Chaffee County Emergency Medical Services

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Chaffee County

Emergency Medical Services

Pre-Hospital Treatment Protocols

Version 10.0













This document has been approved by the Medical Director for Chaffee County Emergency Medical Services



Table of Contents




Acknowledgment Form 6

Introduction 7

Acts Allowed 8
Operating Policies

Trauma Team Activation 13

Roles and Responsibilities 14

Standard of Care 17


Operating Guidelines

Patient Restraint 18 Resuscitation and DNR Orders 19

Field Pronouncement Guidelines 21

Treatment Protocols

Cardiac Emergencies

Cardiac Arrest, Medical 22

Therapeutic Hypothermia 26

Acute Coronary Syndrome 27

STEMI Alert 28

Thrombolytic Checklist 29

Dysrhythmias 31

Hypertension 36
Medical Emergencies

Abdominal Pain 37

Anaphylaxis 38

Behavioral Disorders 39

Cerebral Vascular Accident (CVA) 40

CO Monitoring, Exposure, & Treatment 43

Hyperglycemia 44

Hypoglycemia 45

Hyperthermia 46

Hypothermia Generalized 47

Hypothermia Localized 48

Poisoning/Overdose 49

Seizures 52

Shock 53

Septic Shock Alert 54

Syncope 57

Unconscious Patient 58

Adrenal Insufficiency 66

Treatment Protocols
Pulmonary / Respiratory Emergencies

Respiratory Distress, General 59


Asthma 60

CHF 61

COPD 62

Pediatric Dyspnea 63

Obstetrics / Gynecological Emergencies

Childbirth 67

Neonatal Resuscitation 69

Pregnancy Induced Hypertension &Eclampsia 70

Vaginal Bleeding 71
Trauma Emergencies

Trauma Arrest 72

Amputation Injuries 75

Burns 76

Chest Pain, Traumatic 77

Fractures, Dislocations, and Sprains 79

Head Trauma 80

Hemorrhage 82

Spinal Trauma 83

Selective Spinal Immobilization Tool 84

Crush Injury 86

Drowning/Near Drowning 87
Procedure Protocols



Airway


OPA/NPA 88

Extra-Glottic Airways 89

Endotracheal Intubation, Nasal 90

BAAM 91

Endotracheal Intubation, Oral 92

Endotracheal Intubation, RSI 93


Awake Look 95

Airway Assessment 96

Failed Airway 97

Percutaneous Cricothyrotomy 98
Breathing

Continuous Positive Airway Pressure 100

Apneic Oxygen 101

Chest Decompression 102


Circulation

Peripheral IV Insertion 103

Law Enforcement Blood Draw 104

Venous Blood Draw 105

External Jugular Cannulation 106

Inter Osseous Cannulation 107
Cardiac

Semi-Automated Cardiac Defibrillator 108

Defibrillation 109

Pacing 110



Cardioversion 111

Skills and Monitoring
Pulse Oxymetry 114

Capnometry 115

Automated Transport Ventilator 116

Glucometer 127

Pain Management 128

Bandaging / Bleeding Control 129

Splinting / Immobilization 130

Selective Spine Immobilization 132


Medication Administration 134

Foley Catheter Placement 136

NG / OG Tube Placement 137
Pharmacology / Medication Administration Protocols



Assisted Medications
Metered Dose Inhaler (MDI) 139

EpiPen 140

Nitroglycerine (NG) 141
Medications
Acetylsalicylic Acid (ASA) 142

Adenosine 143

Albuterol 144

Amiodarone 145

Atropine 146

Calcium 147

Dextrose 148

Diazepam 149

Diltiazem 150

Diphenhydramine 151

Epinephrine 152

Epinephrine Drip 154

Fentanyl 156

Furosemide 157

Glucagon 158

Glucose, Oral 159

Hydromorphone 160

Ketamine 161

Ipratropium 162

Lidocaine 163

Magnesium 164

Methylprednisolone 165

Midazolam 166

Morphine 167

Naloxone 168


Nitroglycerine 169

Ondansetron 170

Oxygen 172

Phenylephrine 173

Promethazine 174

Sodium Bicarbonate 175

Succinylcholine 176



Tetracaine 177

Vecuronium 178

Over the Counter Medications 179

EMT-I Direct Order Exception 180

Interfacility Transfer Medications 181

Intravenous Solutions 185
Addendum

Revisions from previous edition 186

Critical Care Protocols 187
CHAFFEE COUNTY EMERGENCY MEDICAL SERVICES

MEDICAL PROTOCOL ACKNOWLEDGEMENT FORM

I, _________________________________, acknowledge that I have received a copy of the Chaffee County Emergency Medical Services Medical Protocols version 10. I understand that I also have access to the Chaffee County Medical Protocols at either station, or in any ambulance, at any time.


I have received the protocols in the form of: (Please circle one)
Hard copy CD Electronic copy

In addition, I agree to review these protocols and accept the responsibility for knowing and practicing as a provider in accordance with them, when appropriate. I further agree to review any additional additions and/or changes that may be made to the protocols as they are distributed.

Name (Print):__________________________________________________

Signature: _______________________________ Date: _________________
Agency: ______________________________________________________

Introduction

This manual is intended to outline the Standard of Emergency Medical Care for the personnel of Chaffee County Emergency Medical Services. As a Standard of Care, this manual is to be used by members certified at the EMT-Basic, EMT-Basic/IV, EMT-Intermediate, Paramedic, and Paramedic – Critical Care Endorsement levels, as a means of determining the level of care to be administered in any given situation. It is also the standard used by the Medical Director to evaluate and guide care throughout the system
Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels. Every attempt will be made by Chaffee County Emergency Medical Services and the Medical Director to provide additional education, but it is the responsibility of the individual provider to seek additional education if it is needed. Each individual within the emergency medical services system is responsible for the following:


  • Performing to the Standard of Care for his/her level of certification

  • Obtaining additional training, beyond initial education, if needed

  • Maintaining current certification

  • Participating in continuing education

These protocols are a guideline and are unable to account for every patient condition, patient presentation, and situation. Deviation from these protocols should be done only with the patient’s best interest in mind and backed with sound clinical judgment. Any deviation must be thoroughly documented and submitted for review


If questions arise concerning a patient’s condition or treatment modalities, contact with the Base Physician should be initiated without hesitation

Acts Allowed

The Medical Director has determined the Acts Allowed for each certification level within Chaffee County Emergency Medical Services
The Acts Allowed for EMT-B’s, EMT-B/IV’s, EMT-I’s, and Paramedics are accordance with the Acts Allowed as determined by the Colorado Department of Public Health and as outlined in Rules Pertaining to EMS Education and Certification, 6 CCR 1015-3, Chapter Two or through approved medical waivers. Providers must be certified to provide patient care in the state of Colorado
Performing an Act that is beyond a provider’s Scope of Practice is considered “practicing without a license” and is not acceptable. Any provider that performs an Act that is beyond his/her Scope of Practice will be subject to disciplinary action that will be determined at the discretion of the Medical Director
A provider may administer a medication that is beyond his/her Scope of Practice only under the direct visual supervision of a provider that has a Standing Order for that medication and to patients in extremis
Certain procedures that are not covered in this document may be performed if adequate training has been obtained and with Base Physician approval. This does not apply to controlled medications
Not all medical skills, acts allowed, and medications are included in the initial education for various EMS provider levels. Every attempt will be made by Chaffee County Emergency Medical Services and the Physician Medical Director to provide additional education, but it is the reasonability of the individual provider to seek additional education if it is needed

X = Standing Order. Can be performed without on-line approval from the Base Physician or the provider of a higher level who has Standing Order allowance for the procedure/medication

DO = Direct Order. Express verbal permission must be obtained from the Base Physician before performing procedure. A provider of a higher level, that has Standing Order allowance, may issue the Direct Order




Procedures

Level of Certification




EMT-B

EMT-BIV

EMT-I

Paramedic

Patient Assessment

x

x

x

x

Airway Management

Suction (Powered or Manual)




  • Pharyngeal suction

x

x

x

x

  • Tracheal suction







x

x

  • Extra-glottic device suctioning

x

x

x

x

Basic Life Support Airways



  • Oropharyngeal placement


x

x

x

x

  • Nasopharyngeal placement

x

x

x

x

Extra-Glottic Airways (King-LTD, King LTSD, LMA)




  • Extra-Glottic Airways

x

x

x

x

Endotracheal Intubation




  • Oral intubation







x

x

  • Nasal intubation










x










x

Cricothyrotomy (Surgical, needle guided)









x

Oxygen Administration

  • Nasal cannula (NC)

x

x

x

x

  • Non-rebreather mask (NRB)

x

x

x

x

  • Bag valve mask (BVM)

x

x

x

x

  • Small volume nebulizer (SVN)

DO

DO

x

x

  • Continuous positive airway pressure (CPAP)

DO

DO

x

x

  • Blow-by oxygen

x

x

x

x

Chest decompression (Needle)







x

x


Circulation Management


CPR

x

x

x

x

Soft tissue management

x

x

x

x

Fractures/dislocations

x

x

x

x

Spinal immobilization

x

x

x

x

Shock management

x

x

x

x

Hemorrhage control




  • Direct Pressure

x

x

x

x

  • Bandaging

x

x

x

x

  • Tourniquet

x

x

x

x

  • Hemostatic Agents (Celox)


x

x

x

x

Intravascular Access

IV initiation

  • Peripheral IV




x

x

x

  • External jugular cannulation







x

x

  • Saline lock




x

x

x

  • Buritrol/Volutrol




x

x

x

  • Blood Y




x

x

x

IV monitor/use/maintenance




  • Peripheral IV




x

x

x

  • External jugular IV








x

x

  • Central venous catheter







x

x

IV fluid administration




  • Normal Saline




x

x

x

  • D5W




x

x

x

  • Medication drip







DO

x

IO insertion







x

x

Patient Monitoring

Vital signs




  • Non-invasive blood pressure

x

x

x

x


  • Pulse rate

x

x

x

x

  • Pulse oximetry

x

x

x

x

  • CO monitoring & treatment

x

x

x

x

  • End tidal C02 detection

x

x

x

x

  • Temperature

x

x

x

x

  • Glucometer

x

x

x

x

  • Lactate monitor

x

x

x

x

Miscellaneous Skills

NG / OG tube placement











x

Foley catheter placement










x

Cardiac Management

Automatic external defibrillation

x

x

x

x

ECG/12 lead monitoring

x

x

x

x

ECG/12 lead interpretation







x

x

Manual defibrillation







x

x

Transcutaneous cardiac pacing







x

x

Synchronized cardioversion











x

Therapeutic hypothermia







DO

x

Medication Administration Routes

Nebulized (SVN)

DO

DO

x /DO

x

Intra nasal (IN)

x

x

x /DO

x

Intra muscular (IM)







x /DO

x

Sub cutaneous (SC)







x /DO

x

Intra venous




x

x /DO

x

Intra osseous







x /DO

x

Oral/Buccal/Lingual


x/DO

x/DO

x/DO

x

Medication Administration

Medication:

Assisted medications:

  • EpiPen/EpiPen Jr

DO

DO

DO

x

  • MDI

DO

DO

DO

x

  • NTG

DO

DO

x

x

  • Acetylsalicylic acid/Aspirin

x

x

x

x

  • Adenosine/Adenocard







DO

x

  • Albuterol


DO

DO

DO

x

  • Amiodarone







DO

x

  • Atropine







DO

x

  • Calcium










x

  • Dextrose 10%




x

x

x

  • Diazepam/Valium







DO

x

  • Diltiazem/Cardizem










x

  • Diphenhydramine/Benadryl







DO

x
  • Dopamine/Inotropin











x

  • Epinephrine







x/DO

x

  • Epinephrine drip







DO

x

  • Fentanyl/Sublimaze







DO

x

  • Furosemide/Lasix







DO

x

  • Glucagon/Glucogen







x/DO

x

  • Ipratropium bromide/Atrovent







DO

x

  • Ketamine/Ketalar










x

  • Lidocaine/Xylocaine (Bolus for procedure)








x

x

  • Lidocaine/Xylocaine (Antidysrhythmic)







DO

x

  • Magnesium Sulfate







DO(OB)

x

  • Methylprednisolone/SoluMedrol







DO

x

  • Midazolam/Versed







DO

x

  • Morphine







DO

x

  • Naloxone/Narcan

x

x

x

x

  • Nitroglycerine/Nitrostat







x/DO

x

  • Ondansetron/Zofran


DO(ODT)

DO(ODT)

x

x

  • Oral glucose

x

x

x

x

  • Oxygen

x

x

x

x

  • Phenylephrine/Neosynephrine










x

  • Promethazine/Phenergan







DO

x

  • Vecuronium Bromide










x

  • Sodium Bicarbonate







DO

x/DO

  • Succinylcholine Chloride










x

  • Tetracaine/Opthaine








x

x

  • Specified OTC medications

x

x

x

x

Interfacilty Transport - Procedures

  • Chest tube monitoring










x

  • Ventilator – Automated Transport Ventilator










x

  • IV Pump







x

x

Interfacility Transport - Medications

  • See Specific Protocol

Trauma Team Activation
The Trauma Team at Heart of the Rockies Regional Medical Center consists of the ED physician, trauma surgeon, EDRN, respiratory therapy technician, radiology technician and laboratory technician

The emergency department, prior to the arrival of patients who meet the criteria listed, will notify the team. Any pre-hospital provider, EDRN, MD, EDMD or surgeon may activate the Trauma Team for patients who meet criteria. The trauma surgeon, when available for consult, will respond within 10 minutes of the arrival of the patient who meets activation criteria


  • Trauma Team Activation – Major

    • GCS <13 due to trauma

    • BP <90 systolic, or pulse >120 in an adult patient

    • BP <70, or pulse >150, or capillary refill time >3 seconds in an pediatric patient (0-12 yrs old)

    • Respiratory rate <10 or >29

    • Flail chest

    • Penetrating injury to neck, chest, or abdomen

    • Spinal cord injury with neurological deficit

    • Multisystem injury (>2 systems injured)

    • Burns >15% TBSA and/or associated injury including inhalation potential

    • Falls >20 feet




  • Trauma Team Activation – Minor




    • GCS <14 due to trauma

    • Pulseless extremity

    • High speed MVA w/ significant vehicle damage

    • Unrestrained occupant of MVC

    • Auto vs. pedestrian / bicycle at speeds >20mph or thrown > 15 feet

    • Separation from conveyance (Includes: horse, ATV, snowmobile, bicycle etc)

    • Death of same car occupant

    • Lightning or electrical injury

    • Contra lateral fractures



  • A trauma team activation may be called at the pre-hospital provider’s discretion even if a patient does not meet the above stated criteria

***Please note that the Trauma Team Activation with surgeon applies only when the trauma surgeon is on call and present for consultation in our facility. All other times, State Trauma Protocol for Trauma and Transfer criteria takes precedence ***






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