MICR care
Airway Leader:
 Inserts advanced airway
 Uses confirmatory adjuncts (waveform capnography)
 Ventilates asynchronously at 8-10 per minute
Compression Tech:
 Assist with compressions alternating with Compression Leader
Medication Leader:
 Provide post MICR care
 Contact Base Hospital if no ROSC
General:
 Prepare for patient transport if appropriate
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ALS Ventricular Fibrillation/Pulseless
Ventricular Tachycardia
EMS Policy No. 5711
Effective: October 16, 2013
Supersedes: January 1, 2012
5711 - ALS Ventricular Fibrillation/Pulseless VTach
POLICY:
I. If ALS personnel witness a change in patient condition to
ventricular fibrillation or pulseless VTach, immediately defibrillate
the patient one time using manufacturer recommended dose of
energy.
II. After completing four rounds of MICR, confirm pulselessness and
rhythm and proceed with treatment as described below in section
III.
III. Treatment:
A. Continue administering continuous chest compressions and
ventilate the patient 8-10 times per minute. DO NOT
HYPERVENTILATE.
B. Establish an advanced airway and administer 100% oxygen via
BVM.
C. Defibrillate patient one time using manufacturer recommended
dose of energy (usually 120-200 joules in biphasic
defibrillators). If not stated, use 200 joules (biphasic); or 360
joules (monophasic); then resume chest compressions
immediately.
D. Establish IV/IO of normal saline TKO.
E. Administer Epinephrine 1 mg (1:10,000) via IV/IO. Repeat
every 3-5 minutes followed by 200 compressions.
F. Defibrillate 1 x @ 120 - 200 joules (biphasic); or 1 x @ 360
joules (monophasic); immediately resume compressions
without waiting for a rhythm check.
G. Administer Lidocaine 1mg/kg IVP/IO (may repeat once in 3-5
minutes).
H. For return of spontaneous circulation, see EMS Policy
No.5726, Return of Spontaneous Circulation.
I. If the patient remains pulseless and apneic following four
rounds of MICR and seven (7) minutes of ALS resuscitative
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ALS Ventricular Fibrillation/Pulseless
Ventricular Tachycardia
EMS Policy No. 5711
Effective: October 16, 2013
Supersedes: January 1, 2012
measures, ALS personnel shall contact the Base Hospital
Physician to determine whether to continue or discontinue
resuscitative measures.
IV. Special Considerations:
A. Suspected hyperkalemia in renal dialysis patients – Consider
IVP/IO administration of 500 mg of 10% Calcium Chloride and1
mEq/kg of Sodium Bicarbonate, and consult Base Hospital
Physician to discuss further management.
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ALS Wide Complex Tachycardia with a Pulse
EMS Policy No. 5712
Effective: October 16, 2013
Supersedes: January 1, 2012
5712 - ALS Wide Complex Tachycardia with a Pulse
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Unconscious:
A. Establish an IV of normal saline TKO.
B. Consult with Base Hospital Physician.
1. Synchronized cardioversion at 100 joules (monophasic
energy dose or equivalent biphasic energy dose).
2. If no response: repeat synchronized cardioversion at 200
joules (or biphasic equivalent).
3. If no response: repeat synchronized cardioversion at 300
joules (or biphasic equivalent).
4. If no response: repeat synchronized cardioversion at 360
joules (or biphasic equivalent).
5. If rhythm does not convert with cardioversion administer
Lidocaine 1 mg/kg IVP (may repeat x 1 in 3-5 minutes).
C. Consult with Base Hospital Physician for further
interventions.
III. Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg
systolic, decreased LOC, shortness of breath, signs of shock):
A. Place on 12 Lead ECG if chest pain is present.
B. Establish an IV of normal saline TKO.
C. In the presence of continuous chest pain, administer
Lidocaine 1mg/kg IVP. May repeat every 5-10 minutes at ½
initial dose up to a total of 3 mg/kg.
D. Lidocaine Drip: 1gm in 250 ml Normal Saline. Utilizing a
dial-a-flow and extension tubing, administer 2-4 mg/min to
decrease or eliminate ventricular ectopy.
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ALS Narrow Complex Tachycardia; AFIB/AFlutter
EMS Policy No. 5713
Effective: January 1, 2012
Supersedes: February 1, 2007
5713 - ALS Narrow Complex Tachycardia; AFib/AFlutter
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine
ALS Care.
II.
Unconscious:
A. Consult Base Hospital Physician.
1. Synchronized cardioversion at 100 joules (monophasic
energy dose or equivalent biphasic energy dose).
2. If no response: repeat synchronized cardioversion at 200
joules (or biphasic equivalent).
3. If no response: repeat synchronized cardioversion at 300
joules (or biphasic equivalent).
4. If no response: repeat synchronized cardioversion at 360
joules (or biphasic equivalent).
III.
Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg
systolic, decreased LOC, shortness of breath, signs of shock):
A. Place on 12 Lead ECG only if chest pain is present.
B. Establish an IV of normal saline TKO.
C. Monitor and transport patient.
D. Consider reversible causes of tachycardia.
E. Consult with Base Hospital Physician for medication orders if
transport time > 10 minutes or change in patient condition.
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ALS Narrow Complex Tachycardia; SVT
EMS Policy No. 5714
Effective: January 1, 2012
Supersedes: February 1, 2007
5714 - ALS Narrow Complex Tachycardia; SVT
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II. Unconscious
A.
B.
C.
Consider reversible causes of tachycardia such as
hypoxia and hypovolemia.
Establish an IV of normal saline TKO.
Consult Base Hospital Physician.
1. Synchronized cardioversion at 100 joules monophasic
energy dose (or equivalent biphasic energy dose).
2. If no response: repeat synchronized cardioversion at
200 joules (or biphasic equivalent).
3. If no response: repeat synchronized cardioversion at
300 joules (or biphasic equivalent).
4. If no response: repeat synchronized cardioversion at
360 joules (or biphasic equivalent).
III. Conscious (stable or unstable) (chest Pain, BP less than 90 mmHg
systolic, decreased LOC, shortness of breath, signs of shock):
A.
B.
C.
D.
E.
Consider reversible causes of tachycardia including
hypoxia and hypovolemia and treat accordingly.
Perform Valsalva’s maneuver.
Establish an IV of normal saline TKO.
Administer Adenosine 6mg rapid IVP immediately
followed by 20 ml of normal saline.
If no response after 2 minutes: Administer Adenosine
12mg rapid IVP immediately followed by 20 ml of normal
saline.
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ALS Narrow Complex Tachycardia; SVT
EMS Policy No. 5714
Effective: January 1, 2012
Supersedes: February 1, 2007
F.
G.
H.
If no response after 2 minutes: Administer Adenosine
12mg rapid IVP immediately followed by 20 ml of normal
saline.
Consider 12 Lead ECG if chest pain is present.
Consult with Base Hospital Physician.
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ALS Asystole
EMS Policy No. 5715
Effective: October 16, 2013
Supersedes: January 1, 2012
5715 - ALS Asystole
PROCEDURE:
I. After completing four rounds of MICR, confirm pulselessness and
rhythm.
II. Treatment:
A. Continue administering continuous chest compressions and
ventilate the patient 8-10 times per minute. DO NOT
HYPERVENTILATE.
B. Establish an advanced airway and administer 100% oxygen via
BVM.
C. Establish IV/IO of normal saline TKO.
D. Consider reversible causes and treat as indicated:
1. Hypovolemia – Start 2 large bore IV/IO lines and administer
rapid 2 liter volume infusion of NS, then 250 ml boluses
until systolic B/P is >90 mmHg .
2. Hypoxia – Administer 100% oxygen
3. Tension pneumothorax. – Perform thoracentesis.
4. IDDM and Dialysis (Acidosis) – Administer 1 mEq/kg of
Sodium Bicarbonate IVP/IO
5. Cardiac tamponade – Continue CPR
6. Drug overdoses – Administer reversal agents as indicated.
Contact Base Hospital Physician for orders if necessary.
7. Hypothermia – Initiate rewarming activities.
8. Renal Failure/Dialysis (Hyperkalemia) - Administer 500 mg
of 10% Calcium Chloride and1 mEq/kg of Sodium
Bicarbonate IVP/IO.
E. Administer Epinephrine 1 mg (1:10,000) IVP/IO every 3 – 5
minutes twice.
F. If the patient remains pulseless and apneic following four
rounds of MICR and seven (7) minutes of ALS resuscitative
measures, ALS personnel shall contact the Base Hospital
Physician to determine whether to continue or discontinue
resuscitative measures.
San Joaquin County
Emergency Medical Services
Page 35 of 216
ALS Pulseless Electrical Activity
EMS Policy No. 5716
Effective: October 16, 2013
Supersedes: February 15, 2010
5716 - ALS Pulseless Electrical Activity (PEA)
PROCEDURE:
I.
After completing four rounds of MICR, confirm pulselessness and
rhythm.
A. Establish an advanced airway.
B. Administer rapid infusion until systolic BP is greater than 90
mmHg or 2 liters has been infused; then reduce infusion rate
TKO.
II. Consider reversible causes and treat as indicated:
A. Hypovolemia – Start 2 large bore IV/IO lines and administer
rapid 2 liter volume infusion of normal saline. Continue
infusions of normal saline in 250 ml bolus increments until
systolic BP is greater than 90 mmHg .
B. Hypoxia – Continue to administer 100% oxygen and manage
ventilations as needed.
C. Tension pneumothorax.
D. IDDM and Dialysis (Acidosis) – Administer 1 mEq/kg of
Sodium Bicarbonate IVP/IO.
E. Cardiac tamponade – Continue CPR.
F. Drug overdoses – Administer reversal agents as indicated.
Contact Base Hospital Physician for orders if necessary.
G. Hypothermia – Initiate rewarming interventions.
H. Renal Failure/Dialysis (Hyperkalemia) - Administer 500 mg of
10% Calcium Chloride and 1 mEq/kg of Sodium Bicarbonate
IVP/IO.
III. Following four round of MICR administer Epinephrine 1 mg
(1:10,000) IVP/IO every 3 - 5 minutes two times before contacting
the Base Hospital.
IV. If the patient remains pulseless and apneic following four rounds
of MICR and seven (7) minutes of ALS resuscitative measures,
ALS personnel shall contact the Base Hospital Physician to
determine if the patient should be transported or to discontinue
resuscitative measures.
San Joaquin County
Emergency Medical Services
Page 36 of 216
ALS Bradycardia
EMS Policy No. 5717
Effective: January 1, 2012
Supersedes: February 15, 2010
5717 - ALS Bradycardia
PROCEDURE:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine
ALS Care.
II. Unstable Patients (systolic BP < 90mmHg, signs of shock,
decreased level of consciousness, chest pain, and shortness of
breath):
A. Establish IV of normal saline TKO.
B. Administer Atropine in increments of 0.5mg IVP every 5
minutes to 1.5 mg.
1. If patient remains unstable, consult with Base Hospital
Physician as described in II. C.
2. Atropine may be administered every five (5) minutes to a
maximum of 3mg as needed.
C. Consult Base Hospital Physician.
1. Initiate transcutaneous pacing.
2. Provide sedation with Midazolam 1-2 mg and/or Morphine
Sulfate 1-2 mg slow IVP, and titrate to effect.
3. If capture is maintained but patient remains symptomatic,
consider fluid challenges of 250 ml NS. Recheck vital signs
after every 250 ml or more frequently as needed.
4. If inadequate response to Atropine and pacing, consider
administering Dopamine 400 mg/250 cc premix. Using a
dial-a-flow start at 10 mcg/kg/min and titrate to systolic BP
of 90mmHg. (See page 2 for Dopamine dosage chart).
D. For Renal Failure/Dialysis (suspected Hyperkalemia) – Consult
with Base Hospital Physician to obtain order for administration
of 500 mg of 10% Calcium Chloride and 1 mEq/kg of Sodium
Bicarbonate IVP.
III. Stable Patients:
A. Monitor patient and transport.
B. Consult Base Hospital Physician as needed.
San Joaquin County
Emergency Medical Services
Page 37 of 216
ALS Bradycardia
EMS Policy No. 5717
Effective: January 1, 2012
Supersedes: February 15, 2010
DOPAMINE
DOPAMINE
400 mg in 250 cc NS or D5W 60 drops/min = 60 ml/hr
Weight (kg)
gtts/min to = 10 mcg/kg/min
Weight (kg)
gtts/min to = 10 mcg/kg/min
35-45
15 gtts/min
85-90
35 gtts/min
45-55
20 gtts/min
95-105
40 gtts/min
60-70
25 gtts/min
110 & up
45 gtts/min
75-80
30 gtts/min
San Joaquin County
Emergency Medical Services
Page 38 of 216
ALS Chest Pain
EMS Policy No. 5719
Effective: October 16, 2013
Supersedes: October 1, 2011
5719 - ALS Chest Pain
POLICY:
I.
Perform routine ALS/BLS medical care.
II. Treatment:
A. Oxygen 12 - 15 lpm via non-rebreather mask.
B. IV of normal saline TKO.
C. Administer nitroglycerin 0.4 mg SL - if systolic blood pressure
is above 90 mmHg. May repeat every 5 minutes if
signs/symptoms persist and systolic BP remains above 90
mmHg.
D. If patient is able to swallow, give Aspirin 325 po.
E. Perform 12 Lead ECG – Initiate STEMI Alert* if indicated.
F. Transport.
III. STEMI ALERT Process:
A. Contact SRC ASAP to announce the STEMI alert, provide an
ETA, and state that transmission of the 12 lead ECG will be
sent when en route (if equipped to do so).
B. Initiate rapid transport to a STEMI receiving center per EMS
Policy No. 5201, Medical Patient Destination.
C. Transmit ECG to SRC when en route to the SRC (if equipped
to do so).
D. Administer morphine sulfate 2 mg slow IVP if patient is still
symptomatic after three (3) Nitroglycerin doses, or if
Nitroglycerin is contraindicated.
1. May repeat morphine sulfate 2-4 mg slow IVP every 3-5
minutes to a maximum of 15 mg total. Monitor BP and
respirations between dosages. Do not repeat doses if
systolic BP less than 90 mmHg.
NOTE: *All STEMI alerts shall be based on the cardiac
monitor/defibrillator manufacture’s operating instructions
San Joaquin County
Emergency Medical Services
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ALS Chest Pain
EMS Policy No. 5719
Effective: October 16, 2013
Supersedes: October 1, 2011
regarding STEMI alerting messages. LP12 (*** ACUTE MI
SUSPECTED ***); LP15 (*** MEETS ST ELEVATION MI
CRITERIA ***); Zoll E Series (** ** ** ** * ACUTE MI * ** ** **
**)
IV. Special Considerations for all patients:
A. If systolic blood pressure less than 90 mmHg, administer a
250 cc fluid bolus.
B. Nitroglycerin is contraindicated and should NOT be
administered to patients of either gender who have taken
Viagra, (sildenafil citrate) or Levitra (vardenafil HCL) within 24
hours or Cialis (tadalafil) within 36 hours.
C. Aspirin should NOT be administered to patients with an
aspirin allergy or active GI bleeding.
San Joaquin County
Emergency Medical Services
Page 40 of 216
ALS Cardiogenic Shock
EMS Policy No. 5720
Effective: January 1, 2012
Supersedes: February 15, 2010
5720 - ALS Cardiogenic Shock
PROCEDURE:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care and EMS Policy No. 5701, Routine
ALS Care.
II. Treatment:
A.
B.
C.
D.
E.
Apply Oxygen at 10 to 15 LPM via a non-rebreather mask.
Obtain 12 Lead ECG and transport to an SRC if indicated.
Treat significant arrhythmias.
Establish IV of normal saline TKO.
Administer a NS fluid challenge of up to 1 liter while rechecking
vital signs and lung sounds after every 250 mls. If patient’s
lungs are not clear, discontinue the fluid challenge and consult
the base hospital physician.
F. If systolic blood pressure remains less than 90 mmHg following
fluid challenges, or if the patient’s lungs are not clear, consult
Base Hospital Physician. Anticipate an order for an infusion of
Dopamine, titrated at 10mcg/kg/min to a systolic blood
pressure of 90 mmHg using a dial-a-flow with extension tubing.
G. Transport immediately.
DOPAMINE
400 mg in 250 cc NS or D5W - 60 drops/min = 60 ml/hr
Weight
gtts/min to = 10
Weight
gtts/min to = 10
(kg)
mcg/kg/min
(kg)
mcg/kg/min
35-45
15 gtts/min
85-90
35 gtts/min
45-55
20 gtts/min
95-105
40 gtts/min
60-70
25 gtts/min
110 & up
45 gtts/min
75-80
30 gtts/min
San Joaquin County
Emergency Medical Services
Page 41 of 216
ALS Ventricular Ectopy
EMS Policy No. 5724
Effective: January 1, 2012
Supersedes: February 1, 2007
5724 - ALS Ventricular Ectopy
DEFINITIONS:
A.
Ventricular ectopy: Couplets or multifocal PVCS > 6 BPM, or
non-sustained runs of ventricular tachycardia.
PROCEDURE:
I.
II.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
Treatment:
A. Obtain 12 lead ECG and transport to a STEMI Receiving
Center if indicated.
B. Establish IV of normal saline.
C. In the presence of continuous chest pain, administer
Lidocaine 1mg/kg IVP. May repeat every 5-10 minutes at ½
initial dose up to a total of 3 mg/kg.
D. Lidocaine Drip: 1gm in 250 ml Normal Saline. Utilizing a
dial-a-flow with extension tubing, administer 2-4 mg/min to
decrease or eliminate ventricular ectopy.
San Joaquin County
Emergency Medical Services
Page 42 of 216
ALS Return of Spontaneous Circulation
EMS Policy No. 5726
Effective: January 1, 2012
Supersedes: February 15, 2010
5726 - ALS Return of Spontaneous Circulation
POLICY:
I. Perform routine ALS/BLS medical care while confirming palpable
carotid pulse and blood pressure.
II. Monitor for reoccurrence or cardiac instability.
III. Treatment:
A. For adult patients begin therapeutic hypothermia as indicated
in accordance with EMS Policy No 5727, ALS Therapeutic
Hypothermia.
B. Establish IV of normal saline TKO.
C. B/P greater than 90 systolic:
1. Monitor cardiac rhythm and vital signs.
2. If patient was resuscitated from VF/VT or ventricular ectopy
is present, administer Lidocaine 1mg/kg IVP. May repeat
every 5-10 minutes at ½ initial dose up to a total of 3 mg/kg.
3. Lidocaine Drip: Utilizing a dial-a-flow and extension tubing
administer 1gm in 250 ml normal saline or D5W.
Administer 2-4 mg/min to decrease or eliminate ventricular
ectopy.
D. B/P less than 90 systolic
1. Administer fluid challenge of 500ml IV.
2. If heart rate is less than 60 BPM:
a. Administer Atropine 0.5mg IVP. Repeat every 5
minutes as needed to a maximum dose of 3 mg.
b. Initiate transcutaneous pacing if HR and B/P do not
improve following administration of Atropine.
3. Consider Dopamine infusion. Using a dial-a-flow and
extension tubing start at 10mcg/kg/min and titrate to a
systolic blood pressure of 90 mmHg.
San Joaquin County
Emergency Medical Services
Page 43 of 216
ALS Therapeutic Hypothermia
EMS Policy No. 5727
Effective: January 1, 2012
Supersedes: NA
5727 - ALS Therapeutic Hypothermia
POLICY: Implementation of therapeutic hypothermia for comatose
cardiac arrest patients with Return of Spontaneous Circulation
(ROSC) is a procedure endorsed by the American Heart Association
and outlined in the 2003 Advisory Statement by the ALS Task Force
of the International Liaison Committee on Resuscitation (ILCOR).
Mild hypothermia is thought to reduce cerebral oxygen demand post
arrest, and reduce the damage caused by inflammatory responses
that occur once cerebral perfusion is restored. Inducing mild
hypothermia in comatose patients post out-of-hospital cardiac arrest
has been shown to improve neurological function and decrease
mortality
I. INDICATIONS:
A. Patients 18 years of age and over:
1. The sustained return of spontaneous circulation for a
minimum of 5 minutes following cardiac arrest.
2. Persistent coma following cardiac arrest (VF, pulseless
VT, PEA, and Asystole): unresponsive, not following
verbal commands, not presenting with any purposeful
movements, GCS < 8. Brainstem reflexes and posturing
movements may be present.
3. Blood pressure ≥ 90 mmHg systolic.
4. SpO2 > 85%.
5. Blood glucose > 50 mg/dL.
II. CONTRAINDICATIONS:
A. Traumatic cardiac arrest.
B. GCS ≥ 8, and/or rapidly improving GCS.
C. Pregnancy.
D. DNR.
San Joaquin County
Emergency Medical Services
Page 44 of 216
ALS Therapeutic Hypothermia
EMS Policy No. 5727
Effective: January 1, 2012
Supersedes: NA
III. Treatment:
A. In conjunction with EMS Policy No. 5726, ALS Return of
Spontaneous Circulation, the paramedic should begin cooling
measures as follows:
1. Expose patient and apply eight (8) cold packs:
a. 2 on head
b. 2 on the neck over the carotid arteries
c. 1 in each axilla
d. 1 on each femoral artery at groin
2. Institute other cooling measures (e.g. removal of the
patient’s clothes, turn on ambulance AC in the patient
compartment and direct air flow over the patient).
3. Obtain a 12-lead ECG.
4. If patient begins to shiver contact the base hospital contact
for administration of Midazolam or if patient becomes
responsive, discontinue therapeutic hypothermia.
5. Advise the emergency department personnel upon arrival
that you have initiated the cooling process.
B.
Patient Transportation Considerations:
1. If the 12 lead ECG indicates a ST Elevated Myocardial
Infarction (STEMI), the patient shall be transported to a
STEMI receiving center.
2. If the 12 lead ECG does not indicate a STEMI, the patient
shall be transported to a receiving hospital with therapeutic
hypothermia capabilities.
San Joaquin County
Emergency Medical Services
Page 45 of 216
ALS Allergic Reaction/Anaphylaxis
EMS Policy No. 5731
Effective: January 1, 2012
Supersedes: February 1, 2007
5731 - ALS Allergic Reaction/Anaphylaxis
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II. Treatment:
A.
B.
C.
D.
Remove allergen if possible.
Mild reaction (urticaria only):
1. Consider diphenhydramine 50mg IM.
Moderate to severe reaction (Urticaria with one or more
of the following: swelling of mucous membranes, dyspnea,
wheezing, chest or throat tightness, abdominal cramps).
1. Consider epinephrine 1:1000, 0.01mg/kg SQ.
Maximum dose 0.5mg. (Use with caution in patients
over the age of 35 years and in patients with known
coronary artery disease or HTN.)
2. If wheezing, initiate hand held nebulizer dose of
Albuterol 5mg in 6 ml NS. May repeat as needed.
3. Consider IV NS TKO or saline lock.
4. Administer diphenhydramine 1mg/kg to maximum
dose of 50mg IM or IVP.
Anaphylaxis (Urticaria and signs of shock with any or all of
the following: swelling of mucous membranes, dyspnea,
wheezing, chest or throat tightness, abdominal cramps).
1. Administer epinephrine 1:1000, 0.01mg/kg SQ.
Maximum dose 0.5mg. (Use with caution in patients
over the age of 35 years and in patients with known
coronary artery disease or HTN.)
2. Establish large bore IV of NS and administer 250ml
fluid boluses as indicated.
3. If wheezing, initiate hand held nebulizer dose of
Albuterol 5mg in 6 ml NS. May repeat as needed.
San Joaquin County
Emergency Medical Services
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ALS Allergic Reaction/Anaphylaxis
EMS Policy No. 5731
Effective: January 1, 2012
Supersedes: February 1, 2007
4.
5.
6.
7.
Administer diphenhydramine 1mg/kg to maximum
dose of 50mg IM or IVP.
Consider intubation.
If patient is unresponsive with no palpable pulses,
administer epinephrine (1:10,000) 0.01mg/kg to max
dose of 0.5mg IV.
Consult base hospital physician for further orders.
San Joaquin County
Emergency Medical Services
Page 47 of 216
ALS Poisoning/Overdose
EMS Policy No. 5733
Effective: January 1, 2012
Supersedes: January 1, 2007
5733 - ALS Poisoning/Overdose
DEFINITIONS:
A.
Poisoning/Overdose: Ingestion and/or exposures to one or
more toxic substances, including alcohol.
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Identify substance. Bring any containers, labels or a sample (if
safe) into the hospital with the patient. Determine type, amount,
and time of the exposure.
III.
Treatment:
A. Establish IV of normal saline TKO or saline lock if indicated.
B. Initiate early transport and receiving hospital notification.
IV.
Substance Specific Treatment:
A. Opiates:
1. Manage airway and adequate ventilation.
2. Administer Naloxone titrated to maintain adequate
ventilation and airway control. Initial dose is 0.4mg - 2
mg IVP (maximum dose of 4mg). May administer
Intranasally (IN), IM, or SL if unable to start IV.
B. Cocaine/Amphetamines:
1. Consider activated charcoal 1gm/kg PO, not to exceed
50gms given orally if within the first 60 minutes of
ingestion.
2. Monitor for seizures and/or dysrhythmias and treat
accordingly.
3. For immediate control of psychomotor agitation,
consult Base Hospital Physician for sedative order.
San Joaquin County
Emergency Medical Services
Page 48 of 216
ALS Poisoning/Overdose
EMS Policy No. 5733
Effective: January 1, 2012
Supersedes: January 1, 2007
C. Insecticides (organophosphates, carbonates):
1. Skin exposure: decontaminate patient as soon as
possible (remove clothes, wash skin).
2. Avoid contamination of prehospital personnel.
3. Assess for SLUDGE (salivation, lacrimation, urination,
diaphoresis/diarrhea, gastric hypermotility, and
emesis/eye [small pupils and/or blurry vision]).
4. If indicated, administer Atropine 2.0 mg IVP slowly. If
no tachycardia or pupil dilation, give second dose of
2.0mg IVP. Note: Atropine does not reverse muscle
weakness that leads to respiratory failure.
5. Atropine can be toxic and orders for repeated doses
above 4 mg should be given by the Base Hospital
Physician Only.
D. Cyclic Antidepressants:
1. Anticipate rapid deterioration of condition.
2. In the presence of life-threatening dysrhythmias:
a. Hyperventilate if assisting ventilation.
b. Administer Sodium Bicarbonate 1mEq/kg IVP.
3. For seizures, see EMS Policy, No. 5753, Seizures.
4. For signs of shock see EMS Policy No. 5720,
Cardiogenic Shock.
E. Beta Blockers:
1. Consider activated charcoal 1gm/kg PO, not to exceed
50gms given orally if within the first 60 minutes of
ingestion.
2. Obtain blood glucose level.
F. Calcium Channel Blockers:
1. Consider activated charcoal 1gm/kg PO, not to exceed
50gms given orally if within the first 60 minutes of
ingestion).
2. If bradycardic and/or hypotensive, consult Base
Hospital Physician for order to administer Calcium
Chloride 500mg slow IVP over five (5) minutes. May
repeat x 1 in ten (10) minutes.
San Joaquin County
Emergency Medical Services
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ALS Poisoning/Overdose
EMS Policy No. 5733
Effective: January 1, 2012
Supersedes: January 1, 2007
G. Phenothiazine Reactions:
1. Administer Diphenhydramine 1 mg/kg IVP/IO to a
maximum of 50 mg. If unable to establish IV access,
administer IM.
H. Other Non-Caustic Drugs:
1. If patient is awake and alert consider activated
charcoal orally—1gm/kg PO, not to exceed 50gms if
within the first 60 minutes of ingestion.
2. Consider contacting Poison Control Center.
I. Hydrocarbons (kerosene, gasoline, lighter fluid,
turpentine, furniture polish, etc):
1. Do not induce vomiting-transport immediately.
J. Caustic Substances (acids/alkalis):
1. Do not induce vomiting.
San Joaquin County
Emergency Medical Services
Page 50 of 216
ALS Heat Illness
EMS Policy No. 5735
Effective: January 1, 2010
Supersedes: February 1, 2007
5735 - ALS Heat Illness
DEFINITIONS:
A.
Heat Cramps: Cramping of the most worked muscles
following replacement of exertion induced fluid losses
(sweating) with water; exhaustion, fatigue, flu-like symptoms,
normal/slightly elevated body temperature, normal mental
status with clear lung sounds.
B.
Heat Stroke: Triad of exposure to heat stress, altered
mental status and elevated body temperature; often
associated with absence of sweating, tachycardia and
hypotension.
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Specific Heat Cramps/Heat Exhaustion Treatment:
A. Move patient to cool environment and initiate passive cooling
measures.
B. If lungs clear, give fluid challenge of 250mls of NS. May
repeat x 4.
C. Recheck vital signs and lungs after every 250 mls.
III.
Specific Heat Stroke Treatment:
A. Move to cool environment and begin cooling measures:
1. Remove clothing and splash/sponge with water.
2. Place cool packs on neck, axilla, and inguinal areas.
3. Promote cooling by fanning.
4. IV NS 10 cc/kg (maximum of 2 liters) while repeating
vital signs and listening to lung sounds after every 250
mls.
San Joaquin County
Emergency Medical Services
Page 51 of 216
ALS Hypothermia
EMS Policy No. 5736
Effective: January 1, 2012
Supersedes: February 1, 2007
5736 - ALS Hypothermia
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Treatment:
A. Early receiving hospital notification.
B. Ensure patent airway.
C. Move to sheltered area minimizing patient’s physical exertion
or movement. Remove patient’s wet clothing and cover
with warm, dry sheet or blankets.
D. Establish IV of normal saline. If lungs clear, consider fluid
challenge of 10 ml/kg warm normal saline. Recheck vitals
following each infusion of 250 mls of normal saline.
E. Severe hypothermia (stuporous or comatose, dilated pupils,
hypotensive or pulseless, slowed to absent respirations):
1. Prepare to support ventilations using appropriate
airway adjuncts. If spontaneous respirations are
present, intubate only if necessary to prevent
aspiration or if ventilations are inadequate (4-6/min
may be adequate).
2. Ventilate using warm, humidified oxygen if available.
Avoid hyperventilating the patient.
3. Observe for organized rhythm and pulses for one
minute. If organized rhythm present, move quickly
but gently to warm environment (ambulance) and
provide appropriate treatment for cardiac rhythm per
EMS Agency policy.
San Joaquin County
Emergency Medical Services
Page 52 of 216
ALS Envenomation
EMS Policy No. 5738
Effective: February 1, 2007
Supersedes: SJ-A61
5738 - ALS Envenomation
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Treatment:
A. Refer to EMS Policy No. 5535, Basic Life Support
Envenomation.
B. Insect bite:
1. Scrape away stinger (if appropriate).
2. Observe for Allergic Reaction/Anaphylaxis and treat
accordingly (EMS Policy No. 5731).
3. Apply cold packs for pain management.
C. Snake bite:
1. Immobilize extremity at or below heart level.
2. Circle swelling and note time.
3. Apply a light constricting band about 2" above and
below the bite. The purpose of constricting bands is
to restrict lymphatic flow, not blood, so they should
not be too tight. Check pulses below the bands and
readjust the bands as necessary when they tighten
due to swelling.
4. Consider pain management.
5. Initiate early receiving hospital notification.
6. Expedite transport.
For snakebite, do NOT:
1. Apply ice to site.
2. Make incisions over bite.
3. Apply a tourniquet.
4. Delay transport to initiate IV.
San Joaquin County
Emergency Medical Services
Page 53 of 216
ALS ALOC
EMS Policy No. 5751
Effective: October 16, 2013
Supersedes: January 1, 2012
5751 - ALS Altered Level of Consciousness (ALOC)
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Obtain a complete patient history including current medications.
III.
Identify and document neurological deficits.
IV.
Consider indications for spinal immobilization precautions, per
EMS Agency Policy No. 5115 Cervical Spine Immobilization.
V.
Consider potential causes (hypoglycemia, stroke, neurological
injury, syncope, overdose, and sepsis).
VI.
Treatment:
A.
B.
C.
D.
Establish IV/IO of normal saline and administer a 10ml/kg
bolus if signs of shock are present (maximum infusion of
2 liters).
Check blood glucose.
1. Glucose paste may be administered if the patient is a
known diabetic, can hold head upright, can self administer medication, and has an intact gag reflex.
2. If blood sugar is less than 60 mg/dl, administer either
Dextrose 50% 25 Gms IVP; or Dextrose 10% 50 ml
IV/IO bolus, repeated every minute until GCS is 15.
Maximum dose of Dextrose 10% is 10 ml/kg.
If narcotic overdose is suspected, administer Naloxone
0.4mg-2mg IV titrated to achieve effective respirations
(maximum dose 4 mg).
If unable to obtain IV access, may administer Naloxone 2
mg IM or Intranasally (1mg in each nares using approved
San Joaquin County
Emergency Medical Services
Page 54 of 216
ALS ALOC
EMS Policy No. 5751
Effective: October 16, 2013
Supersedes: January 1, 2012
E.
F.
atomizer attached to syringe).
Treat rhythm disturbances as appropriate.
Transport immediately if progressive neurologic deficit is
evident or unable to maintain effective airway.
San Joaquin County
Emergency Medical Services
Page 55 of 216
ALS Seizures
EMS Policy No. 5753
Effective: October 16, 2013
Supersedes: January 1, 2012
5753 - ALS Seizures
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Protect from injury.
III.
Initiate cooling measures, if febrile patient.
IV.
Treatment:
A.
B.
C.
D.
If witnessed by prehospital personnel to be seizing for > 2
minutes or patient has two or more seizures without
regaining consciousness;
Establish IV of normal saline TKO.
1.
Administer Midazolam 2 mg slow IVP or 4 mg
intranasally (2 mg in each nares using a mucosal
atomizer device).
a.
May be administered IM if unable to obtain
vascular access, or IN device unavailable.
b.
May be repeated if necessary every 5 minutes
to a maximum dose of 10 mg.
Obtain blood glucose level.
1.
If glucose less than 60 mg/dl, administer Dextrose
50% 25Gms IV/IO or administer Dextrose 10% 50ml
IV/IO bolus, repeated every minute until GCS is 15.
Maximum dose is 10 ml/kg.
If narcotic overdose suspected:
1.
Administer Naloxone IVP in 0.4 mg increments
titrated to achieve effective respirations (maximum
dose 4 mg) or administer IN 1 mg in each nares.
2.
If unable to establish an IV and narcotic overdose
suspected, may administer Naloxone 2mg IM, SQ,
or SL.
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Emergency Medical Services
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ALS Seizures
EMS Policy No. 5753
Effective: October 16, 2013
Supersedes: January 1, 2012
E.
V.
For pregnant patients, treat as indicated for seizures per
this policy and refer to EMS Policy No. 5761, ALS
Gynecological Emergencies.
Continued Seizure Activity:
A.
B.
Be prepared to assist ventilations.
Make base contact if seizures continue after maximum
dose of Midazolam.
San Joaquin County
Emergency Medical Services
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ALS Acute Stroke
EMS Policy No. 5754
Effective: February 1, 2012
Supersedes: February 1, 2007
5754 - ALS Acute Stroke
PROCEDURE:
I. Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II. Assess patient using the Cincinnati Prehospital Stroke Scale
(CPSS) and document findings. The patient is considered a
possible stroke if any of the tested signs/symptoms is
abnormal.
III. Initiate early notification and transport to the receiving hospital.
IV. Treat patient according to EMS Policy No. 5751, ALS Altered
Level of Consciousness (ALOC), including blood glucose level
determination.
V. Transport without delay if progressive neurologic deficit is evident
or unable to maintain effective airway.
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Emergency Medical Services
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ALS Gynecological Emergencies
EMS Policy No. 5761
Effective: January 1, 2012
Supersedes: February 1, 2007
5761 - ALS Gynecological Emergencies
DEFINITIONS:
A. “Severe Pre-Eclampsia” means a third trimester pregnancy with
hypertension (BP systolic greater than 160 mmHg, diastolic
greater than 110 mmHg), mental status changes, visual
disturbances and/or peripheral edema.
B. “Eclampsia” means third trimester pregnancy with hypertension
(BP systolic greater than 160 mmHg, diastolic greater than 110
mmHg), mental status changes, visual disturbances, peripheral
edema, seizures and/or coma.
C. “High Risk Obstetrical” means a pregnancy is one in which
some condition puts the mother, the developing fetus, or both at
higher-than-normal risk for complications during or after the
pregnancy and birth.
INFORMATION NEEDED:
A. Last menstrual period and possibility of pregnancy.
B. Duration and amount of any bleeding.
C. If pregnant – month of pregnancy, any anticipated problems
e.g. pre-eclampsia, lack of prenatal care, expected multiple
births).
D. Presence of contractions, cramps, or discomfort.
E. Pertinent past medical history.
OBJECTIVE FINDINGS:
A. Estimated blood loss.
B. Low blood pressure or high blood pressure.
C. Spontaneous abortion – passage of products of conception,
fetus less than 20 weeks gestation.
D. Headaches, blurred vision.
E. Severe abdominal cramps or sharp abdominal pain.
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ALS Gynecological Emergencies
EMS Policy No. 5761
Effective: January 1, 2012
Supersedes: February 1, 2007
PROCEDURE:
I. Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II. Obtain appropriate gynecological medical history.
III. Without Shock:
A. Treatment:
1. Non-pregnant patient:
a. Establish IV of normal saline TKO.
b. If post-partum and placenta has delivered, perform
fundal massage and put infant to breast (as
appropriate).
2. Pregnant patient:
a. Place patient in left lateral position.
b. If any bleeding in third trimester, establish two (2) large
bore IVs of normal saline TKO.
c. Consult base hospital.
IV. With Shock:
A. Treatment:
1. Non-pregnant patient:
a. Establish a large bore IV of normal saline. Administer a
fluid challenge of 10 ml/kg. Recheck vital signs after
each infusion of 250 mls normal saline.
b. Consider second large bore IV of normal saline.
c. If post-partum and placenta delivered, perform fundal
massage and put infant to breast (as appropriate).
2. Pregnant Patient:
a. Position in left lateral position if concern for spinal
injury is not present. If concern is present, keep in
spinal precaution and manually attempt movement of
uterus towards left side with gentle traction.
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Emergency Medical Services
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ALS Gynecological Emergencies
EMS Policy No. 5761
Effective: January 1, 2012
Supersedes: February 1, 2007
b. Establish a large bore IV of normal saline. Administer
a fluid challenge of10 ml/kg. Recheck vital signs after
each infusion of 250 mls normal saline.
c. Consider second IV of normal saline.
V. Pre-Eclampsia/Eclampsia:
A. Treatment:
1. Position patient on left side.
2. Transport quickly in a quiet environment (no siren).
3. Establish IV of normal saline TKO, while enroute to
hospital.
4. Treat seizures according to EMS Policy No. 5753,
Seizures.
5. Consult Base Hospital Physician to obtain order for
Magnesium Sulfate 2 gms slow IVP over 3 – 5 minutes.
VI. High Risk Obstetrical:
A. High Risk Obstetrical patients are patients that are pregnant
who have signs and symptoms of active labor or vaginal
bleeding with one or both of the following conditions:
1. No history of prenatal care.
2. Estimated gestational age from 20 to 33 weeks.
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ALS Childbirth
EMS Policy No. 5764
Effective: January 1, 2012
Supersedes: January 1, 2010
5764 - ALS Childbirth
DEFINITIONS:
A.
B.
C.
Imminent Delivery: Regular contractions, bloody show, low
back pain, feels like bearing down, crowning.
Breech Presentation: Presentation of buttocks or both feet.
Limb Presentation: Presentation of single extremity.
INFORMATION NEEDED:
A. Estimated due date, month of pregnancy, any anticipated
problems (e.g. pre-eclampsia, lack of prenatal care, expected
multiple births).
B. Onset of regular contractions, current frequency of contractions,
rupture of membranes.
C. Urge to bear down, number of previous pregnancies and live
births.
OBJECTIVE FINDINGS:
A. Observe perineal area for fluid, bleeding, crowning (during
contraction), abnormal presentation (breech, extremity, cord).
PROCEDURE:
I.
II.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
Treatment:
A. Normal Delivery:
1. Establish IV of normal saline TKO.
2. Assist mother with delivery, using clean, preferably sterile
technique.
3. Check for cord around the neonate’s neck, and gently slide
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Emergency Medical Services
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ALS Childbirth
EMS Policy No. 5764
Effective: January 1, 2012
Supersedes: January 1, 2010
4.
5.
6.
7.
8.
overhead if possible. If the cord is tight, clamp and cut the
cord to unwind the cord and deliver neonate as quickly as
possible.
Suction the neonate’s mouth and nose with bulb syringe.
Perform neonatal resuscitation if needed.
Dry and wrap the neonate (especially the head). Keep the
neonate warm and place with mother (if possible).
Deliver placenta and place in a bio-hazard bag and transport
to hospital.
Perform fundal message to help stop postpartum bleeding.
B. Complicated Delivery:
1. Apply high flow oxygen.
2. Establish IV of normal saline TKO.
3. Begin rapid transport to a Neonate/High Risk Pregnancy
receiving hospital and make early base hospital contact.
4. Prepare for neonatal resuscitation.
5. Breech Delivery:
a. Assist with and continue delivery if possible.
b. Provide airway for neonate with gloved hand if unable to
continue delivery.
c. If unable to deliver, place mother in shock position.
6. Prolapsed Cord:
a. Place mother in shock position, elevate hips with pillows,
if possible place mother in knee chest position.
b. If cord is present, assess cord for palpable pulse.
c. If strong regular pulse is absent, gently insert gloved
hand into vagina to relieve pressure on cord.
d. Cover exposed cord with saline soaked dressing.
7. High Risk Delivery: Any newborn who meets one or more of
the following conditions shall be transported to a
designated Neonatal Intensive Care Center in accordance
with EMS Policy No. 5201, Medical Patient Destination:
a. Significant anoxia either prior to or during transport.
b. Estimated gestational age less than 33 weeks.
8. Neonatal patients who are in cardiac/respiratory arrest
should be treated in accordance with EMS Policy No. 5201,
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ALS Childbirth
EMS Policy No. 5764
Effective: January 1, 2012
Supersedes: January 1, 2010
Medical Patient Destination and be transported to the
closest receiving hospital.
Notes:
 First priority in childbirth is assisting mother with delivery of
child.
 The primary enemy of the newborn is hypothermia which can
occur in minutes.
 Ensure the newborn has a clear airway. Suction with bulb
syringe as needed.
 Keep baby at or below the level of the mother’s heart until cord
is clamped.
 Do not pull on the umbilical cord.
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Emergency Medical Services
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ALS Bronchospasm
EMS Policy No. 5771
Effective: January 1, 2010
Supersedes: June 1, 2008
5771 - ALS Bronchospasm
DEFINITIONS:
A.
Bronchospasm: Acute onset of respiratory difficulty, including
toxic inhalation, asthma, COPD and other etiologies that may
induce bronchospasm.
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Treatment:
A. Mild to moderate bronchospasm:
1. Initiate nebulizer dose of Albuterol 2.5mg in 3 ml NS
and Atrovent 0.5mg in 2.5 ml NS.
2. Repeat Albuterol prn.
B. Severe bronchospasm:
1. Assist ventilations with 100% oxygen and initiate an
inline nebulizer treatment of Albuterol 2.5 mg in 3 ml
NS and Atrovent 0.5mg in 2.5 ml NS
2. Continue Albuterol 2.5 mg nebulizer/bag-valve-mask.
3. Epinephrine 1:1000, 0.01 mg/kg SQ. Maximum dose
0.5 mg. (Use with caution in patients over 35 years
of age and in patients with coronary artery disease).
4. Consider CPAP (see EMS Policy No. 2554,
Continuous Positive Airway Pressure).
5. Ensure early receiving hospital notification.
Note: Breath actuated nebulizer should only be utilized with patients
who have adequate spontaneous respirations. Patients that require
ventilatory support should have nebulized medications administered
via standard nebulizer equipment.
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Emergency Medical Services
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ALS Acute Pulmonary Edema
EMS Policy No. 5772
Effective: October 16, 2013
Supersedes: February 2, 2010
5772 - ALS Acute Pulmonary Edema
DEFINITIONS:
A.
Acute Pulmonary Edema: Acute onset of respiratory difficulty
with systolic blood pressure over 120. May have history of
cardiac disease, rales, or occasional wheezes.
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Treatment:
A.
B.
C.
D.
E.
Oxygen 12 - 15 lpm via non-rebreather mask.
Initiate IV access.
Nitroglycerin 0.4 mg spray or tablets, repeat every 5
minutes if systolic blood pressure remains greater than
100mmHg.
If patient is in severe respiratory distress, consider CPAP
(Policy No. 2554, Continuous Positive Airway Pressure).
If using CPAP and patient cannot tolerate further
sublingual nitroglycerin, apply one (1) inch of
nitroglycerine paste to the patient’s chest wall. Remove
the paste if systolic blood pressure falls below 90mmHg.
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ALS Airway Obstruction
EMS Policy No. 5774
Effective: January 1, 2010
Supersedes: February 1, 2007
5774 - ALS Airway Obstruction
DEFINITION:
A. Severe obstruction: Signs of severe obstruction include poor air
exchange, increased breathing difficulty, silent cough, cyanosis,
and/or inability to speak or breathe.
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Follow EMS Policy No. 5573, BLS Obstructed Airway – Adult.
III.
If no signs of severe obstruction present, maintain airway
and apply oxygen.
IV.
If patient has signs of severe obstruction and/or is
unconscious:
A. Continue abdominal and chest thrusts.
B. Assist ventilation with BVM.
C. Use direct laryngoscopy and Magill forceps to remove
foreign body.
D. If unsuccessful, attempt endotracheal intubation.
E. If unsuccessful and unable to ventilate adequately with BVM,
consider Needle Cricothyrotomy (Policy No. 2549).
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ALS Burn Care
EMS Policy No. 5782
Effective: February 24, 2012
Supersedes: February 1, 2007
5782 - ALS Burn Care
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Treatment:
A. Stop the burning process.
B. Follow EMS Policy No. 5586, Basic Life Support Burns.
C. Consider early advanced airway intervention if airway and/or
facial burn is involved.
D. Superficial burns:
1. Consider initiating IV of NS at TKO rate.
2. For pain management, in absence of hypotension and
no narcotic allergies, administer Morphine Sulfate per
Adult Pain protocol.
E. Major burns (>20% total body surface area [BSA]):
1. Initiate large bore IV access. Initiate fluid replacement
using the Parkland Formula.
2. For pain management, in absence of hypotension and
no narcotic allergies, administer Morphine Sulfate per
EMS Policy No. 5707, Adult Pain Management.
III.
Initiate early notification of receiving hospital and consult with
base hospital as appropriate.
Parkland Formula: Amount of IV fluid infused during the first 24 hours = weight in kg X 4 ml
X % BSA burned. Administer one-half of the calculated fluid during the first 8 hours. Note: The
starting time is considered the time at which the burn occurred and not the time at which
medical care is initiated. To obtain an initial hourly infusion rate, use the following
formula:
(4ml x kg x % BSA) / 8
Example: 120kg male with 20% BSA burn = (4 x 120 x 20) / 8 = 1200 ml/hr infusion rate
San Joaquin County
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ALS Adult Trauma Treatment
EMS Policy No. 5783
Effective: October 16, 2013
Supersedes: January 1, 2012
5783 - ALS Adult Trauma Treatment
PROCEDURE:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
II.
Do not delay transport.
III.
Treatment:
A. Patient with Unstable Airway:
1. Secure airway using the simplest, effective method, while
maintaining spinal immobilization, if indicated.
B. Hypovolemic Patient
1. Establish 1-2 large bore IV(s) of normal saline.
a. If patient is hypotensive, administer normal saline wide
open until systolic blood pressure greater than 90
mmHg or 2 liters has been infused, and then reduce
infusion TKO.
b. Continue to monitor blood pressure and if the systolic
blood pressure remains less than 90 mmHg after initial
bolus, give 250 ml boluses until BP greater than 90.
c. Reassess the patient after each bolus.
C. Pain Management: In absence of hypotension and no
narcotic allergies, administer Morphine Sulfate per EMS
Policy No. 5707, Adult Pain Management.
D. Head, Neck, and Facial Trauma Considerations:
1. If brain injury is suspected, elevate the head of the
patient, (as long as no signs of shock are present).
2. Maintain patent airway. If intubation is indicated and time
allows, premedicate brain injury patients with Lidocaine
1.5mg/kg IVP prior to intubation.
E. Chest Trauma Considerations:
1. Impaled object – Immobilize and leave in place.
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Emergency Medical Services
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ALS Adult Trauma Treatment
EMS Policy No. 5783
Effective: October 16, 2013
Supersedes: January 1, 2012
2. Flail chest – Stabilize chest, observe for tension
pneumothorax.
3. Open chest wound – Cover wound with loose dressing
(do not seal). Continuously monitor patient for tension
pneumothorax.
4. Tension pneumothorax – Perform needle thoracostomy
(or remove any occlusive dressing covering an open
chest wound).
5. Cardiac Tamponade – If systolic BP is less than 90
mmHg, treat as traumatic shock.
6. Cardiac Contusion – Monitor for dysrhythmias and treat
accordingly.
F. Abdominal Trauma Considerations:
1. Impaled object – Immobilize and leave in place.
2. Evisceration of organs – Cover eviscerated organs with
saline soaked gauze. Do not attempt to replace organs
into the abdominal cavity.
3. Genital injuries – Cover genitalia with saline soaked
gauze. If necessary, apply direct pressure to control
bleeding. Treat amputation as extremity amputation.
G. Extremity Trauma Considerations: EMS Policy No. 5585,
BLS Extremity Trauma.
H. Amputation – Cover amputated part with dry sterile dressing
and place in sealed plastic bag (or wrapped with plastic)
on top of ice or cold pack.
I. Traumatic Arrest:
1. Patient transport considerations:
a. If the estimated transport time (from time of traumatic
arrest to arrival at the Trauma Center) is < ten minutes,
continue BLS resuscitation and immediately transport
the patient to the Trauma Center. Consider providing
an advanced airway enroute.
b. If the estimated transport time (from time of traumatic
arrest to arrival at the Trauma Center) is > ten minutes
begin BLS resuscitation and attach the ECG for rhythm
check.
2. Treatment:
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Emergency Medical Services
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ALS Adult Trauma Treatment
EMS Policy No. 5783
Effective: October 16, 2013
Supersedes: January 1, 2012
a. For patients in asystole provide BLS resuscitation and
contact the Base Hospital Physician to request orders
to cease resuscitative efforts.
b. For patients in ventricular fibrillation or pulseless VTach, provide BLS resuscitation and defibrillate the
patient once.
i. If no ROSC contact the Base Hospital Physician to
request orders to cease resuscitative efforts.
ii. If ROSC transport the patient to the trauma center.
While enroute start two large bore IVs and
administer Lidocaine 1mg/kg IVP/IO. Consider
providing an advanced airway enroute.
c. For patients in PEA provide BLS resuscitation and
consider treating for tension pneumothorax and
hypovolemia:
i. If no ROSC contact the Base Hospital Physician to
request orders to cease resuscitative efforts.
ii. If ROSC transport the patient to the trauma center.
Consider providing an advanced airway enroute.
San Joaquin County
Emergency Medical Services
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ALS Nerve Agent
EMS Policy No. 5790
Effective: July 1, 2010
Supersedes: NA
5790 - ALS Nerve Agent Exposure
DEFINITIONS:
A. “CHEMPACK” means a voluntary component of the Federal
Strategic National Stockpile Program (SNS) operated by the
Centers for Disease Control and Prevention (CDC) for the benefit
of the U.S. civilian population. The CHEMPACK program’s
mission is to provide state and local governments a sustainable
nerve agent antidote cache that increases their capability to
respond quickly to a nerve agent event such as a terrorist attack.
B. “Nerve Agents” mean an extremely toxic organophosphate-type
chemicals, including GA (tabun), GB (sarin), GD (soman), GF
(cyclosarin), and VX, which attack the nervous system and
interfere with chemicals that control nerves, muscles, and glands.
They are odorless and invisible and can be inhaled, absorbed
through the skin, or swallowed.
C. “Nerve agent antidotes” means to counteract the effects of nerve
agent by 1) decreasing symptoms and 2) regenerating an enzyme
that is wiped out by nerve agents. Nerve agent antidotes are
among the five (5) actions taken after exposure to nerve agent, as
follows:
1. Terminate the exposure (stop breathing and move quickly to
good air; decontaminate victims and emergency medical
staff within minutes of exposure; don personal protective
equipment; ventilate pre-hospital and hospital treatment
areas).
2. Support ventilation.
3. Provide atropine therapy.
4. Provide oxime therapy.
5. Provide antiseizure therapy.
6. Document treatment on the triage tag.
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Emergency Medical Services
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ALS Nerve Agent
EMS Policy No. 5790
Effective: July 1, 2010
Supersedes: NA
PROCEDURE
I. As soon as the scene is identified as hazardous materials incident,
secure, isolate, and deny entry, ensure appropriate resources are
responding, and notify the base hospital.
II. Decontamination should precede any treatment by EMS
personnel.
III. All Providers will ensure personal safety by assuring adequate
decontamination of victims is conducted and all response
personnel will utilize appropriate personal protective (PPE).
Medical procedures within the Exclusion Zone (Hot
Zone/contaminated area) will only be performed by personnel who
have specific training to allow them to function in that area. Under
no circumstances should responding personnel at any level of
expertise use Personal Protective Equipment or assist in patient
decontamination without completing the required training.
IV. EMTs and paramedics that have been trained and equipped may
utilize the nerve agent protocol to self-administer EMS
CHEMPACK auto-injectors when they have been exposed to
nerve agents and are symptomatic.
V. Once the EMS CHEMPACK is deployed to an active incident, the
Medical Group Supervisor may contact the Base Hospital and
request that all paramedics on that incident operate under
standing orders.
VI. TREATMENT:
A. Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care and EMS Policy No. 5701,
Routine ALS Care.
B. Position the patient on side (recovery position).
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Emergency Medical Services
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ALS Nerve Agent
EMS Policy No. 5790
Effective: July 1, 2010
Supersedes: NA
C. Monitor Respiratory status closely. Use airway adjuncts,
administer high flow O2, suction, ventilate, and advanced
airways as indicated.
D. Establish IV, NS. Titrate to maintain Systolic BP of greater
than 90 mm Hg.
E. Nerve agent medications should never be given
prophylactically.
F. The auto-injectors included in EMS CHEMPACK Nerve Agent
Antidote Kits will be used only by those paramedics that have
been trained in their use. Paramedics may administer atropine
IM/IV in situations where EMS CHEMPACK Nerve Agents
Antidote Kits are not available.
G. Administer antidotes as outlined below.
H. Seizure: After Atropine administration: Valium: Adults - titrate
2.5 - 10 mg slow IV push to effect. If unable to obtain and IV
administer IM 10 mg given deep IM (slowly). If recurrent or
persistent seizure, repeat X 1 IV/IM to a maximum of 20 mg.
Pediatric (less than 40kg, or 9 years old) 0.05-0.3 mg IV over
2-3 min q 15-30 min, titrated to effect; not to exceed 10 mg
LEVELS OF EXPOSURE
MILD
MODERATE
Rhinorrhea
Salivation
Chest tightness
Lacrimation
Dyspnea
Urination
Bronchospasm
Defecation
GI symptoms
Emesis
Miosis
San Joaquin County
Emergency Medical Services
SEVERE
Jerking
Twitching
Staggering
Headache
Drowsiness
Coma
Seizures
Apnea
Page 74 of 216
ALS Nerve Agent
EMS Policy No. 5790
Effective: July 1, 2010
Supersedes: NA
Exposure:
Onset
"Exposed," but
Asymptomatic:
N/A
MILD (Vapor):
Seconds
MILD
(Liquid):
Minutes
to Hours
MODERATE:
Seconds
to Hours
TREATMENT
ATROPINE (2 Mg Auto-injector)
2-PAM (600 Mg Auto-injector)
NONE
Monitor every 15 minutes
Adult: One (1) Auto-injector, (2 mg) IM.
Peds: 0.02 mg/kg, min. dose 0.1 mg.
Seconds
to Hours
Monitor every 15 minutes
Adult: One (1) Auto-injector, (600 mg) IM,
one time only, prn. If S & SX continue 5
min. after administering Atropine, administer
2-Pam Cl.
MR q 3-5 min. prn.
Adult: Two (2) Auto-injectors, (4mg) IM.
Peds: 0.02 mg/kg, min. dose 0.1 mg.
MR q 3-5 min. prn.
Three (3) Auto-injectors (6 mg) IM.
SEVERE:
NONE
Peds: If Bp unobtainable, consider
administering MARK I Kit(s).
San Joaquin County
Emergency Medical Services
Peds: N/A, DO NOT Administer.
Adult: One (1) Auto-injector, (600 mg) IM.
MR X1 in 5-10 min. prn.
Peds: N/A, DO NOT Administer.
Adult: Three (3) Auto-injectors, (1.8 Gms)
IM, MAX dose. Do NOT repeat.
Peds: N/A, DO NOT Administer.
Page 75 of 216
San Joaquin County EMS Agency
San Joaquin County
Emergency Medical Services
Page 76 of 216
San Joaquin County EMS Agency
SAN JOAQUIN COUNTY
EMERGENCY MEDICAL SERVICES
Pediatric Advanced Life Support Treatment Policies
San Joaquin County
Emergency Medical Services
Page 77 of 216
Pediatric Routine Medical Care
EMS Policy No. 5800
Effective: January 1, 2012
Supersedes: June 1, 2007
5800 - Pediatric Routine Medical Care
POLICY:
I. Pediatrics – Patients that are fourteen (14) years of age or
younger, and fall within the limits of the Broselow Pediatric
Emergency Tape shall be treated per the San Joaquin County
ALS Pediatric Protocols. The Broselow Pediatric Emergency Tape
is considered an accurate source of medical information and is in
line with San Joaquin County ALS Pediatric Policies. If in doubt
concerning whether to treat patient as an adult or pediatric (i.e.,
obese child or smaller adult) contact the base hospital.
A.
B.
C.
Neonate/newborn: Birth to one month of age.
Infant: One month to one year of age.
Child: One year to twelve years of age.
II. If at any time during the primary survey further intervention is
required, refer to the appropriate treatment policies.
III. A pediatric length-based resuscitation tape will be used to
determine drug doses, fluid volumes, defibrillation settings, and
equipment sizes. The tape is designed to estimate a child’s weight
based on length (head to heel). The tape also includes information
about abnormal vital signs.
A. All patients will have a complete physical assessment
completed including:
B. Complete a primary survey.
1. Airway: Assessment of airway patency and protective
reflexes.
2. Breathing: Assessment of ventilatory status including signs
and symptoms of respiratory distress/failure. This
assessment shall include a respiratory rate and pulse
oximetry.
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Pediatric Routine Medical Care
EMS Policy No. 5800
Effective: January 1, 2012
Supersedes: June 1, 2007
3. Circulation: Assessment of perfusion and circulatory status
to include: heart rate, mental status, skin signs, quality of
pulse, capillary refill, and blood pressure.
4. Disability: Evaluation of level of consciousness using the
AVPU pneumonic (alert, verbal, pain, unresponsive).
C. Perform a secondary survey.
1. Perform a head to toe assessment: A complete physical
assessment shall be completed with supporting
documentation.
2. Obtain patient history.
3. Assess environment and provide psychosocial support to
patient and family.
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Pediatric Pulseless Arrest: Asystole/PEA
EMS Policy No. 5810
Effective: July 24, 2014
Supersedes: January 1, 2012
5810 - Pediatric Pulseless Arrest: Asystole/PEA
POLICY:
I.
Perform routine ALS/BLS medical care while confirming
pulselessness and appropriate (non shockable) rhythm on the
cardiac monitor.
II. Treatment:
A.
B.
C.
D.
E.
F.
G.
H.
Perform immediate, effective CPR.
Continue CPR, maintain patent airway with 100% oxygen
via BVM.
Provide appropriate airway management with simplest
most effective airway adjunct.
Establish IV/IO of normal saline TKO. Do not delay
transport. If unable to obtain vascular access, begin
transport and continue efforts while en route.
Consider reversible causes and treat as indicated.
Administer Epinephrine 0.01 mg/kg (1:10,000) IVP/IO,
max of 1 mg. Repeat every 3-5 minutes.
Continue CPR for 5 cycles/2 minutes and recheck
pulse/rhythm.
Initiate transport to receiving hospital if not already en
route. Note: In cases where transport is not available or
practical an order to terminate resuscitation efforts may
be given by the Base Hospital Physician for patients in
Asystole or PEA < 30 that are unresponsive to treatment
(See EMS Policy No. 5103, Determination of Death).
Note: CPR should be administered for complete sequences
of 5 cycles/2 minutes. During 5 cycles/2 minutes, establish
IV/IO and administer medications during CPR to minimize
interruptions in chest compressions.
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Pediatric Pulseless Arrest: VFIB/VTACH
EMS Policy No. 5811
Effective: January 1, 2012
Supersedes: June 1, 2007
5811 - Pediatric Pulseless Arrest: Ventricular
Fibrillation/Ventricular Tachycardia
POLICY:
I.
Perform routine ALS/BLS medical care while confirming
pulselessness and appropriate (shockable) rhythm on the cardiac
monitor.
II.
Treatment:
A. If unwitnessed arrest, perform and complete initial CPR
sequence (5 cycles/2 minutes) while preparing equipment.
B. Defibrillate patient one (1) time at 2J/kg and then resume CPR
immediately for 5 cycles/2 minutes (do not check rhythm or
pulse after shock).
C. Continue CPR and maintain patent airway with 100% oxygen
via BVM.
D. Provide appropriate airway management.
E. Check rhythm/pulse. If shockable rhythm, defibrillate 1 x @
4J/kg and resume CPR immediately after the shock.
F. Continue CPR for 5 cycles/2 minutes while performing
appropriate airway management.
G. Establish IV/IO of normal saline TKO.
H. After 2 minutes of CPR, check pulse and rhythm. If no pulse,
resume CPR and administer Epinephrine 0.01 mg/kg IVP/IO.
Repeat every 3-5 minutes.
I. After 2 minutes of CPR, check rhythm and if appropriate
defibrillate at 4J/kg.
J. Resume and continue CPR for 5 cycles/2 minutes.
K. Administer Lidocaine 1mg/kg IVP/IO (may repeat x 1 in 3-5
minutes).
L. After 2 minutes of CPR, check rhythm and if appropriate
defibrillate at 4J/kg. If non shockable rhythm present, treat
according to appropriate policy.
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Pediatric Pulseless Arrest: VFIB/VTACH
EMS Policy No. 5811
Effective: January 1, 2012
Supersedes: June 1, 2007
Note: CPR should be administered for complete sequences of 5 cycles/2
minutes, between each shock. During 5 cycles/2 minutes, establish
IV/IO and administer medications during CPR (before or after shock) to
minimize interruptions in chest compressions.
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Pediatric Bradycardia
EMS Policy No. 5812
Effective: January 1, 2012
Supersedes: February 15, 2010
5812 - Pediatric Bradycardia
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care, and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. Treatment:
A. Assure adequate oxygenation and ventilation. Most
bradycardia in children is due to hypoxia.
B. Check blood glucose.
C. Check temperature and begin warming if hypothermic.
D. Normal Perfusion:
1. Establish IV of normal saline TKO.
E. Decreased Perfusion and/or Respiratory Distress:
1. Establish IV of normal saline and administer a fluid bolus of
20ml/kg.
2. Recheck vital signs.
3. If patient remains bradycardic despite adequate
oxygenation and ventilation, administer Epinephrine
0.01mg/kg IVP/IO to a maximum dose of 1mg. May repeat
epinephrine dose every 3-5 minutes as indicated.
4. If increased vagal tone or AV block present, administer
Atropine 0.02mg/kg IVP/IO, minimum dose 0.1mg and
maximum dose 1mg. May repeat once.
5. If bradycardia remains, consult with Base Hospital
Physician.
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Pediatric Tachycardia with Pulses
EMS Policy No. 5813
Effective: June 15, 2007
Supersedes: SJ-P05
5813 - Pediatric Tachycardia with Pulses
DEFINITIONS:
A. “Sinus Tachycardia” indicates a rapid heart rate with a narrow
QRS (less than or equal to 0.08 sec.) that is less than 220/min. in
an infant or less than 180/min. in a child.
B. “Supraventricular Tachycardia” indicates a rapid heart rate with
a narrow QRS (less than or equal to 0.08 sec.) that is greater
than 220/min. in an infant or greater than 180/min. in a child.
C. “Ventricular Tachycardia” indicates a rapid heart rate with a wide
QRS (greater than 0.08 sec.).
POLICY:
I.
Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II.
Treatment:
A. Consider pediatric normal values for heart rate. Infants may
have heart rates as high as 220/minute and children may have
heart rates as high as 180/minute in the presence of fever,
anxiety, and/or pain.
B. Manage airway and ventilations as indicated.
C. Establish IV of normal saline TKO.
D. Treat according to rhythm:
1. Sinus Tachycardia:
a. Consider and treat underlying cause (fever, pain, trauma,
hypovolemia).
b. Consider fluid bolus of normal saline 20 ml/kg IVP/IO.
May repeat as indicated.
c. Recheck vital signs after each bolus.
d. If suspected trauma, refer to EMS Policy No. 5833,
Pediatric Trauma.
2. Supraventricular Tachycardia:
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Pediatric Tachycardia with Pulses
EMS Policy No. 5813
Effective: June 15, 2007
Supersedes: SJ-P05
a. Conscious:
1. Attempt vagal maneuver.
2. If unsuccessful, administer Adenosine 0.1mg/kg rapid
IVP/IO push to a maximum dose of 6 mg followed by
rapid 20ml flush of normal saline.
3. If unsuccessful, administer Adenosine 0.2mg/kg rapid
IVP/IO push (to a maximum dose of 12 m) followed by
rapid 20ml flush of normal saline.
b.
Unconscious:
1. Transport without delay.
2. Administer Adenosine 0.1mg/kg rapid IVP/IO push, to
a maximum dose of 6mg followed by rapid 20ml
flush of normal saline while setting up to perform
cardioversion.
3. Consult Base Hospital Physician for orders:
a) Perform synchronized cardioversion at 1 J/kg.
b) If no response at 1 J/kg, perform synchronized
cardioversion at 2 J/kg.
3. Ventricular Tachycardia:
a. If no pulse refer to EMS Policy No. 5811, Pulseless
Arrest: VFIB/VTACH.
b. Conscious :
1. Administer Lidocaine 1mg/kg IVP/IO. May repeat once
in 3-5 minutes.
c. Unconscious:
1. Transport without delay.
2. Administer Lidocaine 1 mg/kg IV/IO while setting up to
perform cardioversion.
3. Consult Base Hospital Physician for orders:
a) Perform synchronized cardioversion at 1 J/kg.
b) If no response at 1 J/kg, perform synchronized
cardioversion at 2 J/kg.
c) If no response, perform synchronized
cardioversion at 4 J/kg.
d. If cardioversion is successful, consult with Base Hospital
Physician for post cardioversion medication orders.
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Pediatric Apparent Life Threatening Event
EMS Policy No. 5815
Effective: June 1, 2007
Supersedes: NA
5815 - Pediatric Apparent Life Threatening Event
DEFINITIONS:
“Apparent Life Threatening Event (ALTE)” indicates an
episode that is frightening to the observer (may think the
infant has died) and involves some combination of:
 Apnea (central or obstructive)
 Color change (cyanosis, pallor, erythema, plethora)
 Marked change in muscle tone (limpness)
 Choking or gagging
POLICY:
A.
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. These events usually occur in infants < 12 months old, however,
any child less than 2 years old who exhibits the symptoms listed
above may be considered an ALTE.
III. Treatment:
A. Assume the history given is accurate.
B. Determine the severity, nature and duration of the
episode.
C. Obtain a medical history.
D. Perform a complete physical exam that includes the
general appearance of the child, skin color, extent of
interaction with environment, and evidence of trauma.
E. If hypoglycemia suspected or ALOC, obtain glucose level.
F. Consider and treat any identifiable causes.
G. Transport patient to the hospital.
Note: Most patients will have a normal physical exam when assessed by
responding field personnel. Contact the base physician for consultation
if the parent/guardian is refusing medical care and/or transport, prior to
completing a Refusal of Care form.
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Pediatric Airway Obstruction
EMS Policy No. 5817
Effective: January 1, 2012
Supersedes: June 1, 2007
5817 - Pediatric Airway Obstruction by Foreign Body
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
Treatment:
A.
B.
C.
D.
E.
Attempt to clear the airway using BLS maneuvers.
1. For infants administer back blows and chest
thrusts.
2. For children > 1 year of age, administer abdominal
thrusts.
If unable to clear foreign body, visualize the larynx and
remove the foreign body with Magill forceps.
Assist ventilation with BVM and 100% oxygen.
If unsuccessful, attempt endotracheal intubation.
If patient has a complete airway obstruction and you
are unable to clear foreign body using BLS maneuvers
and direct visualization, consider Cricothyrotomy.
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Pediatric Respiratory Distress: Stridor
EMS Policy No. 5819
Effective: January 1, 2012
Supersedes: June 1, 2007
5819 - Pediatric Respiratory Distress: Stridor
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II.
For suspected airway obstruction refer to EMS Policy No. 5817,
Pediatric Airway Obstruction.
III.
For suspected allergic reaction refer to EMS Policy No. 5826,
Pediatric Allergic Reaction.
IV. Treatment:
A.
B.
C.
D.
E.
Place patient in position of comfort.
If suspected croup, consider saline nebulizer
treatment.
If suspected epiglottis, do not attempt to visual airway.
Administer oxygen, allow parent to administer if
appropriate. If patient deteriorates, or becomes
completely obstructed, attempt to ventilate via BVM.
Perform endotracheal intubation only if BVM ventilation
is unsuccessful or impossible.
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Pediatric Respiratory Distress: Bronchospasm
EMS Policy No. 5820
Effective: March 10, 2010
Supersedes: June 1, 2008
5820 - Pediatric Respiratory Distress: Bronchospasm
DEFINITIONS:
A.
“Mild Respiratory Distress” indicates mild wheezing,
shortness of breath and/or cough. Able to speak full
sentences.
B.
“Moderate Respiratory Distress” indicates spontaneous
breathing and adequate tidal volume with significant
wheezing/SOB accompanied by any of the following signs:
accessory muscle use, nasal flaring, grunting, and/or inability
to speak full sentences.
C.
“Severe Respiratory Distress” indicates ineffective
ventilations and/or inadequate tidal volume which may be
accompanied by any of the following signs: accessory
muscle use, cyanosis, inability to speak, gasping
respirations, and/or decreased level of consciousness.
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care, and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. Treatment:
A. Place patient in position of comfort.
B. Administer oxygen, allow parent to administer if appropriate.
C. Treat according to severity:
1. Mild Distress:
a. Monitor heart rate, respiratory rate, and pulse oximetry.
b. Administer Albuterol 2.5mg in 3 ml NS via nebulizer.
May repeat as indicated.
2. Moderate Distress:
a. Monitor heart rate, respiratory rate, and pulse oximetry.
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Pediatric Respiratory Distress: Bronchospasm
EMS Policy No. 5820
Effective: March 10, 2010
Supersedes: June 1, 2008
b. Administer Albuterol 2.5mg in 3 ml NS by nebulizer with
Atrovent 0.5mg in 2.5 ml NS
c. May repeat Albuterol as indicated.
d. Consider epinephrine 0.01 mg/kg Sub-Q (Maximum
dose is 0.3 mg).
3. Severe Distress:
a. Assist ventilations with BVM and 100% oxygen.
b. If unable to adequately oxygenate and ventilate patient,
perform endotracheal intubation.
c. Administer Albuterol 2.5mg in 3 ml NS and Atrovent
0.5mg in 2.5 ml NS by nebulizer/BVM/ETT. May repeat
Albuterol as indicated (not to exceed 20mg per hour).
d. Consider epinephrine 0.01 mg/kg Sub-Q (Maximum
dose is 0.5mg).
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Pediatric Shock
EMS Policy No. 5824
Effective: January 1, 2012
Supersedes: June 1, 2007
5824 - Pediatric Shock
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. For suspected or known trauma refer to EMS Policy No. 5833,
Pediatric Trauma.
III. For suspected allergic reaction refer to EMS Policy No. 5826,
Pediatric Allergic Reaction.
IV. Treatment:
A. Assure adequate oxygenation and ventilation.
B. Establish IV/IO of normal saline TKO.
C. Administer rapid fluid bolus of normal saline 20 ml/kg. May
repeat as indicated.
D. If suspected Cardiogenic Shock, consult with Base Hospital
Physician for Dopamine orders.
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Pediatric Allergic Reaction
EMS Policy No. 5826
Effective: January 1, 2012
Supersedes: June 1, 2007
5826 - Pediatric Allergic Reaction
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
Treatment:
A. Remove allergen if possible.
B. Mild reaction (urticaria only):
1. Consider diphenhydramine 1 mg/kg IM (maximum of 50
mg).
C. Moderate to severe reaction (Urticaria with one or more of
the following: swelling of mucous membranes, dyspnea,
wheezing, chest or throat tightness, abdominal cramps).
1. Epinephrine 1:1000, 0.01mg/kg SQ (maximum dose
0.3mg).
2. Administer diphenhydramine 1 mg/kg IM (maximum of 50
mg).
3. If wheezing, initiate hand-held nebulizer dose of Albuterol
2.5mg in 3 ml NS. May repeat as needed.
4. Consider IV normal saline TKO or saline lock.
D. Anaphylaxis (Urticaria and signs of shock with any or all of the
following: swelling of mucous membranes, dyspnea,
wheezing, chest or throat tightness, abdominal cramps).
1. Epinephrine 1:1000, 0.01mg/kg SQ (maximum dose
0.3mg).
2. Establish IV/IO access and administer normal saline fluid
bolus of 20 ml/kg. May repeat as indicated.
3. If wheezing, administer Albuterol 2.5mg in 3 ml normal
saline. May repeat as needed.
4. If patient is unresponsive with no palpable pulses,
administer epinephrine (1:10,000) 0.01mg/kg to max dose
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Pediatric Allergic Reaction
EMS Policy No. 5826
Effective: January 1, 2012
Supersedes: June 1, 2007
of 0.5mg IVP/IO and diphenhydramine 1mg/kg to maximum
dose of 50mg IM or IVP/IO.
5. Consider intubation.
6. Consult Base Hospital Physician for further orders.
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Pediatric Seizure
EMS Policy No. 5828
Effective: October 1, 2012
Supersedes: January 1, 2012
5828 - Pediatric Seizure
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. Midazolam should not be given unless the patient is actively
seizing (two (2) or more seizures without regaining consciousness
or a seizure that is witnessed by the paramedic to last for longer
than two (2) minutes).
III. Treatment:
A. Protect from injury, do not restrain.
B. Initiate cooling measures if febrile.
C. If two (2) or more generalized seizures occur without regaining
consciousness or the paramedic observes seizure activity that
lasts for two (2) or more minutes:
1. Establish IV/IO normal saline TKO.
a) Evaluate blood glucose level. If blood glucose level is
less than 60 mg/dl refer to EMS Policy No. 5829,
Pediatric Altered Level of Consciousness.
2. If continued seizure activity, administer Midazolam:
a) 0.2 mg/kg IN (half dose in each nostril) to a maximum
dose of 5 mg or
b) 0.1mg/kg IVP/IO/IM to a maximum dose of 5 mg).
3. For continued seizure activity not controlled by the initial
dose of Midazolam, consult Base Hospital Physician for
consideration of further Midazolam orders.
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Pediatric ALOC
EMS Policy No. 5829
Effective: October 16, 2013
Supersedes: October 1, 2012
5829 - Pediatric Altered Level of Consciousness
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care, and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. Treatment:
A. Initiate appropriate airway management.
B. Establish IV/IO of normal saline.
C. Evaluate blood glucose level. If blood glucose level is less
than 60 mg/dl, administer dextrose:
1. Child older than two years of age – Dextrose 50% 1 ml/kg
IV/IO or Dextrose 10% 10 ml/kg IV/IO.
2. Child less than two years of age – Dextrose 50% 0.5 ml/kg
IV/IO or Dextrose 10% 10 ml/kg IV/IO.
3. Neonate – Dextrose 10% 3 ml/kg IV/IO (Base Hospital
Physician order).
D. If mental status and respiratory effort are depressed,
administer Naloxone:
1. 0.1 mg/kg IN (half dose in each nostril) to a maximum initial
dose of 2 mg, or;
2. 0.4 mg - 2 mg IV/IO. Titrate in small increments to maintain
adequate ventilation and airway control to a total initial dose
of 2 mg.
E. If positive response to initial dose of Naloxone and strong
suspicion of opiate overdose, may repeat Naloxone dose one
(1) time only in five minutes.
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Pediatric ALOC
EMS Policy No. 5829
Effective: October 16, 2013
Supersedes: October 1, 2012
Pediatric Glasgow Coma Scale:
Pediatric Glasgow Coma Scale
<1 year
1 – 4 years
>4 years
EYE Opening
4
Open
Open
Open
3
To voice
To voice
To voice
2
To pain
To pain
To pain
1
No response
No response
No response
Verbal response
5
Coos & babbles
Oriented, speaks,
Alert & oriented
interacts socially
4
Irritable cry
Confused speech,
Disoriented
disoriented, consolable
3
Cries to pain
Inappropriate words,
Inappropriate words
inconsolable
2
Moans to pain
Incomprehensible
Incomprehensible sounds
agitated
1
No response
No response
No response
Best Motor Response
6
Normal,
Obeys commands
Obeys commands
spontaneous
movement
5
Withdraws to
Localizes stimuli
Localizes stimuli
touch
4
Withdraws from
Withdraws from pain
Withdraws from pain
pain
3
Abnormal flexion
Abnormal flexion
Abnormal flexion
2
Abnormal
Abnormal Extension
Abnormal extension
Extension
1
No response
No response
No response
Note: Always document and report GCS as a breakdown of scores (i.e. GCS =
Eye 3, Verbal 3, Motor 4 for a total score of 10).
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Pediatric Poisoning/Overdose
EMS Policy No. 5830
Effective: October 1, 2012
Supersedes: January 1, 2012
5830 - Pediatric Poisoning/Overdose
POLICY:
I. Perform routine ALS/BLS medical care as directed in EMS Policy
No. 5502, Routine BLS Care, EMS Policy No. 5701, Routine ALS
Care and EMS Policy No. 5800, Pediatric Routine Medical Care.
II. Identify substance. Bring any containers, labels or a sample (if
safe) into the hospital with the patient. Determine type, amount
and time of the exposure.
III. Treatment:
A. Establish IV normal saline TKO or saline lock if indicated.
B. Initiate early transport and receiving hospital notification.
IV. Substance Specific Treatment:
A. Opiates:
1. Manage airway and ensure adequate oxygenation and
ventilation.
2. If mental status and respiratory effort are depressed
administer Narcan:
a. 0.1 mg/kg IN, (half dose in each nostril) or;
b. 0.4 mg - 2 mg IVP/IO. Titrate in small increments to
maintain adequate ventilation and airway control to a
total initial dose of 2 mg. May administer IM, SL or SQ
if unable to start IV.
B. Insecticides (organophosphates, carbonates):
1. Decontaminate patient as soon as possible (remove
clothes, wash skin).
2. Avoid contamination of prehospital personnel.
3. Assess for SLUDGE (salivation, lacrimation, urination,
diaphoresis/diarrhea, gastric hypermotility, and emesis/eye
[small pupils and/or blurry vision]).
4. If indicated, administer Atropine 0.05 mg/kg IVP/IO slowly.
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Pediatric Poisoning/Overdose
EMS Policy No. 5830
Effective: October 1, 2012
Supersedes: January 1, 2012
C.
D.
E.
F.
G.
H.
May give second dose of Atropine 0.05 mg/kg in 5 minutes
if indicated to a maximum dose of 4 mg.
5. If further doses of Atropine are required, consult the base
hospital physician.
Cyclic Antidepressants:
1. Anticipate rapid deterioration of condition.
2. Consider activated charcoal 1gm/kg PO, not to exceed 50
gms given orally if within the first 60 minutes of ingestion.
3. In the presence of life-threatening dysrhythmias or rapid
deterioration:
a. Hyperventilate if assisting ventilation or if intubated.
b. Administer Sodium Bicarbonate 1 mEq/kg IVP.
4. For seizures, see EMS Policy, No. 5828, Pediatric
Seizures.
Beta Blockers:
1. Consider activated charcoal 1 gm/kg PO, not to exceed 50
gms given orally if within the first 60 minutes of ingestion.
2. Obtain blood glucose level.
Calcium Channel Blockers:
1. Consider activated charcoal 1gm/kg PO, not to exceed
50gms given orally (if within the first 60 minutes of
ingestion).
2. Calcium Chloride 10% 20 – 30 mg/kg IVP over 3 – 5
minutes.
3. If bradycardic and/or hypotensive, consult base hospital
physician.
Phenothiazine Reactions:
1. Administer Diphenhydramine 1 mg/kg slow IVP to a
maximum of 50 mg. If unable to establish IV access,
administer IM.
Other Non-Caustic Drugs:
1. If patient is awake and alert consider activated charcoal
orally—1 gm/kg PO, not to exceed 50gms if within the first
60 minutes of ingestion.
2. Consider contacting Poison Control Center.
Hydrocarbons (kerosene, gasoline, lighter fluid, turpentine,
etc):
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Pediatric Poisoning/Overdose
EMS Policy No. 5830
Effective: October 1, 2012
Supersedes: January 1, 2012
1. Do not induce vomiting.
2. Transport without delay.
I. Caustic Substances (acids/alkalis):
1. Do not induce vomiting.
2. Consider diluting by having the patient drink 1-2 glasses of
milk or water.
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Pediatric Burns
EMS Policy No. 5837
Effective: October 16, 2013
Supersedes: June 1, 2007
5837 - Pediatric Burns
POLICY:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care, EMS Policy No. 5701,
Routine ALS Care and EMS Policy No. 5800, Pediatric Routine
Medical Care.
II.
For major burns, consider direct air ambulance transport to an
approved pediatric trauma center. Refer to EMS Policy No.
5215 Trauma Patient Destination.
III.
Use caution in children to prevent hypothermia.
A.
Stop the burning process.
1. For burns that are less than 10% of the patient’s total
body surface area (TBSA) consider initial cooling of
burn with moist dressings.
2. For burns that cover more than 10% of the patient’s
TBSA, cover affected body surface with dry, sterile
dressing or sheet. Do not use wet or cool dressings.
IV.
Treatment:
A.
B.
C.
D.
E.
F.
Assure adequate oxygenation and ventilation.
Administer high flow oxygen if inhalation injury is
suspected.
Establish vascular access if indicated.
Monitor for dysrhythmias and treat as appropriate.
For major burns (greater than 10% TBSA), administer
fluid bolus of NS 20 ml/kg. May repeat as necessary.
For severe pain, refer to EMS Policy No. 5839, Pediatric
Pain Management.
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Pediatric Pain Management
EMS Policy No. 5839
Effective: June 1, 2007
Supersedes: SJ-P81
5839 - Pediatric Pain Management
DEFINITIONS:
A.
“Pain” indicates a significantly unpleasant sensation, occurring
in varying degrees of severity, which results because of injury,
disease, or emotional disorder.
POLICY:
I.
The use of morphine to manage moderate to severe pain is an
advanced life support procedure that is indicated for patients
who are complaining of moderate to severe pain in the
presence of adequate vital signs and level of consciousness.
II.
Morphine may be used to treat stable pediatric patients when
extrication, movement, or transport is required and is
anticipated to cause considerable pain to the patient when
there are no known contraindications to administering
analgesia.
III.
Morphine is a potent analgesic and should be used with
caution.
IV.
Document pain scale before and after medication
administration.
A. For children under the age of 3, use the behavioral or the
FACES scale.
B. For children over the age of 3, use the FACES or the visual
analog scale.
V.
Treatment:
A. Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5502, Routine BLS Care, EMS Policy No. 5701,
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Pediatric Pain Management
EMS Policy No. 5839
Effective: June 1, 2007
Supersedes: SJ-P81
Routine ALS Care and EMS Policy No. 5800, Pediatric
Routine Medical Care.
B. Monitor patient closely.
C. Establish IV access (IV NS or NS lock as appropriate).
D. Obtain full set of vital signs.
E. Administer Morphine 0.05mg/kg slow IV. May repeat once in
five minutes.
F. If unable to secure IV access, administer Morphine 0.1mg/kg
IM, may repeat one dose in 30 minutes.
G. Monitor patient and vital signs carefully; ensure patent
airway. Do not administer morphine sulfate for pain if the
patient has any absolute or relative contraindications without
base hospital physician order.
VI.
Base Physician Order Requirements:
A. Do not administer morphine sulfate for pain if the patient has
any contraindications without base hospital physician order.
B. Contraindications:
1. Allergy or sensitivity to the medication being
administered.
2. Nausea/Vomiting
3. Altered level of consciousness
4. Hypotension
5. Suspected drug and/or alcohol intoxication
6. Head injury
7. Respiratory distress/failure
8. Pregnancy
9. Multiple systems trauma
VII.
Pain Scales
A. Behavioral Pain Scale
Select the most appropriate description for each row and
total the numbers.
San Joaquin County
Emergency Medical Services
Page 102 of 216
Pediatric Pain Management
EMS Policy No. 5839
Effective: June 1, 2007
Supersedes: SJ-P81
Face
0
No expression or smile
Legs
0
Normal or relaxed
position
0
Lying quietly, normal
position, moves easily
Activity
Cry
0
No cry
(awake or asleep)
Consolability
0
Content, relaxed
1
Occasional grimace,
withdrawn, frown
1
Uneasy, restless,
tense
1
Squirming, tense,
shifting back and
forth
1
Moans or whimpers,
occasional complaint
1
Reassured by voice,
hugging. Distractible.
2
Frequent frown, clenched
jaw, quivering chin
2
Kicking or legs drawn up
2
Arched, rigid, or jerking
2
Cries steadily, screams,
sobs, frequent
complaints
2
Difficult to console or
comfort
B. Wong-Baker FACES Scale
C. Visual Analog Scale
0
1
No
Pain
2
San Joaquin County
Emergency Medical Services
3
4
5
6
7
8
9
10
Worst
Pain Ever
Page 103 of 216
Neonatal Resuscitation
EMS Policy No. 5850
Effective: June 1, 2007
Supersedes: SJ-P81
5850 - Neonatal Resuscitation
POLICY:
I.
Perform routine ALS/BLS medical care as directed in EMS
Policy No. 5800, Pediatric Routine Medical Care.
II.
Resuscitation should be initiated on all premature infants who
weigh 1 pound and are reported to be over 20 weeks gestation.
III.
Obtain pertinent history before delivery if possible (e.g. multiple
births, preterm, medical treatment, drug use, and presence of
meconium).
IV.
Treatment:
A.
Position Airway.
B.
Suction mouth and nasopharynx with bulb syringe.
C.
Dry and keep warm with dry towel or blanket.
D.
Stimulate by drying vigorously including head and back.
E.
Clamp and cut cord.
F.
Evaluate respirations:
1.
Mild distress - Administer blow by oxygen.
2.
Respiratory depression, failure, or gasping
respirations – Assist ventilations with 100% oxygen
at a rate of 40-60 breaths/min.
G.
Check heart rate at cord:
1.
HR less than 60/minute
a. Continue assisted ventilations.
b. Begin chest compressions at a rate of
120/min.
c. If no improvement in 1 minute, establish
vascular access and administer epinephrine
0.01 mg/kg (1:10,000) IV/IO.
d. If no improvement in 30 seconds, perform
endotracheal intubation.
San Joaquin County
Emergency Medical Services
Page 104 of 216
Neonatal Resuscitation
EMS Policy No. 5850
Effective: June 1, 2007
Supersedes: SJ-P81
e. Reassess heart rate and respiratory rate while
en route to the hospital. If heart rate is above
80/minute, stop chest compressions and
continue assisting ventilations.
2.
HR 60-80/minute
a. Continue to assist ventilations with 100%
oxygen.
b. If no improvement after 30 seconds of
assisted ventilations, begin chest
compressions.
c. Reassess heart rate and respiratory rate while
en route to the hospital. If heart rate is above
80/minute, stop chest compressions and
continue assisting ventilations.
3.
HR 80-100/minute and rising
a. Continue oxygen via mask or blow by.
b. Stimulate and reassess heart rate and
respirations after 15-30 seconds.
c. If heart rate is less than 100/minute, begin
assisted ventilations with 100% oxygen.
4.
HR above 100/minute
a. Check skin color. If peripheral cyanosis is
noted, administer blow by oxygen.
b. Reassess heart rate and respiratory rate while
en route to the hospital.
H.
If narcotic induced respiratory depression is suspected
administer Naloxone 0.1mg/kg via IV/IO/ETT.
San Joaquin County
Emergency Medical Services
Page 105 of 216
San Joaquin County EMS Agency
San Joaquin County
Emergency Medical Services
Page 106 of 216
San Joaquin County EMS Agency
SAN JOAQUIN COUNTY
EMERGENCY MEDICAL SERVICES
Advanced Life Support Skills Policies and Interfacility Transfer
Medication Policies
San Joaquin County
Emergency Medical Services
Page 107 of 216
Paramedic Infrequently Used Skills
EMS Policy No. 2541
Effective: October 16, 2013
Supersedes: July 1, 2010
2541- Paramedic Infrequently Used Skills
PURPOSE: The purpose of this policy is to specify the requirements
ALS providers shall adhere to in demonstrating competency for
infrequently used skills by ALS personnel.
DEFINITIONS:
A. “Infrequently Used Skills “means ALS procedures that have been
identified through the CQI process as an area performed on an
infrequent basis within the San Joaquin EMS system which
requires on-going training to maintain competency.
POLICY:
I.
Provider Responsibilities:
A. Demonstration of competency in infrequently utilized skills is
to be performed in a training environment using mannequins.
B. Providers are required to develop a process that affords all
ALS personnel the opportunity to demonstrate competency
at the required intervals.
C. Providers and ALS personnel shall follow the process
specified in EMS Agency Policy when verifying an
infrequently used skill.
D. Providers shall track individual employees training records
using a spreadsheet or other EMS Agency approved format.
The spreadsheet or other approved format may be used to
track infrequently used skills training in lieu of the EMS
Agency’s performance criteria check sheets. Regardless of
the record keeping format providers are required to utilize
San Joaquin County
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Paramedic Infrequently Used Skills
EMS Policy No. 2541
Effective: October 16, 2013
Supersedes: July 1, 2010
the EMS Agency’s performance criteria when verifying skills.
E. Providers shall ensure sufficient training equipment and
supplies are available to implement this Policy.
F. Providers shall make records available to the EMS Agency,
upon request, to demonstrate compliance with this Policy.
G. The infrequently used skills and minimum intervals at which
competency shall be demonstrated by ALS personnel are as
follows:
1. Adult Endotracheal Intubation – Quarterly
2. Pediatric Endotracheal Intubation – Quarterly
3. Nasotracheal Intubation – Quarterly
4. Nasogastric Suctioning - Quarterly
5. King Airway – Quarterly
6. MICR: Two Rounds and Transition to Advanced Airway
- Quarterly
7. Transcutaneous Cardiac Pacing – Annually
8. Intraosseous Infusions – Annually
9. Needle Thoracostomy – Annually
10. Needle Cricothyrotomy – Annually
H. Upon recommendation of the majority of the members of the
CQI Council, the Medical Director may increase the
frequency of the training intervals to bi-monthly. However,
the Medical Director reserves the right to increase or
decrease the frequency of infrequently used skills’ training
based on his/her professional medical judgment regardless
of the recommendations from the CQI Council.
San Joaquin County
Emergency Medical Services
Page 109 of 216
Intraosseous Cannulation Performance Criteria – EZ-IO
EMS Policy No. 2544
Effective: January 1, 2012
Supersedes: NA
2544 – Intraosseous Cannulation – EZ-IO
Intraosseous cannulation provides a safe and reliable method for
rapidly achieving a route for administration of medications, fluids, and
blood products in a non-collapsible vascular space.
A. .Assessment/Treatment Indicators:
1. Resuscitation.
2. Altered mental status (GCS 8 or less).
3. Status epilepticus with prolonged seizure activity greater than
10 minutes, and refractory to IM anticonvulsants.
B. Contraindications
1. Fractures of the involved bone.
2. Fourth Degree burn, infection or area of cellulitis overlying the
site of insertion.
3. Congenital deformity or history of osteogenesis imperfecta or
osteoporosis.
4. Previous IO attempt at chosen site.
5. Patient < 3kg.
C. Potential Complications and Interventions:
1. Tubing becomes obstructed with bone or bone marrow:
replace the tubing extension set.
2. Local infiltration of fluids, medications, or local bleeding: stop
infusion, remove needle, and apply pressure with sterile gauze.
D. Approved Sites (listed in order of use):
1. Primary site is the proximal tibia. Palpate the landmarks at the
proximal tibia (patella and tibial tuberosity). Insertion site
should be approximately one finger width to the medial side of
the tibial tuberosity. This is the only approved site for pediatric
patients.
2. Secondary site is the distal tibia. Palpate the landmarks at the
distal tibia. Insertion site should be two finger widths proximal
to the medial malleolus along the midline of the tibia.
San Joaquin County
Emergency Medical Services
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Intraosseous Cannulation Performance Criteria – EZ-IO
EMS Policy No. 2544
Effective: January 1, 2012
Supersedes: NA
3. Proximal Humerus shall only be used if both tibias are
unavailable. Insertion site is located directly on the most
prominent aspect of the greater tubercle. Slide thumb up the
anterior shaft of the humerus until you feel the greater tubercle,
this is the surgical neck. Approximately 1 cm (depending on
patient anatomy) above the surgical neck is the insertion site.
Ensure that the patient’s hand is resting on the abdomen and
that the elbow is adducted (close to the body).
E. Equipment:
1. Laryngoscope with appropriate size handle
2. Endotracheal tube
3. Water soluble lubricating jelly
4. 10 ml syringe
5. Endotracheal tube inducer (ETTI)
6. Oxygen
1.
2.
3.
4.
5.
6.
Uses universal precautions.
States: Indications and contraindications.
Demonstrates the ability to correctly select the primary,
secondary, and tertiary sites for IO cannulation.
Selects the correct size needle
A. 15mm (Pink) for patients 3 – 39 kg
B. 25mm (Blue) for patients > 40 kg.
C. 45mm (Yellow) for patients > 40 kg with excessive tissue
over the insertion site.
Assembles equipment, attaches extension (EZ-Connect)
tubing to IV tubing, and correctly assembles the EZ-IO driver
and needle set.
Cleans insertion site using aseptic technique.
San Joaquin County
Emergency Medical Services
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Intraosseous Cannulation Performance Criteria – EZ-IO
EMS Policy No. 2544
Effective: January 1, 2012
Supersedes: NA
7.
8.
9.
10.
11.
12.
13.
14.
15.
Needle Insertion: Stabilize the selected site and begin
insertion from a 90-degree angle to the plane of the site.
Inserts the needle until the needle is touching the bone.
Ensures that the 5mm mark is visible before powering the
driver. If 5 mm mark is not visible uses a larger needle.
Powers the driver, using limited pressure and advances the
needle until you feel a change in resistance.
Flushes the needle with Lidocaine (See # 11 Pain
Management below) if patient semi-conscious or with saline
if patient is unconscious.
Stabilizes the needle set and removes the drill and then the
stylet.
Confirms placement by aspiration, ability to infuse a 10ml
saline flush without signs of infiltration, leakage or local
edema. Understands that a flash of blood in the catheter
may (but does not always) occur to confirm placement.
Pain Management:
A. For conscious or semi-conscious patients administer 0.5
mg/kg 2% Lidocaine (not to exceed 50 mg) slowly (over
30-45 seconds) through the IO site. Wait approximately
30–60 seconds before “power” flushing with normal
saline.
B. In the event a patient regains consciousness and
complains of severe pain secondary to the IO insertion,
temporarily stop infusing the fluids, and administer
Lidocaine as listed above.
Attaches IV tubing to EZ connect tubing. It is unlikely that
fluid will run freely on a gravity drip. Applies pressure to IV
bag and adjust flow as required.
Secure the EZ-IO needle and tubing in place. If the EZ IO is
placed in the humerus, or in a pediatric patient, the EZ
stabilizer shall be used.
States: Potential complications and interventions.
Place EZ-IO identification band on patient, document time,
date, and person completing the procedure.
San Joaquin County
Emergency Medical Services
Page 112 of 216
Intraosseous Cannulation Performance Criteria – EZ-IO
EMS Policy No. 2544
Effective: January 1, 2012
Supersedes: NA
16.
17.
18.
Restrain patient prn to prevent inadvertent dislodging of the
needle.
States: Document IO placement on PCR.
Removal Process: States: Attach syringe to needle, then
twists the needle in a clockwise direction and pulls straight
out. Once needle has been removed applies direct pressure
to control any bleeding, then covers area with a sterile
dressing.
San Joaquin County
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Page 113 of 216
Endotracheal Intubation – Adult Performance Criteria
EMS Policy No. 2545
Effective: October 16, 2013
Supersedes: October 1, 2012
2545 – Endotracheal Intubation – Adult Performance Criteria
In the absence of a protected airway, BVM ventilation may result in
the generation of pharyngeal pressure high enough to cause gastric
distention. In addition, gastric distension promotes regurgitation and
increases the potential for aspiration of gastric contents.
A. Assessment/Treatment Indicators:
1. Inability of patient to protect the airway (coma, decreased level
of consciousness without gag reflex).
2. Inability to ventilate or oxygenate the patient using BLS airways
and BVM.
3. Cardiac arrest. Adhere to sequence as specified in EMS Policy
No. 5710 ALS Medical Cardiac Arrest.
4. Agonal or failing respirations, respiratory arrest.
5. Base Hospital Physician Order.
B. Relative Contraindications:
1. Intubation may be contraindicated on patients that are known
diabetics or narcotics overdoses, prior to the administration of
Dextrose or Narcan.
C. Potential Complications:
1. Esophageal Intubation
2. Mainstem Intubation
3. Perforation or laceration of upper esophagus, vocal cords,
larynx
4. Laryngospasm or bronchospasm
5. Dental and soft-tissue trauma
6. Aspiration of oral or gastric contents
7. Dysrhythmias
8. Hypertension/Hypotension
D. Equipment:
1. Laryngoscope with appropriate size blade
2. Endotracheal tube & King Airway
3. Water soluble lubricating jelly
4. 10 ml syringe
San Joaquin County
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Endotracheal Intubation – Adult Performance Criteria
EMS Policy No. 2545
Effective: October 16, 2013
Supersedes: October 1, 2012
5. Endotracheal tube inducer (ETTI)
6. Oxygen
7. Magill forceps
8. Battery powered suction unit
9. Yankauer Tonsil Tip suction catheter
10. Appropriate size suction catheter
11. ET tube holder
12. End tidal CO2
13. Disposable bag valve device – BVM
Performance Criteria
1.
Use universal precautions.
2.
States this is a two (2) person procedure
3.
Assures an adequate BLS airway.
4.
States: Will ventilate with 100% oxygen for a minimum of
(15) fifteen seconds prior to intubation attempt (unless
transitioning to an advanced airway per EMS Agency Policy
No. 5710 ALS Medical Cardiac Arrest).
5.
States: Indications and contraindications.
6.
States: Each attempt should last no longer than thirty (30)
seconds. If during any attempt patient desaturates below
90%, immediately cease and reventilate to increase
saturation.
7.
Ensures that all required equipment is present & quickly
accessible s listed above.
8.
Ensures suction is available and working.
9.
Checks light source, ensures a bright, tight, white light.
10. Select appropriate size ET tube and King Airway.
11. Checks tube cuffs for leaks by injecting air into cuff with
syringe and deflates cuff.
12. Position patient in the “ear to sternal notch position.”
13. Places right hand on patient larynx to prepare for bimanual
laryngoscopy (external laryngeal manipulation [ELM])
14. Prepares to insert tube.
San Joaquin County
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Page 115 of 216
Endotracheal Intubation – Adult Performance Criteria
EMS Policy No. 2545
Effective: October 16, 2013
Supersedes: October 1, 2012
15.
16.
17.
18.
19.
20.
21.
22.
23.
Gently inserts laryngoscope blade into mouth and applies
upward traction with left hand to visualize the vocal cords.
Does not use teeth as a fulcrum.
Asks for assistance to use the ETTI.
If patient has a Cormack-Lehane grade of three (3) or four
(4) (epiglottis is not or is barely visible), does not attempt the
insertion of an endotracheal tube; reinserts a BLS airway
and provides respirations via BVM. Provides the patient with
a King Airway as described in Agency policy No. 2552 King
Airway.
The paramedic introduces the ETTI into the patient's mouth,
and gently advances it through the glottic opening. HINT:
The Coude tip is felt bouncing off the tracheal rings in 6590% of cases, and it stops advancing at 24-40 cm because
of the narrowing airways. Occasionally, the tip will impinge
on a tracheal ring and stop; slight clockwise rotation rotates
the tip off of the trachea ring permitting insertion. The ETTI
should rest midline in the trachea and should not be
advanced past 35 cm or the black line on the ETTI should
not pass the lips. Does not preload ET on ETTI.
Assistant places ET over ETTI and gently rotates down
toward mouth.
Paramedic takes over tube and rotates it in a counter
clockwise motion, until the tube is placed in the trachea. If
resistance is felt, the tube is rotated 90˚ clockwise and
advanced.
The paramedic continues to visualize the cords until the tube
is placed. HINT: the average tube placement for females is
21 cm and for males 24 cm.
Once the tube is in place, the assistant removes the ETTI
while stabilizing tube manually.
Inflates cuff with 10 ml of air and detaches syringe.
San Joaquin County
Emergency Medical Services
Page 116 of 216
Endotracheal Intubation – Adult Performance Criteria
EMS Policy No. 2545
Effective: October 16, 2013
Supersedes: October 1, 2012
24.
25.
26.
27.
28.
29.
30.
Simultaneously maintains tube position, ventilates patient
and confirms tube placement and:
a. Notes capnography readings. PPV at the appropriate
CO2 level as well as respiratory rate.
b. Observes bilateral rise and fall of chest wall.
c. Auscultates bilateral breath sounds with absence of
sounds over abdomen.
d. Confirms placement with end tidal CO2 device.
If initial attempt at intubation fails, reattempts after ventilating
the patient for a period of 30 seconds by BVM.
If air was heard on the right side only, what would you do?
(States: would deflate the cuff, pull tube back slightly -1 cm,
re-inflate the cuff, and auscultate for bilateral air entry).
Secures tube using commercially approved tube holder
Notes tube markers at front teeth, secures tube, and places
oral airway.
Provides ventilations at 10 – 12 per minute.
Successfully intubates in no more than two (2) attempts per
patient with ventilations between attempts. If unsuccessful
after two (2) attempts, verbalizes the other airways that can
be used.
San Joaquin County
Emergency Medical Services
Page 117 of 216
Intraosseous Cannulation - Manual
EMS Policy No. 2546
Effective: January 1, 2012
Supersedes: February 15, 2010
2546 – Intraosseous Cannulation - Manual
Intraosseous cannulation provides a safe and reliable method for
rapidly achieving a route for administration of medications, fluids, and
blood products in a non-collapsible vascular space.
A. Assessment/Treatment Indicators:
1. Resuscitation.
2. Altered mental status (GCS 8 or less).
3. Status epilepticus with prolonged seizure activity greater than
10 minutes, and refractory to IM anticonvulsants.
B. Contraindications:
1. Fractures of the involved bone.
2. Fourth Degree burn, infection or area of cellulitis overlying the
site of insertion.
3. Congenital deformity or history of osteogenesis imperfecta or
osteoporosis.
4. Previous IO attempt at chosen site.
5. Patient < 3kg.
C. Potential complications and interventions:
1. Tubing becomes obstructed with bone or bone marrow:
replace the tubing extension set.
2. Local infiltration of fluids, medications, or local bleeding: stop
infusion, remove needle, and apply pressure with sterile gauze.
D. Insertion site:
1. Previous IO attempt at chosen site.
Proximal tibia is the only approved site for manual insertion of
the IO needle. Palpate the landmarks at the proximal tibia
(patella and tibial tuberosity). Insertion site should be
approximately one finger width to the medial side of the tibial
tuberosity.
E. Equipment:
1. Intraosseous needles: 15ga or 18ga
2. Betadine solution or swabs
3. Sterile gauze and gloves
San Joaquin County
Emergency Medical Services
Page 118 of 216
Intraosseous Cannulation - Manual
EMS Policy No. 2546
Effective: January 1, 2012
Supersedes: February 15, 2010
4.
5.
6.
7.
Extension tubing
Syringes (2) 10 ml
Broselow Pediatric Resuscitation Tape (Pediatric patients only).
Adhesive tape
Performance Criteria
1.
2.
Uses universal precautions.
States: Indications, contraindications, and selects insertion
site for IO cannulation
3. Assembles equipment, attaches extension tubing to IV tubing,
and checks the needle to ensure bevels of the outer needle
and internal stylet are properly aligned.
4. Cleans insertion site using aseptic technique.
5. After skin prep, places patient in supine position and holds leg
firmly.
6. Directs and inserts needle perpendicular to bone using a
boring or screwing motion until needle “pops” into the bone
marrow space (marked by sudden lack of resistance). Needle
should stand-alone.
7. Attempts aspiration of bone marrow to assist in placement
confirmation.
8. Disconnects first syringe and connects second syringe,
flushing with at least 3 ml of normal saline, observing for fluid
extravasation.
9. Attaches extension tubing to needle and adjusts flow as
required. If fluid does not run freely apply a pressure infuser
and adjust flow as required.
10. Secures needle with sterile gauze and tape.
11. Restrains patient prn to prevent inadvertent dislodging of the
needle.
12. States: Document IO placement on PCR.
San Joaquin County
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Page 119 of 216
Transcutaneous Pacing Performance Criteria
EMS Policy No. 2547
Effective: February 15, 2010
Supersedes: January 1, 2010
2547 – Transcutaneous Pacing Performance Criteria
Transcutaneous pacing is used for short intervals as a bridge until
transvenous pacing can be initiated or until the underlying cause of
the bradyarrhythmia (e.g., hyperkalemia, drug overdose) can be
reversed.
A. Assessment/Treatment Indicators:
1. Indicated for adult patients with hemodynamically unstable
bradycardia.
2. Is authorized as a standing order for paramedics in treating
adult patients with unstable bradycardia. Hemodynamically
unstable bradycardia means a patient with a BP < 90, related to
a bradycardic rhythm (HR <60) with serious signs and
symptoms related to heart rate, (i.e.: chest pain, SOB, ALOC,
shock, pulmonary congestion, CHF).
3. TCP should not be delayed for hemodynamically unstable
bradycardia patients while waiting for IV access or for atropine
to take effect.
4. Base Hospital Physician order is required to perform TCP.
B. Contraindications: TCP is not authorized for use on patients less
than 15 years of age. Not authorized for hypothermic patients
because the bradycardia is usually a physiologic response to the
body temperature.
C. Equipment:
1. Transcutaneous cardiac pacemaker
2. Cardiac monitor with defibrillator
3. Versed
4. 10 ml syringe
5. ECG electrodes
6. Pulse oximetry device
San Joaquin County
Emergency Medical Services
Page 120 of 216
Transcutaneous Pacing Performance Criteria
EMS Policy No. 2547
Effective: February 15, 2010
Supersedes: January 1, 2010
Performance Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
Uses universal precautions.
Explain procedure to the patient.
States indications and contraindications for pacing.
Apply pre-gelled adhesive pacing pads to chest wall
according to manufacturer’s recommendations.
Apply ECG electrodes
Confirm rhythm.
Activate pacing device per manufacturer’s instructions.
Set heart rate
Increases output until capture occurs (and increase output
10% above threshold)
Confirms capture by correlating QRS spike with pulses.
Reassesses BP and LOC. Increases rate prn (not to exceed
100) if patient remains hypotensive and symptomatic from
inadequate perfusion.
Determines what the lowest threshold response and
maintains output control at this level. NOTE: Any movement
of patient may increase the capture threshold response;
subsequently, the output may have to be adjusted to
compensate for this.
Provides patient with sedation/pain relief prn.
Continue monitoring. Contact base hospital for further orders
if patient symptoms are not resolving (consideration for
dopamine, further alteration of pacer settings or if further
sedation/pain control orders required).
San Joaquin County
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Needle Thoracostomy Performance Criteria
EMS Policy No. 2548
Effective: January 1, 2010
Supersedes: January 1, 2009
2548 – Needle Thoracostomy Performance Criteria
Tension pneumothorax is defined as air under pressure in the pleural
space. Needle thoracostomy should be performed to aid in a rapidly
deteriorating adult or pediatric patient with severe respiratory distress.
A. Assessment/Treatment Indicators:
1. Restlessness, anxiety, or decreased LOC.
2. Diminished or absent breath sounds on the affected side.
3. Possible tracheal deviation away from the affected side (late
sign).
4. Shock syndrome (weak rapid pulse, hypertensive initially, with
hypotension a late find).
5. Distended neck veins (JVD).
6. Progressively worsening dyspnea/cyanosis.
B. Potential complications:
1. Conversion from a closed pneumothorax to an open one
2. If there is not a pneumothorax, insertion of a needle will
produce a pneumothorax.
3. Laceration of the lung or laceration of the intercostal vessels.
C. Equipment:
1. 14 or 16 gauge 2 to 2 ½ inch needle and cannula or patients >
50kg or 14 or 16 gauge 2 to 2 ½ inch needle and cannula, 18g,
1 to 1 1/4 inch needle and cannula for patients less than 50kg
2. Betadine swab
3. 10 ml syringe
4. Tape
5. Disposable bag valve device – BVM
6. One-way flutter valve
Performance Criteria
1.
2.
3.
Uses universal precautions.
States indications and possible complications of the procedure.
Assembles equipment and selects appropriate size needle and
cannula.
San Joaquin County
Emergency Medical Services
Page 122 of 216
Needle Thoracostomy Performance Criteria
EMS Policy No. 2548
Effective: January 1, 2010
Supersedes: January 1, 2009
4.
5.
6.
7.
8.
9.
10.
Locates insertion site at the second intercostal space, midclavicular line or the fourth intercostal space at the midaxillary
line.
Prepare area with Betadine swap.
Firmly inserts the needle (attached to syringe) perpendicular to
the chest wall, over the top of the rib until pleura is penetrated
as indicated by one or more of the following:
a. A “popping sound” is heard, or giving away sensation is felt.
b. A “hissing” noise follows evidence of a tension
pneumothorax.
c. Ability to aspirate free air or blood into the syringe.
Advances the catheter and removes needle and syringe. Adds
flutter or Heimlich Valve to prevent re-accumulation of air in the
pleural space.
Secures needle hub in place with tape over Benzoin tincture or
with other approved device.
Reassesses patient lung sounds, respiratory status
immediately, and every five (5) minutes thereafter.
Considers the following:
a. The procedure may have to be repeated if the tension is not
relieved.
b. Air transport: The needle thoracostomy should be done prior
to takeoff to allow for escape of air that may accumulate in
the pleural space with atmospheric pressure changes.
San Joaquin County
Emergency Medical Services
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Needle Cricothyrotomy TLJV
EMS Policy No. 2549
Effective: January 1, 2012
Supersedes: January 1, 2010
2549 – Needle Cricothyrotomy Translaryngeal Jet Ventilator
Transtracheal catheter ventilation is a temporary emergency
procedure to provide oxygenation when airway obstruction cannot be
relieved by other methods.
A. Assessment/Treatment Indicators for the unconscious patient :
1. Patient is unconscious and unresponsive.
2. Total airway obstruction following unsuccessful attempts of BLS
and ALS obstructed airway procedures.
3. Massive facial trauma in a patient who cannot be intubated by
either oral or nasotracheal means.
4. Injury to the trachea/larynx in a patient who cannot adequately
ventilated or intubated by either oral or nasotracheal means.
5. Airway obstruction due to infection.
B. Contraindications: NONE.
C. Potential Complications:
1. With the high pressure used during ventilation and the
possibility of air entrapment, may produce a pneumothorax.
2. Hemorrhage may occur at the site of the needle insertion,
especially if the thyroid is perforated.
3. Perforation of the esophagus.
4. Subcutaneous or meditational emphysema.
5. Usually does not allow enough ventilation to adequately
eliminate carbon dioxide.
D. Equipment:
1. Translaryngeal jet ventilator with push-button and high-pressure
tubing with locking device (Adult) or disposable Bag-Valve
device (Pediatric)
2. Endotracheal tubes: 3.0 or 3.5 ET
3. Providone iodine
4. Oxygen supply @ 50 PSI
5. 10 - 12 gauge needle for adult, 12 – 14 gauge needle for
pediatrics
6. Battery powered suction device
San Joaquin County
Emergency Medical Services
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Needle Cricothyrotomy TLJV
EMS Policy No. 2549
Effective: January 1, 2012
Supersedes: January 1, 2010
7. Yankauer Tonsil Tip Suction Catheter Non-rigid
8. 10 ml syringe
9. End-tidal CO2 device
Performance Criteria
1.
Uses universal precautions.
2.
States: Indications and contraindications.
3.
8.
Locates and prepares insertion site at the cricothyroid membrane
between the thyroid and cricoid cartilage of larnyx.
Performance Criteria
Place 5 ml of normal saline in the syringe. Attaches the IV catheter to the
syringe and inserts the needle midline at a 45 angle with a quick smooth
downward motion following the direction of the trachea. Applies negative
pressure to the syringe during insertion. Bubbles in the syringe indicate
that the needle is in the trachea.
Advances the catheter over the needle, and withdraws the needle and
syringe. If using cricothyrotomy cannula, removes obturator. Attaches
oxygen delivery device.
Assesses for hemorrhage or subcutaneous emphysema, which may
indicate improper placement.
Ventilates using TLJV - one (1) second on and three (3) seconds off.
9.
States if TLJV fails can attach 3.5 ET hub and ventilates with BVM.
4.
5.
6.
7.
10. Auscultates lungs while manually holding needle.
11. Secures needle hub in place with tape over Benzoin or with other
approved device.
12. Transport immediately to closest hospital for airway management.
13. Contact Base Hospital if unable to adequately ventilate patient.
14. States: Document needle cricothyrotomy placement on PCR.
San Joaquin County
Emergency Medical Services
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Naso/Orogastric Intubation Performance Criteria
EMS Policy No. 2550
Effective: January 1, 2010
Supersedes: January 1, 2009
2550 – Naso/Orogastric Intubation Performance Criteria
A. Assessment/treatment indicators:
1. Gastric distention which impedes ABC’s:
a. Full arrest
b. Near drowning
2. Gastrointestinal bleeding.
3. Possible drug overdose.
4. Insertion considerations:
a. Nasal route for children and adults (if nasal flaring occurs in
children, take out and use oral route).
b. Oral route for infants under six (6) months.
c. Oral route for patients with mid-facial trauma.
B. Contraindications:
1. Known esophageal strictures, varices and/or other esophageal
disease.
2. Ingested caustics.
3. Significant facial or head trauma.
4. Patients with bleeding disorders.
C. Potential complications and interventions:
1. Insertion of N/G or O/G tube into trachea/lung. If patient
experiences respiratory distress at any time during the
procedure remove the tube immediately.
D. Equipment:
1. Adults: 1 6 - 18 Fr tube; Peds: 10 Fr tube
2. Yankauer Tonsil Tip Suction Catheter
3. Appropriate size Suction Catheter
4. Battery powered suction equipment, should be immediately
available.
5. 60 ml cath-tipped syringe.
6. Water-soluble lubricating jelly.
7. Adhesive tape
8. Stethoscope
9. 2% Lidocaine Jelly
San Joaquin County
Emergency Medical Services
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Naso/Orogastric Intubation Performance Criteria
EMS Policy No. 2550
Effective: January 1, 2010
Supersedes: January 1, 2009
Performance Criteria
1.
2.
3.
4.
5.
6.
7.
Uses universal precautions.
States indications and contraindications.
Places patient in High Fowlers, unless otherwise
contraindicated.
Assembles equipment and checks suction equipment.
NASOGASTRIC
OROGASTRIC INSERTION
INSERTION
Measures combined distance Measures the combined
between the tip of the nose
distance between the corner of
to the ear lobe to the xiphoid the mouth to the ear lobe to
process.
the xiphoid process.
Examines nares to determine Examines oropharyngeal
nare with best airflow.
cavity for
obstructions/secretions.
Lubricates distal 2-3” of N/G Lubricates distal 2-3” of O/G
tube with water-soluble
tube with water-soluble
lubricant. 2% Lidocaine Jelly lubricant.
not to exceed 5 ml, may also
be applied to distal end of
N/G tube.
San Joaquin County
Emergency Medical Services
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Naso/Orogastric Intubation Performance Criteria
EMS Policy No. 2550
Effective: January 1, 2010
Supersedes: January 1, 2009
8.
9.
10.
11.
12.
13.
Inserts nasogastric tube:
Inserts orogastric tube:
a. Gently passes tube into
a. Gently passes tube into the
selected nostril.
oral cavity and instructs the
b. When resistance is met,
patient to swallow (if
has the patient lower chin
conscious).
to chest.
b. Slowly rotates tube while
c. Then rotates tube inward
inserting to desired length.
toward the other nostril
c. If resistance is met,
while inserting.
removes tube and red. Instructs patient to
attempts.
swallow (if conscious).
e. If resistance is still met,
removes and attempts
other nostril.
Advances N/G or O/G tube to previously measured location
Confirms proper placement by:
a. Aspiration of stomach contents.
b. Injection of 30-60 ml of air into tube as you auscultate for
the sound of air over the epigastric region.
Secures tube to bridge of nose (N/G), or to side of mouth
(O/G).
Attaches tube to suction and adjust to low suction.
Reassesses vital signs and notes response to therapy.
San Joaquin County
Emergency Medical Services
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12 Lead ECG Performance Criteria
EMS Policy No. 2551
Effective: January 1, 2012
Supersedes: January 1, 2010
2551 – 12 Lead ECG Performance Criteria
Medical history and/or presenting complaints consistent with coronary
ischemia.
A. Indications:
Only Patients with one or more of the following signs/symptoms:
1. Chest or upper abdominal discomfort suggestive of coronary
ischemia.
2. Acute onset
of unexplained
hypotension.
3. Return of spontaneous
circulation (ROSC).
4. Acute onset congestive
heart failure.
B. Precaution:
1. Performing a 12 lead
ECG on a patient without
proper indications
increases the likelihood
of obtaining a false
positive STEMI finding.
Performance Criteria
1.
2.
3.
Uses universal precautions.
Do not delay assessment and treatment. Follow appropriate
policies regarding the patient’s clinical assessment.
Explain to the patient the procedure and the importance of
obtaining an ECG.
San Joaquin County
Emergency Medical Services
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12 Lead ECG Performance Criteria
EMS Policy No. 2551
Effective: January 1, 2012
Supersedes: January 1, 2010
States: Exposes the chest and prepare the patient’s skin for
electrode placement. Dry the skin if it is excessively moist. If
there is significant chest hair, use a razor to shave areas
where leads will be placed.
5. Attach ECG leads to the patient:
1. Place the electrodes on the limbs. The limb leads can be
placed anywhere from the shoulders to the wrist and the
thighs to the ankles – not the torso.
2. Place the electrodes on the chest. The six precordial
(chest) lead electrodes:
a. V1: right 4th intercostal space, just to the right of the
sternum.
b. V2: left 4th intercostal space, to the left of the sternum.
c. V3: Halfway between V2 and V4.
d. V4: Left 5th intercostals space, midclavicular line.
e. V5: Horizontal to V4, anterior axillary line.
f. V6: Horizontal to V5, mid-axillary line.
6. Encourage the patient to remain as still as possible and not to
talk.
7. Run the 12-Lead ECG.
8. The 12-Lead/Age menu will appear. Select the patient’s age.
9. If the monitor detects noise (such as patient motion or a
disconnected electrode), the 12-Lead is interrupted. Take
appropriate action and run the 12-Lead again.
10. If the 12-lead ECG indicates an acute STEMI, based on
cardiac monitor/defibrillator manufacture’s operating
instructions regarding STEMI alerting messages.
 LP12 (*** ACUTE MI SUSPECTED ***)
 LP15 (*** MEETS ST EVELVATION MI CRITERIA ***)
 Zoll E Series (** ** ** ** * ACUTE MI * ** ** ** **)
1. States: Notify the STEMI Receiving Center (SRC).
2. States: Transport to SRC.
11. Attaches a copy of the 12-lead ECG to the PCR.
4.
San Joaquin County
Emergency Medical Services
Page 130 of 216
King Airway Performance Criteria
EMS Policy No. 2552
Effective: October 16, 2013
Supersedes: October 1, 2012
2552 – King Airway Performance Criteria
The KING LTS-D is an effective alternative to endotracheal
intubation. The KING LTS-D also allows three additional benefits with
the use of secondary lumen which is open at the distal tip of the tube:
1). Passage of gastric tube up to 18 French; 2). A channel for
regurgitation, and; 3). A "vent" for gastric pressure and stomach
decompression.
A. Assessment/Treatment Indicators:
1. Inability to ventilate in a setting in which endotracheal intubation
is not successful or the patient has a Cormack Lehan score is a
3 or 4.
2. Inability to ventilate or oxygenate the patient using a BVM and
BLS airway.
3. Inability of patient to protect the airway (coma, decreased LOC
without gag reflex).
4. Cardiac arrest. Adhere to sequence as specified in EMS Policy
No. 5710 ALS Medical Cardiac Arrest as appropriate.
5. Agonal or failing respirations, respiratory arrest.
B. Contraindications:
1. Patient with GCS > 3
2. Patient has a gag reflex.
3. Patient has a tracheostomy or stoma.
4. Patient height less than 4 feet
C. Relative Contraindications:
1. Ingestion of caustic substance.
2. Known history of esophageal disease.
3. Inhalation Burns.
D. Equipment:
1. King Airway LTS-D Kit (Size 3, 4, or 5)
2. Battery powered suction unit
3. Appropriate size suction catheter
4. Yankauer Tonsil Tip suction catheter
5. Disposable bag valve device – BVM
San Joaquin County
Emergency Medical Services
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King Airway Performance Criteria
EMS Policy No. 2552
Effective: October 16, 2013
Supersedes: October 1, 2012
6. End tidal CO2 device
7. Stethoscope
Performance Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Uses universal precautions.
Assures an adequate BLS airway.
States: Indications and contraindications.
States: Placement should be completed within 30 seconds.
Ensures suction is available and working.
Preoxyegnates with BVM for a minimum of (15) fifteen
seconds with supplemental oxygen when conditions permit
(unless transitioning to an advanced airway per EMS Agency
Policy No. 5710 ALS Medical Cardiac Arrest)..
States appropriate size tube based on height.
a. Size 3 – 4 and 5 feet tall
b. Size 4 – 5 and 6 feet tall
c. Size 5 – Over 6 feet tall
Prepares King LTS-D
a. Tests cuffs for leaks
b. Lubricates device with water-soluble lubricant to the
beveled distal tip and posterior aspect of tube, taking care
to avoid introduction of lubricant in or near ventilatory
openings.
States: Will have a spare King Airway available for immediate
use.
Positions the head. The ideal head position for insertion is
the “sniffing position.” A neutral position can also be used
(e.g. spinal injury concerns).
Grasps the patient's tongue and jaw with gloved hand and
pulls forward. A laryngoscope may be used. With the King
LTS-D rotated laterally at 45-90 degrees such that the blue
orientation line is touching the corner of the mouth, introduces
tip into mouth and advances it behind base of tongue. Never
force the tube into position.
San Joaquin County
Emergency Medical Services
Page 132 of 216
King Airway Performance Criteria
EMS Policy No. 2552
Effective: October 16, 2013
Supersedes: October 1, 2012
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
TIP
As the tube tip passes under tongue, rotates tube back to
midline (blue orientation stripe faces chin).
Without exerting excessive force, advances tube until base of
connector aligns with teeth or gums.
Inflates cuff to required volume. States: Required cuff
pressure based on tube size. Note: Do not exceed
maximum recommended pressure.
Connects the King LTS-D to a BVM and ventilates the patient.
While ventilating the patient, gently withdraws the tube until
ventilation becomes easy and free flowing (large tidal volume
with minimal airway pressure). Adjusts cuff inflation if
necessary to obtain a seal of the airway at the peak
ventilatory pressure employed.
Confirms proper position by auscultation, chest movement,
and verification of CO2 by capnography. Do not use
esophageal detector device with esophageal airway. The
method of confirmation must be documented.
Secures the tube. Notes depth marking on tube.
If placement is unsuccessful, removes tube, ventilate with
BVM and repeats sequence of steps. If unsuccessful on
second attempt, BLS airway management shall be resumed.
Continues to monitor the patient for proper tube placement
throughout prehospital treatment and transport. Capnography
should be done in all cases.
Provides ventilations at 10 – 12/minute.
States: Document King Airway placement on PCR.
The key to insertion is to get the distal tip of the airway
around the corner in the posterior pharynx, under the base of
the tongue. It is important that the tip of the device is
maintained at the midline. If the tip is placed or deflected
laterally, it may enter the piriform fossa and cause the tube to
appear to “bounce back” upon full insertion and release.
San Joaquin County
Emergency Medical Services
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Endotracheal Intubation – Pediatric Performance Criteria
EMS Policy No. 2553
Effective: January 1, 2010
Supersedes: NA
2553 – Endotracheal Intubation – Pediatric Performance Criteria
In the absence of a protected airway, attempts to provide adequate
lung inflation with a BVM may result in the generation of pharyngeal
pressure high enough to cause gastric distention. In addition, gastric
insufflation promotes regurgitation with the potential for aspiration of
gastric contents into the lungs and may on occasion elevate the
diaphragm enough to interfere with lung expansion. Pediatric
intubation should only be attempted if an adequate BLS Airway
cannot be maintained.
A. Assessment/Treatment Indicators:
1. Inability of ALS personnel to ventilate or oxygenate the patient.
2. Inability of patient to protect the airway (coma, decreased level
of consciousness with non-intact gag reflex).
3. Cardiac arrest, including traumatic arrest.
4. Agonal or failing respirations, respiratory arrest.
5. Base Hospital Physician Order
B. Contraindications: Intubation may be contraindicated on patients
that are known diabetics or narcotics overdoses, prior to the
administration of Dextrose or Narcan.
C. Potential Complications:
1. Esophageal Intubation
2. Mainstem Intubation
3. Perforation or laceration of upper esophagus, vocal cords,
larynx
4. Laryngospasm or bronchospasm
5. Dental and soft-tissue trauma
6. Aspiration of oral or gastric contents
7. Dysrhythmias
8. Hypertension/Hypotension
San Joaquin County
Emergency Medical Services
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Endotracheal Intubation – Pediatric Performance Criteria
EMS Policy No. 2553
Effective: January 1, 2010
Supersedes: NA
D. Equipment:
1. Broselow Pediatric Resuscitation Tape for sizing
recommendations
2. Laryngoscope with appropriate size handle
3. Endotracheal tube
4. Malleable stylet
5. Water soluble lubricating jelly
6. Syringe: 10 ml
7. Magill forceps
8. Battery powered suction unit
9. Yankauer Tonsil Tip suction catheter
10. Appropriate size suction Catheter
11. ET tube holder
12. End tidal CO2 device
Performance Criteria
1. Use universal precautions.
2. Assure an adequate BLS airway.
3. State indications and contraindications
4. States placement should be completed within 30 seconds.
5. Ensure suction and is available and working. .
6. Checks light source, ensures a bright, tight, white light.
7. Select appropriate size tube.
8. Check tube cuff for leaks by injecting air into cuff with syringe
and deflates cuff if present.
9. Position stylet (if used) so that the end is recessed within tube,
then lubricates the tube.
10. Instructs assistant to preoxyegnate the patient.
11. Positions the patient with neck slightly extended. Understands
bimanual laryngoscopy and when and how it is used.
12. Perform tube insertion. Gently inserts laryngoscope blade into
mouth and applies upward traction with left hand to visualize
the vocal cords. Inserts tube through open cords with right
hand when visualized. Does Not Use Teeth As A Fulcrum.
San Joaquin County
Emergency Medical Services
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Endotracheal Intubation – Pediatric Performance Criteria
EMS Policy No. 2553
Effective: January 1, 2010
Supersedes: NA
13. Remove laryngoscope from mouth and removes stylet while
stabilizing tube manually.
14. Inflate cuff (if present) with 10 ml of air and detaches syringe.
15. Simultaneously maintains tube position, ventilates patient and
confirms tube placement by:
a. Notating capnography readings.
b. Observing bilateral rise and fall of chest wall.
c. Auscultating bilateral breath sounds with absence of sounds
over abdomen.
d. Confirm placement with end tidal CO2 device.
16. If initial attempt at intubation fails, reattempt after
hyperventilation period of 15-30 seconds by BVM.
17. If air was heard only on the right side, what would you do?
(Indicates would deflate the cuff, if present, pull tube back
slightly -1 cm, re-inflate the cuff, and auscultate for bilateral air
entry).
18. Note tube markers at front teeth, secures tube, and places oral
airway.
19. Provide ventilations at 10 – 12/minute
20. Successfully intubates in no more than two (2) attempts per
patient with hyperventilation between attempts. If unsuccessful
after two (2) attempts, assure an adequate BLS airway.
San Joaquin County
Emergency Medical Services
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Continuous Positive Airway Pressure (CPAP)
Performance Criteria
EMS Policy No. 2554
Effective: January 1, 2010
Supersedes: NA
2554 – Continuous Positive Airway Pressure (CPAP)
Performance Criteria
The goal of CPAP is to improve ventilation and oxygenation in an
effort to avoid intubation in patients who present with severe
respiratory distress.
A. Assessment/Treatment Indicators: CPAP is authorized for use in
patients who are age 8 or older with one of the following:
1. Congestive Heart Failure (CHF) with acute pulmonary edema
2. Near drowning/submersion
3. Other causes of severe respiratory distress, excluding trauma
B. Contraindications:
1. Respiratory or cardiac arrest
2. Failing respirations
3. Inability to maintain airway
4. Severely depressed level of consciousness (LOC)
5. Systolic blood pressure < 90mmHg
6. Signs and symptoms of pneumothorax
7. Major trauma, especially head injury or suspected chest injury
8. Facial anomalies or inability to obtain a mask seal
C. Relative Contraindications
1. Decreased LOC
2. Claustrophobia or unable to tolerate mask
D. Equipment:
1. CPAP (pressure generator and circuit set with ability to deliver
7.5 cm to 10 cm of H20 pressure with appropriate sized
facemask and straps).
2. Nebulizer, if required for bronchodilator administration
3. Oxygen source
4. Cardiac monitor
Performance Criteria
1.
Use universal precautions.
San Joaquin County
Emergency Medical Services
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Continuous Positive Airway Pressure (CPAP)
Performance Criteria
EMS Policy No. 2554
Effective: January 1, 2010
Supersedes: NA
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
State indications and contraindications.
Position the patient in a seated position with legs dependant.
Apply cardiac monitor and assess vital signs.
Repeat vital signs every five minutes; SpO2 must be used to
continuously monitor the patient’s oxygen saturation.
Treat the patient according to appropriate treatment policy
(i.e. pulmonary edema).
Set up the CPAP system following manufacturer directions.
Explain the procedure to the patient. It is important to
reassure the patient throughout the procedure.
Verify that oxygen is flowing to the mask and then apply
mask.
Do not exceed 10 cm of H20 pressure.
Continuously monitor patient for improvement or failure to
improve.
The patient should improve in the first five minutes with
CPAP, evidenced by decreased heart rate and blood
pressure, decreased respiratory rate and an increased SpO2.
If the patient does not improve or becomes worse with CPAP,
remove the CPAP device and assist ventilations with BVM as
needed.
Notify the receiving hospital of the type of CPAP device that is
being used.
DOCUMENTATION:
A. The use of CPAP must be documented on the patient care
record.
B. Vital signs to include heart rate, blood pressure, respiratory
rate, and SpO2 must be documented every 5 minutes.
C. Narrative documentation should include a description of
the patient’s response to treatment.
D. Additional narrative documentation should include if the
patient does not respond to CPAP and endotracheal
intubation is required.
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Emergency Medical Services
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Nasotracheal Intubation – Adult
Performance Criteria
EMS Policy No. 2555
Effective: January 1, 2012
Supersedes: February 15, 2010
2555 – Nasotracheal Intubation – Adult Performance Criteria
To provide an advanced airway in patients that cannot be intubated
endotracheally. Nasotracheal intubation requires a Base Hospital
Physician order.
A. Assessment/Treatment Indicators:
1. Possible cervical spine injury with clenched jaw and gag reflex.
2. Trapped and inaccessible for direct laryngoscopy.
3. Severe respiratory distress secondary to smoke inhalation,
asthma, emphysema
4. Patient nare is able to accommodate size 7.0, 7.5 or 8.0
endotracheal tubes.
5. Severe respiratory depression secondary to ETOH, OD, CVA.
6. Need to control and provide airway protection.
7. Compromised airway in spontaneously breathing patients.
8. Base Hospital Physician Order.
B. Contraindications:
1. Apneic patient.
2. Lack of proper training.
3. Loss of nasal passage integrity.
4. Basilar skull fracture.
5. Pediatrics as defined in pediatric routine medical care policy.
6. Unstable mid-face fractures with loss of nasal passage integrity.
C. Relative Contraindications:
1. For significant trauma to the face or nose and/or possible
basilar skull fracture.
2. For patients on anticoagulant therapy.
D. Potential Complications:
1. Epistaxis and/or emesis can be induced in patients with
clenched teeth, further compromising the airway.
2. Perforation of pyriform sinus.
3. Perforation of the pharynx.
4. Cranial intubation and possible infection in the patient with a
basal skull fracture.
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Emergency Medical Services
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Nasotracheal Intubation – Adult
Performance Criteria
EMS Policy No. 2555
Effective: January 1, 2012
Supersedes: February 15, 2010
E. .Equipment:
1. Endotracheal tube
2. Water soluble lubricating jelly
3. 10 ml syringe
4. BAMM
5. Oxygen
6. Neosynephrine
7. Battery powered suction unit
8. Yankauer Tonsil Tip suction catheter
9. Appropriate size suction catheter
10. ET tube holder
11. End tidal CO2
12. Disposable bag valve device – BVM
Performance Criteria
1.
2.
3.
4.
5.
6.
7.
8.
9.
Use universal precautions.
Support ventilations with appropriate basic airway adjuncts
and explain the procedure to a conscious patient.
States: Indications and contraindications.
Select the nostril to be used and inspect for patency and
airflow. Select the appropriate cuffed tube and pre-oxygenate
patient with 100% oxygen prior to attempting procedure.
If patient becomes apneic, discontinue procedure and attempt
oral intubation.
Lubricate the distal tip of endotracheal tube with viscous
Lidocaine.
Position the patient as tolerated. Hold in-line cervical
stabilization if neck injury is suspected.
Administer one (1) metered dose, 0.5mg of phenylephrine
HCL to the selected nostril. May be repeated once prior to
additional attempt.
If first attempt is unsuccessful, recontact Base Hospital
Physician, for approval for second attempt.
San Joaquin County
Emergency Medical Services
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Nasotracheal Intubation – Adult
Performance Criteria
EMS Policy No. 2555
Effective: January 1, 2012
Supersedes: February 15, 2010
10.
11.
12.
13.
With one hand, advance ET tube into the selected nostril with
bevel against septum. Monitor breath sounds continuously
while gently guiding the tube into the trachea. Use BAAM
device to assist in proper placement.
Inflated cuff with 10 ml of air and detaches syringe.
Simultaneously maintains tube position, ventilates patient
and confirms tube placement:
a. Notes capnography readings. PPV at the appropriate
CO2 level as well as respiratory rate.
b. Observes bilateral rise and fall of chest wall.
c. Auscultates bilateral breath sounds with absence of
sounds over abdomen.
d. Confirms placement with end tidal CO2 device.
States: Document Nasotracheal intubation placement on the
PCR
San Joaquin County
Emergency Medical Services
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Needle Cricothyrotomy – ENK Flow O2 Modulator
Performance Criteria
EMS Policy No. 2556
Effective: January 1, 2012
Supersedes: NA
NEEDLE CRICOTHYROTOMY – ENK FLOW OXYGEN
MODULATOR
Transtracheal catheter ventilation is a temporary emergency procedure
to provide oxygenation when airway obstruction cannot be relieved by
other methods.
A. Assessment/Treatment Indicators:
1. Patient is unconscious and unresponsive.
2. Total airway obstruction following unsuccessful attempts of BLS
and ALS obstructed airway procedures.
3. Massive facial trauma in a patient who cannot be intubated by
either oral or nasotracheal means.
4. Injury to the trachea/larynx in a patient who cannot be adequately
ventilated or intubated by either oral or nasotracheal means.
5. Complete airway obstruction due to infection or allergic reaction.
B. Contraindications: NONE.
C. Potential Complications:
1. With the high pressure used during ventilation and the possibility
of air entrapment, may produce a pneumothorax.
2. Hemorrhage may occur at the site of the needle insertion,
especially if the thyroid is perforated.
3. Perforation of the esophagus.
4. Subcutaneous or mediastinal emphysema.
5. Usually does not allow enough ventilation to adequately eliminate
carbon dioxide.
D. .Equipment:
1. ENK Flow Oxygen Modulator Kit
2. Endotracheal tubes: 3.0 or 3.5 ET
3. Providone iodine
4. Oxygen supply @ 25 PSI
5. Battery powered suction device
6. Yankauer Tonsil Tip Suction Catheter Non-rigid
7. 10 ml syringe
8. End-tidal CO2 device
9. Tape
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Needle Cricothyrotomy – ENK Flow O2 Modulator
Performance Criteria
EMS Policy No. 2556
Effective: January 1, 2012
Supersedes: NA
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
Uses universal precautions.
States: Indications and contraindications.
States: Extend the patient’s neck, if not a trauma victim.
Locates and prepares insertion site at the cricothyroid
membrane between the thyroid and cricoid cartilage of larnyx.
Stabilizes the larynx by holding the cartilage between fingers.
Places 5 ml of normal saline in the syringe. Attaches the IV
catheter to the syringe and inserts the needle midline at 90
angle, slowly advances the needle ½” to ¾” with plastic
catheter.
Attempts to aspirate free air as needle advances. If the needle
is in the correct location bubbles should be seen in the syringe.
If unable to aspirate free air, back the needle up 1 cm at a time
while aspirating until bubbles are seen in the syringe.
States: Once free air has been aspirated, then directs the
needle toward the sternal notch, advances the catheter over
the needle, then withdraws the needle and syringe.
Attaches the catheter to the ENK Flow Oxygen Modulator.
Assesses for hemorrhage or subcutaneous emphysema, which
may indicate improper placement.
Directs assistant to attach distal end of ENK Flow Oxygen
Modulator to oxygen source and set @ 15 – 25 LPM.
Ventilates the patient by covering the holes on the modulator
for four (4) seconds.
Uncovers the holes for six (6) seconds to allow for passive
exhalation.
Auscultates lungs while manually holding needle.
Secures needle hub in place by wrapping tape around the hub
twice and then behind the patients neck and wrap the hub twice
again after coming around the neck.
States: Monitors end-tidal CO2 and/or pulse oximetry, and
chest expansion.
States: Transports immediately to closest hospital for airway
management.
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Performance Criteria
EMS Policy No. 2556
Effective: January 1, 2012
Supersedes: NA
18. States: Contact the Base Hospital if unable to adequately
ventilate patient.
19. States: Document needle cricothyrotomy placement on PCR.
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Paramedic Scope of Practice
EMS Policy No. 2560
Effective: January 1, 2012
Supersedes: February 15, 2010
2560 – Paramedic Scope of Practice
PURPOSE: The purpose of this policy is to define the scope of
practice of San Joaquin County EMS Agency accredited paramedics.
AUTHORITY: Health and Safety Code, Division 2.5, Section
1797.220; 1798 et seq., Title 22, California Code of Regulations,
Chapter 4 et seq.
DEFINITIONS:
A. “Emergency Medical Technician” or “EMT” means a person who
has successfully completed a basic EMT course, which meets the
requirements of Title 22, California Code of Regulations, and
Chapter 2 and has been certified as an EMT by an EMT-I
certifying authority.
B. “Advanced EMT or Emergency Medical Technician – II” or “EMTII” means a person who has successfully completed a basic EMT
course, which meets the requirements of Title 22, California Code
of Regulations, Chapter 3 and has been certified as an EMT-II by
an EMT-II certifying authority.
C. “Paramedic” means a person who is educated and trained in all
elements of the prehospital advanced life support and has been
licensed by the State of California as a paramedic.
POLICY:
I. An accredited paramedic may perform any activity identified in the
scope of practice of an EMT or any activity identified in the scope
of practice of an Advanced EMT or EMT-II.
II. As part of the State approved basic scope of practice, a paramedic
student or accredited paramedic, as part of the organized EMS
system in San Joaquin County, while caring for patients in a
hospital as part of his/her training or continuing education under
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Paramedic Scope of Practice
EMS Policy No. 2560
Effective: January 1, 2012
Supersedes: February 15, 2010
direct supervision of a physician, registered nurse, or physician
assistant, or while at the scene of a medical emergency or during
transport, or during interfacility transfer may perform the following
procedures or administer the following medications in accordance
with the written policies of the San Joaquin County EMS Agency:
A. Perform defibrillation.
B. Perform cardioversion.
C. Visualize the airway by use of laryngoscope and remove
foreign body(ies) with forceps.
D. Perform ECG’s.
E. Perform pulmonary ventilation by use of the esophageal
airway, lower airway lumen, endotracheal intubation or other
airway adjuncts approved by the EMS Agency.
F. Use of ventilators during transport as approved by the EMS
Agency.1
G. Institute intravenous (IV) catheters, saline locks, needles, or
other cannulae in peripheral veins; and monitor and administer
medications through pre-existing vascular access.
H. Administer intravenous glucose solutions or isotonic balanced
salt solutions including Ringer’s lactate solution.
I. Obtain venous blood samples.
J. Use glucose and pulse oximetry measuring devices.
K. Perform Valsalva’s maneuver.
L. Perform needle cricothyrotomy.
M. Perform needle thoracostomy.
N. Monitor thoracostomy tubes.
O. Monitor IV solution containing potassium equal to or less than
20 mEq./L.
P. The following are the only authorized routes for administration
of medications
1. Intravenous
2. Intraosseous
3. Subcutaneous
1 Use limited to specially approved ALS ambulance providers.
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Effective: January 1, 2012
Supersedes: February 15, 2010
4. Intramuscular
5. Sublingual
6. Inhalation
7. Oral
Q. Administer using prepackaged products when available:
1. 25% and 50% dextrose.
2. Activated charcoal.
3. Adenosine.
4. Aerosolized or nebulized beta-2 specific bronchodilators.
5. Aspirin.
6. Atropine sulfate.
7. Calcium chloride.
8. Diazepam2
9. Diphenhydramine hydrochloride.
10. Dopamine hydrochloride.
11. Epinephrine.
12. Furosemide3
13. Glucagon.
14. Lidocaine hydrochloride.
15. Midazolam.
16. Morphine sulfate.
17. Naloxone hydrochloride.
18. Nitroglycerine preparation – sublingual or oral spray.
19. Pralidoxime chloride (2 - PAM)
20. Sodium bicarbonate.
III. An accredited paramedic in San Joaquin County is authorized, as
part of the State approved expanded scope of practice, to perform
the following procedures or administer the following medications in
accordance with the written policies of the San Joaquin County
EMS Agency:
A. Perform pediatric oral endotracheal intubation.
2 As part of a nerve agent antidote kit.
3 As prescribed by the transferring physician during an interfacility transfer.
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Paramedic Scope of Practice
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Effective: January 1, 2012
Supersedes: February 15, 2010
B.
C.
D.
E.
F.
Perform adult naso-tracheal intubation.
Perform intraosseous access.
Perform nasogastric intubation and gastric suctioning.
Perform transcutaneous cardiac pacing.
Monitor and adjust heparin infusion during interfacility
transport. 1
G. Monitor and adjust nitroglycerine infusion during interfacility
transport. 1
H. Administer using prepackaged products when available the
following medications by the routes specified in the ALS
treatment protocols:
1. Magnesium sulfate.
2. Atrovent.
____________________
1 Use limited to specially approved ALS ambulance providers.
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Monitoring an Infusion with Potassium Chloride
EMS Policy No. 5952
Effective: January 1, 2007
Supersedes: NA
5952 - Monitoring an Infusion with Potassium Chloride
PURPOSE: The purpose of this policy is to provide a mechanism for
paramedics to be permitted to monitor infusions of
Potassium Chloride (KCL) during interfacility transfers.
POLICY:
I.
All ALS Ambulance providers approved by the San Joaquin
County EMS Agency Medical Director will be permitted to
provide the service of monitoring potassium chloride infusions
during interfacility transports from approved hospital(s) within
their service area.
II.
Only those paramedics who have successfully completed
training program(s) approved by the San Joaquin County EMS
Agency Medical Director on potassium chloride infusions will be
permitted to monitor them during interfacility transports.
III.
Patients that are candidates for paramedic transport will have
preexisting KCL infusions in peripheral lines. Prehospital care
providers are not allowed to start or add KCL to the I.V.
solution.
IV.
Infusions containing KCL
In accordance with the provisions of this policy, a paramedic
may transport a patient who has a preexisting I.V. solution
containing KCL only when following these parameters:
A.
Signed transfer orders from the transferring physician
must be obtained prior to transport. Infusions containing
KCL may be monitored only.
B.
C.
Patient is placed on cardiac and pulse oximetry monitors
and monitored continuously during transport.
KCL infusion concentration will not exceed 20 mEq/liter
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Monitoring an Infusion with Potassium Chloride
EMS Policy No. 5952
Effective: January 1, 2007
Supersedes: NA
D.
E.
F.
V.
administered at a mechanically controlled rate not to
exceed 10 mEq/hour.
If fluid bolus or I.V. medications are needed, the KCL
infusion shall be discontinued and a new I.V. solution
without KCL and administration device shall be used as
replacement. DO NOT BOLUS FLUIDS CONTAINING
KCL.
Vital signs will be monitored and documented no less
than every 10 minutes during patient transport.
Monitor patient for adverse effects during transport
including:
1.
Cardiovascular: dysrhythmias, cardiac arrest
2.
Respiratory: depression/arrest
3.
Gastrointestinal: nausea/vomiting, diarrhea,
abdominal pain
4.
Neurological: paresthesia of extremities, muscular
paralysis, confusion
5.
I.V. infiltration: monitor I.V. site as infiltration may
cause necrosis. If patient complains of burning or
irritation at the insertion site, the I.V. should be
checked for patency and the infusion rate slowed or
discontinued.
General Information on Potassium Chloride
A. Potassium is an essential macromineral in human nutrition
with a wide range of biochemical and physiological roles.
Among other things, it is important in the transmission of
nerve impulses, the contraction of cardiac, skeletal and
smooth muscle, the production of energy, the synthesis of
nucleic acids, the maintenance of intracellular tonicity and
the maintenance of normal blood pressure.
B.
Indications for the use of Potassium Chloride
1.
The treatment of potassium depletion in patients
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Supersedes: NA
C.
D.
E.
F.
with hypokalemia when oral replacement is not
feasible.
2.
Treatment of digitalis intoxication.
Contraindications:
1. Renal impairment with oliguria or azotemia
2.
Untreated Addison's disease
3.
Hyperadrenalism associated with adrenogenital
syndrome
4.
Extensive tissue breakdown as in severe burns
5.
Adynamia episodica hereditaria
6.
Hyperkalemia of any etiology
Precautions:
1.
Pregnancy Category C
2.
Chronic renal disease
3.
Adrenal insufficiency
4.
Any other condition which impairs potassium
excretion
5.
Potassium should be used with caution in diseases
associated with heart block
Adverse Effects:
1.
Fever
2.
Venous Thrombosis, Infection at injection site
3.
Extravasation, Phlebitis, Pain at Injection Site
4.
Hypervolemia
5.
Hyperkalemia
6.
Abdominal Pain
7.
Nausea/Vomiting;
8.
Paresthesias of the extremities
9.
ECG Abnormalities, Heart Block
10. Mental Confusion
11. Hypotension
Interactions:
1.
Cardiac arrest can occur with high potassium
conditions, such as chronic renal failure, burns,
acidosis, dehydration, and potassium sparing
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Monitoring an Infusion with Potassium Chloride
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Supersedes: NA
G.
H.
diuretic usage.
2.
Drug interactions causing elevation of potassium
can occur with ACE inhibitors (used to treat high
blood pressure) and certain diuretics (aldactone and
triamterene).
Standard Dosages for Potassium Chloride Infusions:
1.
For serum potassium level > 2.5mEq/L
a.
Continuous IV Infusion: 10mEq/hour in a
concentration up to 40mEq/L. Max dose of
200mEq/day.
2.
For serum potassium level < 2.0 with
electrocardigraphic changes and/or muscle
paralysis, potassium chloride may be administered
at a rate up to 40mEq/hour. (This rate is not
approved for EMS personnel).
Special Considerations:
1. MUST BE DILUTED BEFORE ADMINISTRATION.
2. Administer at a rate not to exceed 10mEq/hour.
3. Monitor electrolyte, fluid, and acid-base balances.
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Monitoring an Infusion of Heparin
EMS Policy No. 5954
Effective: January 1, 2007
Supersedes: 530.14
5954 - Monitoring an Infusion of Heparin
PURPOSE: The purpose of this policy is to authorize paramedics to
monitor intravenous heparin infusions during interfacility
transport.
POLICY:
I.
Only those ALS Ambulance providers approved by the San
Joaquin County EMS Agency will be permitted to provide the
service of monitoring heparin infusions during interfacility
transports from approved hospital(s) within their service area.
II.
Only those paramedics who have successfully completed
training program(s) approved by the San Joaquin County EMS
Agency on heparin infusions will be permitted to monitor them
during interfacility transports. Training must include the use of
mechanical infusion pumps.
III.
Patients that are candidates for paramedic transport will have
preexisting heparin drips in peripheral lines. Prehospital
personnel will not initiate heparin drips.
IV.
Paramedics may restart heparin infusions if the heparin infusion
is interrupted due to infiltration, accidental disconnection of the
IV line, malfunctioning pump, etc. All lines must be restarted in
accordance with the transferring physician’s orders.
Paramedics will ensure new IV line is patent prior to re-starting
the infusion.
V.
Heparin Infusions:
The following parameters shall apply in all cases where
paramedics transport patients with preexisting heparin drips:
A.
Patient shall be placed on cardiac, blood pressure and
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Monitoring an Infusion of Heparin
EMS Policy No. 5954
Effective: January 1, 2007
Supersedes: 530.14
B.
C.
D.
E.
F.
G.
pulse oximetry monitors and monitored continuously
during transport.
Signed transfer orders from the transferring physician
must be obtained prior to transport. Transfer orders must
certify that the patient is stable for transfer and provide
orders for maintaining the heparin infusion during
transport.
Infusion fluid must be D5W, NS or ½ NS.
Medication concentration shall be 100 units/ml of IV fluid
such as 25,000 units/250 ml.
Infusion rates must remain constant during transport with
no regulation rates being performed by the paramedic,
except for the discontinuation the infusion.
Infusion rates may not exceed 1600 units per hour.
Vital signs shall be monitored and documented every 1520 minutes during transport.
VI.
Continuous Quality Improvement:
All calls involving the transfer of patients with preexisting
heparin infusions shall be reviewed through the ambulance
provider’s CQI program to determine compliance with policy
and transferring physician orders. Reports of audits will be
submitted to the EMS agency on a monthly basis.
VII.
General Information on Heparin:
A.
B.
Heparin is an anticoagulant which acts to: prevent the
conversion of fibrinogen to fibrin, prevent the conversion
of prothrombin to thrombin, inactivate Factor X and
enhance the inhibitory effects of antithrombin III.
Pharmacokinetics:
1.
SC: Onset 20-60 minutes; duration 8-12 hours;
2.
IV: Onset immediate; peak 5 minutes; duration 2-6
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Monitoring an Infusion of Heparin
EMS Policy No. 5954
Effective: January 1, 2007
Supersedes: 530.14
C.
D.
E.
F.
hours;
3.
Metabolized in the liver and the spleen;
4.
Excreted in urine;
5.
Half-life of 1.5 hours.
Indications for the use of Heparin:
1.
In preventing additional clot formation or growth in
DVT, MI, pulmonary embolism, DIC, stroke or
arterial thrombosis;
2.
Prophylactically to keep IV lines open (i.e. heparin
flushes and locks);
3.
Prophylactically before open heart surgery;
4.
Prophylactically post DVT, PE and MI to prevent
clotting;
5.
Atrial fibrillation to prevent embolization;
6.
As an anticoagulant in transfusion and dialysis.
Contraindications:
1.
Allergy to heparin;
2.
Bleeding disorders - hemophilia, etc.
3.
Blood dyscrasias such as leukemia with bleeding;
4.
Peptic ulcer disease;
5.
Severe hypertension;
6.
Severe hepatic disease;
7.
Severe renal disease;
8.
Subacute bacterial endocarditis;
9.
Active bleeding from any site.
Precautions:
1.
Pregnancy (class C);
2.
Alcoholism (due to decreased liver function);
3.
Elderly (due to decrease liver and renal function and
increased injury capability).
Adverse Effects:
1.
Hemorrhage from any site. May manifest as easy
bruising, petechiae, epistaxis, bleeding gums,
hemoptysis, hematuria, melena;
2.
Fever, chills (due to allergy);
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Effective: January 1, 2007
Supersedes: 530.14
3.
G.
H.
I.
Abdominal cramps, nausea, vomiting, diarrhea (due
to allergy);
4.
Anorexia (secondary to above);
5.
Rash, uticaria (due to allergy).
Interactions:
1.
Oral anticoagulants (coumadin, warfarin) - increase
the actions of heparin;
2.
Salicylates (aspirin) - increase the actions of
heparin;
3.
Corticosteriods - increase the actions of heparin;
4.
Corticosteriods - actions are decreased;
5.
Dextran - increases the action of heparin;
6.
Nonsteriodal anti-inflammatory drugs (ibuprofen,
Aleve, Midol, naprosyn, toradol, voltaren, feldene,
indocin, clinoril) - increase the actions of heparin;
7.
Diazepam - action increase by heparin.
Standard Dosages and Routes:
1.
DVT/PE prophylaxis: 5,000 units subcutaneous
every 8-12 hours.
2.
Active Clot Suppression:
a)
Loading Dose
(1) Adult: 5000-7000 units IVP.
(2) Child: 50-100 units/kg IVP.
b)
Maintenance
(1) Adult: 1000-1600 units per hour IV
titrated to PTT/ACT/INR level.
(2) Child 15-25 units per hour IV titrated to
PTT/ACT/INR level.
Special Considerations:
1.
Avoid IM injections or other procedures which may
cause bleeding.
2.
Overdoses are treated in hospital with protamine
sulfate 1:1 solution (protamine is not authorized for
paramedic use.)
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Monitoring an Intravenous Infusion of Nitroglycerin
EMS Policy No. 5955
Effective: January 1, 2007
Supersedes: NA
5955 - Monitoring an Intravenous Infusion of Nitroglycerin
PURPOSE: The purpose of this policy is to authorize paramedics to
monitor and adjust intravenous nitroglycerin (NTG)
infusions in adult patients during interfacility transport.
POLICY:
I.
Only those ALS Ambulance providers approved by the San
Joaquin County EMS Agency are permitted to provide the
service of monitoring nitroglycerin infusions during interfacility
transports from approved hospital(s) within their service area.
II.
Only those paramedics who have successfully completed a
training program(s) approved by the San Joaquin County EMS
Agency on nitroglycerin infusions will be permitted to monitor
and adjust them during interfacility transports. Training must
include the use of mechanical infusion pumps.
III.
Patients that are candidates for paramedic transport will have
preexisting nitroglycerin drips infusing into peripheral lines.
Prehospital personnel will not initiate nitroglycerin drips.
IV.
Paramedics may restart nitroglycerin infusions if the
nitroglycerin infusion is interrupted due to infiltration, accidental
disconnection of the IV line, malfunctioning pump, etc. All lines
must be restarted in accordance with the transferring
physician’s orders. Paramedics will ensure new IV line is patent
prior to restarting the infusion.
V.
Nitroglycerin Infusions
The following parameters shall apply in all cases where
paramedics transport patients with preexisting nitroglycerin
drips:
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Monitoring an Intravenous Infusion of Nitroglycerin
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Supersedes: NA
A.
B.
C.
D.
E.
F.
G.
H.
I.
VI.
Patient shall be placed on cardiac, blood pressure and
pulse oximetry monitors and monitored continuously
during transport.
Signed transfer orders from the transferring physician
must be obtained prior to transport. Transfer orders must
certify that the patient is stable for transfer and provide
orders for maintaining the nitroglycerin infusion during
transport.
Nitroglycerin infusions must be regulated by a mechanical
intravenous infusion pump. If pump failure occurs and
cannot be corrected, the paramedic will stop the
nitroglycerin infusion and notify the transferring hospital.
Infusion fluid shall be D5W or NS.
Nitroglycerin infusion concentration shall be 25 mg/250 ml
or 50 mg/250 ml.
Regulation of the drip rate will be within parameters as
defined by the transferring physician, but in no case will
changes be in greater than 5 mcg/minute increments
every 10 minutes.
In cases of hypotension (SBP < 90), the medication drip
will be discontinued and the transferring hospital and
base hospital will be notified.
Maximum drip rate shall not exceed 200 mcg per minute.
Vital signs shall be monitored and documented every 10
minutes during transport or every 5 minutes if an increase
in the drip rate is ordered by the base physician.
Continuous Quality Improvement
All calls involving the transfer of patients with preexisting
nitroglycerin infusions shall be reviewed through the ambulance
provider’s CQI program to determine compliance with policy
and transferring physician orders. Reports of audits will be
submitted to the EMS agency on request.
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Monitoring an Intravenous Infusion of Nitroglycerin
EMS Policy No. 5955
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Supersedes: NA
VII.
General Information on Nitroglycerin
A.
B.
C.
Nitroglycerin is a vasodilating agent that belongs to a
group of drugs referred to as nitrates. Nitroglycerin acts
to: relax vascular smooth muscle; vasodilate both arteries
and veins (especially veins); increase venous pooling;
decrease venous return to the heart; increase arterial
relaxation; decrease systemic vascular resistance;
decrease cardiac workload; decrease cardiac oxygen
consumption; dilate the large epicardial arteries; and
lower diastolic more than systolic blood pressure.
Pharmacokinetics:
1. SL: Onset 1-3 minutes; duration 30 minutes;
2. Transdermal (patch): Onset 0.5 - 1 hour; duration 1224 hours;
3. Transdermal (ointment): Onset 0.5-1 hour; duration 212 hours;
4. PO (sustained release): Onset 20-40 minutes;
duration 3-8 hours;
5. IV: Onset usually immediate; duration is variable;
6. Metabolized by the liver;
7. Excreted in urine;
8. Half-life of 1-4 minutes.
Indications for the use of Nitroglycerin:
1.
Sublingual:
a. Relief of acute anginal pain or related
ischemic symptoms;
b. Congestive Heart Failure (CHF) to decrease
myocardial workload.
2.
Intravenous:
a. Diagnosed MI or unstable angina pectoris,
even in the absence of chest pain, to
decrease myocardial workload;
b. Relief of persistent ischemic chest pain that
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Monitoring an Intravenous Infusion of Nitroglycerin
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D.
E.
F.
G.
does not respond to other medications;
c.
Hypertension when associated with diagnosed
MI or unstable angina pectoris (not used
solely for blood pressure control).
Contraindications:
1.
Allergy to nitrates;
2.
Increased intracerebral pressure such as in cases
of stroke, head trauma or intracerebral bleeding;
3.
Hypotension;
4.
Hypovolemia;
5.
Treatment of hypertension without progressively
worsening signs of organ damage, ischemia or
neurologic deficit.
Precautions:
1.
Pregnancy (class C);
2.
Glaucoma patients (can increase intraocular
pressure);
3.
Lactation (fetal effects in animal studies);
4.
May require decreased dosing in patients with liver
disease.
Adverse Effects:
1.
Hypotension;
2.
Headache (from vasodilation);
3.
Dizziness and syncope (from hypotension);
4.
Nausea/Vomiting;
5.
Tachycardia (in response to hypotension);
6.
Paradoxical bradycardia (in rare instances);
7.
Pallor, sweating (from hypotension);
8.
Flushing, sweating (from vasodilation);
9.
Rash, if allergic to nitrates.
Interactions:
1.
Alcohol - combined with nitroglycerin can worsen
hypotension;
2.
Aspirin - can increase serum nitrate concentrations;
3.
Calcium channel blockers - combined with
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Monitoring an Intravenous Infusion of Nitroglycerin
EMS Policy No. 5955
Effective: January 1, 2007
Supersedes: NA
H.
I.
nitroglycerin can worsen orthostatic hypotension;
4.
ß-blockers, diuretics, anti-hypertensives - can
increase actions of nitroglycerin.
Standard Dosages for Nitroglycerin drips:
1.
For diagnosed patients with ischemic symptoms:
a.
Continuous IV Infusion: starting at 10-20
mcg/min and increased by 5 or 10 mcg/min
every 5 to 10 minutes until the desired
hemodynamic or clinical response is
achieved. Most patients respond to 50 to 200
mcg/minute and the lowest possible dose
should be used. When indicated, rates should
be decreased in 10 minute intervals.
Special Considerations:
1.
Glass infusion bottles and non-polyvinyl tubing must
be used as plastics will absorb nitroglycerin and
alter the dose administered.
2.
Do not use in-line filters.
Attach drip to port closest to catheter insertion.
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San Joaquin County EMS Agency
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EMERGENCY MEDICAL SERVICES
Related Policies
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Authority for Medical Emergency Management
EMS Policy No. 5001
Effective: November 14, 2006
Supersedes: 530.03
5001 - Authority for Medical Emergency Management
PURPOSE: The purpose of this policy is to define the authority for
patient health care management in the San Joaquin
County EMS system.
POLICY:
I.
In order to ensure accountability and medical control for patient
care management throughout the pre-hospital process the
following shall apply:
A. In the event that both transport and non-transport
emergency medical services personnel are on the scene
with the same qualifications, patient health care
management will rest with the San Joaquin County
emergency ambulance service transport provider. The first
arriving paramedic shall initiate care and shall transfer care
to the transport provider as soon as the “task at hand” is
completed (i.e., starting IV, etc.). All pre-hospital personnel
shall cooperate with one another to ensure rapid and
efficient care and transport of all patients.
B. During multi-casualty incidents (MCIs) the senior most
qualified representative from the exclusive emergency
ambulance service provider, which may include field
supervisors or management personnel, shall determine who
shall serve as the “Medical Group Supervisor” or if
established the “Medical Branch Director.”
C. The list below defines the assignment of responsibility for
patient care management in the San Joaquin EMS system
based on resources available on scene from the lowest level
to highest level with the emergency ambulance service
transport provider paramedic having the highest level of
responsibility for patient care management:
1. Public Safety First Aid;
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Authority for Medical Emergency Management
EMS Policy No. 5001
Effective: November 14, 2006
Supersedes: 530.03
2.
3.
4.
5.
6.
7.
First responder;
Non-transport EMT-I;
Transport EMT-I;
Non-transport Paramedic;
Transport Paramedic.
Notwithstanding paragraphs A, B, and C above, the
authority of the San Joaquin County Health Officer and
Medical Health Operational Area Coordinator shall not
be infringed.
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Determination of Death in the Field
EMS Policy No. 5103
Effective: October 16, 2013
Supersedes: January 1, 2012
5103 - Determination of Death in the Field
PURPOSE: The purpose of this policy is to provide EMS personnel
and base hospital physicians with direction for determining death in
the field.
POLICY:
I. All EMS personnel shall conduct an initial patient assessment and
either initiate treatment or make a determination of obvious death.
II. Obvious Death
A. If a patient meets criteria for obvious death upon an initial
assessment EMS personnel shall not initiate resuscitative
measures including cardiopulmonary resuscitation (CPR) on
the patient.
B. Obvious death is defined as a patient exhibiting apnea and
pulselessness accompanied by one or more of the following
conditions:
1. Decomposition of tissue;
2. Decapitation;
3. Rigor mortis and post mortem lividity characterized by
rigidity or stiffening of muscular tissues and joints in the
body usually appearing in the head, face and neck muscles
and the pooling of venous blood in dependent body parts;
4. Incineration of the torso and/or head;
5. Massive crush injury and/or penetrating injury with
evisceration or total destruction of the heart, lung, and/or
brain;
6. Gross dismemberment of the torso;
7. Submerged underwater for greater than sixty (60) minutes;
8. Presence of a valid Do-Not-Resuscitate (DNR) order.
C. EMS personnel are not required to use a cardiac monitor (i.e.
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Determination of Death in the Field
EMS Policy No. 5103
Effective: October 16, 2013
Supersedes: January 1, 2012
“run a strip”) to confirm obvious death.
D. Non-transport EMS personnel shall cancel a responding
ambulance if obvious death is determined prior to arrival of the
ambulance unless the responding ambulance is needed for
another patient or patients on scene.
III. Considerations for determining death after the initiation of
resuscitative measures:
A. If the initial patient assessment does not reveal obvious death,
EMS personnel shall initiate treatment or resuscitative
measures in accordance with applicable treatment protocols.
B. EMS personnel shall initiate rapid transport and continue
resuscitation until transfer of care in the emergency department
when the following factors are present:
1. The patient has a return of spontaneous circulation.
2. Traumatic cardiac arrest when the time from on-set of
cardiac arrest to arrival at the Trauma Center will be less
than 10 minutes.
a. Follow treatment regimen for patients in traumatic
cardiac arrest as specified in EMS Policy No. 5783
ALS Adult Trauma Treatment.
3. Submerged underwater for less than thirty (30) minutes.
C. In the absence of factors requiring rapid transport, as identified
in the paragraph above, EMS personnel shall remain on scene
and provide resuscitation to cardiac arrest patients per
applicable treatment policies.
D. If a patient in medical cardiac arrest remains pulseless and
apneic following eight (8) minutes of MICR and ALS
interventions appropriate for the ECG rhythm as indicated per
EMS protocol for a combined total of fifteen (15) minutes, ALS
personnel shall contact the base hospital and on-duty Base
Hospital Physician and request orders to either transport the
patient or to discontinue resuscitative measures.
1. The attending paramedic shall continue ALS resuscitative
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Determination of Death in the Field
EMS Policy No. 5103
Effective: October 16, 2013
Supersedes: January 1, 2012
measures while making base contact.
2. The BHP shall (after receiving the patient report):
a. Determine death and grant permission to discontinue
resuscitation, or;
b. Order resuscitation to continue and the patient
transported to the closest receiving hospital.
E. If the BHP grants permission to discontinue resuscitative
measures the attending paramedic shall:
1. Attach a code summary from the electrocardiograph to the
Patient Care Report (PCR).
2. Document the name of the BHP authorizing the request for
determination of death on the PCR.
IV. Actions following a determination of death:
A. EMS personnel shall follow their agency’s process to notify
both the San Joaquin County Sheriff Coroner’s Office and the
law enforcement agency with jurisdiction following a
determination of death in the field.
B. EMS personnel may not move or disturb a dead body until
disposition has been made by law enforcement or coroner
representative.
C. EMS personnel shall leave in place all invasive therapeutic
modalities initiated during the resuscitation for the coroner’s
review. These modalities may include but are not limited to
advanced and basic airways, intravenous catheters, cardiac
electrodes, etc.
D. EMS personnel shall not transport dead bodies by ambulance
except in the extremely rare occurrence that a patient is
determined to be dead during transport. In such situations,
EMS personnel shall deliver the body to the intended hospital.
E. If family or significant other request resuscitative efforts for a
patient with obvious death ALS and BLS personnel shall
decline the request to initiate resuscitation and provide an
explanation, reassurance and support to the family or
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Determination of Death in the Field
EMS Policy No. 5103
Effective: October 16, 2013
Supersedes: January 1, 2012
significant other.
V. EMS personnel shall utilize S.T.A.R.T. guidelines in determining
death at the scene of multi-casualty incidents. As EMS resources
become available patients initially determined to be dead per
S.T.A.R.T may be re-assessed.
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Do Not Resuscitate Orders
EMS Policy No. 5105
Effective: February 1, 2007
Supersedes: 540.06
5105 - Do Not Resuscitate Orders
PURPOSE:
The purpose of this policy is to establish criteria for prehospital
emergency medical care personnel working in the San Joaquin
County EMS System to easily recognize and follow a Do Not
Resuscitate (DNR) Order.
DEFINITIONS:
A.
B.
“Do Not Resuscitate (DNR”) means no chest compression, no
assisted ventilation, no defibrillation, no intubation, and no
cardiac medications.
“Pre-hospital Emergency Medical Care Personnel” means
those persons who have been certified or licensed as qualified
to provide prehospital emergency medical care pursuant to the
provisions of Health and Safety Code, Division 2.5.
POLICY:
I. All patients whose initial assessment does not reveal “obvious
death” as defined in EMS Policy No. 5103 Determination of Death,
shall be treated in accordance with applicable treatment protocols,
unless the prehospital emergency medical care personnel are
presented with a valid DNR Order evidenced by one of the
following:
A. A written and signed physician’s order in the patient’s
medical record stating DNR;
B. A completed State of California Prehospital DNR Request
Form;
C. A Medic Alert® bracelet inscribed “Do Not Resuscitate
EMS”.
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Do Not Resuscitate Orders
EMS Policy No. 5105
Effective: February 1, 2007
Supersedes: 540.06
II. When prehospital emergency medical care personnel are
presented with a valid DNR order no resuscitative measures shall
be carried out. Prehospital Emergency Medical Care personnel
shall otherwise provide the patient with appropriate medical
treatment other than resuscitative measures. Appropriate
treatment may include but is not limited to:
A. Oxygen administration;
B. Treatment of hemorrhage;
C. Treatment for pain;
D. Treatment of airway obstruction;
E. Transport to a receiving facility.
III. If the patient is conscious and states he/she wishes resuscitative
measures, the DNR order shall be ignored.
IV. If a patient with a valid DNR order is unconscious and family
members request resuscitative measures prehospital emergency
medical care personnel are to honor the DNR order. If necessary
to preserve scene safety, prehospital emergency medical care
personnel may initiate basic life support resuscitation while
contacting the Base Hospital for assistance and direction.
V. In the absence of a DNR order, if family members of an
unconscious patient request that resuscitative measures are not to
be undertaken, prehospital emergency medical care personnel are
to initiate appropriate basic life support treatment while contacting
the Base Hospital for assistance and direction.
VI. If the patient is transported, the DNR order is to be transported
with the patient to the receiving facility. DNR orders are to be
honored during transport.
VII.
The presence of a DNR order is to be documented on the
Patient Care Report.
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Interaction with Physician or
Other Health Care Provider On Scene
EMS Policy No. 5106
Effective: October 15, 2010
Supersedes: August 31, 2010
5106 - Interaction with Physician or Other Health Care Provider
On Scene
PURPOSE: The purpose of this policy is to establish the procedures
to be followed by Emergency Medical Service (EMS)
personnel while at the scene of a medical emergency
when bystanders identify themselves as a physician or a
registered nurse (R.N.).
POLICY:
I.
Physician At Scene
A.
B.
In the event that an unknown physician offers assistance on
scene, ask the person his/her name and request to see
his/her State of California physician or surgeon’s license. If
doubt about the person’s license request to see proof of
identity, i.e. state driver’s license or identity card.
Pre-hospital personnel have the following responsibilities in
the event that a physician is on scene:
1. Remain tactful, calm, and courteous.
2. Provide the physician with a California Medical
Association – EMS Authority physician involvement on
scene card (Appendix A) describing his/her options.
EMS personnel should keep these cards readily
available.
3. The identity of a physician shall be confirmed prior to
EMS personnel relinquishing responsibility for patient
care.
4. Offer assistance to the physician on scene. The EMS
provider cannot perform orders given outside normal
scope of practice as defined in the San Joaquin County
EMS Treatment Protocols.
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Interaction with Physician or
Other Health Care Provider On Scene
EMS Policy No. 5106
Effective: October 15, 2010
Supersedes: August 31, 2010
5.
C.
D.
E.
Maintain control of medications and equipment from the
unit, and inform the physician of drug and equipment
availability.
6. Make initial contact with the base hospital physician
(BHP), and communicate newly implemented plan for
scene management.
Once identification has been confirmed, the physician may
choose one of the alternatives listed below:
1. Offer assistance with another pair of eyes or hands, or
offer suggestions, but allow the ALS provider to remain
under EMS on-line and off-line medical control; OR
2. Request to talk to a Base Hospital Physician (BHP) and
directly offer medical advice and assistance; OR
3. Take total responsibility for the care given by the ALS
provider and physically accompany the patient until the
patient arrives at a hospital and the receiving physician
assumes responsibility. Physicians exercising the right
to assume patient care must document and sign for all
care provided and instructions given to EMS personnel
following transport to the receiving facility.
Conflict Resolution: In the event that any unresolved conflict
arises regarding the delivery of patient care, EMS personnel
shall contact a BHP immediately. The BHP has final
authority over medical care to be provided by EMS
personnel.
Private Physicians - If the patient's private physician
intervenes in person or by telephone, EMS personnel shall
inform the patient's physician that they will need to make
BHP contact.
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Interaction with Physician or
Other Health Care Provider On Scene
EMS Policy No. 5106
Effective: October 15, 2010
Supersedes: August 31, 2010
II. Other Non-physician Providers on Scene:
A.
B.
C.
D.
If off-duty EMS personnel are on scene, they may assist with
BLS patient care at the discretion of attending paramedic or
EMT.
An off-duty San Joaquin County accredited paramedic and
an employee of the on scene ALS provider may provide ALS
care and treatment under the direction of the attending
paramedic.
An off-duty paramedic not accredited in San Joaquin County
or not an employee of the on scene ALS provider which
provides proof of current paramedic licensure in California
may at the discretion of the attending paramedic, and while
under direct supervision provide assistance not to exceed
the State’s basic paramedic scope of practice.
All other types of licensed medical personnel (Physician
Assistant, Registered Nurse, Respiratory Therapist, etc.)
may, at the discretion of the attending paramedic or EMT,
may assist with BLS patient care.
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Note to Physician on Involvement with EMT-Ps
EMS Policy No. 5106A
Effective: January 1, 2009
Supersedes: NA
5106A - Note to Physician on Involvement with EMT-Ps
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Use of Restraints
EMS Policy No. 5107
Effective: November 1, 2006
Supersedes: NA
5107 - Use of Restraints
PURPOSE: The purpose of this policy is to provide guidelines on
the use of restraints in the field or during transport for
patients who are violent, potentially violent, or who may
harm themselves or others.
DEFINITIONS:
A.
“Medical Restraint” means a physical restraint that is used to
limit mobility or temporarily immobilize a patient for nonbehavioral management reasons. (e.g., to promote healing by
preventing the dislodgment of medical devices, or to protect a
child or adult who is confused and/or disoriented and unable to
follow instructions for his/her personal safety).
B.
“Behavioral Restraint” means a physical restraint that is used to
limit mobility or temporarily immobilize a patient who presents
with behavior management symptoms. The use of behavioral
restraint is used only in an emergency or crisis situations. Do
not release the restraint until you have transported the patient
to the hospital.
C.
“Chemical Restraint” means a medication used with the
expressed intent to control behavior or to restrict the patient’s
freedom of movement and is not a standard treatment for the
patient’s medical or psychiatric condition.
POLICY:
I. When restraints are necessary such activity will be undertaken in a
manner that protects the patient’s health and safely preserves his
or her dignity, rights, and well-being. The safety of the patient,
community, and responding personnel is of paramount concern
when following this policy. The use of a restraint is a last resort
after alternative interventions have either been considered or
attempted.
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Use of Restraints
EMS Policy No. 5107
Effective: November 1, 2006
Supersedes: NA
II. Behavioral restraints are to be used only when necessary in
situations where the patient is potentially violent and is exhibiting
behavior that is dangerous to self or others. Only reasonable
force sufficient to restrain the patient shall be used.
III. Prehospital personnel must consider that aggressive or violent
behavior may be a symptom of medical conditions such as head
trauma, alcohol, drug-related problems, metabolic disorders,
stress, and psychiatric disorders. Appropriate protocols shall be
followed for those conditions that require it.
IV. EMS prehospital personnel shall determine medical intervention
and patient destination.
V. The method of restraint used shall allow for adequate monitoring
of vital signs and shall not restrict the ability to protect the patient’s
airway or compromise neurological or vascular status.
PROCEDURES
I. The following procedures should guide prehospital personnel in
the application of restraints and the monitoring of a restrained
patient:
A. Restraint equipment, applied by prehospital personnel, must be
either padded leather restraints or soft restraints. Both
methods must allow for quick release.
B. The following forms of restraint shall NOT be used by
prehospital personnel:
1. Hard plastic ties or any restraint device requiring a key to
remove.
2. Sandwiching patients between backboards, scoopstretchers, or flat, as a restraint.
3. Restraining a patient’s hands and feet behind the patient,
i.e. hog-tying.
4. Methods or other materials applied in a manner that could
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Use of Restraints
EMS Policy No. 5107
Effective: November 1, 2006
Supersedes: NA
cause respiratory, vascular, or neurological compromise,
including prone restraints.
C. Restraint equipment applied by law enforcement (handcuffs,
plastic ties, or hobble restraints) must provide sufficient slack in
the restraint device to allow the patient to straighten the
abdomen and chest and to take full tidal volume breaths.
D. Restraint devices applied by law enforcement require the
officer’s continued presence to ensure patient and scene
management safety. The officer should, if possible,
accompany the patient in the ambulance, or follow by driving in
tandem with the ambulance on a predetermined route. A
method to alert the officer of any problems that may develop
during transport should be discussed prior to leaving the
scene.
E. Patients shall not be transported in a prone position.
Prehospital personnel must ensure that the patient’s position
does not compromise the patient’s respiratory/circulatory
systems, or does not preclude any necessary medical
intervention to protect the patient’s airway should vomiting
occur.
F. Restrained extremities should be evaluated for pulse quality,
capillary refill, color, nerve, and motor function every 15
minutes. It is recognized that the evaluation of nerve and
motor status requires patient cooperation, and thus may be
difficult or impossible to monitor.
G. Restrained patients shall be transported to the most accessible
basic emergency department facility within the guidelines of the
Patient Destination Policy.
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Use of Restraints
EMS Policy No. 5107
Effective: November 1, 2006
Supersedes: NA
DOCUMENTATION
I. Documentation on the EMS Report Form shall include:
A. The reasons restraints were needed.
B. Which agency applied the restraints (i.e. EMS/law
enforcement).
C. Information and data regarding the monitoring of circulation to
the restrained extremities.
D. Information and data regarding the monitoring of respiratory
status while restrained.
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Care of Minors in the Field
EMS Policy No. 5108
Effective: January 1, 2009
Supersedes: NA
5108 - Care of Minors in the Field
PURPOSE: The purpose of this policy to provide guidance for field
personnel providing emergency care to minors in the
prehospital setting.
DEFINITIONS:
“Minor” means a person less than eighteen years of age who is
not emancipated. Except for specific circumstances prescribed
by law, a minor is not legally competent to consent to or refuse
medical care.
B.
“Emancipated Minor” means a person less than eighteen years
of age who:
1. Is married or previously married.
2. Is on active duty in the military.
3. Is an emancipated minor (decreed by court, identification
card by DMV).
C. “Legal Representative” means a person who is granted custody or
conservatorship of another person by a court of law.
D. “Emergency” means a condition or situation in which an individual
has a need for immediate medical attention or where the
potential for need is perceived by EMS personnel or a public
safety agency.
A.
POLICY:
I.
Voluntary Consent: Treatment or transport of a minor child
shall be with the verbal or written consent of the parents or
legal representative. If the minor child is legally able to
consent, then treatment or transport shall be with the verbal or
written consent of the minor.
II.
Implied Consent: In the absence of a parent or legal
representative, life or limb threatening emergency treatment
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Care of Minors in the Field
EMS Policy No. 5108
Effective: January 1, 2009
Supersedes: NA
and/or transport of a minor child shall be initiated without
consent.
PROCEDURE:
I. Life-threatening situations: If a parent or qualified legal
representative is not present, treatment and/or transport to a
medical facility shall be initiated immediately in accordance with
SJCEMSA Policies
II. Non-life-threatening situations: If, in the opinion of the base
hospital physician, a minor child requires treatment and/or further
evaluation at a hospital, EMS personnel should make a
reasonable attempt to contact a parent or other legally qualified
representative before initiating treatment or transport. However, if
a parent or legally qualified representative cannot be reached,
EMS personnel will transport the minor to the hospital.
III. Parental consent is not required before initiating care or transport
when:
A. The minor is emancipated.
B. The parent has given written authorization to procure medical
care to any adult over 18 years of age taking care of the minor.
C. A minor, 12 years or older, consents to the furnishing of
hospital, medical and surgical care related to treatment or
diagnosis of infectious, contagious or communicable diseases.
D. A minor, living separate and apart from parent (for any period
of time), managing own economic affairs, regardless of source
of income and regardless of whether parent(s), consented to
separation. Parents are not liable for care provided pursuant to
this section.
E. A minor, 12 years or older, is an alleged rape victim.
F. A minor, is a victim of a sexual assault (applies to both boys
and girls and has no age limit).
G. A minor, seeks pregnancy prevention or treatment of
pregnancy (does not include sterilization).
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Care of Minors in the Field
EMS Policy No. 5108
Effective: January 1, 2009
Supersedes: NA
H. A minor, 12 years or older, seeks medical or hospital care or
counseling relating to diagnosis and treatment of drug and
alcohol related problem.
IV. If a minor refuses any indicated treatment or transport, EMS
personnel should attempt the following:
A. To contact base hospital and advise them of the situation.
B. To contact the minor’s parent(s) or legal representative for
permission to treat or transport the minor.
V. Provided the parent or legal representative is unavailable, contact
law enforcement and request the minor be taken into temporary
custody in order that treatment and/or transport can begin.
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Anatomical Donor Cards
EMS Policy No. 5110
Effective: March 1, 2008
Supersedes: 530.09
5110 - Anatomical Donor Cards
PURPOSE: The purpose of this policy is to establish a process to
search for anatomical donor information.
DEFINITIONS:
A.
B.
“Imminent Death”: means for the purpose of this policy any
situation in which illness in the adult unconscious patient (18
years of age or older) are so severe that death is likely to occur
prior to or shortly after the patient arrives at the hospital.
“Reasonable Search”: means for the purpose of this policy a
brief, rapid search by law enforcement, coroner, hospital,
ambulance, or emergency medical personnel of an individual
and his/her wallet/purse with the intention of locating an
anatomical donor card attached to that individual’s driver’s
license or state issued identification card.
POLICY:
I. If the patient requires medical attention, defer any search for an
anatomical donor card until after arrival at the receiving hospital.
At no time should the search for an anatomical donor card be at
the expense of treatment and/or transport of the patient.
II. If law enforcement personnel are present and time permits request
that law enforcement perform the search.
III. If the patient is declared dead by law enforcement personnel or
determined to be obviously dead in accordance with EMS Policy
No. 5103, ambulance or emergency medical personnel shall defer
any search to coroner personnel.
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Anatomical Donor Cards
EMS Policy No. 5110
Effective: March 1, 2008
Supersedes: 530.09
IV. Document any search for an anatomical donor card on the patient
care record and verbally report the presence or absence of an
anatomical donor card to the receiving physician or registered
nurse.
V. When requesting an order for a determination of death in
accordance with EMS Policy No. 5103, paramedic personnel shall
report the presence or absence of an anatomical donor card to the
base hospital physician or mobile intensive care nurse.
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Cervical Spine Immobilization
EMS Policy No. 5115
Effective: July 1, 2013
Supersedes: N/A
5115 – Cervical Spine Immobilization
PURPOSE:
The purpose of this policy is to provide direction to prehospital
personnel on the application of cervical spine immobilization and to
reduce the risk of negative effects caused by traditional spinal
immobilization.
POLICY:
I.
II.
The San Joaquin County EMS Agency is supporting efforts to
decrease unnecessary immobilizations in the field and reduce
the risks and complications associated with spinal
immobilization. Studies show immobilizing trauma patients
may cause more harm than good to the patient especially
penetrating trauma patients (stabbings and gunshot wounds)
which benefit most from rapid assessment and transport to a
trauma center.
Prehospital personnel shall apply cervical spine immobilization
to patients injured from blunt force trauma in the following
circumstances:
A.
Conscious patients exhibiting one or more of the following
signs or symptoms:
1. Posterior midline cervical tenderness or pain;
2. Distal numbness, tingling, weakness, or parethesia;
3. Paralysis;
4. Neck guarding or restricted range of motion;
5. Glasgow Coma Scale (GCS) motor score of less than
5 as a result of blunt force trauma or intoxicants, e.g.
alcohol or other drugs.
B.
Unconscious adult patients suffering a blunt force
mechanism of injury, except ground level falls.
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Cervical Spine Immobilization
EMS Policy No. 5115
Effective: July 1, 2013
Supersedes: N/A
III.
Prehospital personnel shall not apply cervical spine
immobilization to patients in the following circumstances:
A. Patients injured solely from penetrating trauma;
B. Unconscious adult patients experiencing a ground level fall;
C. Patients in cardiac arrest.
IV.
Pediatric cervical spine immobilization shall be performed as
follows:
A.
Cervical spine immobilization shall be conducted using
soft collars and should be immobilized using a Kendrick
Extrication Device (KED) or other commercially available
device approved by the EMS Agency.
B.
Pediatric Patients and Car Seats:
1.
Infants restrained in a rear-facing car seat may be
immobilized and extricated in the car seat. The
child may remain in the car seat if the
immobilization is secure and his/her condition
allows (no signs of respiratory distress or shock.)
2.
Children restrained in a car seat (with a high back)
may be immobilized and extricated in the car seat;
however, once removed from the vehicle, the child
should be placed in a padded pediatric
immobilization device or other commercially
available immobilization device approved by the
EMS Agency. If placing the child in the pediatric
immobilization device causes increased agitation,
movement, and potential further harm, the child may
be immobilized in the car seat.
3.
Children restrained in a booster seat (without back)
need to be extricated using standard techniques
and immobilized using a padded pediatric
immobilization device or other commercially
available immobilization device approved by the
EMS Agency.
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Cervical Spine Immobilization
EMS Policy No. 5115
Effective: July 1, 2013
Supersedes: N/A
4.
If applying spinal immobilization to a patient in a car
seat, prehospital personnel shall conduct a posterior
assessment by palpation.
V.
Adult cervical spine immobilization shall be performed by
selecting the most effective methods and tools for the specific
situation with the goal to prevent gross movement of the spine
while allowing necessary treatment including airway
management.
VI.
Equipment approved to perform cervical spine immobilization
includes soft collars, Kendrick Extrication Device (KED) or
Fasplint or similar device, or any combination of equipment
including pillows and blankets or other commercially available
immobilization device approved by the EMS Agency to ensure
comfort and spinal immobilization on the gurney.
VII.
Long backboards and Miller Boards may be used for extrication
or movement at the scene. However, backboards shall not to
be used to transport a patient to the hospital.
VIII. Movement on scene:
A.
Pull sheets, other flexible devices, scoops, scoop-like
devices may be used. Unpadded long backboards should
have limited utilization.
B.
If an unpadded longboard or scoop stretcher device is
used to move patients on scene due to issues of space or
distance, such devices should only be used as a
temporary means of transporting the patient to a gurney
prior to the application of the KED or other approved
immobilization method.
C.
Keeping with the goals of restricting gross movement of
the cervical spine and preventing further pain and
discomfort, patient self-extrication is allowable.
San Joaquin County
Emergency Medical Services
Page 187 of 216
Cervical Spine Immobilization
EMS Policy No. 5115
Effective: July 1, 2013
Supersedes: N/A
IX.
Special Considerations:
A.
Patients who are agitated or restless due to shock,
hypoxia, head injury or intoxication may be impossible to
immobilize adequately. It may be necessary to remove
immobilization devices or modify immobilization
techniques to reduce the risk of further injury.
B.
Paramedics may discontinue or clear spinal
immobilization initiated by BLS personnel, if in the opinion
of the paramedic cervical spine is not required by policy
or compromises the ability to render patient care.
Paramedics are required to document on the patient care
record each instance of discontinuing cervical spine
immobilization and their basis for removal.
C.
When using spinal immobilization, patients may be placed
in semi or high fowlers position to address respiratory
conditions or for patient comfort.
D.
Prohibited equipment and practices:
1. Hard collars;
2. Adhesive tape applied to the patient’s skin.
X.
EMS Policy No. 5506 BLS Spinal Immobilization is hereby
rescinded.
San Joaquin County
Emergency Medical Services
Page 188 of 216
ALS Without Base Hospital Contact
EMS Policy No. 5130
Effective: January 1, 2009
Supersedes: 540.02
5130 - ALS Without Base Hospital Contact
PURPOSE: The purpose of this policy is to provide a mechanism for
advanced life support (ALS) personnel to perform skills
and administer medications requiring a base hospital
order when base hospital contact cannot be established
and immediate treatment of the patient is required.
POLICY:
I. ALS personnel are authorized to perform skills and administer
medications requiring a base hospital order when base hospital
contact cannot be established and immediate treatment of the
patient is required.
II. ALS personnel shall complete an ALS without Base Hospital
Contact Report (Appendix A).
III. Each occurrence shall be reported using one or more of the
following classification(s):
A. Patient's clinical status demanded intervention prior to voice
contact with the base hospital.
B. Field communication equipment not available at the patient's
side.
C. No response from the base hospital, after three (3) attempts
D. Scene environment not suitable for radio and/or land line
communications.
E. EMS communication equipment malfunction(s).
F. Radio interference/inability to establish radio contact.
IV. Upon completion of the call requiring ALS without base hospital
contact ALS personnel shall:
San Joaquin County
Emergency Medical Services
Page 189 of 216
ALS Without Base Hospital Contact
EMS Policy No. 5130
Effective: January 1, 2009
Supersedes: 540.02
A. Determine the cause of the communications failure and report
or replace faulty equipment.
B. Complete the ALS without Base Hospital Contact Report and
submit the report to their provider’s quality improvement
coordinator before close of shift but no later than 24 hours after
the occurrence.
C. The Provider’s quality improvement coordinator shall complete
a review and submit the ALS without Base Hospital Contact
Report with their findings and a copy of the patient care report
(PCR) to EMS Agency CQI Coordinator within 72 hours of the
occurrence.
San Joaquin County
Emergency Medical Services
Page 190 of 216
5130A - ALS WITHOUT BASE HOSPITAL CONTACT REPORT
Paramedics must compete this form whenever base hospital
contact is required, yet cannot be made. A copy of the PCR must
be attached and submitted to the organizations CQI liaison within
24 hours of the incident. The CQI liaison must submit the report
to SJCEMSA with 24 hours of receipt. Attach additional pages if
necessary.
Report initiated by:
License #:
Employer:
Phone:
Address:
Base Hospital:
Receiving Facility:
Reason for initiating treatment without a base hospital order:
(check all that apply)
□ Patient's clinical status demanded intervention prior to voice contact
with the base hospital
□ Field communication equipment not available at the patient's side
□ No response from the base hospital after three (3) attempts
□ Scene environment not suitable for radio and/or land line
communications (please explain)
□ EMS communication equipment malfunction
□ Radio interference/inability to establish radio contact
□ Other (please attach additional sheets as necessary)
Treatment(s) performed without a base hospital order:
Patients condition prior to treatment:
Patients condition after treatment:
Signature:
San Joaquin County
Emergency Medical Services
Date of Report:
Page 191 of 216
EMS Agency Evaluation:
Treatment initiated was:
□
□
appropriate for the patient’s condition
appropriate for the patient’s condition but could have been
delayed pending radio
contact or upon arrival at the emergency department
□
questionable but discussion and resolution of concerns occurred
after patient arrival
□
questionable and not resolved at time of call
□
inappropriate for the patient’s condition
EMS CQI Document - Do Not Place in the Patient Medical
Record
San Joaquin County
Emergency Medical Services
Page 192 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
5201 – Medical Patient Destination
PURPOSE: The purpose of this policy is to provide direction to EMS
personnel on determining the appropriate destination for medical
patients.
DEFINITIONS:
A.
B.
C.
D.
E.
“Base Hospital” and “Disaster Control Facility (DCF)” means
San Joaquin General Hospital which is responsible for directing
the prehospital care system in accordance with the policies and
procedures of the EMS Agency.
“Life Threatening Condition” means a patient with
unmanageable airway, or uncontrolled bleeding, or rapidly
deteriorating vital signs, or with CPR in progress.
“Receiving Hospital” means a licensed general acute care
hospital with a permit for basic or comprehensive emergency
services.
“STEMI Receiving Center” or “SRC” means a licensed acute
care hospital with the capability to perform PCI which has
satisfied the requirements for designation as set forth by the
EMS Agency.
“Unmanageable Airway” means a patient without the ability to
manage their own airway, or a patient without an established
BLS or ALS airway, or a patient being ventilated through a
needle cricothyrotomy.
POLICY:
I.
Patients in the San Joaquin County EMS System shall be
transported to an appropriately staffed and equipped
emergency department of a licensed general acute care
hospital.
San Joaquin County
Emergency Medical Services
Page 193 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
II.
Priorities in determining transport destinations for medical
patients :
A. Medical patients shall be transported to a receiving hospital
based on the following priorities:
1.
Multi-casualty incident – destination based on DCF
direction.
2.
Acute STEMI – closest STEMI Receiving Center.
3.
Life threatening condition – closest receiving
hospital or base hospital direction.
4.
High Risk Obstetrical or Neonate – San Joaquin
General Hospital or Doctors Medical Center,
whichever is closest.
5.
Active labor with complications – closest hospital
with labor and delivery (L&D) service.
6.
Non-emergent condition – patient choice.
7.
No preference specified – closest receiving hospital.
III.
Parameters affecting transport destinations for medical
patients:
A.
Acute ST Elevated Myocardial Infarction (STEMI) Patient
Considerations:
1.
Patients with signs and symptoms of an acute
STEMI as specified in EMS Policy No. 5719 Chest
Pain, shall be transported to a designated STEMI
Receiving Center (SRC) by-passing all other
receiving hospitals.
2.
The following receiving hospitals are designated as
SRCs for the San Joaquin County EMS System:
a.
Dameron Hospital.
b.
St. Joseph’s Medical Center.
c.
Doctors Medical Center.
d.
Memorial Medical Center.
3.
The travel distance between Dameron Hospital and
San Joaquin County
Emergency Medical Services
Page 194 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
B.
C.
St. Joseph’s Medical Center is determined to be
inconsequential. If a STEMI patient expresses a
preference the patient may be transported to either
SRC in Stockton. The same patient preference
applies to the choice between Doctors Medical
Center and Memorial Medical Center.
High Risk Obstetrical or Neonate:
1.
High Risk Obstetrical patients are patients without
prenatal care or patients with an estimated
pregnancy of 20 to 33 weeks.
2.
High Risk Obstetrical with signs and symptoms of
vaginal bleeding or active labor without
complications shall be transported to San Joaquin
General Hospital or Doctors Medical Center
whichever is closest.
3.
High Risk Neonatal patients are prehospital live
births with an estimated gestational age of 20 to 33
weeks.
4.
High Risk Neonatal patients shall be transported to
San Joaquin General Hospital or Doctors Medical
Center whichever is closest.
Active Labor Considerations:
1.
Active labor without complications is deemed to be
a non-emergent condition and these patients may
be taken to the receiving hospital with labor and
delivery services (L&D) of their choice as listed in
subparagraph D. 3.
2.
Active labor with complications (prolapsed cord,
breech presentation) shall be transported to the
closest receiving hospital with L&D services.
3.
The following is a list of receiving hospitals with L&D
services in San Joaquin County and in areas
immediately adjacent to San Joaquin County:
a.
Dameron Hospital.
b.
Doctors Hospital of Manteca.
San Joaquin County
Emergency Medical Services
Page 195 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
c.
d.
e.
f.
g.
h.
i.
j.
D.
Lodi Memorial Hospital.
San Joaquin General Hospital.
St. Joseph’s Medical Center.
Sutter-Tracy Community Hospital.
Kaiser Medical Center, Modesto.
Oak Valley District Hospital, Oakdale.
Doctors Medical Center, Modesto.
Memorial Medical Center, Modesto.
Non-Emergent Medical Patient Destination
Considerations:
1.
In a non-emergent situation, as determined by EMS
personnel on scene or following base hospital
consultation, the patient may be transported to the
receiving hospital of their choice. If the patient is
unable or unwilling to express a choice, defer to the
wishes of the patient’s private physician and/or
family. In the absence of such direction, patients
should be transported to the closest receiving
hospital.
a.
Whenever possible ambulance personnel
should determine where the patient normally
receives their medical care and encourage
the patient to return to that hospital.
b.
EMS personnel should only provide the
patient and/or family with the available
destination options. EMS personnel should
not endorse a receiving facility or otherwise
provide their personal opinion on the quality
or merits of any receiving hospital.
c.
If the patient is a member of a health plan
with a preferred hospital an attempt should
be made to transport the patient to a
participating or preferred receiving hospital.
San Joaquin County
Emergency Medical Services
Page 196 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
2.
3.
IV.
Medical Multi-casualty Incidents:
A.
V.
Non-emergent medical patients may choose to be
transported to any of the following receiving
hospitals in San Joaquin County:
a.
Dameron Hospital.
b.
Doctors Hospital of Manteca.
c.
Kaiser Hospital Manteca.
d.
Lodi Memorial Hospital.
e.
San Joaquin General Hospital.
f.
St. Joseph’s Medical Center.
g.
Sutter-Tracy Community Hospital.
Non-emergent medical patients may choose to be
transported to receiving hospitals outside of San
Joaquin County as follows:
a.
From Ambulance Zone A (Lodi):
i. Methodist Hospital, Sacramento.
ii. Kaiser Medical Center South Sacramento.
b.
From Ambulance Zones D (Manteca); E
(Ripon); and F (Escalon):
i. Doctors Medical Center, Modesto.
ii. Kaiser Medical Center, Modesto.
iii. Memorial Medical Center, Modesto.
iv. Oak Valley District Hospital, Oakdale.
During a medical MCI the DCF may direct the transport of
patients to receiving hospitals outside of San Joaquin
County.
Hospital Diversion:
A.
B.
Non-emergent patients shall not be transported to a
receiving hospital with a facility status of diversion.
Patients shall not be transported to a receiving hospital
with a facility status of internal disaster/closed.
San Joaquin County
Emergency Medical Services
Page 197 of 216
Medical Patient Destination
EMS Policy No. 5201
Effective: July 24, 2014
C.
Patients requiring specialty care services (e.g. STEMI,
labor and delivery, neonatal intensive care) should not be
transported to a receiving hospital with a facility status
advising that such specialty services are unavailable. In
such instances another receiving hospital offering such
services should be utilized.
San Joaquin County
Emergency Medical Services
Page 198 of 216
Medical Patient Destination
Estimated Distance Time
EMS Policy No. 5201A
Effective: October 1, 2011
5201A – Medical Patient Destination Ground Ambulance Estimate of Driving Time and
Distance
Chrisman Road and Hwy
132
Southwest San Joaquin Co.
Sutter-Tracy
9.5
14 mins miles
Kaiser Manteca
SJMC
DMC
33 mins
142 S. Stockton St. Ripon
CA
Ripon
19 mins
18 miles
33 mins
25 miles
Kaiser South Sac
71 mins 69 miles
UCDMC
75 mins
76 miles
Kaiser Modesto
DHM
5.5 miles
9 mins
Sutter-Tracy
24
mins
21 miles
Oak Valley
Kaiser South Sac
64
mins
57 miles
UCDMC
San Joaquin County
Emergency Medical Services
26 mins
71 mins
22 mins
DHM
34 mins
25 mins
26
miles
Emanuel Turlock
36.5
46 mins
miles
DMC
7 miles
13 mins
28 mins
23
miles
Kaiser Manteca
10
SJMC
18 miles
Dameron
22
miles
MMC
28 miles
8 mins
SJGH
13 mins
10.5
Dameron
22
miles
28 mins
64 miles
Page 199 of 216
23
miles
30 mins
28
miles
Kaiser Modesto
24
30 mins
miles
Lodi Memorial
42
47 mins
miles
Oak Valley
MMC
SJGH
14 mins
11
miles
Emanuel Turlock
24
29 mins
miles
51 mins
20 mins
37.5
miles
19
miles
Lodi Memorial
31.5
37 mins
miles
Medical Patient Destination
Estimated Distance Time
EMS Policy No. 5201A
Effective: October 1, 2011
Kaiser Modesto
Hwy 120 and McHenry Ave
Escalon
12 mins
9 miles
SJGH
23 mins
Hwy 4 x Escalon-Bellotta
Rd
Farmington
DHM
15 mins
DMC
11 miles
SJMC
Dameron
18 miles
31 mins
24 miles
Kaiser South Sac
67 mins 58 miles
UCDMC
75 mins
66 miles
SJMC
Dameron
25 mins
19 miles
DMC
28 mins
28 mins
31 mins
16 mins
10 miles
Sutter-Tracy
24
miles
32 mins
16 mins
10 miles
Emanuel Turlock
27 miles
38 mins
28 miles
DHM
19 miles
Oak Valley
25
18.5
mins
miles
Lodi Memorial
35
mins
28 miles
Sutter-Tracy
19 miles
Kaiser Manteca
32
26.5
mins
miles
UCDMC
69 mins
Oak Valley
Kaiser Modesto
25
18.5
mins
miles
MMC
18.5
miles
Kaiser South Sac
53.5
61 mins miles
San Joaquin County
Emergency Medical Services
25 mins
15 mins
MMC
10
miles
60.5
miles
Page 200 of 216
26 mins
44 mins
Kaiser Manteca
20
16
mins
miles
Lodi Memorial
41
33.5
mins
miles
SJGH
21.5
miles
40 miles
27 mins
23
miles
Emanuel Turlock
36
48 mins miles
Medical Patient Destination
Estimated Distance Time
EMS Policy No. 5201A
Effective: October 1, 2011
Lodi Memorial
I-5 and Highway 12
Flag City
9 mins
6.5 miles
18 mins
SJGH
14.5
miles
Kaiser South Sac
33
mins
30 miles
Methodist Hospital
28.5
33 mins
miles
DMC
49
mins
MMC
45.5
miles
Lodi Memorial
Hwy 99 and Hwy 12
E Victor Rd, Lodi
Dameron
7 mins
4 miles
50 mins
Kaiser Manteca
DMC
45
mins
MMC
40 miles
San Joaquin County
Emergency Medical Services
46 mins
22 mins
35
miles
Sutter General
36.5
37 mins miles
Sutter-Tracy
37 mins
Dameron
13
miles
Kaiser South Sac
29
26.5
mins
miles
31 mins
21 mins
16.5
miles
Kaiser Manteca
29.5
31 mins miles
DHM
UCDMC
Kaiser Modesto
38 mins
37.5
miles
32 mins
30 miles
43 mins
41 miles
46
miles
SJMC
17 mins
SJMC
19
miles
26.5
20 mins
SJGH
14
miles
Sutter General
33
35 mins
miles
24 mins
Methodist Hospital
27
mins
25 miles
DHM
21
miles
Kaiser Modesto
39
35.5
mins
miles
Sutter-Tracy
33.5
miles
UCDMC
37 mins
41
miles
Page 201 of 216
28 mins
40 mins
25 miles
36 miles
Major Trauma Triage Criteria
EMS Policy No. 5210
Effective: August 1, 2013
5210 – Major Trauma Triage Criteria
PURPOSE:
The purpose of this policy is to define criteria for identifying major
trauma patients.
DEFINITIONS:
A.
“Adult major trauma patient” means a patient 15 years of age or
older that meets one or more of the major trauma triage criteria.
B.
“Pediatric major trauma patient” means a patient 14 years of
age or younger that meets one or more of the major trauma
triage criteria.
POLICY:
I.
Prehospital personnel shall assess all patients suffering acute
injury or suspected acute injury using the trauma triage criteria
established in this policy and shall document the findings of
such an assessment on the patient care record.
II.
Major Trauma Triage Criteria:
A.
Physiologic :
1.
Glasgow coma scale (GCS) motor score of less
than 5 (patient withdraws from painful stimuli.)
2.
Systolic blood pressure of less than:
a. 90 for age 14 and older.
b. 80 for age 7 to 14 years.
c. 70 for age 1 to 6 years.
3.
Respiratory rate <10 or >29 (<20 in infant < one
year).
San Joaquin County
Emergency Medical Services
Page 202 of 216
Major Trauma Triage Criteria
EMS Policy No. 5210
Effective: August 1, 2013
B.
Anatomic:
1.
Penetrating injuries to the head, neck, chest,
abdomen, and proximal to the elbow or knee.
2.
Flail chest.
3.
Two or more long bone fractures (humerus or
femur).
4.
Crushed, degloved, or mangled extremity.
5.
Amputation proximal to wrist or ankle.
6.
Pelvic fracture.
7.
Open or depressed skull fracture.
8.
Traumatic paralysis.
9.
Extremity injury with loss of distal circulation.
10. Partial or full thickness thermal, chemical, or
electrical burns greater than 9% total body surface.
11. Inhalation burns.
C.
Mechanism of Injury:
1.
Auto versus pedestrian or bicyclist with the patient
being:
a. Run over.
b. Thrown a significant distance.
2.
Falls involving a pediatric patient from a height
greater than 10 feet or twice the height of the child.
D.
Paramedic judgment: Paramedics may use their
judgment to classify a patient as major trauma patient
when the patient:
1.
Has a significant complaint or obvious signs of
injury, and;
2.
Has experienced a high risk mechanism of injury;
and
3.
Has one or more of the following comorbid factors:
a. Age greater than 55 or less than 10.
b. Anticoagulation therapy.
c. Burns.
San Joaquin County
Emergency Medical Services
Page 203 of 216
Major Trauma Triage Criteria
EMS Policy No. 5210
Effective: August 1, 2013
E.
III.
d. Time-sensitive extremity injury.
e. Pregnancy greater than 20 weeks.
4.
Examples of high risk mechanism of injury include:
a. High energy motor vehicle or motorcycle crash.
b. Blast injuries.
c. Falls involving an adult patient greater than 20
feet.
Examples of the application of paramedic judgment
include:
1.
Motor vehicle crash, with a pregnant patient
complaining of abdominal pain, with seatbelt marks
across abdomen.
2.
Fall from the top of a bunk bed, with a child less
than 5 years of age, with an obvious femur fracture.
3.
Fall from an extension ladder, adult greater than 60
years of age, on anticoagulation therapy,
complaining of pain all over.
Multi-casualty Incidents (MCIs):
A.
B.
Initial triage:
1.
Prehospital personnel shall use START triage
methodology for the initial assessment of patients
during a trauma MCI.
2.
Patients classified as “Immediate” using START
criteria are major trauma patients.
Secondary triage:
1.
When resources and circumstances allow
prehospital personnel shall re-triage patients using
the criteria in this policy.
2.
Patients meeting physiologic or anatomic criteria
shall be classified as “Immediate” patients.
3.
Patients meeting mechanism of injury or paramedic
judgment criteria shall be classified as “Delayed”
patients.
San Joaquin County
Emergency Medical Services
Page 204 of 216
Trauma Patient Destination
EMS Policy No. 5215
Effective: July 24, 2014
Supersedes: August 1, 2013
5215 – Trauma Patient Destination
PURPOSE:
The purpose of this policy is to guide prehospital, base hospital, and
disaster control facility personnel in determining the appropriate
destination for trauma patients.
DEFINITIONS:
A.
“Adult major trauma patient” means a patient 15 years of age or
older that meets one or more of the major trauma triage criteria.
B.
“Pediatric major trauma patient” means a patient 14 years of
age or younger that meets one or more of the major trauma
triage criteria.
C.
“Unmanageable Airway” means a patient whose upper airway
is compromised by an obstruction (e.g. mandibular fractures,
tongue, hematoma, blood, vomitus) preventing effective
ventilations, or a patient being ventilated through a needle
cricothyrotomy.
POLICY:
I.
Prehospital personnel shall assess all patients suffering acute
injury or suspected acute injury using the trauma triage criteria
established in EMS Policy No. 5210 Major Trauma Triage
Criteria.
II.
San Joaquin County is divided into two (2) primary trauma
center catchment areas:
A.
Northern Catchment Area – All of San Joaquin County,
San Joaquin County
Emergency Medical Services
Page 205 of 216
Trauma Patient Destination
EMS Policy No. 5215
Effective: July 24, 2014
Supersedes: August 1, 2013
B.
except for the southern catchment area.
Southern Catchment Area – South of State Highway 120
in San Joaquin County Ambulance Zones E and F; and
the area east of Escalon Bellota Road and south of Lone
Tree Road.
III.
Adult Major Trauma Patient Destinations:
A.
Northern catchment area – San Joaquin General
Hospital.
B.
Southern catchment area – Doctors Medical Center or
Memorial Medical Center.
C.
If the assigned trauma center is unavailable or at
capacity, adult major trauma patients shall be transported
to the next closest trauma center.
IV.
Pediatric Major Trauma Patients:
A.
Northern catchment area – U.C. Davis Medical Center.
B.
Southern catchment area – U.C. Davis Medical Center.
C.
If the U.C. Davis Medical Center is unavailable or at
capacity, pediatric major trauma patients shall be
transported to the closest trauma center.
V.
Multi-casualty Incidents (MCIs):
A.
Trauma patients triaged as “Immediate” shall be
preferentially transported to designated trauma centers
utilizing available trauma centers in San Joaquin,
Stanislaus, and Sacramento Counties.
B.
When possible pediatric trauma patients triaged as
“Immediate” shall be preferentially transported to the U.C.
Davis Medical Center.
C.
During a trauma MCI, the Disaster Control Facility (DCF)
shall include at a minimum all of the following trauma
centers in their emergency department poll:
1.
San Joaquin General Hospital;
2.
Doctors Medical Center;
San Joaquin County
Emergency Medical Services
Page 206 of 216
Trauma Patient Destination
EMS Policy No. 5215
Effective: July 24, 2014
Supersedes: August 1, 2013
D.
3.
Memorial Medical Center;
4.
U.C. Davis Medical Center;
5.
Kaiser Hospital South Sacramento.
As specified in EMS Policy No. 5210, on secondary triage
an “Immediate” patient includes patients meeting START
criteria and patients meeting physiologic or anatomic
major trauma triage criteria.
VI.
Specialty Considerations:
A.
Unmanageable Airway: Transport to closest receiving
hospital.
B.
Isolated Burn Injuries:
1.
Patients with partial or full thickness thermal,
chemical or electrical burns greater than 9% total
body surface shall be transported to the trauma
center at the UC Davis Medical Center.
2.
Inhalation burns with a manageable airway shall be
transported to the closest trauma center based on
assigned trauma service area.
3.
Paramedics should consult with the base hospital
on all other types of burns injuries to obtain a
destination.
C.
Isolated Spinal Cord Injuries: Patients with spinal cord
trauma or traumatic paralysis without comorbid trauma
injuries shall be transported to the trauma center at the
UC Davis Medical Center.
VII.
Trauma Center Bypass:
A.
When San Joaquin General Hospital (SJGH) places itself
on trauma center bypass due to the unavailability of a
trauma surgeon, operating suite, CT scanner:
1.
The DCF shall place an advisory notice on
EMResource stating: “Contact DCF for major
trauma patient destination”.
2.
The DCF shall direct prehospital personnel to
San Joaquin County
Emergency Medical Services
Page 207 of 216
Trauma Patient Destination
EMS Policy No. 5215
Effective: July 24, 2014
Supersedes: August 1, 2013
B.
transport major trauma patients meeting physiologic
or anatomic major trauma triage criteria to an
unencumbered trauma center in Sacramento
County or Stanislaus County.
San Joaquin General Hospital may continue to accept
major trauma patients meeting mechanism of injury and
paramedic judgment criteria, when on trauma center
bypass.
VIII. Air ambulance transport considerations:
A.
When ground ambulance transport is readily available air
ambulance scene time should be kept to an absolute
minimum.
B.
Ground ambulance transport of a major trauma patient
should not be delayed for the arrival of an air ambulance.
IX.
Non-Emergent Trauma Patient Destination Considerations:
A.
In a non-emergent situation (patient does not meet major
trauma triage criteria) the patient may be transported to
the receiving hospital of their choice. If the patient is
unable/unwilling to express a choice, defer to the wishes
of the patient’s physician and/or family. In the absence of
such direction, patients should be transported to the
closest receiving hospital.
1.
Whenever possible prehospital personnel should
determine where the patient normally receives their
medical care and encourage the patient to return to
that hospital.
2.
Prehospital personnel should only provide the
patient and/or family with the available destination
options. Prehospital personnel should not endorse
a receiving hospital or otherwise provide their
personal opinion on the quality or merits of any
receiving hospital.
3.
If the patient is a member of a health plan with a
San Joaquin County
Emergency Medical Services
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Trauma Patient Destination
EMS Policy No. 5215
Effective: July 24, 2014
Supersedes: August 1, 2013
B.
C.
preferred hospital an attempt should be made to
transport the patient to a participating or preferred
receiving hospital.
Non-emergent trauma patients may choose to be
transported to any of the following receiving hospitals in
San Joaquin County:
1.
Dameron Hospital.
2.
Doctors Hospital of Manteca.
3.
Kaiser Hospital Manteca.
4.
Lodi Memorial Hospital.
5.
San Joaquin General Hospital.
6.
St. Joseph’s Medical Center.
7.
Sutter-Tracy Community Hospital.
Non-emergent trauma patients may choose to be
transported to receiving hospitals outside of San Joaquin
County as follows:
1.
From Ambulance Zone A (Lodi):
a. Methodist Hospital, Sacramento.
b. Kaiser Medical Center South Sacramento.
2.
From Ambulance Zones D (Manteca); E (Ripon);
and F (Escalon):
a. Doctors Medical Center, Modesto.
b. Kaiser Medical Center, Modesto.
c. Memorial Medical Center, Modesto.
d. Oak Valley District Hospital, Oakdale.
San Joaquin County
Emergency Medical Services
Page 209 of 216
Ground Ambulance Transport (Time/Distance)
Ground Ambulance Transport (times/distance)
Chrisman Road and
Hwy 132,
SW San Joaquin Co.
142 S. Stockton St,
Ripon
Hwy 120 and McHenry
Ave, Escalon
Hwy 4 and EscalonBellotta Rd,
Farmington
I-5 and Hwy 12,
Flag City
Hwy 99 and Hwy 12 E
Victor Road,
Lodi
SJGH
DMC
MMC
Kaiser South
Sacramento
UCDMC
22 min.
22 miles
33 min.
25 miles
34 min.
26 miles
71 min.
69 miles
75 min.
76 miles
20 min.
19 miles
13 min.
10 miles
14 min.
11 miles
64 min.
57 miles
71 min.
64 miles
23 min.
18 miles
15 min.
10 miles
16 min.
10 miles
67 min.
58 miles
75 min.
66 miles
27 min.
23 miles
28 min.
18.5 miles
28 min.
19 miles
61 min.
53.5 miles
69 min.
60.5 miles
21 min.
19 miles
49 min.
45.5 miles
50 min.
46 miles
33 min.
30 miles
38 min.
37.5 miles
24 min.
21 miles
45 min.
40 miles
46 min.
41 miles
29 min.
26.5 miles
37 min.
33.5 miles
San Joaquin County
Emergency Medical Services
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San Joaquin County
Emergency Medical Services
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San Joaquin County
Emergency Medical Services
Page 212 of 216
San Joaquin County
Emergency Medical Services
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San Joaquin County
Emergency Medical Services
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San Joaquin County
Emergency Medical Services
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San Joaquin County
Emergency Medical Services
Page 216 of 216
San Joaquin County Emergency Departments
Dameron Hospital E.D.
209-461-3166
525 W Acacia St
Stockton, CA 95203
Doctors Hospital Manteca E.D.
209-239-8301
1205 E North St
Manteca, CA 95336
Kaiser Hospital Manteca E.D.
209-825-3555
1777 E Yosemite Ave
Manteca, CA 95336
Lodi Memorial E.D.
209-339-7576
975 S Fairmont Ave
Lodi, CA 95240
San Joaquin General Hospital E.D.
209-468-6322 or 209-468-6301
500 W Hospital Rd
French Camp, CA 95231
St. Josephs Medical Center E.D.
209-467-6400 or 209-467-6469
1800 N California St
Stockton, CA 95204
Sutter-Tracy Community Hospital E.D.
209-832-6018
1420 N Tracy Blvd
Tracy, CA 95376
San Joaquin County Base Hospital
San Joaquin General Hospital
Recorded Line: 209-982-1975
EMS Duty Officer Emergency Contact Number: 209-236-8339
San Joaquin County
Emergency Medical Services Agency
Mailing Address:
PO Box 220
French Camp, CA 95231
Physical Address:
Health Care Services Complex
Benton Hall
500 W. Hospital Rd.
French Camp, CA 95231
Website:
http://www.sjgov.org/ems
Phone Number:
(209) 468-6818
Fax Number:
(209) 468-6725
Follow us on Twitter@SJCEMSA