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BLS Local Protocol Program
12-Lead – Cardiac Arrest Management
King LT Airway – Glucose Monitoring – Glucagon
Trauma Triage – Spinal Immobilization
Student Manual
Central Shenandoah EMS Council
2014 Edition
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Table of Contents
Program Overview................................................................................................................. 3
Training Overview Matrix ...................................................................................................... 4
Program Completion ............................................................................................................. 4
Student Enrollment Requirements ......................................................................................... 5
Provider Eligibility to Practice ................................................................................................ 5
Module 1-1 – 12-Lead ECG Acquisition ................................................................................... 6
Module 1-2 – Cardiac Arrest Management ........................................................................... 18
Module 2 – King Laryngotracheal Airway ............................................................................. 35
Module 3 – Diabetic Emergencies ........................................................................................ 54
Module 4 – Trauma Triage ................................................................................................... 64
Module 5 – Spinal Immobilization ........................................................................................ 70
Skill Sheets .......................................................................................................................... 77
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Program Overview
The Central Shenandoah EMS Council Local Protocol Program provides instruction to EMS providers in
the region on specific local protocols that differ from the Virginia EMS Education Standards (VEMSES)
and the National EMS Education Standards for the Emergency Medical Responder and Emergency
Medical Technician levels. Modules of the curriculum include cardiac arrest management, 12-lead ECG
acquisition, King LT airway, use of glucagon, trauma triage and spinal immobilization. The goal of the
program is to have adequately trained BLS providers who can provide advanced interventions for critical
patients.
Students attending a Local Protocol program shall be certified as Emergency Medical Technician (EMT)
or Emergency Medical Responder (EMR). Students will complete the various sections of the program as
outlined in the “Student Enrollment Requirements” section of this manual.
The Local Protocol Program - Training Manual covers training, medical control, provider course
completion procedures, and all procedures governing the cardiac arrest management, use of a King LT
airway, a glucose monitor (EMR only), the acquisition of 12-lead ECGs, and the administration of
glucagon.
The first half of the local protocol program is presented on Edu-Net, the CSEMS Council learning
management system and covers the material contained in the program manual. Students must score
80% or better on the evaluations conducted in Edu-Net in order to participate in instructor-led skill
training and examination. Course completion is awarded to participants who complete the course
satisfactorily.
Regional EMT level providers are required to complete all of the modules of the local protocol training
program before being released to practice as an attendant-in-charge.
Annual provider review is required. A provider may complete a standard local protocol course or may
complete a renewal course. Renewing providers must complete the update on Edu-Net and the
minimum required skills at an instructor-led skills training session.
Local Training is the responsibility of each EMS agency in the CSEMS Council region and should be
provided by the local instructor. A formal review for all agency BLS providers is required to be done
once a year.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Training Overview Matrix
Initial Training
Module 1:
12-Lead Acquisition
Cardiac Arrest Management
Annual Review
Edu-Net
LMS
Skills
Testing
Edu-Net
LMS1
Skills
Testing
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Module 2:
BLS Airway Management
King LT Airway
Module 3:
Glucose Monitoring (EMR)
Glucagon
Module 4:
Trauma Triage
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Module 5:
Spinal Immobilization
1
Annual review update on Edu-Net as needed. Review will not necessarily cover material from each module.
Program Completion
Student completes on-line local
protocol training on CSEMS Edu-Net.
http://csems.centrelearn.com/
Student attends BLS local protocol
program skill training testing session
led by CSEMS local protocol instructor.
Instructor reports completion to CSEMS.
Student is awarded CE credit and can
print course completion certificate in
Edu-Net.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Student Enrollment Requirements
The following table summarizes the requirements for participation by level of certification.
Module 1:
12-Lead Acquisition
EMR
EMT
ALS Providers
Required
Required
Optional
Cardiac Arrest management
Required
Required
Optional
Module 2:
BLS Airway Management
Required
Required
Optional
Required
Optional
Optional
Optional
King LT Airway
Module 3:
Glucose Monitoring
Optional
Glucagon
Module 4:
Trauma Triage
Required
Required
Optional
Module 5:
Spinal Immobilization
Required
Required
Optional
EMTs are required to complete all of the modules, except the glucagon section of Module 3, during
initial training. The glucagon section is optional. Only EMTs who desire to administer glucagon should
attend this section.
Emergency Medical Responders are required to complete Module 1: Cardiac Arrest Management, 12Lead Acquisition and the trauma triage module. Optionally, EMRs may complete glucose monitoring
training.
Advanced life support providers are not required to attend local protocol training by region-wide policy.
However, operational medical directors may require attendance on an agency-specific basis.
Providers are required to obtain Virginia Emergency Medical Responder or Emergency Medical
Technician certification prior to attending local protocol training.
Provider Eligibility to Practice
Providers may not practice local protocol skills until the following criteria are met:
1. Provider must possess a current Virginia EMS certification.
2. Provider must be active with an authorized EMS agency and complete any training and/or
mentoring required by the agency
3. Provider must successfully complete the local protocol training program.
4. Provider must attend annual practical reviews to remain eligible.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Module 1-1: 12-Lead ECG Acquisition
Introduction
Out-of-hospital 12-lead ECGs and advance notification to the receiving facility speeds the diagnosis,
shortens the time to fibrinolysis or catheterization, and may be associated with decreased mortality
rates.
Common indications for acquiring 12-lead ECGs include patients complaining of chest pain, difficulty
breathing, palpitations, or sensations of irregular and/or forceful beating of the heart, syncope,
generalized weakness and dizziness.
Treatment of lethal dysrhythmias and life threatening problems associated with ABCs should be initiated
prior to obtaining a 12-lead ECG. Treatments such as oxygen, aspirin and nitroglycerin should never be
delayed to acquire a 12-lead ECG. Ideally, the team should obtain 12-lead ECGs and treat the patient at
the same time. Providers must be vigilant to keep time on the scene to a minimum.
The equipment used to obtain 12-lead ECGs include the cardiac monitor, cables, batteries/chargers, ECG
paper and electrodes.
Local Protocol – 12-Lead ECG
CSEMS Council EMS providers may acquire 12-lead ECGs in accordance with “Protocol 4.4 - CHEST PAIN
(NON-TRAUMATIC)” and “Protocol 5.1 – 12 Lead ECG.”
Obtaining Quality 12-Lead ECGs
Accurate 12-lead ECG interpretation requires a tracing in which the waveforms and intervals are free of
distortion. Distortion of an ECG tracing by electrical activity that is non-cardiac in origin is called artifact.
One of the methods you can use to reduce artifact is to help the electrode gel penetrate the patient's
skin. The heart's electrical signal as measured on the skin is as small as 1/10,000 of a single volt. If the
gel can penetrate the skin well, the result is increased signal strength and reduced artifact. However,
several natural barriers can keep the electrode gel from penetrating the skin.
Hair Removal
The first barrier to adequate gel penetration is hair. When hair is present in large quantities, it may
interfere with electrode adhesion. When the gel is in contact with hair instead of skin, penetration will
be hindered. A simple disposable razor may be used to remove hair before placing the electrodes, but
many prefer to use electric clippers instead. Whatever device is used, it is important to remove the hair
in the area where the electrodes will be applied.
Skin Preparation
The next barrier is skin oil. Designed to retain the body's moisture, skin oil can also keep the electrode
gel out. Below the skin oil is a layer of dead dried-out cells called the stratum corneum. The stratum
corneum is an electrical insulator. It is desirable to remove the skin oil and dead cells before applying
the electrode.
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Skin oil and dead cells can be removed by a variety of techniques. For some time, alcohol swabs were
used for this purpose. The alcohol helped to remove the oil, and a brisk rub with the swab eliminated
some of the dead cells. Although alcohol works to remove the skin oil, it further dries out the stratum
corneum. Therefore most electrode manufacturers recommend not using alcohol. A brisk, dry rub of the
skin should be used instead. Many electrode manufacturers include an abrasive area on the disposable
backing of the electrode for this purpose, but a gauze sponge works well too. Specific skin prep tools are
also commercially available.
Accurate
Each lead of a standard 12-lead ECG correlates with a specific anatomic region of the left ventricle. An
accurate 12-lead ECG requires placing the electrodes correctly, positioning the patient, and selecting the
correct settings for a diagnostic quality tracing. Although most 12-lead devices will default to the proper
setting for these considerations, it is important to understand the significance of each and to be able to
verify that they have been properly set. A description of each is included here.
Limb-Lead Placement
Limb leads are conventionally placed on the
wrists and ankles but may be positioned
anywhere on the appropriate limb. Be sure that
the patient's limbs are resting on a supportive
surface. This decreases muscle tension in the
patient's arms and legs and helps minimize
artifact.
The following are standard locations for limb
lead electrodes (Figure 1-1):
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Right arm electrode on the inside of the
patient's right wrist
Left arm electrode on the inside of the
patient's left wrist
Left leg electrode on the inner aspect of
the patient's left leg near the ankle
Right leg electrode on the inner aspect
of the patient's right ankle
Figure 1-1: Limb lead placement
If circumstances require that the limb leads be placed on the torso, be certain to position them as close
to the appropriate limb as possible.
Chest Lead Placement
Proper placement of the chest leads (Figure 1-2) requires the ability to pinpoint specific anatomic
locations, particularly certain intercostal spaces. Various landmarks can be used to determine the
correct location of these intercostal spaces. The particular method used is of little consequence as long
as the leads are properly located. The key is to position correctly V1, which lies in the fourth intercostal
space. Two methods of locating the fourth intercostal space are described.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Method 1 – Find the right clavicle, and place your finger just below it. Staying below the clavicle, follow
it until you encounter the sternum. Palpate along the border of the sternum to find the second, third,
and fourth intercostal spaces.
Method 2 – Begin by placing your finger at
the notch in the top of the sternum. This is
the sternal notch (also called the jugular
notch). Move your finger slowly downward
until you feel a slight horizontal ridge or
elevation. This is the Angle of Louis (sternal
angle), where the manubrium joins the
body of the sternum. Following that
horizontal ridge to the right sternal border
will lead to the second rib. The depression
felt immediately below the second rib is the
second intercostal space. Move down two
intercostal spaces to the fourth intercostal
space, just right of the sternum.
Once the fourth intercostal space has been
found, position the Vl electrode just to the
right of the sternum. Once the Vl electrode
has been positioned, move across the
sternum to the corresponding intercostal
Figure 1-2: Chest lead placement
space on the left side. Position the V2 electrode
in the fourth intercostal space, just to the left of the sternum. From the V2 position, palpate down one
intercostal space, and follow the fifth intercostal space to the midclavicular line. The fifth intercostal
space, at the midclavicular line, marks the position for the V4 electrode. Usually this is near the fold
under the breast in women or just below the pectoralis muscle in men.
The remaining three chest electrodes do not have specific intercostal landmarks but are positioned in
relation to the V2 and V4 positions. The position of the V3 electrode is midway between V2 and V4. If a
horizontal line is drawn from the V4 position, V5 and V6 will fall on that line. The position of V5 is in the
anterior axillary line, level with V4. Lead V6 is positioned in the midaxillary line, level with V4 and V5.
KEY POINT!
Always place limb leads on the limbs and palpate the
intercostal spaces to position the chest (V) leads.
Patient Position
Although it may not be immediately obvious, the position of the patient can affect the ECG. One reason
for differences between tracings obtained in various positions is that although the electrode does not
move when the patient changes position, the position of the heart does move relative to that electrode.
Strictly speaking, a patient should be supine when the ECG is acquired. This makes comparison of serial
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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ECGs more meaningful. However, this is not always possible or desirable in the chest-pain patient. If the
patient is not supine when the tracing is obtained, simply note the patient's position on the 12-lead.
Fast
When treating cardiac patients, much has to be accomplished in a short time. Fortunately, a 12-lead can
be obtained very quickly, even in these circumstances. Speed of acquisition is particularly important to
prehospital professionals because the goal is to be able to obtain a 12-lead without an increase in scene
time. The solution is to gain proficiency in the skill.
As with virtually every other skill, 12-lead acquisition can be done more quickly with practice. Ideally
practice would be gained on various body types and both genders. In addition to practice, a few other
tips will prove helpful. One such tip is to apply the limb electrodes to the limbs whenever you think a 12lead might be done. Clearly not every patient you monitor will need a 12-lead. If you have already
placed the limb leads on the limbs and not the torso, then they may be used for both rhythm monitoring
and a diagnostic 12-lead ECG.
Another tip is to remove the patient's clothes from the waist up. Of course, the patient's modesty must
be maintained with a gown, sheet, or towel.
12-Lead Acquisition
Once the electrodes have been properly positioned, the cables can be attached. With a 12-lead monitor,
it is simply a matter of following the manufacturer's instructions and pushing the right button(s) to
record the tracing. Most 12-lead monitors record all 12 leads simultaneously but display them in the
conventional three-row by four-column format. Therefore all the QRS complexes in a row are
consecutive, whereas QRS complexes that are aligned vertically represent a simultaneous recording of
the same beat.
Troubleshooting 12-Leads
The presence of artifact can interfere with a 12-lead machine's ability to acquire or interpret the ECG. If
you have removed the necessary hair, prepped the skin, and correctly applied the electrodes, these
steps are usually sufficient to obtain a good 12-lead on most patients. However, sometimes there still
may be some artifact or baseline wander. Consider the following possible causes.
Equipment-related Causes
Electrocardiogram Electrodes
Always use fresh electrodes when obtaining a 12-lead ECG. If the electrode gel has dried out, it is not
able to penetrate the skin. If the gel does not penetrate the skin, the signal to the monitor is weak and
artifact results.
Loose, Cracked, or Damaged Cables
The signal from the patient's heart is conducted through the cables to the monitor. If the cable's
insulation is cracked or if a lead wire is damaged, the signal to the monitor is affected and artifact can
result. Check and reconnect the cable connections. Inspect the cables and replace them if they are
damaged.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Technique-related Causes
Patient Movement
When the position of the baseline is in a state of flux, ECG analysis is very difficult. Subtle patient
movements, such as that resulting from the patient's respirations, talking, shivering, tapping toes, or
rolling his or her fingers can be enough to produce artifact. When the tracing quality precludes a good
interpretation, the tracing should be repeated. Efforts made to reduce
muscle tension and the source of patient movement, such as having the patient relax and take a deep
breath before acquisition, can improve the tracing quality.
Cable Movement
Cable movement is another possible cause of artifact. The cables may tug on the electrodes or pull away
from the patient. Many manufacturers provide a cable clasp to secure the cable assembly during
acquisition. The cable can be secured by clipping the cable clasp to the sheet or to the patient's clothing.
Electromagnetic Interference
We are surrounded by electrical devices, all of which emit electromagnetic waves. Occasionally these
devices interfere with each other. During takeoff and landing, the Federal Aviation Administration (FAA)
requires that cell phones and laptop computers be turned off because they could interfere with the
plane's navigational equipment. Similarly, some electrical devices may interfere with the 12-lead
monitor. If artifact persists after removing hair, prepping the skin, and normal troubleshooting did not
turn up any problems, electromagnetic interference (EMI) might be the reason. The problem might be
corrected by ensuring that power cords are not touching or lying near the ECG cable. If equipment is
causing EMI (such as a radio transmitter or bed control) it needs to be relocated or unplugged;
alternately, the patient could be moved to a different area.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Local Protocol Excerpts
 Protocol 4.4 – CHEST PAIN (NON-TRAUMATIC)
 Protocol 5.1 – 12 LEAD ECG
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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EMR
EMT
AEMT
INT
PM
Protocol 4.4
1. Perform general patient management (SECTION 1).
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2. Support life-threatening problems associated with airway, breathing, and
circulation.
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3. Treat dysrhythmias. Be prepared to initiate CPR and defibrillation, if necessary.
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4. Administer oxygen to patients experiencing respiratory distress or titrate oxygen to
minimum necessary to achieve SpO2 ≥94%.
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5. Obtain patient history. Reassure the patient.
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6. Transport as soon as feasible.
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MEDICAL – CARDIAC CHEST PAIN
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a. Obtain a 12 Lead ECG in accordance with 12-LEAD ECG ACQUISITION.
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b. Consider ALS rendezvous, especially when the 12-lead indicates the
patient is experiencing an acute myocardial infarction; apply defibrillation
electrodes; be prepared to defibrillate if needed.
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7. Place patient on cardiac monitor.
c.
When a 12 lead ECG indicates “ACUTE MI” or “…INFARCT, ACUTE,”
notify [Medical Control] immediately and, if able, transmit 12 lead ECG to
hospital. Consider air medical support if the transport time to the cardiac
catheterization facility is greater than 30 minutes.
d. Follow the ST–ELEVATION MYOCARDIAL INFARCTION (STEMI)
TRIAGE guidelines.
8. Give ASPIRIN 324 mg PO.
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9. Establish an INT or IV of normal saline at KVO.
10. Give NITROGLYCERIN.
a. Assist patient with PRESCRIBED NITROGLYCERIN.
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b. Give nitroglycerin 0.4 mg SL. If the pain persists, repeat nitroglycerin 0.4 mg
SL in 3 to 5 minutes (up to total of three SL doses).
11. If pain persists following administration of nitroglycerin SL, apply one (1) inch of
nitroglycerin paste.
12. If pain persists following administration of a minimum of two SL (2) nitroglycerin,
consider FENTANYL 50 mcg IV, repeat every 5 minutes (up to 150 mcg).
13. Perform reassessment as indicated.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Protocol 4.4 – MEDICAL – CARDIAC CHEST PAIN
Key Points: CHEST PAIN (NON-TRAUMATIC)
 Non-traumatic chest pain is a common pre-hospital patient complaint. It should be considered life
threatening until proven otherwise. The pain or discomfort is often associated with acute
myocardial infarction or angina pectoris which is a sign of inadequate oxygen supply to the heart
muscle. Common signs and symptoms associated with the pain are dyspnea, diaphoresis,
nausea, vomiting, weakness, fatigue, anxiety and restlessness.
 Ideally, 12-lead acquisition and treatment of the patient (i.e. administration of oxygen, aspirin,
etc.) should occur concurrently.
 The preferred IV site location is left arm, especially for STEMI patients.
 If the patient has taken nitroglycerin before without problems, nitroglycerin may be administered
sublingually before an INT or IV is established. If the patient has never taken nitroglycerin, an IV
must be initiated prior to nitroglycerin administration.
 Bradycardia with hypotension may be due to inferior wall MI associated with right ventricular MI.
In this instance, pacing and IV fluids may improve patient’s hemodynamic status. Provided that
SBP is greater than 100 mmHg, chest pain relief is warranted as specified in this protocol. Avoid
use of nitroglycerin.
 Avoid nitroglycerin with hypotension (SBP less than 100 mmHg) or bradycardia (less than
60/min.).
 Administration of nitroglycerin is contraindicated in patients who are using anti-impotence agents
since these agents have been shown to potentiate the hypotensive effects of organic nitrates.
 ST-segment elevation >1 mm (0.1 mV) in 2 or more contiguous precordial leads or 2 or more
adjacent limb leads and is classified as ST-elevation MI (STEMI).
 Transport performing interventions en route. Time is muscle!
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Example of 12-lead ECG indicating acute myocardial infarction (MI)
The picture shows an example of what a 12-lead ECG will display, in this case a Medtronic Lifepak 12,
when the machine has detected an acute myocardial infarction. Users need to be familiar with what their
particular machine will display when an acute MI is susptected.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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12 LEAD ECG
Protocol 5.1
Scope
EMR
EMT
AEMT
INT
PM
Out-of-hospital 12-lead ECGs and advance notification to the receiving facility speeds the diagnosis,
shortens the time to fibrinolysis or catheterization, and may be associated with decreased mortality rates.
The reduction in door-to-reperfusion therapy interval in most studies ranges from 10 to 60 minutes.
TRAINING
Providers shall complete training for 12-lead ECG acquisition prior to utilizing this protocol and ECG
machines.
INDICATIONS (any of the following)
1. Chest pain
2. Dyspnea
3. Palpitations
4. Syncope
5. General weakness or dizziness
6. Activation of an implantable cardioverter defibrillator (ICD)
PRECAUTIONS
1. Treatment of lethal dysrhythmias (e.g., VF, pulseless VT) and life threatening problems associated
with airway, breathing, and circulation should be initiated prior to obtaining a 12-lead ECG.
2. Treatments such as oxygen, aspirin and nitroglycerin, or requesting advanced life support, should
never be delayed to acquire a 12-lead ECG. Ideally, 12-lead acquisition and treatment of the patient
should occur concurrently.
3. Keep time on the scene to a minimum by moving the patient to ambulance prior to ECG if possible.
4. Dirt, oil, sweat and other materials on the skin can interfere with obtaining a quality tracing.
5. Being in a moving vehicle and engine vibration can interfere with obtaining a quality tracing.
PROCEDURE
1. Prepare all of the equipment and ensure the
cable is in good repair. Check to make sure
there are adequate leads and materials for
prepping the skin.
2. Prep the skin by first drying sweat or water.
Lightly buff the electrode placement areas with
an alcohol prep or the abrasive pad which may
be found on the removable cover of some
electrodes.
3. Place the four limb leads in accordance with
manufacturer’s recommendations. Limb lead
electrodes are typically placed on the deltoid
area and the lower leg or thigh as shown in
Figure 5.1-A. Move limb leads proximally if
artifact is experienced. Avoid placing limb leads
on the torso unless necessary to minimize
artifact. Avoid placing limb leads over bony
prominences.
CONTINUED ON NEXT PAGE
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12 LEAD ECG
Protocol 5.1
Scope
EMR
EMT
AEMT
INT
PM
4. Place the precordial leads (a.k.a. chest or V leads) in accordance with manufacturer’s
recommendations. Precordial leads are typically placed as shown in Figure 5.1-B. Proper placement
is important for accurate diagnosis. Leads locations are identified as V1 through V6.
Lead
Lead Location
V1
Fourth intercostal space to the right of the sternum
V2
Fourth intercostal space to the left of the sternum
V3
Directly between leads V2 and V4
V4
Fifth intercostal space at midclavicular line
V5
Level with V4 at left anterior auxiliary line
V6
Level with V5 at left midaxillary line
a. Locating the V1 position (fourth intercostal space) is critically important because it is the
reference point for locating the placement of the remaining V leads. To locate the V 1 position:
i. Place your finger at the notch in the top of the sternum.
ii. Move your finger slowly downward about 1.5 inches (3.8 centimeters) until you feel a
slight horizontal ridge or elevation. This is the Angle of Louis where the manubrium
joins the body of the sternum.
iii. Locate the second intercostal space on the patient’s right side, lateral to and just
below the Angle of Louis.
iv. Move your finger down two more intercostal spaces to the fourth intercostal space,
which is the V1 position.
v. Place V1 by attaching the positive electrode to the identified location.
b. Place V2 by attaching the positive electrode to the left of the sternum at the further intercostal
space.
c. Place V4 by attaching the positive electrode at the midclavicular line at the fifth intercostal
space (Note: V4 must be placed prior to V3).
d. Place V3 by attaching the positive electrode in the line midway between lead V 2 and V4.
e. Place V5 by attaching the positive electrode at the anterior axillary line as the same level as
V4.
f. Place V6 by attaching the positive electrode to the midaxillary line at the same level as V4.
CAUTION: When placing electrodes on female patients, always place leads V3-V6 under the breast
rather than on the breast.
CAUTION: Never use the nipples as reference points for locating the electrodes for male or female
patients, because nipple locations may vary widely.
CONTINUED ON NEXT PAGE
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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12 LEAD ECG
Protocol 5.1
Scope
5.
6.
7.
8.
9.
10.
EMR
EMT
AEMT
INT
PM
Ensure that all leads are attached.
Turn on the machine.
Record the tracing by following the machine specific acquisition procedure and function.
Document on the tracing the patient’s name and the date and time the tracing was obtained.
Refer to the ST–ELEVATION MYOCARDIAL INFARCTION (STEMI) TRIAGE.
Provide copies of all 12-lead ECGs acquired to the receiving hospital.
CONSIDERATIONS
1. Perform the 12-lead ECG as soon as possible.
2. For a patient with 12-lead indicated myocardial infarction, follow the ST–ELEVATION MYOCARDIAL
INFARCTION (STEMI) TRIAGE.
3. Acquire an additional 12-lead ECG every 15 minutes or if the patient’s clinical condition changes.
4. Each agency should have a procedure to ensure the time on each ECG machine is synchronized. It
is recommended the time be synchronized at least once each week. Atomic clocks or wireless
telephones are recommended sources for the correct time.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
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Module 1-2: Cardiac Arrest Management
Each year, at least 295,000 Americans experience sudden cardiac arrest (SCA) outside of a hospital. SCA
affects people of all ages and with many types of heart problems, but occurs most commonly in adults
with coronary artery disease, and so it will only become more common as America ages. On average in
the U.S., just 8% of SCA victims survive. Cardiopulmonary resuscitation (CPR) and early defibrillation
with an automated external defibrillator (AED) more than double a victim’s chance of survival. In fact,
early defibrillation with CPR is the only way to restore the SCA victim’s heart rhythm to normal. For
every minute that passes without CPR and defibrillation, the chances of survival decrease by 7–10%.
Local Protocol
The Central Shenandoah EMS Council cardiac arrest protocols are based on the 2010 American Heart
Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care and
research supporting cardiocerebral resuscitation (CCR).
Cardiocerebral resuscitation (CCR) is an approach to patients with out-of-hospital cardiac arrest that has
been shown to improve rates of neurologically intact survival, when compared to a cardiopulmonary
resuscitation (CPR) approach, in with certain presentations of cardiac arrest. The algorithm is for use by
all EMS providers to outline the initial management of a patient in cardiac arrest and determine which
resuscitation method to employ – CCR or CPR.
In cardiac arrest, time is critical. Delaying treatment to call for orders reduces the patient's chance of
survival. Therefore, CPR and defibrillation must be performed immediately without a delay to contact
Medical Control.
The "on duty” medical control physician is responsible for in-field defibrillation and must sign the patient
care report filled out by the provider after the event. All calls should be reviewed by the agency quality
management program. A completed PPCR form is an essential element of this review process.
On the following pages, excerpts from the CSEMS Council protocols and Virginia regulations that are
relative to cardiac arrest, AED use, do not resuscitate orders, and death in the field will be presented.
Documentation
A PPCR and/or other approved form shall be completed in compliance with standard documentation
procedures. The following pertinent information should be included on the PPCR for resuscitation
attempts:








Witnessed or non-witnessed arrest.
Time of event.
Time to CPR initiated.
Time of AED use initiated.
Number of shocks delivered.
Airway management method.
Availability of ALS.
Time medical control notified.
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

Patient outcome.
Physician signature.
Any time you perform an invasive procedure you must get the signature of the medical practitioner who
assumes responsibility for the patient. The signature is to be included on the prehospital patient care
report for the incident. Any incident when a medication is administered, or self-administration is
assisted (excluding oxygen), or an invasive procedure is performed, requires the signature of the medical
practitioner. The medical practitioner signature documents that the physician has been notified of the
medications administered and procedures performed by the EMS personnel. The signature does not
infer that the medical practitioner approves, authorizes or verifies compliance with protocol, standing
orders or medical control orders.
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Local Protocol Excerpts
 Protocol 2.1.1 – CARDIAC ARREST – ADULT
 Protocol 2.1.2 – CARDIOCEREBRAL RESUSCITATION (CCR) –
ADULTS ONLY
 Protocol 2.1.3 – CARDIOPULMONARY RESUSCITATION (CPR)
 Protocol 3.1 – BASIC LIFE SUPPORT – PEDIATRIC
 Protocol 2.7 – DEATH DETERMINATION – ALL AGES
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GENERAL - CARDIAC ARREST (ADULT)†
Protocol 2.1.1
Scope EMR
EMT
AEMT
INT
PM
†
Patients who have reached puberty, defined as breast development in females and the presence of
axillary hair in males, are considered adults.
Cardiocerebral resuscitation (CCR) is an approach to patients with out-of-hospital cardiac arrest that has
been shown to improve rates of neurologically intact survival, when compared to a cardiopulmonary
resuscitation (CPR) approach, in with certain presentations of cardiac arrest. This algorithm is for use by
all EMS providers to outline the initial management of a patient in cardiac arrest and determine which
resuscitation method to employ – CCR or CPR.
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CARDIOCEREBRAL RESUSCITATION (CCR) – ADULTS ONLY
Scope EMR
EMT
AEMT
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Protocol 2.1.2
INT
PM
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GENERAL - CARDIAC ARREST (ADULT)
Scope
EMR
EMT
AEMT
Protocol 2.1
INT
PM
1
For biphasic defibrillators, use the manufacturer's recommended energy dose (120 to 200 J). If the
manufacturer's recommended dose is not known, deliver shocks at the maximal energy dose. If a
monophasic defibrillator is used, providers should deliver an initial shock of 360 J and use that dose for
subsequent shocks.
2
Only EMT providers that have successfully completed local protocol training on the King LT airway are
authorized to utilize the device.
Key Points: GENERAL - CARDIAC ARREST
 The foundation of ALS care is good BLS care, beginning with prompt high-quality chest
compressions and, for VF/pulseless VT, attempted defibrillation within minutes of collapse as
soon as it can be accomplished.
 The most critical interventions during the first minutes of VF or pulseless VT are
immediate chest compressions, with minimal interruption in chest compressions, and
defibrillation.
 If the arrest IS witnessed by EMS, use the defibrillator as soon as it is available. Do not delay
use of an AED, initial rhythm analysis or defibrillation to provide a period of chest compressions
for patients in cardiac arrest.
 If the arrest IS NOT witnessed, give one cycle (two minutes) of chest compressions before
attempting defibrillation.
 When a rhythm check reveals VF/VT, chest compressions should be provided while the
defibrillator charges (when possible), until it is time to “clear” the victim for shock delivery. Give
the shock as quickly as possible. Immediately after shock delivery, resume chest compressions
without delay and continue for 2 minutes and then check the rhythm.
 Minimize the frequency and duration of interruptions in compressions to maximize the
number of compressions delivered per minute.
 When providing ventilator support, it is critical that ventilations be slow, gentle and not
given with a lot of pressure. Six ventilations per minute is adequate while compression
are ongoing.
 “Effective” chest compressions are essential for providing blood flow during resuscitation. To
give “effective” chest compressions, “push hard and push fast.” Compress the adult chest at a
rate of at least 100 compressions per minute, with a compression depth of 2 inches
(approximately 5 cm). Allow the chest to recoil completely after each compression, and allow
approximately equal compression and relaxation times.
 Resuscitation may be terminated by BLS or ALS providers under the direction of [Medical
Control].
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GENERAL - CARDIAC ARREST (PEDIATRIC)
Scope
EMR
EMT
Unresponsive
Not breathing or only gasping
Check pulse:
DEFINITE pulse
within 10 seconds?
Definite
pulse
AEMT
Protocol 3.1
INT
PM
 Give 1 breath every 3
seconds
 Add compressions if
pulse remains
<60/min with poor
perfusion despite
adequate oxygenation
and ventilation
 Recheck pulse every
2 minutes
No pulse
One Rescuer: Begin cycles of 30 COMPRESSIONS and 2 BREATHS
Two Rescuers: Give cycles of 15 COMPRESSIONS and 2 BREATHS
Give 5 cycles of CPR
Check rhythm
Shockable rhythm?
Shockable
Give 1 shock
Resume CPR immediately
for 2 minutes
[AEMT] Establish IV or IO access
[EMT1,AEMT] Continue BVM
ventilations. Secure airway with a
King LT airway is an appropriate
size is available (minimize CPR
disruption).
 Once a King LT airway is in
place, perform asynchronous
chest compressions and
ventilation.
1
Not Shockable
Resume CPR immediately
for 2 minutes
Check rhythm every 2 min
High-Quality CPR
 Compression depth to at least
1/ anterior-posterior diameter
3
of chest, about 1 ½ inches (4
cm) in infants and 2 inches (5
cm) in children
 Allow comlete chest recoil after
each compression
 Minimize interruptions in chest
compressions
 Avoid excessive ventilation
Only EMT providers that have successfully completed local protocol training on the King LT airway are
authorized to utilize the device.
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DEATH DETERMINATION – ALL AGES
Protocol 2.7
Scope
EMR
EMT
AEMT
INT
PM
Resuscitation efforts are to be withheld on patients in cardiopulmonary arrest in accordance with the
criteria listed below.



Patient has a valid do not resuscitate order in accordance with Virginia DDNR regulations.
Situations where attempts to perform CPR would place the rescuer at risk of serious injury or
mortal peril.
Clinical signs of obvious, irreversible death
o Decomposition.
o Signs of rigor mortis such as rigidity or stiffening of muscular tissues and joints in the body,
which occurs anytime after death and usually appears in the head, face and neck muscles
first.
o Obvious signs of venous pooling in dependent body parts, lividity such as mottled bluishtinged discoloration of the skin, often accompanied by cold extremities.
o Decapitation.
o Incineration of the torso and/or head.
o Massive crush injury and/or penetrating injury with evisceration of the heart, and/or brain.
o Gross dismemberment of the trunk.
Procedure: When it is determined the patient is not a candidate for resuscitation or [Medical Control]
has ordered discontinuation of resuscitative efforts, take the following steps.
1.
2.
3.
4.
Look, listen and feel for breathing for one minute.
Check for a carotid pulse AND check one additional pulse point (i.e. femoral, radial)
Listen for heart sounds with a stethoscope.
When immediately available on the scene, attach a cardiac monitor to check for a viable ECG
rhythm [INT, PM].
It is preferable these steps be performed by two providers. Ideally, the assessments are performed by
providers who are highly trained and experienced. Both providers must agree with the determination of
death. If there's any disagreement, resuscitation is immediately initiated.
Once the death determination has been made, see DECEASED PATIENT GUIDELINES.
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Virginia Durable Do Not Resuscitate Guidelines
CHAPTER 66
REGULATIONS GOVERNING DURABLE DO NOT RESUSCITATE ORDERS
Part I
Definitions
12VAC5-66-10. Definitions.
The following words and terms when used in this chapter shall have the following meanings unless the
context clearly indicates otherwise:
"Agent" means an adult appointed by the declarant under an advance directive, executed or made in
accordance with the provisions of § 54.1-2983 of the Code of Virginia to make health care decisions for
him.
"Alternate Durable DNR jewelry" means a Durable DNR bracelet or necklace issued by a vendor
approved by the Virginia Office of Emergency Medical Services. A Durable DNR Order must be obtained
by the patient, from a physician, to obtain Alternate Durable DNR jewelry.
"Board" means the State Board of Health.
"Cardiac arrest" means the cessation of a functional heartbeat.
"Commissioner" means the State Health Commissioner.
"Durable Do Not Resuscitate Order" or "Durable DNR Order" means a written physician's order issued
pursuant to § 54.1-2987.1 of the Code of Virginia in a form or forms authorized by the board to withhold
cardiopulmonary resuscitation from an individual in the event of cardiac or respiratory arrest. For
purposes of this chapter, cardiopulmonary resuscitation shall include cardiac compression, endotracheal
intubation and other advanced airway management, artificial ventilation, defibrillation, administration of
cardiac resuscitative medications, and related procedures. As the terms "advance directive" and "Durable
Do Not Resuscitate Order" are used in this article, a Durable Do Not Resuscitate Order or other DNR
Order is not and shall not be construed as an advance directive. When used in these regulations, the
term "Durable DNR Order" shall include any authorized Alternate Durable DNR jewelry issued in
conjunction with an original Durable DNR Order.
"Emergency Medical Services" or "EMS" means the services rendered by an agency licensed by the
Virginia Office of Emergency Medical Services, an equivalent agency licensed by another state or a
similar agency of the federal government when operating within this Commonwealth.
"Emergency medical services agency" or "EMS agency" means any agency, licensed to engage in the
business, service, or regular activity, whether or not for profit, of transporting and/or rendering immediate
medical care to such persons who are sick, injured, wounded or otherwise incapacitated or helpless.
"Incapable of making an informed decision" means the inability of an adult patient, because of mental
illness, mental retardation, or any other mental or physical disorder that precludes communication or
impairs judgment, to make an informed decision about providing, withholding, or withdrawing a specific
medical treatment or course of treatment because he is unable to understand the nature, extent, or
probable consequences of the proposed medical decision, or to make a rational evaluation of the risks
and benefits of alternatives to that decision. For purposes of this article, persons who are deaf or
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dysphasic or have other communication disorders but who are otherwise mentally competent and able to
communicate by means other than speech, shall not be considered incapable of making an informed
decision. The determination that the patient is "incapable of making an informed decision" shall be made
in accordance with § 54.1-2983.2 of the Code of Virginia.
"Office of EMS" or "OEMS" means the Virginia Office of Emergency Medical Services. The Virginia Office
of Emergency Medical Services is a state office located within the Virginia Department of Health (VDH).
"Other Do Not Resuscitate Order" or "Other DNR Order" means a written physician's order not to
resuscitate a patient in the event of cardiac or respiratory arrest on a form other than the authorized state
standardized Durable DNR Form under policies and procedures of the health care facility to which the
individual who is the subject of the order has been admitted.
"Person authorized to consent on the patient's behalf" means any person authorized by law to consent on
behalf of the patient incapable of making an informed decision or, in the case of a minor child, the parent
or parents having custody of the child or the child's legal guardian or as otherwise provided by law.
"Physician" means a person licensed to practice medicine in the Commonwealth of Virginia or in the
jurisdiction where the treatment is to be rendered or withheld.
"Qualified emergency medical services personnel" means personnel certified to practice as defined by
§ 32.1-111.1 of the Code of Virginia when acting within the scope of their certification.
"Qualified health care facility" means a facility, program, or organization operated or licensed by the State
Board of Health or by the Department of Behavioral Health and Developmental Services (DBHDS) or
operated, licensed, or owned by another state agency.
"Qualified health care personnel" means any qualified emergency medical services personnel and any
licensed healthcare provider or practitioner functioning in any facility, program or organization operated or
licensed by the State Board of Health or by DBHDS or operated, licensed, or owned by another state
agency.
"Respiratory arrest" means cessation of breathing.
Part II
Purpose and Applicability
12VAC5-66-20. Authority for regulation.
Section 54.1-2987.1 of the Code of Virginia vests authority for the regulation of Durable DNR Orders in
the State Board of Health and directs the board to prescribe by regulation the procedures, including the
requirements for forms to authorize qualified health care personnel to follow Durable DNR Orders. All
EMS DNR Orders and all Durable Do Not Resuscitate Orders issued or in effect between July 1, 1999,
and March 27, 2002, are to be considered valid Durable DNR Orders and shall remain valid until revoked.
12VAC5-66-30. Purpose of regulations.
The board has promulgated these regulations in order to carry out the intent of Virginia law that a person
shall have the opportunity to execute a Durable DNR Order that comports with his wishes.
Part III
Requirements and Provisions
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12VAC5-66-40. The Durable Do Not Resuscitate Order Form.
The Durable DNR Order Form shall be a standardized document as approved by the board and
consistent with these regulations. The following requirements and provisions shall apply to the approved
Durable DNR Order Form.
1. Content of the Form - A Durable DNR Order Form shall contain, from a physician with whom the
patient has a bona fide physician/patient relationship, a do not resuscitate determination, signature and
the date of issue, the signature of the patient or, if applicable, the person authorized to consent on the
patient's behalf.
2. Effective Period for a Signed Durable DNR Order - A signed Durable DNR Order shall remain valid until
revoked in accordance with § 54.1-2987.1 of the Code of Virginia and 12VAC5-66-80 E or until rescinded,
in accordance with accepted medical practice, by the provider who issued the Durable Do Not
Resuscitate Order.
3. Durable DNR Order Form - A Durable DNR Order or Alternate Durable DNR jewelry that complies with
12VAC5-66-50 shall be valid for the purposes of withholding or withdrawing cardiopulmonary
resuscitation by qualified health care personnel in the event of cardiac or respiratory arrest.
4. Availability of the Durable DNR Order Form. The Durable DNR Order Form that complies with this
section or Alternate Durable DNR jewelry that complies with 12VAC5-66-50 shall be maintained and
readily available to qualified health care personnel at the patient's current location or residence.
5. Qualified health care personnel may honor a legible photocopy of a Durable DNR Form or Other
Durable DNR Order as if it were an original.
6. A patient who is traveling outside his home or between health care facilities should have an original or
photocopied Durable DNR Order, Other Durable DNR Order, or Alternate Durable DNR jewelry
accompany him.
7. Distribution of Durable DNR Order Forms - The authorized Virginia Durable DNR Order Form shall be a
standardized form available for download via the Internet from the Office of Emergency Medical Services
website. The downloadable form will contain directions for completing the form and three identical
Durable DNR Order Forms: one original form to be kept by the patient, the second to be placed in the
patient's permanent medical record, and the third to be used by the patient for requesting Alternate
Durable DNR jewelry.
8. Hard copies of the Durable DNR Order Form shall also be made available to physicians or licensed
health care facilities by the Office of EMS. The Office of EMS may utilize a vendor to print and distribute
the Durable DNR Order Form and a nominal fee may be charged in an amount necessary to cover
printing and shipping fees.
12VAC5-66-50. Authorized alternate Durable DNR jewelry.
The board authorizes the use of Alternate Durable DNR jewelry in conjunction with the issuance of a
Durable DNR Order. These Alternate Durable DNR jewelry items shall be uniquely-designed and
uniquely-identifiable bracelets and necklaces that are available only from a vendor approved by the
Virginia Department of Health, Office of EMS. The Alternate Durable DNR jewelry must be purchased
from the approved vendor by the person to whom a Durable DNR Order Form applies, or the person
authorized to consent on the patient's behalf. An original Durable DNR Order Form must be obtained from
a physician and provided to the vendor in order to receive Alternate Durable DNR jewelry. Such a
necklace or bracelet may be utilized either to validate the Durable DNR Order Form or in place of an
original Durable DNR Order Form in the event that the original order is not readily available at the site
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where the person to whom the order applies is found. In order to be honored by qualified health care
personnel in place of the standard Durable DNR Order Form, the Alternate Durable DNR jewelry must
contain the minimum information approved by the State Board of Health in 12VAC5-66-60.
12VAC5-66-60. Other DNR Orders.
A. Nothing in these regulations shall be construed to preclude licensed health care practitioners from
following any Other Do Not Resuscitate Order in accordance with the applicable policies and procedures
of the health care facility in which they practice.
B. Qualified health care personnel are authorized to honor any Other Do Not Resuscitate (DNR) Order as
if it were a Durable Do Not Resuscitate Order when the patient is currently admitted to a hospital or other
qualified health care facility or is in transit from a qualified health care facility provided that such order
includes the same information as listed in subdivision 1 of 12VAC5-66-40, except that an Other DNR
Order shall not be required to include the signature of the patient or a person authorized to consent for
the patient on the order itself.
C. Nothing in these regulations shall prohibit qualified health care personnel from following any direct
verbal order issued by a licensed physician not to resuscitate a patient in cardiac or respiratory arrest
when such physician is physically present.
Part IV
Implementation Procedures
12VAC5-66-70. Issuance of a Durable DNR Order.
A. A Durable DNR Order may be issued to a patient by a physician, with whom the patient has
established a bona fide physician/patient relationship, as defined by the Board of Medicine in their current
guidelines, only with the consent of the patient or, if the patient is a minor or is otherwise incapable of
making an informed decision regarding consent for such an order, upon the request of and with the
consent of the person authorized to consent on the patient's behalf.
B. The use of the authorized Durable DNR Order Form is encouraged to provide uniformity throughout
the health care continuum.
C. The authorized Durable DNR Order can be honored by qualified health care personnel in any setting.
D. Qualified health care personnel are authorized to honor only a Durable DNR Order on an authorized
form or Alternate DNR jewelry, except as provided in 12VAC5-66-60 of these regulations.
E. Prior to issuing a Durable DNR Order, the physician shall explain to the patient or the person
authorized to consent on the patient's behalf, the alternatives available for response in the event of
cardiac or respiratory arrest. If the option of a Durable DNR Order is agreed upon, the physician shall
have the following responsibilities:
1. Explain the circumstances under which qualified health care personnel may follow a Durable DNR
Order.
2. Explain how to and who may revoke the Durable DNR Order.
3. Document the patient's full legal name.
4. Document the execution date of the Durable DNR Order.
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5. Obtain the signature of the patient or the person authorized to consent on the patient's behalf on all
three forms: the patient's copy, medical record copy, and the copy used for obtaining Alternate DNR
jewelry.
6. Make sure that the issuing physician's name is clearly printed and the form is signed.
7. Record the contact telephone number for the issuing physician.
8. Issue the original Durable DNR Order Form, and the patient and Alternate DNR jewelry copies to the
patient and maintain the medical record copy in the patient's medical file.
F. The person to whom a Durable DNR Order applies or the person authorized to consent on the patient's
behalf must present the following information to the approved vendor in order to purchase and be issued
an approved Alternate Durable DNR necklace or bracelet. The necklace or bracelet must contain the
following information:
1. The following words: Do Not Resuscitate;
2. The patient's full legal name;
3. The physician's name and phone number; and
4. The Virginia Durable DNR issuance date.
12VAC5-66-80. Durable DNR Order implementation procedures.
A. Qualified health care personnel shall comply with the following general procedures and published
Virginia Durable DNR Order Implementation Protocols when caring for a patient who is in cardiac or
respiratory arrest and who is known or suspected to have a Durable DNR Order in effect.
B. Initial assessment and intervention. Perform routine patient assessment and resuscitation or
intervention until a valid Durable DNR Order, Alternate DNR jewelry, or Other DNR Order can be
confirmed, as follows:
1. Determine the presence of a Durable DNR Order, approved Alternate Durable DNR jewelry, or Other
DNR Order.
2. If the patient is within a qualified health care facility or in transit between qualified health care facilities,
any qualified health care personnel may honor an Other DNR Order as set forth in 12VAC5-66-60.
3. Determine that the Durable DNR form or Alternate DNR jewelry is not altered.
4. Verify, through driver's license or other identification with photograph and signature or by positive
identification by a family member or other person who knows the patient, that the patient in question is the
one for whom the Durable DNR Order, Alternate DNR jewelry, or Other DNR Order was issued.
5. If the Durable DNR Order, Alternate DNR jewelry, or Other DNR Order is intact, unaltered, and verified
as issued for the patient, qualified health care personnel may consider it valid.
C. Resuscitative measures to be withheld or withdrawn. In the event of cardiac or respiratory arrest of a
patient with a valid Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR Order under the
criteria set forth in subsection B of this section, qualified health care personnel shall withhold or withdraw
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cardiopulmonary resuscitation (CPR) unless otherwise directed by a physician physically present at the
patient location. CPR shall include:
1. Cardiac compression;
2. Artificial ventilation;
3. Defibrillation;
4. Endotracheal Intubation or other advanced airway management including supra-glottic devices such as
the LMA, or other airway devices that pass beyond the oral pharynx, such as the Combi Tube, PTL etc.;
or
5. Administration of related procedures or cardiac resuscitation medications as prescribed by the patient's
physician or medical protocols.
D. Procedures to provide comfort care or to alleviate pain. In order to provide comfort care or to alleviate
pain for a patient with a valid Durable DNR Order of any type or Other DNR Order the following
interventions may be provided, depending on the needs of the particular patient:
1. Airway management, including positioning, nasal or pharyngeal airway placement;
2. Suctioning;
3. Supplemental oxygen delivery devices;
4. Pain medications or intravenous fluids;
5. Bleeding control;
6. Patient positioning; or
7. Other therapies deemed necessary to provide comfort care or to alleviate pain.
E. Revocation.
1. If a patient is able to, and does, express to a health care provider or practitioner the desire to be
resuscitated in the event of cardiac or respiratory arrest, such expression shall revoke the provider's or
practitioner's authority to follow a Durable DNR Order or Other DNR Order. In no case shall any person
other than the patient have authority to revoke a Durable DNR Order or Other DNR Order executed upon
the request of and with the consent of the patient himself.
If the patient is a minor or is otherwise incapable of making an informed decision and the Durable DNR
Order or Other DNR Order was issued upon the request and with the consent of the person authorized to
consent on the patient's behalf, then the expression by said person to a health care provider or
practitioner of the desire that the patient be resuscitated shall so revoke the provider's or practitioner's
authority to follow a Durable DNR Order or Other DNR Order.
2. The expression of such desire to be resuscitated prior to cardiac or respiratory arrest shall constitute
revocation of the order; however, a new order may be issued upon consent of the patient or the person
authorized to consent on the patient's behalf.
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3. The provisions of this section shall not authorize any qualified emergency medical services personnel
or licensed health care provider or practitioner who is attending the patient at the time of cardiac or
respiratory arrest to provide, continue, withhold or withdraw treatment if such provider or practitioner
knows that taking such action is protested by the patient incapable of making an informed decision. No
person shall authorize providing, continuing, withholding or withdrawing treatment pursuant to this section
that such person knows, or upon reasonable inquiry ought to know, is contrary to the religious beliefs or
basic values of a patient incapable of making an informed decision or the wishes of such patient fairly
expressed when the patient was capable of making an informed decision.
F. Documentation. When following a Durable DNR Order or Other DNR Order for a particular patient
admitted to a qualified health care facility, qualified health care personnel shall document care rendered
or withheld as required by facility policies and procedures. When following a Durable DNR Order or Other
DNR Order for a particular patient who is not admitted to a qualified health care facility or who is in transit
from a health care facility, qualified health care personnel shall document in the patient's medical record
the care rendered or withheld in the following manner:
1. Use standard patient care reporting documents (i.e. patient chart, pre-hospital patient care report).
2. Describe assessment of patient's cardiac or respiratory arrest status.
3. Document which identification (Durable DNR Order, Alternate Durable DNR jewelry, or Other DNR
Order or alternate form of identification) was used to confirm Durable DNR status and that it was intact,
not altered, not canceled or not officially revoked.
4. Record the name of the patient's physician who issued the Durable DNR Order, or Other DNR Order.
5. If the patient is being transported, keep the Durable DNR Order, Alternate Durable DNR jewelry, or
Other DNR Order with the patient.
G. General considerations. The following general principles shall apply to implementation of all Durable
DNR Orders.
1. If there is misunderstanding with family members or others present at the patient's location or if there
are other concerns about following the Durable DNR Order or Other DNR Order, contact the patient's
physician or EMS medical control for guidance.
2. If there is any question about the validity of a Durable DNR Order, resuscitative measures should be
administered until the validity of the Durable DNR Order or Other DNR Order is established.
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Virginia Durable Do Not Resuscitate Order
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Module 2: King Laryngotracheal Airway
Basic Airway Management
The cells of the human body must have oxygen to survive. The reason ABCs – airway, breathing and
circulation – are so important is that they are the means by which oxygen is brought into the body and
carried to the cells. Before we can learn about an advanced airway device such as the King LT airway,
we must ensure understanding and competence of basic airway management. For this reason, your
operational medical director has made a review a basic airway management part of the local protocol
program.
Opening the Airway
A patient without an open airway has no chance of survival.
If the airway is not open, there is no breathing. Without
breathing, the patient's heart will stop beating unless you
open the airway and begin breathing for the patient.
Therefore, one of the most important actions that you can
perform is opening the airway of an unresponsive patient.
An unresponsive patient loses the ability to keep his own
airway open because he loses muscle tone. This loss of
muscle tone causes the soft tissues of the throat and the
base of the tongue to relax. If the patient is lying on his back,
the tongue falls into the back of the throat, blocking the
airway. Because the tongue is attached to the lower jaw,
moving the jaw forward will lift the tongue away from the
back of the throat.
Head Tilt–Chin Lift
The head tilt-chin lift maneuver is the most effective method
for opening the airway in a patient with no known or
suspected trauma to the head or neck. It requires no equipment and is simple to perform. When done
correctly, the base of the tongue will be displaced from blocking the back of the throat.
Steps in performing a head tilt—chin lift:
1. Position the patient on his back.
2. Place your hand that is closest to the patient's head on his forehead. Apply downward pressure
with your palm, gently tilting the patient's head backward.
3. Place the fingers of your hand that is closest to the patient's feet under the bony part of his chin.
Do not compress the soft tissues under the chin; doing so can result in an airway obstruction.
4. Lift the chin forward and support the jaw.
5. Make sure the patient's mouth is open. If the patient is wearing dentures and they fit well, leave
them in place. If the dentures are loose or do not fit well, remove them.
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Jaw Thrust
An unresponsive patient's airway can be opened by placing
your fingers behind the angle of the patient's jaw, displacing
the jaw forward toward the patient's face, and performing a
gentle head tilt while thrusting the jaw forward. This
technique is called the jaw thrust maneuver. Use a modified
jaw thrust maneuver to open the airway of an unresponsive
patient when trauma to the head or neck is suspected. The
modified jaw thrust maneuver is also called the jaw thrust
without head tilt maneuver, trauma jaw thrust, or the jaw
thrust without head extension maneuver. The modified jaw
thrust is a variation of the conventional jaw thrust. With this
procedure, the patient's lower jaw is moved forward while the
head and cervical spine are stabilized in a neutral position to
minimize movement. Although this method of opening the
airway is effective, it is less effective than the head tilt—chin
lift and is more tiring for rescuers. Because this technique
requires the use of both hands, a second rescuer will be
needed if the patient requires ventilation.
Steps in performing a modified jaw thrust maneuver:
1. Position the patient on his back, and kneel at the top of the patient's head.
2. While keeping the patient's head and neck in line with the rest of his body, place your hands on
each side of the patient's lower jaw. It may be helpful to rest your elbows on the surface on
which the patient is lying.
3. While stabilizing the patient's head in a neutral position, gently grasp the angles of the patient's
lower jaw. Lift with both hands, gently moving the lower jaw forward. Make sure the patient's
mouth
The head tilt—chin lift and jaw thrust maneuvers may cause some movement of the cervical spine when
they are performed. Healthcare professionals should use the modified jaw thrust maneuver to open the
airway of a trauma victim if cervical spine injury is suspected. However, if the airway is not open and the
modified jaw thrust does not open the airway, use the head tilt—chin lift maneuver.
KEY POINT!
While opening the airway is an important procedure for any patient, recall that
during CPR, you should initiate chest compressions before ventilations.
Additionally, “Look, listen, and feel” was removed from the CPR sequence.
After delivery of 30 compressions, open the victim’s airway and delivers two
breaths.
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Oropharyngeal Airway
An oral airway is a curved device made of rigid plastic. An oral airway is also called an oropharyngeal
airway (OPA). An OPA is inserted into the patient's mouth and used to keep the tongue away from the
back of the throat. It may be used only in unresponsive patients without a gag reflex.
OPAs are available in a variety of sizes. Before inserting an OPA, you must determine the correct size for
your patient. To select the correct size, hold the OPA against the side of the patient's face. Select an OPA
that extends from the corner of the patient's mouth to the tip of the earlobe, or from the center of the
patient's mouth to the angle of the jaw. If you select an airway of the wrong size, you can cause an
airway obstruction. An airway that is too long can press the epiglottis against the entrance of the larynx,
resulting in a complete airway obstruction. An OPA that is too short may come out of the mouth or it
may push the tongue into the back of the throat, causing an airway obstruction. A properly sized OPA is
one of the best tools for maintaining an open airway.
Sizing and Inserting an Oral Airway
1. Place the patient on his back. Position yourself
at the patient's head.
2. Open the patient's airway with a head tilt—chin
lift maneuver. If trauma is suspected, use the
modified jaw thrust maneuver to open the
airway.
3. Select the correct-size oral airway. An oral
airway is the correct size if it extends from the
corner of the patient's mouth to the tip of the
earlobe, or from the center of the mouth to the
angle of the jaw.
4. Open the patient's mouth. Suction any
secretions from the mouth, if present.
5. Insert the airway upside down, with the tip pointing toward the roof of the patient's mouth.
6. Advance the oral airway gently along the roof of the mouth.
7. When the tip of the airway approaches the back of the throat, rotate the airway 180 degrees so
that it is positioned over the tongue. Be careful not to push the tongue into the back of the
throat.
8. When the oral airway is correctly positioned, the flange end should rest on the patient's lips or
teeth. Remove the device immediately if the patient begins gagging as you slide it between the
tongue and the back of the throat.
9. Ventilate the patient.
Use the following alternate method to insert an oral airway:
1. Place the patient on her back. Position yourself at the patient's head.
2. Open the patient's airway.
3. Select the correct-size oral airway.
4. Open the patient's mouth. Suction any secretions from the patient's mouth, if present.
5. Use a tongue blade to press the tongue down.
6. Insert the oral airway with the tip following the base of the tongue.
7. Advance the device until the flange rests on the patient's lips or teeth.
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8. Remove the oral airway immediately if the patient begins gagging as you slide it between the
tongue and the back of the throat.
9. Ventilate the patient.
Special Considerations
An oral airway should not be used in a patient who has a gag reflex. If you try to use an OPA in a patient
with a gag reflex, he may vomit and aspirate the vomitus into his lungs. Use of an oral airway does not
eliminate the need for maintaining proper head position.
Nasopharyngeal Airway
A nasal airway is a soft, rubbery tube with a hole in it that is placed in the patient's nose. A nasal airway
is also called a nasopharyngeal airway (NPA) or trumpet airway. The NPA allows air to flow from the hole
in the NPA down into the lower airway. To select an NPA of proper size, hold the NPA against the side of
the patient's face. Select an airway that extends from the tip of the patient's nose to his earlobe. When
an NPA of the proper size is correctly positioned, the tip rests in the back of the throat. This positioning
helps keep the tongue from blocking the upper airway. It can be placed in either nostril to help maintain
an open airway. Remember that the bevel of the NPA needs to be kept against the nasal septum. This
airway can be used in an unresponsive patient. A nasal airway may be useful in semi-responsive patients
who have a gag reflex.
Special Considerations
Use of a nasal airway does not eliminate the need for maintaining proper head position. If the airway
cannot be inserted into one nostril, try the other nostril. A nasal airway should be inserted gently into
the nose along the "floor" of the nasal cavity. Do not try to insert the nasal airway up the nose along the
"roof' of the nasal cavity.
Forceful insertion of a-nasal airway may cause cuts or tears of the delicate mucous membranes of the
nose. In some cases this can result in significant bleeding that may not be controlled by direct pressure.
If the nasal airway is too long, it may enter the esophagus. This can cause gastric distention and
inadequate ventilation. A nasal airway does not prevent aspiration. This means that although a nasal
airway may be properly positioned, it is still possible for blood, vomitus, or other secretions to enter the
patient's lungs if they are not quickly removed with suctioning.
A nasal airway should not be used in situations involving trauma to the middle of the face or those in
which a skull fracture is suspected (blood or clear fluid coming from the nose or ears).
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Sizing and Inserting a Nasal Airway
1. Place the patient on his back. Position yourself at
the patient's head.
2. Open the patient's airway.
3. Choose the proper-size nasal airway.
4. To select an airway adjunct of proper size, hold
the nasal airway against the side of the patient's
face. Select an airway that extends from the tip of
the patient's nose to his earlobe.
5. Lubricate the outside of the nasal airway with a
water-soluble lubricant.
6. Gently push the tip of the patient's nose back
slightly.
7. Gently insert the nasal airway with the bevel pointing toward the nasal septum. During insertion,
do not direct the airway upward. Do not force the device into position. Serious bleeding that is
hard to control can result.
8. Stop advancing the NPA when the bevel of the device is flush against the opening of the nostril.
9. Assess placement by feeling for air coming-from the device.
Positive-Pressure Ventilation
After ensuring that your patient has an open and adequate airway, you must assess breathing. If your
patient's breathing is inadequate or absent, you will need to begin breathing for him immediately. When
a patient is not breathing, he has only the oxygen-rich blood remaining in her lungs and bloodstream to
survive on. You can assist breathing by forcing air into the patient's lungs. This action is called positivepressure ventilation.
There are-differences between normal ventilation and positive-pressure ventilation. During normal
ventilation, negative pressure is created inside the chest and air is sucked into the lungs. During positivepressure ventilation, a healthcare professional is pushing air into the patient's lungs. During normal
ventilation, blood returns to the heart from the body and blood is pulled back to the heart. During
positive-pressure ventilation, blood return to the heart is decreased when the lungs are inflated. As a
result, less blood is available for the heart to pump, and the amount of blood pumped out of the heart is
reduced. During normal ventilation, the esophagus remains closed and no air enters the stomach.
During positive-pressure ventilation, air is pushed into the stomach during ventilation. Excess air in the
stomach (gastric distention) may lead to vomiting and subsequent aspiration. If enough air builds up in
the patient's stomach to push on the lungs and diaphragm, effective breathing can be compromised.
When delivering positive-pressure ventilation, avoid using too much volume. Use only enough volume to
cause a gentle chest rise. An excessive rate or depth of positive-pressure ventilation can harm the
patient. For example, ventilating too fast or too deep may cause low blood pressure, vomiting, and
decreased blood flow when the chest is compressed during CPR.
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Applying Cricoid Pressure
The routine use of cricoid pressure in cardiac arrest is not
recommended. Cricoid pressure is a technique of applying pressure
to the victim’s cricoid cartilage to push the trachea posteriorly and
compress the esophagus against the cervical vertebrae. Cricoid
pressure can prevent gastric inflation and reduce the risk of
regurgitation and aspiration during bag-mask ventilation, but it may
also impede ventilation. Studies show that cricoid pressure can delay
or prevent the placement of an advanced airway and that some
aspiration can still occur despite application of cricoid pressure. In
addition, it is difficult to appropriately train rescuers in use of the maneuver. Therefore, the routine use
of cricoid pressure in cardiac arrest is not recommended.
Summary of BLS Airway Maneuvers and Ventilation Rates
Adult
Adolescent and older
Maneuver
Airway
Infant/Child
1 month to adolescent
Neonate
Newborn to 1 month
Head tilt – chin lift (use jaw thrust for suspected trauma)
Breathing Initial
Rescue breathing without
chest compressions
2 breaths at 1
sec/breath
10 to 12 breaths/min
2 effective breaths at 1 sec/breath
12 to 20 breaths/min
40 to 60 breaths/min
Bag-Mask Ventilation
A bag-mask (BM) device is a self-inflating bag with a one-way valve and mask used for bag-mask
ventilation (using a self-inflating bag to force air into a patient's lungs). Most are equipped with an
oxygen reservoir. The one-way valve on the BM prevents the patient's exhaled air from reentering the
bag. The reservoir is an oxygen collector, allowing the delivery of a higher concentration of oxygen to
the patient. A see-through mask with an air-filled cuff is attached to the bag. The see-through mask
allows you to notice blood, vomit, or other secretions in the patient's mouth. The mask on most BMs has
an inflatable cushion. A syringe is used to increase or decrease the amount of air in the cushion.
Adjusting the amount of air in the cushion is important. Too much air in the cushion will not allow a tight
seal between the patient's face and the mask. Inflate the cushion with air so that it is flexible enough to
make a tight seal over the patient's mouth and nose. This will limit the amount of room air that enters or
oxygen that escapes from the mask.
It is important to select a mask of the proper size. A properly sized mask extends from the bridge of the
patient's nose to the groove between his lower lip and chin. If a mask of the proper size is not used, air
will leak from between the mask and the patient's face. This will result in less oxygen being delivered to
the patient.
BM devices are available in adult, child, and infant sizes. Most adult BM devices can hold a volume of
about 1,600 mL. BM devices used in the field today are disposable, and many come equipped with a
built-in oxygen reservoir. When connected to oxygen, the reservoir collects a volume of 100% oxygen
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equal to the capacity of the bag. When the bag is squeezed, oxygen is delivered to the patient. When
pressure on the bag is released, the bag expands and refills with oxygen.
A BM that is used during artificial ventilation should not have a pop-off (pressure-release) valve, or if a
pop-off valve is present, it should be one that can be manually disabled during resuscitation. To disable
a pop-off valve, depress the valve with a finger during ventilation or twist the pop-off valve into the
closed position. Failure to disable a pop-off valve may result in inadequate artificial ventilation.
Ventilating with a Bag-Mask Device
Ventilation performed with a BM device is often referred to as bagging. Although BM ventilation can be
done using one person, it is best performed with two rescuers. It is not easy for one person to maintain
the proper position of the patient's head, make sure the mask is sealed tightly on the patient's face, and
compress the bag at the same time. When two people are available, one takes responsibility for
compressing the bag. The other is responsible for maintaining the patient's head in the proper position
and making sure the mask is sealed tightly on the patient's face.
One of the advantages of ventilating a patient with a BM device is the ability to feel the compliance of
the patient's lungs. Compliance refers to the ability of the patient's lung tissue to distend (inflate) with
ventilation. A patient who has healthy lungs requires relatively little pressure with the BM device (or
other device used to deliver positive-pressure ventilation) to inflate the lungs. However, some diseases
and injuries can cause changes in the patient's lung compliance. Compliance is considered good if the
patient's lung inflate easily with positive-pressure ventilation. Poor compliance refers to increased
resistance met when attempting to ventilate the lungs. When delivering positive-pressure ventilation, it
is important to notice if there is a change in the ease with which you can ventilate the patient. For
example, if it was initially easy to ventilate a patient with a BM but you now notice that it is becoming
increasingly difficult to ventilate her, the patient's condition is changing. You will need to reassess the
patient and search for the cause of this change.
Although a BM device can be used to assist ventilations in a patient with inadequate breathing, it is
more commonly used to ventilate a nonbreathing patient. When a BM device is not connected to
supplemental oxygen, 21% oxygen (room air) is delivered to the patient. If a BM device is connected to
supplemental oxygen set at a flow rate of 15 L/min but no reservoir is used, about 40% to 60% oxygen
can be delivered to the patient, provided there is a good face-to-mask seal . If the BM device is
connected to supplemental oxygen at a flow rate of 15 L/min and a reservoir is present on the bag,
about 90% to 100% oxygen can be delivered to the patient, provided there is a good face-to-mask seal.
Steps in using a BM device by yourself to ventilate a nonbreathing patient:
1. Connect the bag to the mask.
2. Place the patient on his back. Open his airway with a head tilt—chin lift maneuver. If trauma is
suspected, use the jaw thrust maneuver to open the airway. Size and insert an oral or nasal
airway.
3. Position the narrow portion of the mask over the bridge of the patient's nose. Position the wide
portion of the mask between the patient's lower lip and chin. Lower the mask over the patient's
nose and mouth.
4. Create a face-to-mask seal by forming a C around the ventilation port with your thumb and
index finger. Place the third, fourth, and fifth fingers of the same hand along the bony portion of
the lower jaw, avoiding the soft tissue area. (These fingers form an E.) If no injury to the head or
spine is suspected, lift up slightly on the jaw with these fingers, bringing the patient's jaw up to
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the mask as you tilt his head backward. If injury to the head or spine is suspected, do not tilt the
patient's head backward. Instead, bring the patient's jaw up to the mask without moving the
head or neck.
5. With your other hand, squeeze the bag until you see a gentle chest rise. Deliver each ventilation
over 1 second. Watch for a gentle rise and fall of the patient's chest with each ventilation. Stop
ventilation when you see a gentle chest rise. Allow the patient to exhale between breaths.
6. Ventilate at an age-appropriate rate: once every 3 to 5 seconds for an infant or child and once
every 5 to 6 seconds for an adult.
7. When possible, connect the bag to oxygen at a flow rate of 15 L/min and attach the reservoir.
Creating a face-to-mask seal by using your fingers to form a C and an E is only one of many acceptable
methods of performing this skill.
King LT Airway Overview
The King LT airway is a disposable, supraglottic
airway designed for superior positive pressure
ventilation. Two versions of the King LT airway are
utilized in the CSEMS Council region. The King LT-D,
available in pediatric and adult sizes, is a disposable,
supraglottic airway created as an alternative to
tracheal intubation or mask ventilation. The King LTD is designed for positive pressure ventilation as well
as for spontaneously breathing patients, thereby
allowing maximum versatility as an airway
management tool. The King LT-D consistently
achieves a ventilatory seal of 30 cm H2O or higher. It
is easy to insert and results in minimal airway
trauma. The King LT-D is 100% latex free and is
provided sterile for single patient use.
The King LTS-D, much like the King LT-D, is designed
for positive pressure ventilation over 30 cm H2O and
spontaneously breathing patients, yet offers the
unique ability to easily pass a gastric tube through a
second channel of the airway and into the esophagus
and stomach [Levels INT, PM only]. The
anatomically shaped distal tip and cuff, also exclusive
to the King LTS-D, assist in the airway’s passage behind the larynx and into the normally collapsed
esophagus.
The second lumen of the King LTS-D, which is open at the distal tip of the tube, provides three key
additional benefits:
 Passage of gastric tube up to 18 French [Levels INT, PM only].
 Channel for regurgitation, which significantly reduces potential for regurgitation to get past the
cuff and therefore aids in reducing the chance for aspiration.
 Provides “vent” for gastric pressure and stomach decompression.
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Exhaled CO2 Detection
Physiologically, carbon dioxide is produced in the tissues and diffuses into the venous blood which
reaches the right side of the heart and reaches the lungs via pulmonary circulation. In the lungs, oxygen
enters the blood and carbon dioxide is given out and eliminated during expiration.
The measurement of C02 in the expired air directly indicates changes in the elimination of C02 from the
lungs. Indirectly, it indicates changes in the production of C02 at the tissue level and in the delivery of
C02 to the lungs by the circulatory system. Therefore, capnography constitutes an important noninvasive technique that can monitor C02 production, pulmonary perfusion and alveolar ventilation as
well as respiratory patterns.
The exhaled CO2 (end-tidal CO2, EtCO2) is detected and measured by various devices – colorimetry,
capnometry, and capnography. When CO2 is absent, as measured by these devices, it means either the
advanced airway is in a wrong position or there is an absent or decreased presentation of CO2 to the
lungs as in a cardiac arrest. When cardiac output increases (e.g. after
resuscitation), EtCO2 provides information about adequacy of ventilation
and circulation.
The colorimetric end-tidal CO2 detector is a pH-sensitive chemical
indicator that is enclosed in a plastic housing and is connected to the gas
stream between the advanced airway and the bag-valve-mask. The pH
sensitive indicator changes color when exposed to C02. The color varies
between expiration and inspiration, as the C02 level increases or
decreases. The color changes from purple (when exposed to room air or
oxygen) to yellow (when exposed to 4% C02). The response time of the
device is sufficiently fast to detect changes of C02 breath-by breath.
However, this device is not very sensitive when CO2 output is low as it is during CPR. The Easy Cap II is an
example of such pH sensitive indicator devices.
False negative results may occur even with correct advanced airway placement in patients in cardiac
arrest, in whom sufficient CO2 may not be present in the lungs. Color change is possible in the device
due to agents other than exhaled carbon dioxide (false positive results). Gastric contents, mucus, and
drugs such as epinephrine can cause false positive results.
Capnography
EMTs are authorized to use waveform capnography to
confirm King airway placement. EMTs who have
received device-specific training from their EMS
agency may use waveform capnography ONLY for King
airway placement confirmation. Capnography should
not be used by EMTs for other conditions such as
respiratory emergencies. When using a capnography
device, the EMT shall use only the numeric ETCO2
value to confirm the presence of CO2.
Capnography offers a quantitative numerical reading
and graphic waveform that measures, illustrates and
documents your patient’s exhaled carbon dioxide
Definitions
 Capnography – The measurement of
carbon dioxide in exhaled breath.
 Waveform capnography – Graphical
display of the exhaled CO2.
 Capnometry – Numeric measurement of
exhaled CO2.
 Colorimetry – Uses a color change assay
to measure exhaled CO2. An EasyCap
detector is an example of colorimetry.
 End tidal CO2 – The level of carbon
dioxide released at end of expiration.
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(CO2). All living human beings produce CO2 as a byproduct of metabolism. The carbon dioxide, once
produced, is diffused into the blood and transported to the lungs via the circulatory system. It’s then
released by the alveoli and eliminated from the body during exhalation. Therefore, capnography
enables evaluation the current status of a patient’s
ventilatory, circulatory and metabolic systems by measuring the exhaled CO2 and graphically depicting
its path of exhalation.
By protocol, EMTs are to use on the numeric value provided by the machine to confirm King airway
placement. The numeric readings are derived from a point in the respiratory cycle known as end-tidal
CO2. This is the point at the end of exhalation when the CO2 reaches its highest concentration. This
concentration is generally in the range of 35–45 mmHg. The detection of CO2 on expiration is a
completely objective confirmation of tracheal intubation. Note that values may be less than 10 in a
cardiac arrest situation. EMTs should not use capnography for any other applications.
Documentation
A PPCR and/or other approved patient care report shall be completed in compliance with standard
documentation procedures. The following pertinent information should be included on the patient care
report:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
Chief complaint
SAMPLE history
Assessment findings
Treatment
Method of preoxygenation.
Baseline breath sounds.
Number of insertion attempts.
Suctioning, if required.
Confirmation of placement by physical exam and colorimetric EtCO2 detection.
Complications - broken teeth, aspiration of emesis, etc.
Physician signature
Any time you perform an invasive procedure you must get the signature of the medical practitioner who
assumes responsibility for the patient. The signature is to be included on the prehospital patient care
report for the incident. Any incident when a medication is administered, or self-administration is
assisted (excluding oxygen), or an invasive procedure is performed, requires the signature of the medical
practitioner. The medical practitioner signature documents that the physician has been notified of the
medications administered and procedures performed by the EMS personnel. The signature does not
infer that the medical practitioner approves, authorizes or verifies compliance with protocol, standing
orders or medical control orders.
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Local Protocol Excerpts
 Protocol 5.12 – KING LARYNGOTRACHEAL AIRWAY
 Protocol 5.5 – END-TIDAL CO2 DETECTION / MONITORING,
CAPNOGRAPHY
 Protocol 5.6 – END-TIDAL CO2 DETECTION, COLORIMETRIC
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KING LARYNGOTRACHEAL AIRWAY
Protocol 5.12
Scope
LT-D and LTS-D models
EMR
EMT
AEMT
INT
INDICATIONS
The King LT Airway is an airway device designed
for emergency or difficult intubation in the apneic
or unresponsive patient without a gag reflex.
CONTRAINDICATIONS
1. Responsive patients with an intact gag reflex.
2. Patients with known esophageal disease.
3. Patients who have ingested caustic
substances.
4. Dextrose, naloxone or glucagon to be
administered to the patient (precaution only).
WARNINGS
1. The KING LT airway does not protect the
airway from the effects of regurgitation and
aspiration.
2. High airway pressures may divert gas either to
the stomach or to the atmosphere.
3. Intubation of the trachea cannot be ruled out
as a potential complication of the insertion of
the KING LT airway.
4. After placement, perform standard checks for
breath sounds and utilize an appropriate
carbon dioxide monitor as required by protocol.
5. Lubricate only the posterior surface of the KING LT airway to avoid blockage of the ventilation
apertures or aspiration of the lubricant.
6. The KING LT airway is not intended for re-use.
PROCEDURE – INSERTION (LTS-D & LT-D models)
1. Using the information provided, choose the correct KING LT airway size based on patient height.
Table 5-x: King LT Airway Sizes
Type
Size
LT-D
2
LT-D
2.5
LTS-D
3
LTS-D
4
LTS-D
5
Description
35-45 inches
12-25 kg
41-51 inches
25-35 kg
4-5 feet
(122-155 cm) in height
5-6 feet
(155-180 cm) in height
greater than 6 feet
(180 cm) in height
Connector
Color
OD
ID
Inflation
Volume
Green
11 mm
7.5 mm
25-35 mL
Orange
11 mm
7.5 mm
30-40 mL
Yellow
14 mm
10 mm
45-60 mL
Red
14 mm
10 mm
60-80 mL
Purple
14 mm
10 mm
70-90 mL
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PM
KING LARYNGOTRACHEAL AIRWAY
LT-D and LTS-D models
Scope
Protocol 5.12
EMR
EMT
AEMT
INT
PM
2. Test cuff inflation system by injecting the maximum recommended volume of air into the cuffs (size 3
– 60 ml; size 4 – 80 ml; size 5 – 90 ml). Remove all air from both cuffs prior to insertion.
3. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the tube, taking care to
avoid introduction of lubricant in or near the ventilatory openings.
4. Pre-oxygenate.
5. Position the head. The ideal head position for insertion of
the KING LTS-D is the "sniffing position". However, the
angle and shortness of the tube also allows it to be
inserted with the head in a neutral position.
6. Hold the KING LT airway at the connector with dominant
hand. With non-dominant hand, hold mouth open and
apply chin lift.
7. With the KING LT airway rotated laterally 45-90º such that
the blue orientation line is touching the corner of the mouth, introduce tip into mouth and advance
behind base of tongue. Never force the tube into position.
8. As tube tip passes under tongue, rotate tube back to midline (blue orientation line faces chin).
9. Without exerting excessive force, advance KING LT airway until
proximal opening of gastric access lumen (LTS-D model) or the
base of connector (LT-D model) is aligned with teeth or gums.
10. Inflate cuffs with the minimum volume necessary to seal the airway
at the peak ventilatory pressure employed (just seal volume).
Typical inflation volumes are as follows:
a. Size 2 – 25-35 mL
b. Size 2.5 – 30-40 mL
c.
Size 3 – 45-60 mL
d. Size 4 – 60-80 mL
e. Size 5 – 70-90 mL
If necessary, add additional volume to cuffs to maximize seal
of the airway.
11. Attach the bag-valve-mask the 15 mm connector of the KING LT
airway. While gently bagging the patient to assess ventilation,
simultaneously withdraw the airway until ventilation is easy and
free flowing (large tidal volume with minimal airway pressure).
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KING LARYNGOTRACHEAL AIRWAY
LT-D and LTS-D models
Scope
Protocol 5.12
EMR
EMT
AEMT
INT
PM
12. Depth markings are provided at the proximal end of the KING LT airway which refer to the distance
from the distal ventilatory openings. When properly placed with the distal tip and cuff in the upper
esophagus and the ventilatory openings aligned with the opening to the larynx, the depth markings
give an indication of the distance, in cm, from the vocal cords to the upper teeth.
13. Deliver several breaths with the bag-valve-mask and confirm proper tube placement as follows:
a. Auscultate over the epigastrium.
b. Auscultate the chest bilaterally at the apices and the bases for the presence of equal,
bilateral lung sounds.
c.
Observe for symmetrical chest rise and fall with each breath.
d. Look for moisture condensation in the tube with an exhaled breath.
e. Observe patient for clinical improvement (i.e., pulse oximetry, skin condition).
14. Confirm proper tube placement with a CO2 detection device:
a. END-TIDAL CO2 DETECTION / MONITORING, CAPNOGRAPHY
b. END-TIDAL CO2 DETECTION, COLORIMETRIC
15. Ventilate the patient with the bag-valve-mask supplied with 100% oxygen as indicated.
a. During CPR: Deliver 6 breaths per minute. Deliver each breath over about 1 second while
chest compressions are delivered at a rate of 100 per minute, and do not attempt to
synchronize the compressions with the ventilations.
b. Patients with a perfusing rhythm: Deliver approximately 10 to 12 breaths per minute (1
breath every 5 to 6 seconds). Deliver these breaths over 1 second.
16. Secure the KING LT airway in place with a commercial device while continuing ventilatory support.
17. Re-confirm airway placement after the device is secured, after every patient movement and at regular
intervals. Application of a cervical collar and immobilization device will help prevent the patient from
moving in such a way as to dislodge the KING LT airway.
KING LTS-D MODEL NOTES
1. DO NOT COVER THE PROXIMAL OPENING OF THE GASTRIC ACCESS LUMEN.
2. The gastric access lumen allows the insertion of up to an 18 French diameter gastric tube into the
esophagus and stomach.
PROCEDURE – REMOVAL
1. Once it is in the correct position, the KING LT airway is well tolerated until the return of protective
reflexes.
2. Ensure suctioning equipment is ready.
3. Deflate both cuffs completely. Turn the patient onto side.
4. Remove the King LT airway carefully, suctioning as needed.
5. Insert an oropharyngeal or nasopharyngeal airway as needed.
6. Continue ventilations with a BVM and oxygen at 10-15 LPM as needed.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
48
User Tips
1. The key to insertion is to get the distal tip of the King airway around the corner in the posterior
pharynx, under the base of the tongue. Experience has indicated that a lateral approach, in
conjunction with a chin lift, facilitates placement of the King airway. Alternatively, a tongue
depressor can be used to lift the tongue anteriorly to allow easy advancement of the King airway
into position.
2. Insertion can also be accomplished via a midline approach by applying a chin lift and sliding the
distal tip along the palate and into position in the hypopharynx. In this instance, head extension may
also be helpful.
3. As the King airway is advanced around the corner in the posterior pharynx, 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
into the pyriform fossa and the tube will appear to bounce back upon full insertion and release.
Keeping the tip at the midline assures that the distal tip is properly placed in the hypopharynx/upper
esophagus.
4. Depth of insertion is key to providing a patent airway. Ventilatory openings of the King airway must
align with the laryngeal inlet for adequate oxygenation/ventilation to occur. Accordingly, the
insertion depth should be adjusted to maximize ventilation. Experience has indicated that initially
placing the King airway deeper (base of connector is aligned with teeth or gums), inflating the cuffs
and withdrawing until ventilation is optimized results in the best depth of insertion for the following
reasons:
a. It ensures that the distal tip has not been placed laterally in the pyriform fossa (see item #3
above).
b. With a deeper initial insertion, only withdrawal of the tube is required to realize a patent
airway. A shallow insertion will require deflation of the cuffs to advance the tube farther
(several added steps).
c. As the King airway is withdrawn, the initial ventilation opening exposed to/aligned with the
laryngeal inlet is the proximal opening. Since this proximal opening is closest to and is
partially surrounded by the proximal cuff, airway obstruction is less likely, especially when
spontaneous ventilation is employed.
d. Withdrawal of the King airway with the balloons inflated results in a retraction of tissue away
from the laryngeal inlet, thereby encouraging a patent airway.
5. When the patient is allowed to breathe spontaneously, airway obstruction can occur even though no
obstruction was detected during assisted or positive pressure ventilation. During spontaneous
ventilation, the epiglottis or other tissue can be drawn into the distal ventilatory opening, resulting
in obstruction. Advancing the King airway 1-2 cm or initial deeper placement (see item #4 above)
normally eliminates this obstruction.
KEY POINTS!



Thoroughly lubricate the posterior aspect of the airway. Inadequate lubrication will
cause insertion problems.
Be generous with the amount of air used to inflate the cuffs. It may take more than
the recommended volume to seat the airway and make a good seal.
Be careful to insert the airway with the distal or lower end directed down the midline
of the patient’s airway.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
49
END-TIDAL CO2 DETECTION / MONITORING, CAPNOGRAPHY
Scope
EMR
Protocol 5.5
EMT
AEMT
INT
PM
INDICATIONS
1. Primary confirmation, monitoring and documentation of endotracheal intubation [REQUIRED]
2. Primary confirmation, monitoring and documentation of King LT insertion.
3. Assessment, monitoring and documentation of the respiratory status of the non-intubated patient
experiencing respiratory distress including but not limited to asthma and COPD.
PROCEDURE – INTUBATED PATIENTS (Includes King airways)
1. Turn cardiac defibrillator/monitor ON. If CO2 is not already displayed, select display to monitor the
CO2 waveform.
2. Attach the sampling line to the monitor in accordance with manufacturer recommendations.
3. Attach the sampling line to the patient.
4. Observe the waveform and the ETCO2 values.
5. ETCO2 numerical values and corresponding capnograph should be compared to normal values and
morphology (Figure 5.7A).
Normal ETCO2 Values
35 – 45 mmHg
Waveform Labels
A
End of inhalation
B
Beginning of exhalation
B–D
Exhalation of alveolar gas
D
End exhalation and point
of maximal or highest CO2
concentration (end-tidal
CO2)
D–E
Inhalation
Figure 5.7A The Normal CO2 Waveform
PROCEDURE – NON-INTUBATED PATIENTS
1. Patients should be assessed, oxygenated and ventilated with the appropriate delivery device
dependant upon their presenting degree of respiratory distress or obstruction.
2. Interface the end-tidal CO2 sampling device with the oxygen delivery device being used (i.e., nasal
sampling device used under a non-rebreather mask, ETCO2/O2 nasal cannula used on a patient
requiring less than or equal to 6 LPM).
3. Observe for a waveform and numerical values to appear during exhalation after a total of 6 breaths.
4. ETCO2 numerical values and corresponding capnograph should be compared to normal values and
morphology (Figure 5.7A).
NOTE: ETCO2 monitoring should be discontinued while administering nebulized medications.
5. ETCO2 numerical values and capnographs should be monitored following medication administration
to determine the patient’s response to the intervention and the need for additional intervention.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
50
END-TIDAL CO2 DETECTION / MONITORING, CAPNOGRAPHY
Scope
EMR
EMT
Protocol 5.5
AEMT
INT
PM
CONSIDERATIONS
1. Capnography is only an adjunct to careful patient assessment.
2. Do not use capnography as the sole method of assessing correct tube placement, especially in the
pulseless patient.
3. Capnography may not indicate right mainstem bronchus intubation or pyriform placement.
4. [EMT] EMTs who have received device-specific training from the EMS agency may use waveform
capnography ONLY for King airway placement confirmation. When using the device, the EMT shall
use only the numeric ETCO2 value to confirm the presence of CO2.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
51
END-TIDAL CO2 DETECTION, COLORIMETRIC
Scope
EMR
Protocol 5.6
EMT
AEMT
INT
PM
INDICATION
Use of Easy Cap II and Pedi-Cap end-tidal CO2 (ETCO2) detectors is indicated for all patients that
have been intubated with a King LT airway.


Adult ETCO2 detector – patient weighing greater than 15 kg.
Pediatric ETCO2 detector – patient weighing less than or equal to 15 kg.
NOTE: END-TIDAL CO2 DETECTION / MONITORING, CAPNOGRAPHY is required for endotracheal
intubation.
PRECAUTIONS
1. False-negative readings may be present during cardiac arrest because blood flow and delivery of CO2
to the lungs is low.
2. False-negative results have also been reported in association with pulmonary embolus because
pulmonary blood flow and carbon dioxide delivery to the lungs are reduced.
3. Detector contamination with gastric contents or acidic drugs may cause the detector to display a
constant color rather than breath-to-breath color change.
4. Elimination and detection of CO2 can be drastically reduced following an intravenous bolus of
epinephrine or with severe airway obstruction (e.g., status asthmaticus) and pulmonary edema.
PROCEDURE
1. Confirm tube placement via physical exam as outlined in the KING LT AIRWAY protocol.
2. Open the package and inspect detector for purple color and dryness.
3. Attach the detector between the bag-valve-mask and the airway. Keep detector clean and dry.
4. Resume ventilations at the appropriate rate. Do not use continuous hyperventilation.
5. Observe detector for color changes after 6 full breaths. Follow recommended clinical actions as
indicated in Table 5.8A and Table 5.8B.
Table 5.8A. Patients with adequate perfusion / spontaneous heartbeat
COLOR RANGE “A”
(Purple)
COLOR RANGE “B”
(Tan)
COLOR RANGE “C”
(Yellow)
0.03 to less than 0.5 % ETCO2
less than 4 mmHg

Airway not properly positioned

Reinsert tube

Recheck with CO2 detector
0.5 to less than 2 % ETCO2
4 to less than 15 mmHg

Retained CO2 in esophagus
or low perfusion or hypocarbia

Deliver 6 more breaths

Color remains tan

Airway properly positioned
with low perfusion or
hypocarbia
2 to 5 % ETCO2
15 to 38 mmHg

Airway properly positioned

Secure tube

Continue to observe color
change
CONTINUED ON NEXT PAGE
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
52
END-TIDAL CO2 DETECTION, COLORIMETRIC
Scope
EMR
Protocol 5.6
EMT
AEMT
INT
PM
Table 5.8B. Patients with Poor Perfusion / Cardiac Arrest
COLOR RANGE “A”
(Purple)
COLOR RANGE “B”
(Tan)
COLOR RANGE “C”
(Yellow)
0.03 to less than 0.5 % ETCO2
less than 4 mmHg

Airway not properly positioned
or inadequate perfusion
(ineffective CPR)

Is ET tube through
vocal cords or King ventilating
properly?
Check ET via direct
laryngoscopy
0.5 to less than 2 % ETCO2
4 to less than 15 mmHg

Retained CO2 in esophagus
or low perfusion

Deliver 6 more breaths

Color remains tan

Airway properly positioned
with low perfusion
2 to 5 % ETCO2
15 to 38 mmHg

Airway properly positioned

Secure tube

Continue to observe color
change
No
Airway not
properly
positioned

Reinsert tube

Check with
CO2 detector
Yes
Airway
properly
positioned
with
inadequate
perfusion

Take
appropriate
clinical action
CONSIDERATIONS
1. End-tidal CO2 detectors are only an adjunct to careful patient assessment.
2. Do not use detectors as the sole method of assessing correct tube placement, especially in the
pulseless patient.
3. Keep detector clean and dry.
4. If detector is not purple when removed from the package, discard the detector.
5. Adult detectors have a larger dead air space. This larger space may cause rebreathing of CO2 by
patients who weigh less than 15 kg and a potential inaccurate reading.
6. Detectors may be used for up to 2 hours.
7. Waveform capnography is required for endotracheal intubation. Colorimetric monitoring may be used
temporarily while troubleshooting issues with capnography.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
53
Module 3 – Diabetic Emergencies
Overview
Diabetes is a disease in which the body does not produce or properly use insulin. Insulin is a hormone
that is needed to convert sugar, starches and other food into energy needed for daily life. The cause of
diabetes continues to be a mystery, although both genetics and environmental factors such as obesity
and lack of exercise appear to play roles.
There are 20.8 million children and adults in the United States, or 7% of the population, who have
diabetes. While an estimated 14.6 million have been diagnosed with diabetes, unfortunately, 6.2 million
people (or nearly one-third) are unaware that they have the disease.
Local Protocol
Glucagon is stocked or made available depending on the state licensure level of the EMS agency.
Advanced life support licensed EMS agencies carry a Shock Trauma drug box, a Cardiac drug box, or
both. EMTs trained to administer glucagon are permitted to access these drug boxes to obtain the
glucagon. Once the box is open, the AIC is responsible for the contents of the drug box and is
responsible to ensure the drug box is exchanged or properly restocked at the local hospital.
Basic life support agencies that desire to purchase glucagon because they do not possess drug boxes
need to obtain a Controlled Substance Registration (CSR) certificate from the Virginia Board of Pharmacy
(BOP).
If your agency would like to obtain a CSR, it needs to submit an application to the BOP, pay a fee and
comply with requirements for maintaining a stock of drugs. Such requirements may be found in the
current BOP regulations in Part XVI Controlled Substances Registration for Other Persons or Entities. The
regulations may be found on the Board's website at http://www.dhp.virginia.gov/pharmacy/. Before
issuing the CSR, an inspection would be conducted to determine compliance with physical requirements
for proper storage of prescription drugs. Drugs may not be ordered or stored until such inspection is
conducted and approval is given.
Here are a few areas to assure compliance with the BOP regulations if you choose to obtain a CSR:
1. The stock of drugs must be kept in a central location which will be inspected. This location must
be temperature controlled, locked with access to only authorized individuals. Should there not
be personnel at this central storage location on a twenty-four hour basis, the storage area must
be alarmed. Localities that have CSR permits with restocking supplies located at the various
individual stations are required to have a CSR permit for each of the locations.
2. The EMS agency must have written policies and procedures in place as outlined by the BOP
regulations. These policies must follow the outline as defined in the current inspection form.
3. If an EMS agency wishes to order and stock any Schedule II-V medications (narcotics and such),
it must also have a DEA registration showing the address of the storage location. The CSR alone
does not cover these schedules of drugs.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
54
EMS agencies in the CSEMS Council region stock oral glucose on the EMS units. Oral glucose is available
over-the-counter at drug stores.
Blood Glucose Meters (EMR Level Only)
Blood glucose meters are used as an adjunct to the physical exam to help guide treatment in diabetics
and patients with altered mental status. During local protocol training, agency glucometers are used so
the provider is familiar with the agency-specific glucometer.
Glucagon
Glucagon is a hormone that raises the level of glucose in the blood. Administration of glucagon by
injection counteracts severe hypoglycemia that causes loss of consciousness when oral glucose cannot
be given. The glucagon should be stored at temperatures between 59-86° F (15-30° C).
Glucagon must be injected. These steps outline the basics on how to give a glucagon injection.
1. Obtain the glucagon bottle and the diluent vial or prefilled syringe. If you use a vial with diluent,
withdraw the diluent using a syringe and needle.
2. Insert the needle through the rubber seal disk on the glucagon vial. You may have to push hard
to puncture the seal.
3. Once the needle is in, push the plunger down to inject all the liquid from the syringe into the
glucagon vial.
4. With the syringe still in place, gently shake the bottle until the powder in the bottle is dissolved
completely.
5. Make sure the plunger is down all the way and then pull it out slowly until the solution is drawn
up into the syringe.
6. Cleanse injection site with alcohol prep.
7. Insert the needle into the skin (buttock, thigh, or arm). Push the plunger all the way down.
8. Glucagon can cause severe nausea. Position the person on their side in case they vomit before
regaining consciousness.
The Injection should be given in a large muscle, such as the thigh or the arm. The needle on the syringe
is usually larger than those on insulin syringes. Glucagon can cause vomiting. Be alert in the event
airway management is required.
Documentation
A PPCR and/or other approved patient care report shall be completed in compliance with standard
documentation procedures. The following pertinent information should be included on the patient care
report
1. Chief complaint
2. SAMPLE history
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
55
3.
4.
5.
6.
7.
8.
Assessment findings
Treatment
Drug dose(s) and route(s) of administration used
Effect on patient
Administration times
Physician signature
Any time you perform an invasive procedure you must get the signature of the medical practitioner who
assumes responsibility for the patient. The signature is to be included on the prehospital patient care
report for the incident. Any incident when a medication is administered, or self-administration is
assisted (excluding oxygen), or an invasive procedure is performed, requires the signature of the medical
practitioner. The medical practitioner signature documents that the physician has been notified of the
medications administered and procedures performed by the EMS personnel. The signature does not
infer that the medical practitioner approves, authorizes or verifies compliance with protocol, standing
orders or medical control orders.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
56
Local Protocol Excerpts





Protocol 4.1 – ALTERED MENTAL STATUS
Protocol 4.10 – HYPOGLYCEMIA
Protocol 4.21 – SEIZURES
Protocol 5.9 – GLUCOMETRY
Protocol 6.15 – GLUCAGON (GlucaGen)
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
57
EMR
EMT
AEMT
INT
PM
Protocol 4.1
1. Perform general patient management (SECTION 1).





2. Support life-threatening problems associated with airway, breathing, and
circulation.





3. Assess for signs of trauma. Provide spinal immobilization as necessary.





4. Administer oxygen via non-rebreather mask at 10-15 L/min. as necessary.





5. For altered mental status, perform rapid glucose determination.








MEDICAL – ALTERED MENTAL STATUS
6. Establish an INT or IV of normal saline at KVO.
7. For glucose less than 60 mg/dL, refer to the HYPOGLYCEMIA protocol.




8. For glucose greater than 300 mg/dL, refer to the HYPERGLYCEMIA protocol.












9. For a suspected narcotic overdose complicated by respiratory depression,
refer to the TOXICOLOGY – POISONING/OVERDOSE protocol.

10. Place patient on cardiac monitor.
11. Transport as soon as possible.



Key Points: ALTERED MENTAL STATUS
 The unconscious patient is one of the most difficult patient management problems in prehospital
care. Causes range from benign problems to potentially life-threatening cardiopulmonary or
central nervous system disorders. Frequently, a diabetic patient may present with an altered
mental status. This may be due to hypoglycemia or hyperglycemia. However, the patient often is
unable to give any history and the physical assessment may be inconclusive. The prehospital
goal is to maintain stable vital signs, protect the patient’s airway and C-spine, and assess for
possible causes. Get as complete a history as possible. Treat any potentially reversible cause
such as narcotic overdose or hypoglycemia.
 Possible causes of unconsciousness or altered mental status (AEIOU-TIPS):
A
E
I
O
U
T
I
P
S
Acidosis, alcohol
Epilepsy
Infection
Overdose
Uremia (kidney failure )
Trauma, tumor
Insulin
Psychosis
Stroke
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
58
EMR
EMT
AEMT
INT
PM
Protocol 4.10
1. Perform general patient management (SECTION 1).





2. Support life-threatening problems associated with airway, breathing, and
circulation.





3. Assess for signs of trauma. Provide spinal immobilization as necessary.





4. Administer oxygen via non-rebreather mask at 10-15 L/min. as necessary.





5. For altered mental status or clinical signs/symptoms suggestive of
hypoglycemia, perform rapid glucose determination.









a. Establish an IV of normal saline at KVO.



b. Patient > 2 years old: Give DEXTROSE 50% 1 g/kg up to 25 g IV.
Repeat once in 2 minutes if altered mental status persists.



c. Child < 2 years old: Give DEXTROSE 25% 1 g/kg up to 25 g IV.
Repeat once in 2 minutes if altered mental status persists.



d. Neonate (< 28 days old): Give DEXTROSE 12.5% 1 g/kg (8 mL/kg).













MEDICAL – HYPOGLYCEMIA
6. If glucose less than 60 mg/dL or clinical signs and symptoms indicate
hypoglycemia:
a. If the patient can protect airway, give ORAL GLUCOSE 15 grams.
Repeat in 15 minutes if necessary.
7. If glucose less than 60 mg/dL or clinical signs and symptoms indicate
hypoglycemia and oral glucose is contraindicated:
8. If glucose less than 60 mg/dL or clinical signs and symptoms indicate
hypoglycemia and an IV is not available, give GLUCAGON 1 mg IM.
9. For signs and symptoms of hypovolemic shock or dehydration, follow the
SHOCK – HYPOVOLEMIA protocol

10. Place on cardiac monitor.
11. Transport as soon as possible.





12. Perform reassessment as indicated.





Key Points: HYPOGLYCEMIA
 The body requires a constant supply of glucose to maintain normal function. Known
hypoglycemic patients need glucose levels restored as soon as possible to reduce brain and
other organ damage. Hypoglycemia is a life-threatening problem. The prehospital goal is to
maintain stable vital signs, protect the patient’s airway and C-spine, and assess for possible
causes. Get as complete a history as possible. Restore glucose levels as soon as possible.
Local protocol course training is required for an EMT to administer glucagon. Glucagon may
be obtained from the STT box (or CT box if STT box not available).
 Glucometer reminders:
o
o
o
Use antiseptic techniques to draw blood from a finger. Always use fresh blood.
Allow alcohol to dry completely before drawing blood.
After lancing finger, use only moderate pressure to squeeze blood out. Excessive
pressure may cause rupture of cells, skewing results.
CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
59
EMR
EMT
AEMT
INT
PM
Protocol 4.21
1. Perform general patient management (SECTION 1).





2. Support life-threatening problems associated with airway, breathing,
and circulation.





a. Suction the oro- and nasopharynx as necessary.





b. Place a nasopharyngeal airway as necessary (avoid in head
trauma).





3. Administer oxygen via non-rebreather mask at 10-15 L/min. as
necessary. Support respirations as necessary with a BVM.





4. Do not restrain the patient. Let the seizure take its course. Place a
pillow, rolled blanket or other padding material beneath the patient’s
head to prevent injury.





5. Perform rapid glucose determination. If glucose less than 60 mg/dL
or clinical signs and symptoms indicate hypoglycemia, refer to the
HYPOGLYCEMIA protocol.










a. 0.5 mg/kg up to 10 mg IN, titrated to effect.


b. 5 mg IM. Repeat dose in 5 minutes if seizure persists.




MEDICAL – SEIZURE
6. Establish an INT or IV of normal saline at KVO.
7. If the seizure persists and the rapid glucose determination is greater
than 60 mg/dL, give MIDAZOLAM 5 mg slow IV push. Repeat dose
in 5 minutes if seizure persists. Alternatively, midazolam may be
given as follows.
8. Place patient on cardiac monitor (sometime life-threatening
dysrhythmias can cause seizure-like activity).
9. Consider placing the patient in the recovery position during the
postictal period.





10. Perform reassessment as indicated.





11. Perform steps 1 through 5.





12. Place the patient on left side and transport.






For seizures due to THIRD TRIMESTER ECLAMPSIA:


14. Give MIDAZOLAM as indicated in step 7.


15. If seizure persists, give MAGNESIUM SULFATE 4 g [20% solution 20
mL] IV over 4 minutes.






13. Establish an INT or IV of normal saline at KVO.
a. Repeat dose (if available) in 5 minutes if seizure persists
[Medical Control].
16. Perform reassessment as indicated.


CSEMS Council Local Protocol Program – Training Manual (Rev. 3/1/2014)
60

Protocol 4.21 – SEIZURES
Key Points: MEDICAL – SEIZURE
 There are different presentations for seizure disorders. Most commonly, seizures are
generalized, tonic-clonic, or grand mal. These seizures may involve violent shaking of the upper
and lower extremities, urinary incontinence, and often an injury such as tongue-biting. Other
seizures may be localized to a single muscle group, or may not involve visible seizure activity at
all (i.e., partial seizure). The prehospital goal is to maintain stable vital signs, protect the patient’s
airway and c-spine, minimize trauma, and provide an accurate description of seizure activity for
the emergency physician.Maintain the airway in the best way possible.
 Many patients with seizures develop transient airway obstruction during the seizure.
 Do not insert airways or bite bars between the teeth. Doing so could possibly damage the
patient’s teeth and your fingers.
 Be alert for violent postictal behavior.
 Some patients will have a neurological deficit following a seizure. This deficit may last up to two
hours.
 A small number of patients actually suffer injury to the head or spine during the seizure. If spinal
tenderness or neurological deficit is present, assume that spinal injury has occurred and
immobilize the patient.
 Some patients fail to take antiseizure medication regularly. Some are compliant with medications
but need to have the dosage adjusted. Transport to the hospital for evaluation is recommended
for all patients who have had seizure.
 Be alert for respiratory depression following the administration of benzodiazapines.
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GLUCOMETRY
Protocol 5.9
Scope
EMR
EMT
AEMT
INT
PM
INDICATIONS
1. Patient with altered level of mental status.
2. Seizure patient.
3. Unresponsive patient.
4. Signs and symptoms of hypoglycemia or hyperglycemia.
PRECAUTIONS
1. The glucose reading may be inaccurate if not enough blood has been drawn into the test strip.
2. Inaccurate readings may result if the glucometer has not been properly maintained and tested in
accordance with manufacturer recommendations.
3. Inaccurate readings may result if code numbers on the test strips do not match those on the digital
reading.
4. Alcohol from swab may alter reading if not allowed to dry.
PROCEDURE
1. Use standard isolation precautions.
2. Wipe finger with an alcohol swab and wait for alcohol to dry.
3. Assemble and prepare the glucometer in accordance with manufacturer directions.
4. Using a lancet device, pierce patient’s finger skin.
5. Acquire the blood sample using the glucometer and wait the required time for the glucose reading.
6. Dispose of the lancet and used test strip in sharps container.
CONSIDERATIONS
1. Glucometry is considered an invasive procedure requiring the medical practitioner who assumes
responsibility for the patient sign the patient care report.
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GLUCAGON (GlucaGen)
Protocol 6.15
Scope
Generic Name:
Trade Name:
Chemical Class:
Therapeutic Class:
Actions:
Pharmacokinetics:
Indications:
Contraindications:
Precautions:
Pregnancy Cat. C
Side Effects:
Administration:
Supply:
Notes:
EMR
EMT
AEMT
INT
PM
Glucagon (gloo’ka-gon)
GlucaGen
Polypeptide hormone
Antihypoglycemic
Glucagon is a protein secreted by the  cells of the pancreas. When released, it
causes the breakdown of glycogen, stored in the liver, to glucose. It also inhibits the
synthesis of glycogen from glucose. Both actions tend to cause an increase in
circulating blood glucose. A return to consciousness following the administration of
glucagon usually takes 5 to 20 minutes. Glucagon is only effective if there are
sufficient stores of glycogen in the liver.
Onset within 15 minutes. t½ = 3 to 6 minutes.
When unable to obtain IV access and give dextrose, and
1. Altered mental status of unknown etiology (GCS less than or equal to 12).
2. Hypoglycemia (less than 60 mg/dL) based on rapid glucose determination or
clinical judgment.
3. Status epilepticus.
4. Oral hypoglycemic agent overdose.
Hypersensitivity to the drug.
Glucagon is only effective if there are sufficient stores of glycogen with the liver. In
an emergency situation, intravenous dextrose is the agent of choice.
CNS: dizziness, headache
CV: hypotension
GI: nausea, vomiting
Adult:
1 mg IM
Pediatric:
1 mg IM
Glucagon must be reconstituted before administration. It is supplied in rubberstoppered vials containing 1 mg of powder and 1 mL of diluting solution.
[EMT] Only EMTs who have completed training through a CSEMS local protocol
course are authorized to give glucagon.
Glucagon may be given to reverse effects of beta-blocker drug overdoses. A
significant dose is needed to be effective, usually 3 to 10 mg IV bolus followed by a 2
to 5 mg/h infusion).
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Module 4 – Trauma Triage
Overview
Injury is the leading cause of death for Americans aged 1–44 years. In 2004 alone, approximately
167,000 Americans died from injuries and an additional 41 million Americans sustained injuries serious
enough to require a visit to a hospital emergency department.
In addition, almost half of the 16.6 million transport calls per year that we—the approximately 1 million
EMS providers—respond to are related to injury.
CDC-supported research shows that, if you are severely injured and you are ultimately cared for at a
Level I trauma center, your risk of death is lowered by 25%. This statistic is important to remember
because, as an EMS provider, you know that getting the right patient to the right place at the right time
is critical. However, not all injuries require care at a Level I trauma center. Transporting less severely
injured patients to a lower level trauma center or non-trauma center can help ensure that resources at
Level I trauma centers are available for those patients who need them most.
Throughout most of the CSEMS region the distance to the closest trauma centers is such that direct
ground triage is not feasible. When air evacuation is not available, patients will be taken to the closest
facility for resuscitation and transfer for ultimate care at a Trauma Center. EMS should rendezvous with
a helicopter between the scene and the closest hospital.
If you have a severely injured patient and you can get them to a local hospital faster than you can get a
helicopter, transport the patient to the local hospital and send the helicopter to the hospital landing
zone. Timely notification of air medical services and the local hospitals will help to speed care and
transport.
History of the Decision Scheme
In 1976, the American College of Surgeons-Committee on Trauma developed guidelines to authenticate
trauma centers and set standards for personnel, facilities, and processes necessary for the best care of
injured persons. Studies in the 1970s and early-to-mid-1980s showed a reduction in mortality in those
regions with specialized trauma centers. These studies led to a national consensus conference in 1987
that resulted in the first ACS field triage protocol, known as the “triage decision scheme” for trauma
patients. Since 1987, this decision scheme has served as the basis for field triage for trauma patients in
most EMS systems in the United States. Since its initial publication, the decision scheme has been
revised five times: 1990, 1993, 1999, 2006 and 2012.
The Field Triage Decision Scheme
The national decision scheme was developed to assist local medical directors and EMS providers with
decisions about field triage and destination facility. It is the foundation for our field triage protocols for
trauma patients in the CSEMS region.
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The decision scheme is divided into four steps: Step 1) Physiologic criteria, Step 2) Anatomic criteria,
Step 3) Mechanism of injury criteria, and Step 4) Special patient or system considerations. At each step,
the decision scheme includes two transition boxes. One box indicates if the patient’s condition is serious
enough to require transport to a certain level of trauma care. The other box reveals that the patient’s
condition is not severe enough for trauma center attention but that transporting him or her to a hospital
for observation and/or treatment should be “according to protocol.” In essence, the decision scheme
helps you determine the gravity of the injury and the most appropriate destination facility for your
patient or it helps you move further through the decision scheme criteria.
For more than a year, your operational medical directors and the Medical Control Review Committee
worked with local hospitals, area trauma centers, EMS agencies and state officials to revise the trauma
triage plan based on the national decision scheme. The end product is the CSEMS Field Triage Decision
Scheme and trauma triage protocol. The updated plan does not represent a major change to the way we
triage patients. It does stress the importance of early notification of air medical resources and the
hospital, rapid transport and increased focus on identifying patients who will require trauma center
resources.
The decision scheme provides guidance for you to conduct more effective triage to better match your
trauma patients’ conditions with the medical facilities that are best equipped to treat them.
The trauma triage and management protocol is meant to assist EMS providers in making the critical
decisions necessary to increase the likelihood of favorable outcomes for patients. The best way to
reduce the burden of injuries is to prevent them from occurring. However, when primary prevention
fails, acute care, public health, and public safety practitioners must work
together to provide the best available and most appropriate care for the injured. Trauma systems and
trauma centers save lives. The Decision Scheme is an essential component of the trauma system, guiding
EMS providers in transporting injured patients to the most appropriate facility, ensuring proper
treatment, and thus reducing death and disability.
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Local Protocol Excerpts
 Protocol 4.30 – TRAUMA TRIAGE & MANAGEMENT
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Protocol 4.30 – TRAUMA – TRAUMA TRIAGE & MANAGEMENT
Field Trauma Triage Decision Scheme
1
YES
Take to a trauma center. Steps 1 and 2
attempt to identify the most seriously injured
patients. These patients should be
transported preferentially to the highest level
of care within the trauma system. Early
dispatch of aeromedical evacuation provider
to the scene may be the most reliable and
expedient means for attaining direct transfer
of these patients to the trauma center.
YES
Take to a trauma center. Steps 1 and 2
attempt to identify the most seriously injured
patients. These patients should be
transported preferentially to the highest level
of care within the trauma system. Early
dispatch of aeromedical evacuation provider
to the scene may be the most reliable and
expedient means for attaining direct transfer
of these patients to the trauma center.
YES
Consider transport directly to a trauma center
or contact medical control to discuss patient
disposition.
YES
Consider transport directly to a trauma center
or contact medical control to discuss patient
disposition.
Measure vital signs and level of consciousness
Glasgow Coma Scale ≤ 13 or
Systolic blood pressure < 90 mmHg [<100 for patients > 65 years] or
Respiratory rate
< 10 or > 29 breaths/minute (< 20 in infant < one year) or need for
ventilatory support
NO
Assess anatomy of injury
2
•
•
•
•
•
•
•
•
All penetrating injuries to head, neck, torso, & extremities proximal to elbow or knee
Chest wall instability or deformity (e.g., flail chest)
Two or more proximal long-bone fractures
Crushed, degloved, mangled, or pulseless extremity
Amputation proximal to wrist or ankle
Pelvic fractures or severe abdominal pain/tenderness
Open or depressed skull fracture
Paralysis
NO
Assess mechanism of injury and evidence of high-energy impact
3
Falls
• Adults: > 20 ft. (one story is equal to 10 ft.)
• Children: > 10 ft. or 2-3 times the height of the child
High-Risk Auto Crash
• Intrusion, including roof: > 12 in. occupant site; > 18 in. any site
• Ejection (partial or complete) from automobile
• Death in same passenger compartment
• Vehicle telemetry data consistent with high risk of injury
• Complex extrication by fire / rescue
Auto v. Pedestrian/Bicyclist Thrown, Run Over, or with Significant (> 20 mph) Impact
Motorcycle Crash > 20 mph
NO
Assess special patient or system considerations
4
Age
• Older Adults: Risk of injury death increases after age 55 years
• Older Adults: Low-impact mechanisms (e.g., ground-level falls) might result in severe
injury
• Children: Should be triaged preferentially to pediatric-capable trauma centers
Anticoagulation and Bleeding Disorders
• Patients with head injury are at high risk for rapid deterioration
Significant burns*
Pregnancy > 20 Weeks [Palpable uterus at or above umbilicus]
EMS Provider Judgment
NO
Transport according to protocol
When in doubt, transport to a trauma center. Injured
patients in cardiac arrest with CPR in progress should be
transported to the closest hospital.
If advanced care can be more expediently obtained at a
nearby hospital than by waiting for aeromedical flight
crews, local providers should consider requesting a
change in LZ to the nearest hospital.
* American Burn Association guidelines.
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Protocol 4.30 – TRAUMA – TRAUMA TRIAGE & MANAGEMENT
“Priority” patients are those that are critically ill as defined by the Field Trauma Triage Decision Scheme.
UN-ENTRAPPED “PRIORITY” PATIENTS
Un-entrapped priority patients shall be treated in the following manner:
1. Perform rapid extrication to remove patient from the wreckage. It is acceptable to move the patient
without immobilizing the extremities. C-spine control is to be maintained via an extrication collar and
manual control in accordance with rapid extrication techniques. Extrication techniques should
emphasize speed. Vest style immobilization devices and short backboards should not be used.
2. The following procedures are permitted before the patient is loaded in the ambulance for transport:
a. Bag-valve-mask ventilation, oropharyngeal and nasopharyngeal airways.
b. Suctioning.
c. Control of life-threatening hemorrhage.
d. C-spine control and spinal immobilization.
3. Move the patient rapidly to the ambulance. All procedures, with the exception of those listed above,
should be performed during transport, not on the scene. Brief stops are acceptable at the attendant
in charge’s discretion to facilitate lifesaving procedures.
4. The emergency communications center or on-scene command should notify the closest hospital as
early as possible. If the incident is in close proximity to the hospital, provide notification to the
hospital prior to arrival on the scene if there are reported priority patients.
5. EMS personnel are not to delay transport to wait on higher trained personnel. If ALS support is en
route for a rendezvous, do not wait on the ALS personnel.
ENTRAPPED “PRIORITY” PATIENTS
Medical care should be provided to the extent the entrapment permits. ALS personnel are to be
requested to the incident scene. If possible, helicopter support is to be summoned to the scene.
CARDIAC ARREST IN TRAUMA PATIENTS:
1. Adult and pediatric patients found dead at the scene of a trauma are not to be resuscitated unless
they are hypothermic, recently drowned, or electrocuted. BLS airway and ventilation procedures may
be attempted at the provider’s discretion. If spontaneous respiration or circulation is not detected
within one minute, resuscitative efforts should be ceased.
2. Patients who lose vital signs while care is being administered are to be resuscitated. Prompt
consultation with [Medical Control] is mandatory.
LANDING ZONES
Pre-designated landing zones are preferred. The landing zone should be selected in such a way that the
helicopter would be expected to arrive before the ambulance that is transporting the patient.
SCENE TRANSFER CRITERIA
Transfer from the scene to a designated trauma center via helicopter should be made according to the
following criteria. The decision to call for aeromedical services should be made by the first public safety
entity to arrive and assess the patient, or responding personnel based on dispatch information.
Aeromedical services should not be cancelled until the patient has been assessed by an AIC. Transport
should not be unduly delayed while waiting on Advanced Life Support personnel to arrive at the scene.
However, consideration must be given to the anticipated arrival time of the aeromedical provider when
EMS providers are making decisions regarding the decision to transport critically injured patients to
hospitals that are not designated trauma centers.
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Protocol 4.30 – TRAUMA – TRAUMA TRIAGE & MANAGEMENT
SCENE TRANSFER CRITERIA (continued)
If advanced care can be more expediently obtained at a nearby hospital than by waiting for aeromedical
flight crews, local providers should consider requesting a change in LZ to the nearest hospital.
Patients who are entrapped or pinned and are critically ill as defined by the “Field Trauma Triage Decision
Scheme” should have a helicopter summoned to the scene. When the patient becomes disentangled, the
patient shall be rapidly transferred to the landing zone to rendezvous with the medevac helicopter OR
proceed to an alternate landing zone between the scene and the closest hospital. The communication
center must be notified as soon as possible for every planned change in landing zone or rendezvous
point.
Because of the possibility of bad weather, mechanical failure or communication breakdown, all patients
who have been extricated and prepared for transport prior to the arrival of the helicopter at the scene
should consider initiating transport to the nearest medical facility.
Pre-designated landing zones (LZ) will continue to be developed. The ECC will assign the LZ in such a
way that the helicopter would be expected to arrive before the ambulance transporting the patient.
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Module 5 – Spinal Immobilization
Overview
Change in the standards of prehospital care is often slow to occur. EMS textbooks often take years to
reflect new evidence. The practice of using vehicular damage and mechanism of injury as indicators for
spinal motion restriction are outdated and problematic. Emphasis on the assessment of the patient
before making a decision about immobilization is key.
An estimated five million patients are immobilized in the prehospital environment in the U.S. each year.
Most have no complaints of neck or back pain or other evidence of spine injury. Eight years ago, the
CSEMS Council region introduced the first selective spinal immobilization protocol, giving EMS providers
the authority to make informed decisions about determining the need for prehospital spinal
immobilization. While this protocol was progressive at the time of its introduction, it still supported the
idea that a high mechanism of injury independently indicated the patient should be immobilized. We
now know otherwise. We also know that in some cases, spinal immobilization may not be in the
patient’s best interest.
Consequences of Spinal Motion Restriction
When spinal motion restriction is employed, the patient is placed on a flat, hard surface, is placed in a
rigid cervical collar and has his or her head taped to the board. This can cause discomfort and anxiety, in
addition to several other potentially significant consequences. Backboarding can aggravate underlying
injuries. Trauma patients can experience vomiting, airway hemorrhage and swelling which may be
difficult to manage in the supine patient on a backboard. The risk of aspiration in the backboarded
patient is significantly increased. Studies also show an increased ventilatory effort in patients
immobilized on a backboard.
Immobilization on a backboard can cause pain and pressure injuries. The pain caused by laying on the
hard, flat surface of a backboard has been documented to result in unnecessary radiographs. This pain
also make subsequent assessment of the patient and potential ambiguity regarding the source of the
pain.
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Lose-lose situations are presented when we look at how respiration and ventilation are affected by
spinal motion restriction. Respiratory vital capacity can be reduced by up to 20% in the supine
immobilized patient. Securely strapping the patient adds to the respiratory compromise. To counteract
these problems, strapping is often loosely secured to facilitate easier breathing. While this may aid the
respiratory compromise, the effectiveness of the immobilization system is reduced. These issues are
compounded in patients with pre-existing respiratory pathology, such as COPD, asthma, pneumonia and
congestive heart failure, obese and elderly patients.
The reduction of scene time when caring for trauma patients can be delayed when proper
immobilization practices are employed. Studies indicate there is limited or no benefit when treating
victims of penetrating trauma. Prolonged scene times when caring for patients with penetrating trauma
may increase morbidity and mortality.
Cervical collards my even present problems. Studies have shown increases in intracranial pressure,
abnormal distraction within the upper cervical spine in the presence of severe injury. Cervical collars
can also hide the neck and thus hide injuries or other signs of progressive injuries, such as swelling,
jugular venous distention or tracheal deviation.
Finally, prolonged immobilization can cause cutaneous pressure ulcers in the occipital, sacral or heel
areas, especially in the elderly, unconscious and neurologically impaired patients.
Selective Spinal Immobilization
Mechanism of injury no longer dictates the need for immobilization. Rather, mechanism of injury
triggers the consideration of whether spinal motion restriction should be employed on a particular
patient. Recommendations for the management of a patient with penetrating trauma are geared
towards the general elimination of the need for immobilization with a few exceptions.
The first step in the spinal cord injury protocol is to conduct general patient management followed by
application of the selective spinal immobilization procedure. If spinal immobilization is indicated,
proceed with the rest of the protocol. There is no age restriction for application of this algorithm. You
may apply the algorithm to any patient where you can reliably assess all three criteria listed.
Entry into this algorithm is dictated by the mechanism of injury
and/or whether the patient is at a high risk for spinal cord injury.
Patients who have sustained a mechanism of injury that is
consistent with a spinal cord injury should be assessed using this
algorithm to determine whether spinal immobilization is
indicated. A significant mechanism of injury does not dictate the
need for immobilization. The assessment is what dictates the
need for immobilization. The list of mechanisms of injury shown
in the table to the right is not exclusive. In other words, you may
be faced with other mechanisms that place a patient at risk for
injury. You will need to use you best clinical judgment to make
these decisions in the absence of guidance from the protocols.
Remember that the elderly and patients with bone disease, for
example osteoporosis, are at higher risk of spinal cord injury.
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Once you have determined you have a patient
with the potential for a spinal cord injury, you
will assess three criteria.



Do you have a reliable patient?
Does the patient have a normal spine
exam?
Does the patient have a normal motor
and sensory exam?
Do you have a reliable patient? This means that
your patient needs to be cooperative, sober and
without distracting injuries. You must be able to
effectively communicate with your patient. You
must be confident that when you question your
patient that he or she will give you accurate and
truthful answers. You must be confident that
when you perform a physical exam on your
patient, he or she will respond with appropriate
and dependable responses.
Normal spine exam? Palpate the entire
vertebral (spinal) column thoroughly for pain and
tenderness.
Normal motor/sensory exam? If you have a
reliable patient AND a normal spinal exam,
conduct a motor – sensory exam. Ask the patient
to extend either the fingers on both hands or
both wrists and plantarflex and dorsiflex each
foot. Next, assess sensation in all extremities.
An example of an abnormal finding is
paresthesia. Paresthesia is a sensation of
tingling, tickling, prickling, or burning of a
person's skin, commonly referred to as pins and
needles.
If the answer to all three questions, is yes, that is you have a reliable patient, the spine exam is normal
and the motor-sensory exam is normal, spinal immobilization is not required. If the answer to one or
more of the questions is no, you must immobilize the patient as an unstable spinal injury is possible.
Penetrating Trauma Patients
Reduction of scene time when caring for trauma patients can be delayed when proper immobilization
practices are employed. Studies indicate there is limited or no benefit when treating victims of
penetrating trauma. Prolonged scene times when caring for patients with penetrating trauma may
increase morbidity and mortality. Victims of penetrating trauma, for example stabbings and gunshot
wounds, to the head, neck, and/or torso SHOULD NOT receive spinal immobilization unless there is one
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or more of the following: 1) obvious neurologic deficit to the extremities, 2) significant secondary blunt
mechanism of injury, 3) priapism, 4) neurogenic shock or 5) anatomic deformity to the spine secondary
to injury. Performing spinal immobilization on a patient with penetrating trauma is now rare and the
exception to the rule.
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Local Protocol Excerpts
 Protocol 4.24 – SPINAL CORD INJURY
 Protocol 4.24 – SPINAL IMMOBILIZATION/CLEARANCE

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EMR
EMT
AEMT
INT
PM
Protocol 4.24
1. Perform general patient management (SECTION 1).





2. Apply the Selective Spinal Immobilization procedure.





3. Provide manual in-line stabilization of the head and neck.





4. Apply an appropriately sized rigid cervical collar.
o




5. Assess sensory and motor function in all four extremities.
o




6. Based on the patient’s priority, apply the appropriate spinal immobilization
device or perform the appropriate procedure, including, but not limited to:
o




a. Extrication vest or short board – stable, low-priority patient found in
a sitting position.
o




b. Rapid extrication procedure – high-priority patient, dangers at the
scene requiring rapid movement, or to provide access to more
seriously injured patients.
o




o




o




7. Reassess sensory and motor function in all four extremities.





8. Transport as soon as possible.





9. Perform reassessment as indicated.





INJURY – SPINAL CORD INJURY
c.
Long backboard – patient found in a supine position.
d. Rapid takedown – patient found in a standing position.
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Protocol 4.24 – GENERAL – SPINAL IMMOBILIZATION/CLEARANCE
EMS providers may withhold spinal immobilization if the following algorithm is applied and the end-point is
“Consider no immobilization.”
Potential for unstable spinal injury
High mechanism of injury:
 Violent impact to the head, neck, torso, or
pelvis
ASSESS ALL THREE CRITERIA:
1) Reliable patient?
A reliable patient is cooperative, sober
and alert WITHOUT:
 Significant distracting injuries
 Language/communication barrier
AND
 Moderate to high speed motor vehicle
incident
 Pedestrian struck by a vehicle
 Explosion
 Ejection from a vehicle
 Shallow-water diving incident
 Fall from a height (relative to the patient)
 Axial load
2) Normal spine exam?
 Palpate vertebral column
thoroughly for pain or tenderness
AND
 Penetrating trauma in or near the spine
 Sports injury to the head or neck
High risk patients:
 Fragile elderly
3) Normal motor/sensory exam?
 W rist or finger extension (both
hands)
 Plantarflexion (both feet)
 Dorsiflexion (both feet)
 Check gross sensation in all
extremities
 Check for abnormal sensations to
extremities (e.g. paresthesia)
 Patients with bone disease
Penetrating trauma:
Victims of penetrating trauma (stabbings,
gunshot wounds) to the head, neck, and/or torso
SHOULD NOT receive spinal immobilization
unless there is one or more of the following:
 Obvious neurologic deficit to the extremities
NO for one
or more criteria
YES for all
three criteria
 Significant secondary blunt mechanism of
injury (e.g. fell down stairs after getting shot)
 Priapism
 Neurogenic shock
IMMOBILIZE
Patient
NO immobilization
 Anatomic deformity to the spine secondary
to injury
Key Points: SPINAL IMMOBILIZATION
 If the immobilization process is initiated prior to assessment, STOP and perform spine injury
assessment to determine best course of action.
 Studies show that immobilizing trauma victims may cause more harm than good to the patient.
Penetrating trauma victims benefit most from rapid assessment and transport to a trauma center
without spinal immobilization.
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Local Protocol Program
SKILL SHEETS
The local protocol program skill sheets should be downloaded from the CSEMS
Council website at:
http://www.csems.org/agencies/local-protocol-program/
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