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Section I Procedures R3.0 8-31-15

1. al ap as ys Hold the vial as shown Push the drug vial down into container and grasp the inner cap of the vial through the walls of the container Procedure Cardizem Add Vantage System Wy Pull the inner plug from the drug vial allow drug to fall into diluent container for fast mixing Do not force stopper by pushing on one side of inner cap ata time Page 1 of 2 Verify that the plug and rubber stopper have been removed from the vial The floating stopper is an Indication that the system has been activated Revised 8 2015 5 1 Wilson County Emergency Management Agency Protocol Manual Procedures If the rubber stopper is not removed from the vial and the medication is not release on the first attempt the inner cap may be manipulated back into the rubber stopper without removing the drug vial from the diluent container After repositioning the inner cap repeat the Activate step 3 Mix and Administer Within Specified Time f j f i al J LAJ E ty J 5 IRS a TJ f f Ess fe a J ff h C 73 a w YY ee A 1 S Ca S gt gt Mix container contents thoroughly to Pull up hanger on the vial Remove the white administration port assure complete dissolution Look cover and spike pierce the container through bottom of vial to verify complete with the piercing pin Administer within mixing Check for leak
2. 21 Procedure Vascular Access Page 2 of 2 31
3. Basic Assessment and Management A 3 page 5 10 Reassess airway and breath sounds after transfer to the stretcher and during transport These tubes are easily dislodged and require close monitoring and frequent reassessment Procedure Nasal Intubation Page 1 of 1 24 Wilson County Emergency Management Agency Protocol Manual Procedures NITRO BID Nitroglycerin Ointment Paramedic Standing Order 1 Measure the desired dosage of NITRO BID by means of the dose measuring applicator Supplied Place the applicator on a flat surface printed side down Squeeze the desired amount of ointment from the tube onto the applicator Ensure desired area of skin with little or no hair that is free of scars cuts or irritation Place the applicator ointment side down Spread the ointment using the dose measuring applicator DO NOT rub the skin N O1 amp W PO SFR NDC 0281 0326 08 NITRO a iD Nitroglycerin Ointment USP 2 pi O This product available in tubes FURY EY9681L 1 gram is equivalent to approximately 1 inch as squeezed 2 from a tube Use entire contents of foilpac and FEB18 DISCARD foilpac IMMEDIATELY AFTER USE 2 NETWT1g Ponty NITRO BID gt Nitroglycerin Ointment USP 2 INCHES 1 2 1 11 2 2 O S O E es pe CENTIMETERS 1 25 2 5 3 75 5 the applicator that measures the dose A division of Fougera Pharmaceuticals Inc Melville New York 11747 h A
4. 100 ml bag 5 Place the amount of ML recommended in the Dose Medic reference manual in the Buretrol chamber 6 Close the regulator and chamber to not allow any more medication into the Buretrol set 7 Open the gravity flow controller package extension set remove the protective cover Set the volume selector to the open and ensure the clamp is open 8 Bleed all air from the IV tubing and the gravity control extension set Once all air is bled from the tubing clamp the IV tubing Note The volume selector is very hard to move for the first time do not be afraid to use slight force to open the volume selector Invert the gravity flow controller and tap to dislodge any trapped air while flushing the tubing 9 Clean the medication port on the main line with alcohol 10 Attach the secondary line with the gravity flow controller extension set to your main line tubing 11 Clamp turn off the main IV line make sure secondary line drip is higher than main line 12 Ensure the gravity flow controller is set to the desire amount see below for calculation and open your secondary IV clamp 13 The infusion should be completed in twenty 20 minutes 14 Once the 100 ml bag is empty let the medication pass by the gravity flow controller since there is a significant amount of medication in the IV tubing be extremely careful and monitor do not allow any air to enter into the circulatory system 15 Clamp the secondary IV line off and remo
5. 5 Refer to the Temperature Measurement Procedure J 39 Procedure Temperature Measurement Page 1 of 1 30 1 Wilson County Emergency Management Agency Protocol Manual Procedures Vascular Access AEMT amp Paramedic Standing Order Assessment Indications Any patient where intravascular access Is indicated such as significant trauma or mechanism of injury emergent or potentially emergent medical condition Procedure 1 Saline locks should be used as an alternative to an IV tubing and IV fluid in every protocol at the discretion of the EMS professional 2 Paramedics can use Intraosseuos access where threat to life exists as provided for in the Intraosseous Infusion Procedure 21 3 Use the largest catheter bore necessary based upon the patient s condition and size of veins 4 Select fluid amp tubing Always using aseptic technique connect the IV tubing to the IV bag flush IV tubing of any air bubbles Replace cap using aseptic technique DO NOT allow the end of the IV tubing end to be exposed and potentially contaminate the tubing 5 Apply tourniquet select the site cleanse site with alcohol prep in a circular motion allow alcohol to dry not touching the site to prevent contamination Perform vascular access with the IV catheter ensure flash of blood remove needle and dispose of properly attach IV tubing to IV catheter securely Ensure IV flows without side effects secure IV site
6. Airway is a latex free single use device It consists of a curved tube with ventilation apertures located between two inflatable cuffs Both cuffs are inflated using a single valve pilot balloon The distal cuff is designed to seal the esophagus while the proximal cuff is intended to seal the oropharynx Attached to the proximal end of the tube is a 15 mm connector for attachment to a standard breathing circuit or resuscitation bag 2 Indications When endotracheal intubation is unsuccessful after 2 attempts Patients over 4 feet tall in respiratory or cardiac arrest lt is not necessary to attempt intubation if a difficult airway is anticipated or visualized The King airway may be used as the first line airway in these cases Below is the Cormick and Lehame Grades of Difficult Airway Grades III and IV are considered difficult 3 Contraindications Active gag reflex Caustic ingestion or extensive airway burns Known esophageal disease Laryngectomy with stoma Height less than 4 feet 4 Precautions The King airway may not protect from effects of regurgitation and aspiration High airway pressures may divert gas into the atmosphere or stomach Intubation of the trachea cannot be ruled out a potential complication of insertion of the King airway After placement perform standard checks for chest rise and breath sounds and utilize waveform capnography Lubricate only the posterior surface of the King LT SD to avoid blockage of the v
7. OBESE 40 kg and over Proximal Tibia The insertion point is two 2 fingerbreadths below the patella 1 2 cm medial of the tibial tuberosity Distal Tibia Identify the major structures of the lower leg the Distal Tibia anterior or most forward lower leg bone and the Medial Malleolus medial ankle bone or protrusion The insertion point is two finger widths proximal to the Medial Malleolus and midline on the tibia Proximal Humerus The insertion point is most prominent aspect of the greater tubercle s outer margins Ensure that the insertion site has been identified and that the patient s forearm more specifically the hand is on the patient s abdomen at or near the umbilicus and the elbow is positioned posteriorly Only this orientation will provide the safest most prominent insertion site Failure to properly orient the patients arm may lead to serious injury Deeply palpate the humeral head two fingerbreadths from the superior portion is the greater tubercle EZ IO PEDIATRIC 3 39 kg Proximal Tibia 1 cm distal to tibial tuberosity and then medial along the flat aspect Gently guide the driver do not push Carefully feel for the give indicating penetration into the medullary space Distal Tibia identify the major structures of the lower leg the Distal Tibia anterior or most forward lower leg bone and the Medial Malleolus medial ankle bone or protrusion The insertion point is one finger width proximal
8. Remove EZ IO driver from needle set while stabilizing catheter hub e Remove stylet from needle set place stylet in temporary shuttle provided and then dispose of into sharps container or deposit directly into sharps container e Connect EZ Connect or standard IV tubing to Luer lock hub DO NOT ATTACH A SYRINGE DIRECTLY TO THE EZ IO AD CATHETER HUB Doing so may cause enlargement of the hole at the insertion site and possible extravasation exception when initially drawing a blood sample e Syringe bolus Flush the EZ IO catheter with ml of Normal Saline a IMPORTANT Prior to flush consider the aspiration of a small amount of blood to confirm placement b Consider IO 2 Lidocaine preservation free for conscious patients prior to flush C NO FLUSH NO FLOW Failure to appropriately flush the IO catheter may result in a limited or no flow treatment situation Confirm placement Assess for potential IO complications Disconnect 10 cc syringe from EZ connect extension set Connect EZ Connect extension set to primed IV tubing Begin infusion utilizing pressure delivery system Secure tubing and catheter Monitor EZ IO site for complications Place EZ IO identification band on patient document time date and person starting infusion Procedures EZ IO Page 3 of 4 21 Wilson County Emergency Management Agency Protocol Manual Procedures Catheter Removal 1 2 3 4 3 6 Remove the extension set from the ne
9. accessed External Jugular Veins should never be the first line attempted unless the patient has no limbs for the initial attempts Saline Locks SHOULD NOT be used in External Jugular access The Intraosseuos may be used in patients in whom IV access cannot be established when IV access is critical Refer to the Intraosseous Infusion Procedure 21 Intravascular Fluid Administration Any patient having a condition that requires an IV may receive it if the Advanced EMT or Paramedic deems it necessary Weigh the transport time against the time it would take to start an IV and make a good decision Trauma Minimize on scene time IVs are to be started while en route to the hospital unless the patient is pinned in vehicle or a prolonged scene time is unavoidable Normal Saline or Lactated Ringers may be utilized for trauma patients The rate is based on patient condition and shall be to maintain the patient s systolic blood pressure 80 90 mm Hg Medical IV Normal Saline for chest pain cardiac arrest or other medical conditions requiring possible medication administration If no medications or fluid bolus is required the saline lock is preferred and can always be converted into an IV line Special Notes Pediatric IV tips refer to Pediatric Points A 5 Newborn neonate scalp and umbilical vein access refer to Pediatric IV Reference J 32 This includes the use of the EZ IO refer to Intraosseous Infusion Procedure
10. all treatment necessary using a tourniquet as a LAST RESCAT and Always store the C A T in its one handed configuration should ONLY be applied when bleeding cannot be stopped and the situation is hile thresate mirc proximal side by side to the first and reassess Procedure Bleeding Control Page 3 of 4 3 1 Ie Wilson County Emergency Management Agency Protocol Manual Procedures Storing in the One Handed Configuration To prepare for use store the C A T in its one handed configuration Apply tourniquet proximal to the Pull the bard very tight and securely bleeding site Insert the wounded limb fasten the band backcon itsel th hthe t f d by the bared f throug e loop formed by the ba Pass the red tip through the inside Flatten the loop formed by the f slit in the buckle Pull 6 of band band Place the buckle in the middle through fold it back and adhere of the flattened band the band to itself Adhere the band around the limb Bo Twist the rod until bright red bleeding not adhere the band past the rod clip has stopped and the distal pulse is eliminated Fold the A T in half placing the buckle at one end The A T is now ready to be placed in your medical kit Exclusive distribution in the U S by North American Rescue LLC 1 888 689 6277 www NARescue com info NARescue com Place the rod inside the clip locking it Adhere the band aver the rod Inside the in place Check for blee
11. applied to minimize the potential for infection Secure the dressing with a bandage e Always check Pulse Motor and Sensation PMS after bandaging Hemostatic Agents These agents are first priority for wounds in the groin and axilla to stop bleeding Remember they may be used in conjunction with a tourniquet Procedure e Remove clothing around the wound Remove excess blood Locate the source of active bleeding Pack the hemostatic agent tightly into the wound and onto the source of bleeding More than one may be needed if you do not have any more hemostatic agent use kerlix to continue packing over the hemostatic agent Apply pressure until bleeding stops Hold pressure for AT LEAST 3 MINUTES Reassess Leave agent in place Wrap effectively with a dressing DO NOT REMOVE the hemostatic agent Procedure Bleeding Control Page 1 of 4 3 1 Wilson County Emergency Management Agency Protocol Manual Procedures Tourniquets Tourniquets should be utilized on extremities that have severe uncontrolled bleeding Procedure Apply the tourniquet per manufacturer guidelines Pull the self adhering band tight and secure it back to the Velcro DO NOT past the windless clip Twist the rod until the bleeding has stopped THIS WILL BE PAINFUL Secure the rod in the windless clip Ensure hemorrhage has been controlled Adhere the self adhering band over the rod do not cover the Velcro on the windless clip and around the extremity as far
12. critical patients continuously until arrival at the hospital If recording a one time reading monitor patients for a few minutes as oxygen saturation can vary 6 Document percent of oxygen saturation every time vital signs are recorded and in response to therapy to correct hypoxemia 7 In general normal saturation is 94 99 Below 94 suspect a respiratory compromise hypoxia 8 Use the pulse oximetry as an added tool for patient evaluation Treat the patient not the data provided by the device 9 The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings such as chest pain 10 Factors which may reduce the reliability of the pulse oximetry reading include a Poor peripheral circulation blood volume hypotension hypothermia b Excessive pulse oximeter sensor motion c Fingernail polish may be removed with acetone pad e Irregular heart rhythms atrial fibrillation SVT etc b c d Carbon monoxide bound to hemoglobin e f Jaundice g Placement of BP cuff on same extremity as pulse ox probe Procedure Pulse Oximeter Page 1 of 1 28 Wilson County Emergency Management Agency Protocol Manual Procedures Rectal Medication Administration Paramedic Standing Order Assessment Indications This medication route can be utilized for medication administration The m
13. impaired mental status and is not able to cooperate with the procedure Had failed at past attempts at noninvasive ventilation Has active upper GI bleeding or history of recent gastric surgery Complains of nausea or vomiting Has inadequate respiratory effort Has excessive secretions Has a facial deformity that prevents the use of CPAP Procedure CPAP Page 1 of 5 10 Wilson County Emergency Management Agency Protocol Manual Procedures Procedure Ola 11 12 13 Monitor and document the patient s respiratory response to the treatment 15 16 17 Gather the appropriate equipment Assess vital signs and attach pulse oximeter Make sure patient does not have a pneumothorax EXPLAIN THE PROCEDURE TO THE PATIENT Connect the CPAP to a 50 PSI oxygen outlet Ensure adequate oxygen supply to ventilate device 100 when starting and until Sp02 is greater than 95 Select a sealing face mask and ensure that the mask fits comfortably seals the bridge of the nose and fully covers the nose and mouth Attach the Breathing Circuit to the CPAP insert and align the locking bayonet outlet adapter to the unit and turn clockwise until securely engaged Secure the mask to the patient with provided straps or the other provided devices Prior to setting the pressure always observe that the airway pressure gauge needle indicator is at the zero 0 value with the CPAP adjustment knob in the fully counterclockwise position a
14. is considered to be orthostatic Treat accordingly 6 Ifa patient experiences dizziness upon sitting or is obviously dehydrated based on history or physical exam formal orthostatic examination should be omitted and fluid resuscitation initiated Procedure Orthostatic Vital Signs Page 1 of 1 26 Wilson County Emergency Management Agency Protocol Manual Procedures Pacing Paramedic Standing Order Assessment Indications Monitored heart rate less than 60 per minute with signs and symptoms of inadequate cerebral or cardiac perfusion such as Chest pain Hypotension Pulmonary edema AMS disorientation confusion etc Ventricular ectopy Asystole pacing must be done early to be effective PEA where the underlying rhythm is bradycardic and reversible causes have been treated 3 AVB with AMS and hypotension 2 Type Il AVB with AMS and hypotension Procedure ok Oe SP a oe Attach standard four lead monitor defibrillator to patient Check expiration date before applying pads Apply combo pads one pad to left mid chest next to sternum one pad to mid left posterior chest next to spine The anterior posterior placement may also be utilized Rotate selector switch to pacing Adjust heart rate to 60 70 BPM defaults to 70 bpm for an adult and 100 BPM for a child Note pacer spikes on EKG screen Slowly increase output milliamps until capture of electrical rhythm on the monitor If unable to cap
15. laryngoscopic techniques visualize the vocal cords if possible using Sellick s BURP as needed 5 Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or above the arytenoids if the cords cannot be visualized 6 Once inserted gently advance the Bougie until you meet resistance or hold up if you do not meet resistance you have a probable esophageal intubation and insertion should be re attempted or the failed airway protocol implemented as indicated 7 Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining proximal control of the Bougie 8 Gently advance the Bougie and loaded ET tube until you have hold up again thereby assuring tracheal placement and minimizing the risk of accidental displacement of the Bougie 9 While maintaining a firm grasp on the proximal Bougie introduce the ET tube over the Bougie passing the tube to its appropriate depth 10 If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately lubricated withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn the bevel of the ETT posteriorly If this technique fails to facilitate passing of the ETT you may attempt direct laryngoscopy while advancing the ETT this will require an assistant to maintain the position of the bougie and if so desired advance the ETT 11 Once the ETT is correctly placed hold the ET tube securely and re
16. to the Medial Malleolus for pts less than 12kg As the patient reaches the 39kg mark the insertions point is two finger widths from the Medial Malleolus Proximal Humerus The insertion point is most prominent aspect of the greater tubercle s outer margins Ensure that the insertion site has been identified and that the patients forearm more specifically the hand is on the patient s abdomen at or near the umbilicus Only this orientation will provide the safest most prominent insertion site Failure to properly orient the patients arm may lead to serious injury Deeply palpate the humeral head two fingerbreadths from the superior portion is the greater tubercle Apply non sterile latex free gloves if not already Open the following and drop onto field e Institutions current antiseptic agent e Semi permeable transparent dressing e 2x 2 gauzes e Place needle and extension tubing with attached syringe with in field Using friction scrubbing motion cleanse the skin site with the institutions current antiseptic agent Allow to air dry thoroughly do not blot dry Stabilize site by holding joint proximal to the insertion site Connect weight based needle set to driver Procedures EZ IO Page 2 of 4 21 Wilson County Emergency Management Agency Protocol Manual Procedures e Remove needle cap a Insert EZ IO needle into the selected site IMPORTANT DO NOT touch the needle set with your fingers b Position the driver
17. turn off the main IV line make sure secondary line drip is higher than main line 12 Ensure the gravity flow controller is set to the desired amount see below for calculation and open your secondary IV clamp 13 The infusion should be completed in thirty 30 minutes 14 Once the Buretrol is empty let the medication pass by the gravity flow controller since there is a significant amount of medication in the IV tubing be extremely careful and monitor do not allow any air to enter into the circulatory system 15 Clamp the secondary IV line off and remove it from the main IV line discard accordingly 16 Open main line to an appropriate rate NOTE Calculations are based on the 20 gtts ml gravity flow controller The rate is based on 30 minute infusion Calculations Volume 100 divided by time hour ml per hr on controller 10 kg pt 33 3 ml DIVIDED by 0 5 hr 67 ml hr 30 kg pt 100 ml DIVIDED by 0 5 hr 200 ml hr Procedure Amiodarone Mixture Page 1 of 1 l 2 Wilson County Emergency Management Agency Protocol Manual Procedures Beck Airway Airflow Monitor BAAM Paramedic Standing Order Description The BAAM is a plastic cap that when placed on an endotracheal tube will be activated by the patient s respirations and magnify airway airflow sounds facilitating blind nasotracheal intubation Assessment Indications 1 Assist nasotracheal intubation placement 2 Confirmation of endotrache
18. 6 Fluid and setup choice is preferred e Normal Saline or Lactated Ringers with a macro drip 10 gtt ml for trauma or hypovolemia e Normal Saline with a macro drip 10 gtt ml or Saline Lock for medical conditions and e Normal Saline with a micro drip 60 gtt ml for medication infusions 7 Rates are preferably Adult KVO 40 60 ml hr 1 gtt 6 sec for a macro drip set Pediatric KVO 30 ml hr 1 gtt 12 sec for a macro drip set 8 If shock is present Adult amp Pediatric 20 ml kg boluses repeated PRN for poor perfusion consider additional vascular access sites Procedure Vascular Access Page 1 of 2 31 Wilson County Emergency Management Agency Protocol Manual Procedures Before administration of IV bolus ensure the patient is not in a fluid overload situation such as CHF The preferred site for an IV is the hand followed by the forearm and antecubital and is dependent on the patient s condition and treatment modality AEMT In the event that an IV cannot be established and the IV is considered critical for the care of the patient other peripheral sites may be used feet and legs only Paraemdic In the event that an IV cannot be established and the IV is considered critical for the care of the patient other peripheral sites may be used i e external jugular feet legs If the patient has a central line or porta cath access and the paramedic has received in service training on the procedure they may be
19. N SAVAGE LABORATORIES Procedure NITRO BID Application Page 1 of 1 24 1 Wilson County Emergency Management Agency Protocol Manual Procedures Oral tracheal Intubation Paramedic Standing Order Assessment Indications Hypoxic or obtunded patients Patients with possible increasing ICP Respiratory arrest Contraindications 11 a Presence of gag reflex b Relative contraindications c Blood clotting abnormalities d Upper neck hematomas or infections Procedure 1 Prepare position and oxygenate the patient with 100 Oxygen 2 Select proper ET tube and stylette if used have suction ready 3 Using laryngoscope visualize vocal cords Use Sellick maneuver to assist you 4 Limit each intubation attempt to 30 seconds with BVM between attempts 5 Visualize tube passing through vocal cords 6 Confirm placement and document results refer to the Basic Assessment and Management A 3 page 5 7 Inflate the cuff with 6 to 10 cc of air secure the tube to the patient s face with a commercial device or tape 8 Auscultate for absence of sounds over the epigastrium and bilaterally equal breath sounds If you are unsure of placement you should remove tube and ventilate patient with bag valve mask If you intubate the esophagus you can leave the tube in place push the tube to the left or right of the mouth and place the BVM mask over the ET Tube You may have a slight leaking of air but the pt ca
20. Procedures Sodium Bicarbonate Conversion Paramedic Standing Order 8 4 to 4 2 Procedure Open Sodium Bicarbonate 8 4 and assemble Take a 10ml saline flush and remove 5 ml Place a Double Luer Lock Adaptor on the Sodium Bicarbonate and Saline Flush Pull 5 ml from the Sodium Bicarbonate into the Saline Flush for a total of 10ml This provides you with 4 2 5 mEq 10ml Cee 2 I Procedures Sodium Bi Carb8 4 to 4 2 Page 1 of 1 30 Wilson County Emergency Management Agency Protocol Manual Procedures Temperature Measurement EMT AEMT amp Paramedic Standing Order Assessment Indications Monitoring body temperature in a patient with suspected infection hypothermia hyperthermia or to assist in evaluating resuscitation efforts Procedure 1 If clinically appropriate allow the patient to reach equilibrium with the surrounding environment 2 To obtain a tympanic temperature ensure the patient has no significant head trauma and place the thermometer into the external ear making sure not to force the probe into the ear canal To obtain an oral temperature ensure the patient has no oral trauma and place the device under the tongue 3 Leave the device in place until there is indication an accurate temperature has been recorded per the beep or other indicator specific to the device 4 Record time temperature method tympanic oral or rectal and scale C or F in Patient Care Report PCR
21. Wilson County Emergency Management Agency Protocol Manual Procedures Acetaminophen Medication Preparation Paramedic Standing Order Assessment Indications This medication may be utilized for febrile pediatrics gt 100 4 F and or pediatric patients who have had a febrile seizure Contraindications e Hepatic disease e Patient is unconscious e Patient is unable to swallow or maintain their own airway Medication Packaging e 160 mg 5 ml per unit e 32mg mi Paramedic Standing Order 15 mg kg up to a maximum dose of 500 mg Cannot repeat it is a onetime dose Procedure 1 Determine the amount of drug to be given 2 Selection the smallest appropriate syringe 3 Utilize the syringe or attach an 18g blunt tip catheter to the syringe 4 Partially remove the foil top from the medication container 5 While tilting the medication container slowly draw up the medication 6 Repeat the previous step to obtain the desired amount of medication 7 You may have to use a second syringe if the dose is higher than 320 mg 8 Remove the blunt tip catheter if used from the syringe 9 Slowly administer the medication to the patient via PO route ensuring that you do not give the medication at a rate faster than the patient can tolerate Note lf the calculated dose is unable to be drawn up accurately round down to the nearest dose amount that can be accurately drawn up and administered Procedure Acetaminop
22. ac Patent We 1 Po ba Other Patents Pending Licensed and Manulacurad by Composite Resources Ime B03 26 970 485 Lakeshore Parkway Rock HII SE 29720 Friction Tactical Black Buckle Rod Securing PN 30 0001 Strap Pull the band very tight and securely fasten Twist the rod until bright red bleeding has the band back on itself stopped and the distal pulse is eliminated Wires Self Adherng Barg Rod Locking Clip UU 6515 01 521 7 LIMITATION OF LIABILITY Composite Resources Inc its employees agents comimectors seppliers and distributors shall assuma ne liability for injury or damages asing from the i i application and use of the Combat Application Tourniquet Gh A T Place the rodinside the clip locking it in place Secure the rod inside the clip with the strap The user assumes all risk of liability The CaA T should only be used as Check for bleeding and distal pulse If Prepare the patient for transport and reassess directed by user s military service companent guidelines EMS authority or bleeding Is not controlled consider additional Record the time of application under the supervision of a physician tightening or applying a second tourniquet STANDARD USE GUIDELINES Forthe military in Care under Fire sthation treatment nanmally consists of Ling a tourniquet IMMEDIATELY to stop major Bleeding of the extremities In a Tactical Freld Care situation the Trained and Aughorized Rescuer will perform
23. agency if transporting within another county Remove the faulty equipment from service ASAP and get it to the EMS Chief or your supervisor for a replacement Complete an incident report and document as many details as possible to make the repair process easier and quicker Leave the report with the equipment at Headquarters in the medical supply room Any failure of medical equipment during patient care should have the FDA 3600 form completed Refer to the WEMA policy manual Procedure Equipment Failure Page 1 of 1 16 Wilson County Emergency Management Agency Protocol Manual Procedures Esophageal Intubation Detector Syringe Type Paramedic Standing Order Assessment Indications To assist in determining the correct placement of an endotracheal or nasotracheal tube Procedure s Perform intubation Ensure all air is removed prior to placing the EID on the tube Once the EID is placed on the endotracheal tubes 15 mm adaptor pull back on the syringe A W N If the syringe pulls back easily this indicates probable tracheal intubation Additional confirmation s should be performed at least two 2 more ways 5 If the syringe does not pull back easily this indicates probable esophageal intubation and the need to reassess the airway 6 Document time and result in the patient care report PCR 7 Apply EtCO2 after confirmation with the esophageal bulb for additional confirmation Notes e Be c
24. al tube placement in a patient who is spontaneously breathing Precautions A BAAM can only be used in a patient who has spontaneous respirations with a tidal volume strong enough to create airflow through the device The BAAM will only confirm placement in the bronchial tree it will not determine if the tube tip is placed in the carina or in a bronchial mainstem An unobstructed endotracheal tube with its tip located in the pharynx can produce the whistle sound It is important to know the length of the endotracheal tube within the patient Individual situations will determine the need for pre oxygenation and or sedation Technique 1 Connect the BAAM to a 15 mm endotracheal connector lubricate the endotracheal tube 2 Place the patient in the sniffing position if no trauma is involved 3 Insert the endotracheal tube with the BAAM attached into the nostril to the posterior when the tube is advanced into the posterior nasopharynx the patient s breathing will activate the BAAM and a whistling sound will be produced with inhalation and exhalation 4 The tube is then advanced into the larynx and trachea which will increase the intensity and pitch of whistling sound 5 Deviation out of the airflow tract primarily into the esophagus will result in immediate diminution or loss of the whistle sound and indicate the need to withdraw until the whistle sound is audible and redirect the tip of the tube to maintain whistling the following steps may
25. aline b Repeat syringe bolus flush as needed Pain Insertion of the EZ IO AD amp EZ IO PD in conscious patients has been noted to cause mild to moderate discomfort usually no more painful than a large bore IV a However IO Infusion for conscious patients has been noted to cause severe discomfort b Prior to IO syringe bolus flush or continuous infusion in alert patients SLOWLY administer Lidocaine 2 Be sure the prime the EZ connection extension set with Lidocaine Preservative Free through the EZ IO Ensure that the patient has no allergies or sensitivity to Lidocaine c EZ IO PD Slowly administer 0 5 mg kg of Lidocaine 2 Preservative Free d EZ IO AD and Obese Slowly administer 20 mg 1ml 40 mg 2 ml of Lidocaine 2 Preservative Free LIDOCAINE IS FOR PARAMEDICS ONLY Procedures EZ IO Page 1 of 4 21 Wilson County Emergency Management Agency Protocol Manual Procedures 3 Procedure Explain procedure to patient family Choose appropriate Intraosseuos needle and assemble equipment Obtain assistance as needed Draw up two 2 syringes with normal saline flush 10 mL Inspect needle package to ensure sterility Connect 10 cc syringe to EZ connect prime with normal saline or Lidocaine if conscious Leave 10 mL syringe attached Position patient Supine and palpate site to locate appropriate anatomical landmarks for needle placement Locate appropriate insertion site EZ IO ADULT amp
26. areful documenting negative or positive refill of bulb document the bulb did or did not re inflate e This is one method in confirming proper placement of an endotracheal tube refer to Basic Assessment and Management A 3 page 5 Procedure EID EDD Syringe Page 1 of 1 l 18 Wilson County Emergency Management Agency Protocol Manual Procedures Glucose Analysis AEMT amp EMTP Standing Order Assessment Indications e Patients with suspected hypoglycemia diabetic emergencies change in mental status bizarre behavior etc e All suspected stroke patients Procedure 1 Gather and prepare equipment 2 Check expiration date on reagent strips confirm reagent strips lot number matches the chip in the Glucometer if applicable 3 Blood samples for performing glucose analysis should be obtained by a finger stick capillary blood Do not use venous blood from an IV catheter Place blood on reagent strip or site on glucometer per the manufacturer s instructions Document the glucometer reading and treat the patient as indicated by the protocol Repeat glucose analysis as indicated for reassessment after treatment and as per protocol N O O A Perform calibration HI amp LOW test per manufacturer s instructions Procedure Glucose Analysis Page 1 of 1 19 Wilson County Emergency Management Agency Protocol Manual Procedures Nebulized Normal Saline AEMT amp Paramedic Standing Orde
27. as exchange reduce the work of breathing decrease the sense of dyspnea and decrease the need for endotracheal intubation in patients who suffer from shortness of breath from asthma COPD pulmonary edema CO poisoning Near Drowning CHF and pneumonia In patients with CHF CPAP improves hemodynamics by reducing left ventricular preload and afterload Assessment Indications Any patient who is in respiratory distress for reasons other than trauma or pneumothorax and e Awake and able to follow commands Over 12 years old and is able to fit the CPAP mask Have the ability to maintain an open airway Has a systolic blood pressure above 90 mm Hg Uses accessory muscles during respirations Sign and symptoms consistent with asthma COPD pulmonary edema CHF or pneumonia AND who exhibit one or more of the following e A respiratory rate greater than 25 breaths per minute e Pulse Oximetry of less than 94 at any time e Use of accessory muscles during respirations Contraindications e Patient is in respiratory arrest apneic Patient is suspected of having a pneumothorax or has suffered trauma to the chest Patient has a tracheostomy Patient is actively vomiting or has upper GI bleeding Patient has decreased cardiac output obtundation and questionable ability to protect airway e g stroke obtundation etc penetrating chest trauma gastric distention severe facial injury uncontrolled vomiting e Hypotension Precautions Use care if patient Has
28. as it will go Secure the rod and band with the windless strap Document the time on the windless strap or the patient Special Notes Pitfalls A 2 tourniquet may be needed apply above the first if needed Do NOT put directly over the knee or elbow Do NOT place over a cargo pocket or bulky items Do NOT use for minimal bleeding Do NOT loosen or remove once applied Notify receiving facility ASAP that you have a tourniquet in place Not using one when indicated Placing it to proximally Not tight enough it should eliminate the distal pulse Waiting too long to apply Procedure Bleeding Control Page 2 of 4 l 3 1 Wilson County Emergency Management Agency Protocol Manual Procedures Combat Application Tourniquet Combat Application Tourniquet Instructions for Use Two handed Application Composite Resources Ine 485 Lakeshore Parkway Rock Hall SC 29720 RAW 23140 REV 01 Midi Burepa GmbH Langenhagener Strale 71I D 30E55 Langenhagener CAST combs Applica Tourniquet aod are trademarks registered in the United States and oertain other counties Apply tourniquet proximal to the bleeding Pass the red tip through the outside slit of the site Route the band around the limb and buckle The buckle will lock the band in place pass the red tip through the inside stit of the buckle US Patent Na Fedo es 7092 25 Canada Patent Ne 2569 57 EU Pateni hes 1 759 344 Germany Patent Mo G02 0059 BH 7 fr
29. at the insertion site with the needle set at a 90 degree angle to the bone surface Gently pierce the skin with the needle set until the needle set tip touches the bone c Check to ensure that at least 5mm of the catheter is visible as indicated by the proximal depth indicator If less that 5 mm of the catheter is showing the patient may have excessive soft tissue over the tibial site and the needle set may not reach the medullary space The site you have selected may not be appropriate for the EZ IO consider an alternate location for insertion d Penetrate the bone cortex by squeezing the driver s trigger and applying gentle steady downward Pressure Release the driver s trigger and stop the insertion process when 1 A sudden give or pop is felt upon entry into the medullary space 2 When desired depth is obtained 3 IMPORTANT During Intraosseuos catheter insertion use gentle steady pressure Do not use excessive force on the needle set Allow the catheter tip rotation and gentle downward pressure to provide the penetrating action STOP WHEN YOU FEEL THE POP 4 Note Ifthe driver stalls and will not penetrate the bone you may be applying too much downward pressure 5 CAUTION If catheter insertion into the site cannot be properly completed remove and dispose of the needle set in appropriate sharps biohazard container Repeat the procedure in the patient s opposite extremity or appropriate site with a new needle set e
30. d Administration V3 0 Page 1 of 1 20 2 Wilson County Emergency Management Agency Protocol Manual Procedures Intraosseuos Insertion EZ IO AEMT amp Paramedic Standing Order Assessment Indications When access is needed for a critical patient for fluid replacement or medication administration Equipment 1 2 Appropriate size Intraosseuos needle set based on pt weight Be Oe Ole ge 0 2 10 mL syringes with appropriate volume of normal saline flush minimum 5 mL 1 PD needle set for 3 39 kg If this needle is too short the AD needle may be utilized 2 AD needle set for all patients greater than 40 kg 3 Obese needle excessive tissue Non sterile non latex gloves 2 pairs Low profile EZ connect 1 Institutions current antiseptic agent Semi permeable transparent dressing optional Sterile 2 x 2 gauze if needed for skin cleansing Appropriate IV tubing Appropriate IV solution Pressure infusion system or pressure bag EZ IO driver 1 Indications for Use 1 1 Intraosseous access is useful for infusion therapy medication administration blood drawing or vascular access maintenance 2 Considerations Flow rate To ensure and improve continuous infusion flow rates always use a syringe pressure bag or infusion pump Ensure the administration of an appropriate rapid SYRINGE BOLUS flush prior to infusion NO FLUSH NO FLOW a Rapid syringe bolus flush the EZ IO with 10 ml of normal s
31. d for cardiac emergencies as indicated Procedure Main Line Prep 1 Obtain and setup equipment for vascular access set up according to manufacturer recommendations The IV tubing should always be 10 drop ml 2 Obtain Vascular access and ensure no side effects and the rate is set at TKO unless otherwise indicated Secondary Line Prep 1 Prepare a 100 mli bag of an IV solution 2 Invert the IV bag clean the injection port with alcohol and inject 150 mg of Amiodarone 3 Gently rotate the IV bag to mix medication 4 Attach a Buretrol set to the 100 ml bag 5 Place the amount of ML recommended in the Dose Medic reference manual in the Burertrol chamber 6 Close the regulator and chamber to not allow any more medication into the Buretrol set 7 Open the gravity flow controller package extension set remove the protective cover Set the volume selector to the open and ensure the clamp is open 8 Bleed all air from the IV tubing and the gravity control extension set Once all air is bled from the tubing clamp the IV tubing Note The volume selector is very hard to move for the first time do not be afraid to use slight force to open the volume selector Invert the gravity flow controller and tap to dislodge any trapped air while flushing the tubing 9 Clean the medication port on the main line with alcohol 10 Attach the secondary line with the gravity flow controller extension set to your main line tubing 11 Clamp
32. d from the tubing clamp the IV tubing Note The volume selector is very hard to move for the first time do not be afraid to use slight force to open the volume selector Invert the gravity flow controller and tap to dislodge any trapped air while flushing the tubing 11 Clean the medication port on the main line with alcohol 12 Attach the secondary line with the gravity flow controller extension set to your main line 10 drop tubing 13 Clamp turn off the main IV line make sure main secondary line drip is higher than main IV line 14 Ensure the gravity flow controller is set to 300 ml hr and open your secondary IV clamp 15 Unclamp all clamps on the secondary line 16 The infusion should be completed in about ten 10 minutes 17 Once the 50 ml bag is empty let the medication pass by the gravity flow controller since there is a significant amount of medication in the IV tubing be extremely careful and monitor do not allow any air to enter into the circulatory system 18 Clamp the secondary IV line off and remove it from the main IV line discard accordingly 19 Open main line to an appropriate rate NOTE These calculations are based on the 20 gtts ml gravity flow controller Procedure Amiodarone Mixture Page 1 of 1 l 1 Wilson County Emergency Management Agency Protocol Manual Procedures Amiodarone Mixture Pediatric Paramedic Standing Order Assessment indications This medication may be utilize
33. ding and distal clip and fully around the limb pulse f bleeding is not controlled consider additional tightening or apolying second tourniquet proximal side by side ta the first and reassess Tactical Black NSN 6515 01 521 7976 Trainer Blue NSN 6910 01 560 2972 EMS Orange NSN 6515 Obie 7129 Always store the C A T in its one handed Secure the tod and band with thee strap confi gu ration Prepare for transport and reassess If possible record time of application on white strap Procedure Bleeding Control Page 4 of 4 3 1 Wilson County Emergency Management Agency Protocol Manual Procedures Endotracheal Tube Introducer Bougie Paramedic Standing Order Clinical Indications e Patients meet clinical indications for oral intubation e Initial intubation attempt s unsuccessful e Predicted difficult intubation Contraindications e Three 3 attempts at orotracheal intubation utilize failed airway protocol e Age less than eight 8 e ETT size less than 6 5 mm Procedure 1 Prepare position and oxygenate the patient with 100 oxygen 2 Select proper ET tube without a stylet test cuff and prepare suction equipment 3 Lubricate the distal end and cuff of the endotracheal tube ETT and the distal 1 2 of the Endotracheal Tube Introducer Bougie note Failure to lubricate the Bougie and the ETT may result in being unable to pass the ETT 4 Using
34. e King LT D Once it is in the correct position the King LT D is well tolerated until the return of protective reflexes Suction must always be available when the King airway is removed lt is important that both cuffs are completely deflated prior to removal of the King airway Anticipate vomiting with removal of the King airway and position the patient on the side if possible 8 Special information Complications If unable to place the King airway in two attempts abandon further attempts and utilize bag valve mask ventilation Depth of insertion is key to providing a patent airway Ventilatory openings of the King airway must align with the laryngeal inlet for adequate ventilation to occur Accordingly the insertion depth should be adjusted to maximize ventilation Experience has indicated that initially placing the King airway deep enough to align the base of the connector to the teeth or gums inflating the cuffs and withdrawing the tube until ventilations are optimized will assist in optimal placement Ensure that the cuffs are not over inflated Inflate the cuffs with the minimum volume necessary to seal the airway at the peak ventilatory pressure If the patient becomes more alert it may be helpful in retaining the tube to remove a slight amount of the air from the balloons Most unsuccessful attempts relate to the failure to keep the tube in a midline position during insertion Do not force the tube during insertion this may re
35. e Luer Lock Adaptor on the Dextrose and Saline Flush 4 Pull 2 ml from the Dextrose into the Saline Flush for a total of 10ml 5 This provides you with D10 1Gm 10ml Procedures D50 to D10 amp D25 Page 1 of 1 l 13 INSTRUCTIONS FOR THE USE OF THE DUODOTE AUTO INJECTOR IMPORTANT Do Not Remove Gray Safety Release until ready to use CAUTION Never touch the Green Tip Needle End 1 Tear open the plastic pouch at any of the notches Remove the DuoDote Auto Injector from the pouch 2 Place the DuoDote Auto Injector in your dominant hand If you are right handed your right hand is dominant Firmly grasp the center of the DuoDote Auto Injector with the Green Tip needle end pointing down Gray Safety Release Green tip 3 With your other hand pull off the Gray Safety Release The DuoDote Auto Injector is now ready to be administered Gray Safety Release 4 The injection site is the mid outer thigh area The DuoDote Auto Injector can inject through clothing However make sure pockets at the injection site are empty Emergency Personnel Aid Self Aid 5 Swing and firmly push the Green Tip straight down a 90 angle against the mid outer thigh Continue to firmly push until you feel the DuoDote Auto Injector trigger Self Aid Emergency Personnel Aid Procedure Duodote Page 1 of 2 l 14 IMPORTANT After the auto injector triggers hold the DuoDote Auto Injector firmly in place against the injecti
36. edication in the IV tubing be extremely careful and monitor do not allow any air to enter into the circulatory system 12 Clamp the secondary IV line off and remove it from the main IV line discard accordingly 13 Open main line to an appropriate rate Calculation Volume ml divided by 0 16 time infusion rate ml hr on the gravity flow controller NOTE These calculations are based on the 20 gtts ml gravity flow controller Procedure Cardizem Add Vantage System Page 2of2 Revised 8 2015 5 1 Wilson County Emergency Management Agency Protocol Manual Procedures Central Venous Access Existing Paramedic Standing Order Assessment Indications e Access of an existing venous catheter dual or triple lumen for medication or fluid administration e Central venous access in a patient in cardiac arrest Procedure 1 Clean the port of the catheter with an alcohol wipe Clean the port extremely well 2 If there is no resistance no evidence of infiltration e g no subcutaneous collection of fluid and no pain experienced by the patient then proceed to step 4 If there is resistance evidence of infiltration pain experienced by the patient or any concern that the catheter may be clotted or dislodged do not use the catheter 3 Begin administration of medications or IV fluids slowly and observe for any signs of infiltration If difficulties are encountered stop the infusion and reassess 4 Record p
37. edle hub Attach a 5 10 cc sterile syringe to act as a handle and to cap the open IO port Grasp catheter at hub and rotate catheter and syringe clockwise a few turns to loosen catheter and then begin to gently pull upwards to a 90 degree angle from the insertion site Continue rotating clockwise and pull gently outwards at a 90 degree angle until catheter is removed DO NOT ROCK OR BEND DURING THIS PORTION OF THE PROCEDURE Dispose of catheter into a sharps container Wipe site apply pressure to site if bleeding and then cover with adhesive dressing Possible Complications with removal 1 Catheter separation from plastic hub lf this occurs grasp exposed area of catheter with a hemostat maintaining a 90 degree position Turn clockwise and counter clockwise while gently pulling upwards to remove catheter Place catheter into sharps container Wipe site apply pressure to site if bleeding and then cover with adhesive dressing 2909 Procedures EZ IO Page 4 of 4 21 Wilson County Emergency Management Agency Protocol Manual Procedures King LTSD Airway AEMT amp Paramedic Standing Order 1 Goal Purpose The King Airway LT D is to be used as an alternative to endotracheal intubation for advanced airway management It is placed in the esophagus and serves as a mechanical airway when ventilation is needed for patients who are over 4 feet tall and apneic or unconscious with ineffective ventilations The King
38. ement Agency Protocol Manual Procedures Nasal Intubation Paramedic Standing Order Assessment Indications e CNS trauma e Rigidity or hypoxia from seizures e g clenched teeth e Poisonings e Metabolic disturbance e Patients with severe respiratory distress Contraindications e Non breathing or near apneic patient e Known or likely fracture instability of mid face secondary to trauma e Relative contraindications e Blood clotting abnormalities e Nasal Polyps e Upper neck hematomas or infections e Cautious use in the head injury patient Procedure A W N CO N O O 9 Prepare position and oxygenate the patient with 100 Oxygen Choose proper ET tube about 1 mm less than for oral intubation Lubricate ET tube generously with water soluble lubricant and place BAAM device on the ET tube Pass the tube in the largest nostril with the beveled edge against the nasal septum and perpendicular to the facial plate Use forward and lateral back and forth rotational motion to advance the tube Never force the tube Continue to advance the tube noting air movement through it use the BAAM whistle to assist you Apply firm gentle cricoid pressure and advance the tube quickly past the vocal cords during inspiration Inflate the cuff with 3 to 10 cc of air secure the tube to the patient s face and confirm bilateral breath sounds Confirm placement and document results refer to the
39. endations are from Zoll medical cooperation refer to the Zoll ACLS Defibrillation Protocols The guidelines are provided the patient stays in one rhythm adjust accordingly ADULT GUIDELINES Defibrillation 1 dose ess 120 Joules Pho el R 150 Joules 3rd dose 200 Joules 1 dose 70 joules Pa E 120 Joules 3 dose 150 Joules A dose 200 Joules PEDIATRIC GUIDELINES Defibrillation 1 dose 2 Joules kilogram 2 amp additional doses 4 Joules kilogram Cardioversion 1 dose 0 5 Joule kilogram 2 amp additional doses 1 0 Joule kilogram Procedure Electrical Therapy Page 1 of 1 15 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Procedures Medical Equipment Failure Personnel shall check their vehicle and all medical equipment daily Failure of equipment does not automatically mean blame of anyone equipment will fail at some point in its lifetime If failure of medical equipment occurs follow the procedure below Procedure I 2 3 Advise your supervisor as soon as practical by phone If on a call or if it makes you unavailable for a call notify dispatch If a device fails and the device is still needed for patient care request another unit or your supervisor to respond and bring another device This could include mutual aid from anther county or
40. entilation apertures or aspiration of the lubricant Procedure King LT S D Page 1 of 3 21 1 Wilson County Emergency Management Agency Protocol Manual Procedures 5 Equipment The King LT S D airway comes in three sizes i Size 3 height 4 5 feet li Size 4 height 5 6 feet iii Size 5 height over 6 feet King LT S D Size Recommended Patient Height Cuff Volume Connector Color Yellow Red Purple e Do not use the King LTSD airway in persons lt 4 feet tall e The King airway may come prepackaged in a kit that includes the tube a 60cc or 80 cc syringe and lubricant e A tongue blade may be used to facilitate placement of the King airway 6 Procedure Insertion e Choose the correct size King airway based on the patients height e Test the cuff inflation system by injecting the maximum recommended volume of air into the cuffs e Remove all air from the cuffs prior to insertion e Apply a water based lubricant to the beveled distal tip and posterior aspect of the tube taking care to avoid the introduction of lubricant in or near the ventilatory openings Pre oxygenate the patient e Position the head The ideal head position for insertion of the King airway is the sniffing position tube can also be used with the head in a neutral position e Hold the King airway at the connector end with the dominate hand With the non dominant hand hold the mouth open and apply a chin lift unless contraindicated due
41. hen Page 1 of 2 0 Wilson County Emergency Management Agency Protocol Manual Procedures i i LT HA MEI He SOAM TE gt F MUTOALA Mea N SI ON Ve Gp T as a lt Procedure Acetaminophen Page 2 of 2 Wilson County Emergency Management Agency Protocol Manual Procedures Amiodarone Mixture Adult Paramedic Standing Order Assessment Indications This medication may be utilized for cardiac emergencies as indicated Procedure Main Line Prep 1 Obtain and setup equipment for vascular access set up according to manufacturer recommendations The IV tubing should always be 10 drop ml 2 Obtain Vascular access and ensure no side effects and the rate is set at TKO unless otherwise indicated Secondary Line Prep 1 Prepare a 50 ml bag of an IV solution 2 Prepare the Amiodarone with sterile practices 3 Clean the injection port on the IV solution 4 Invert the IV bag and inject 150 mg 3 ml of Amiodarone into the IV solution 5 Insert the Amiodarone into the medication port of the IV solution 6 Gently rotate the IV bag to mix medication 7 Attach 10 drop IV tubing to the 50 ml bag 8 Attach a gravity flow controller to the IV tubing 9 Open the gravity flow controller package extension set remove the protective cover Set the volume selector to the 300 ml hr and ensure the clamp is open 10 Bleed all air from the IV tubing and the gravity control extension set Once all air is ble
42. hest If the chest is hairy a razor may be utilized to prep the area 3 Consider the use of pain or sedating medications if patient condition allows refer to the Cardioversion and Pacing Sedation Protocol G 2 4 Set monitor defibrillator to synchronized cardioversion sync mode using the soft keys on the front keypad 5 Set energy selection to the appropriate setting see Electrical Therapy Guidelines Procedure I 15 a Multifunction combo pads use the energy selector on the monitor defibrillator 6 Make certain all personnel are clear of patient 7 Prior to attempting synchronized cardioversion ensure that the EKG signal quality is good and that sync marks are displayed above each QRS complex 8 Deliver shock a Multifunction combo pads Press and hold the shock button on the monitor defibrillator to cardiovert NOTE It may take the monitor defibrillator several cardiac cycles to synchronize so there may a delay between activating the cardioversion and the actual delivery of energy Do not release the shock button until the shock has been delivered 9 Note patient response and perform immediate unsynchronized cardioversion defibrillation if the patient s rhythm has deteriorated into pulseless ventricular tachycardia or ventricular fibrillation refer to the Defibrillation Manual Procedure l 11 10 If the patient s condition is unchanged repeat steps 2 to 8 above using escalating energy setti
43. ipple is the 5 rib normally Insert decompression needle with syringe attached at a 90 degree angle to the chest over the top of the rib confirm placement with aspiration or sudden pop or release of pressure resistance Remove the syringe and needle dispose properly and thread catheter until flush with chest wall Secure the flat side of the blue safety disk to the chest with tape Attach stop cock closed position and the Heimlich valve Secure Heimlich valve to chest with tape Slowly open stop cock and attach Heimlich to suction source and adjust suction down to 80 mmHg If needle becomes possible occluded attempt to aspirate occlusion with syringe or insert a second needle next to first site If an Air Release System ARS Needle Decompression System is used The same locations are utilized secure the IV catheter to the chest and place an Asherman chest seal over the angiocath once the needle is removed and disposed properly Pediatric is the same procedure except using an 18 or 20 gauge IV catheter Special Notes Do not administer Dopamine to patient with post traumatic hemorrhaging Do not wait for tracheal deviation and distended neck veins to become visible before decompression Procedure Chest Decompression Page 1 of 6 7 Wilson County Emergency Management Agency Protocol Manual Procedures Procedure Chest Decompression Page 2 of 6 7 Wilson County Emergency Management Agency Protoc
44. ith provided straps If the patient is in moderate distress adjust to 5cm H20 pressure titrate to best effect for the patient If patient is in Severe Distress increase the CPAP to 7 5 10cm H2O pressure titrate to best effect for the patient Check for air leaks Monitor and document the patient s respiratory response to the treatment Evaluate vital signs every 5 10 minutes If respiratory status deteriorates remove device and consider bag valve mask ventilation or other BLS ALS support per appropriate protocol intubate if indicated This device is disposable including the green oxygen adaptor Removal and notes from the Emergent are the same Procedure CPAP Page 4 of 5 10 Wilson County Emergency Management Agency Protocol Manual Procedures Procedure CPAP Page 5of 5 10 Wilson County Emergency Management Agency Protocol Manual Procedures Defibrillation Manual Paramedic Standing Order Assessment Indications Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia Procedure 1 2 3 Ensure chest compressions are adequate and interrupted only when necessary Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation Apply multifunction combo pads to the patient s chest in the proper position Anterior Posterior or sternum Apex Set the appropriate energy level refer to the Electrical Therapy Guidelines P
45. itial stroke screen on suspected stoke patients Explain your actions to the patient BEFORE doing any procedure Facial Droop Directions Normal ABNORMAL Arm Drift Directions Normal ABNORMAL Speech Directions Normal ABNORMAL Have the patient smile or show you their teeth Both sides move equally One side of the face does not move or has noticeably less movement Instruct the patient to hold their arms straight out lift the patient s arms straight out Make sure you support the arm in case the patient is unable to hold them up on their own Patient is able to hold both arms up equally One arm drifts the patient is unable to hold one arm out straight Have the patient repeat You can t teach an old dog new tricks Patient is able to repeat the phrase without slurred or inappropriate speech The patients speech is slurred or has inappropriate speech If the patient has just one 1 ABNORMAL exam there is a 72 chance the patient is experiencing a stroke The MEND exam should be utilized en route to complete a more detailed exam Alert the receiving hospital of your findings as early as possible Procedure Cincinnati Stroke Scale Page 1 of 1 l 8 Wilson County Emergency Management Agency Protocol Manual Procedures Continuous Positive Airway Pressure CPAP Advanced EMT and Paramedic Standing Order Continuous Positive Airway Pressure CPAP has been shown to rapidly improve vital signs g
46. l signs must be obtained every 5 minutes Notify receiving hospital the CPAP has been applied so they can make arrangements to continue treatment Anytime a contraindication present after application the device should be removed Procedure CPAP Page 2 of 5 10 Wilson County Emergency Management Agency Protocol Manual Procedures SIX 6 ROOT AIR PRE UREGAL CORRUGATEDMAIN ie TUBE Ai LO KINGS BAYONET MAIN GUTLET PORT A ND ER EAT HING CIRCUIT ATTACH ENT AREA RATIO PRESSURE BALANCED EXALATIONY 5 BACTERIAL vl RAL ALTER be ma IWE cas INS PR TORY CHECK VALVE PATENTEQS URFIT MASKS J SEES M WaT H HARNESS Procedure CPAP Page 3 of 5 10 Wilson County Emergency Management Agency Protocol Manual Procedures Disposable CPAP Device Procedure oes ey 00 11 12 Continue to coach patient to keep mask in place and readjust as needed 14 15 Notes Gather and assemble equipment Be sure to add the nebulizer adaptor if you think you may need it Ensure adequate oxygen supply Assess vital signs and attach pulse oximeter Make sure patient does not have a pneumothorax EXPLAIN THE PROCEDURE TO THE PATIENT Connect the CPAP to a 50 PSI oxygen outlet Select a proper size face mask and ensure that the mask fits comfortably seals the bridge of the nose and fully covers the nose and mouth Secure the mask to the patient w
47. lity You are expected to use your judgment and to always make decisions that are in the best interest of the patient e If you use more than one protocol when treating your patient you must document your reasoning in the narrative section of the Patient Care Report e If in your judgment following a protocol is not in the best interest of the patient contact medical control direction regarding your treatment Document the rationale for deviation and the name of the physician giving any orders e Any deviation from protocol should be documented in the EPCR with the rationale Procedures Deviation from Protocol Page 1 of 1 12 Wilson County Emergency Management Agency Protocol Manual Procedures Dextrose Conversion AEMT amp Paramedic Standing Order D50 to D25 Procedure 1 Open Dextrose 50 and assemble 2 Remove 25 ml by pressing the syringe waste liquid into a waste container since the contents are corrosive 3 Wipe the medication injection port of the IV bag with an alcohol prep 4 Add a needle to the Dextrose 50 syringe 5 Insert the needle of the Dextrose 50 into the medication port of the IV bag remove 25 ml of Normal Saline 6 Your Dextrose 50 is now Dextrose 25 if the medication is to be utilized more than once label it accordingly to avoid any confusion D50 to D10 Procedure 1 Open Dextrose 50 and assemble 2 Take a 10ml saline flush and remove 2 ml 3 Place a Doubl
48. move the Bougie Confirm tracheal placement according to the intubation protocol inflate the cuff with 3 to 10 cc of air auscultate for equal breath sounds and reposition accordingly 12 When final position is determined secure the ET tube reassess breath sounds apply end tidal CO2 monitor and record and monitor readings to assure continued tracheal intubation Note The Endotracheal Tube Inducer ETTI employed may not a Bougie but the terminology is used here to avoid confusion with the similar abbreviation of endotracheal tube ETT Procedure Bougie Page 1 of 1 3 2 Wilson County Emergency Management Agency Protocol Manual Procedures Capnography Paramedic Standing Order Assessment Indications Capnography shall be used when available with all endotracheal intubation nasotracheal intubation or King LT airways End Tidal C02 Detectors Waveform Procedure 1 2 3 POE 11 The capnography should be monitored as procedures are performed to verify or correct the airway problem 13 Go to the manual mode On the far left soft key press Param hit select until the EtC02 is highlighted then press enter Press enable the EtCO2 and allow it to warm up may take up to one 1 minute Insert the airway adaptor into ETCO2 cable Be sure it is aligned correctly Some adaptors only line up one 1 way do not force it Press return to go back to the main screen Press the Wave 2 soft key to dis
49. n still be effectively ventilated and your intubation should be successful since you have limited to one 1 orifice 9 Consider using a double lumen airway King LT if intubation efforts are unsuccessful 10 Apply ETCO2 detector disposable and ETCO2 Zoll if time permits and record readings Document ETT size time result success and placement location by the centimeter marks either at the patient s teeth or lips on with the patient care report PCR Document all devices used to confirm initial tube placement Also document positive or negative breath sounds before and after each movement of the patient Procedure Oral Intubation Page 1 of 1 25 Wilson County Emergency Management Agency Protocol Manual Procedures Orthostatic Vital Signs EMR EMT AEMT amp Paramedic Standing Order Assessment Indications Patients with suspected intravascular fluid deficit dehydration Contraindications 1 Patients with contraindication to supine position e g spinal immobilization 2 Patients obviously volume depleted based on history or physical exam do not require orthostatic evaluation Procedure s Gather and prepare sohygmomanometer and stethoscope With the patient supine obtain pulse and blood pressure Have the patient sit upright After 30 seconds obtain blood pressure and pulse ON sa Se IN If the systolic blood pressure falls more than 30 mm Hg or the pulse raises more than 20 bpm the patient
50. ncy Protocol Manual Procedures Procedures Rectal Medication Administration Page 2 of 2 Wilson County Emergency Management Agency Protocol Manual Procedures ResQPOD AEMT amp Paramedic Standing Order ResQPOD Circulatory Enhancer A Conventional CPR provides 15 of normal blood flow to the heart and blood flow to the brain is 25 of normal Current survival rates average 5 B The ResQPOD is an impedance threshold device that prevents unnecessary air from entering the chest during the decompression phase of CPR When air is prevented from rushing into the lungs as the chest wall recoils the vacuum negative pressure in the thorax pulls more blood back to the heart resulting in 1 Doubling of blood flow to the heart 2 50 increase in blood flow to the brain 3 Doubling of systolic blood pressure Indications A Cardiopulmonary arrest 12 years and older medical etiology Contraindications A Patients under 12 years of age B Cardiopulmonary arrest related to trauma Procedure A Confirm absence of pulse and begin CPR immediately Assure that chest wall recoils completely after each compression B Using the ResQPOD on a facemask 1 Connect ResQPOD to the facemask 2 Connect ventilation source BVM to top of ResQPOD If utilizing a mask without a bag connect a mouthpiece 3 Establish and maintain a tight face seal with mask throughout chest compressions Use a two handed technique or head s
51. nd the breathing circuit is connected To set continuous positive airway pressure turn the CPAP adjustment clockwise and observe the needle indicator on the airway pressure gauge Turn this on BEFORE applying mask If patient is in moderate distress turn CPAP adjustment clockwise to 5cm H20 pressure titrate to best effect for the patient If patient is in Severe Distress turn CPAP adjust clockwise to 10cm H2O pressure titrate to best effect for the patient Check for air leaks Continue to coach patient to keep mask in place and readjust as needed Evaluate vital signs every 5 10 minutes If respiratory status deteriorates remove device and consider bag valve mask ventilation or other BLS ALS support per appropriate protocol intubate if indicated Removal Procedure Notes CPAP therapy needs to be continuous and should not be removed unless the patient can not tolerate the mask or experiences respiratory arrest or begins to vomit Intermittent positive pressure ventilation with a Bag Valve Mask placement of a non visualized airway and or endotracheal intubation should be considered if the patient is removed from CPAP therapy Do not remove CPAP until hospital therapy is ready to be placed on patient Watch patient for gastric distention that can result in vomiting Procedure may be performed on patient with Do Not Resuscitate Order Due to changes in preload and afterload of the heart during CPAP therapy a complete set of vita
52. ngs 11 Repeat until efforts succeed or rhythm changes that does not require synchronized cardioversion 12 Document procedure response and time in the patient care report PCR Procedure Cardioversion Page 1 of 1 l 5 Wilson County Emergency Management Agency Protocol Manual Procedures Cardizem Using the Add Vantage System Paramedic Standing Order Assessment indications This medication may be utilized for cardiac emergencies as indicated Procedure Main Line Prep 1 Obtain and setup equipment for vascular access set up according to manufacturer recommendations The IV tubing should always be 10 drop ml 2 Obtain Vascular access and ensure no side effects and the rate is set at TKO unless otherwise indicated Secondary Line Prep Gather the Add Vantage bag Cardizem Buretrol set and gravity flow device 1 Assemble Use Aseptic lechniq Swing the pull ring over the top of the vial and pull down far enough to start the opening Then pull straight up to remove the cap Avoid touching the rubber stopper and vial threads 2 Activate Pul Hold diluent container and gently grasp the tab on the pull ring Pull up to break the tie membrane Pull back to remove the cover Avoid touching the inside of the vial port Screw the vial into the vial port until it will go no further Recheck the vial to assure that it is tight Label appropriately Plug Stopper to Mix Drug with Diluent
53. ol Manual Procedures T eb it Procedure Chest Decompression Page 3 of 6 Wilson County Emergency Management Agency Protocol Manual Procedures Procedure Chest Decompression Page 4 of 6 7 Wilson County Emergency Management Agency Protocol Manual Procedures Air Release System ARS Procedure Chest Decompression Page 5 of 6 7 Wilson County Emergency Management Agency Protocol Manual Procedures Procedure Chest Decompression Page 6 of 6 7 Wilson County Emergency Management Agency Protocol Manual Procedures Asherman Chest Seal EMT AEMT amp Paramedic Standing Order Assessment Indications Open pneumothorax Procedure 1 Gather equipment 2 Open the Asherman Chest Seal package 3 Clean and dry the area around the wound with a sterile 4x4 or ABD pad 4 Remove the protective liner from the adhesive coated surface Have the patient exhale and place the dressing over the wound adhesive side down with the valve directly over the wound Special Notes Be careful when you pull off the adhesive backing if you remove it fast it may fold back on itself and stick together rendering the chest seal useless Procedures Asherman Chest Seal Page 1 of 1 7 1 Wilson County Emergency Management Agency Protocol Manual Procedures Cincinnati Pre Hospital Stoke Scale EMR EMT AEMT amp Paramedic Standing Order This scale should be used for the in
54. on and IV access unobtainable or presents high risk of needlestick injury due to patient condition e Seizures Behavioral Control Midazolam Versed may be given intranasal until IV access is available e Altered Mental Status from Suspected Narcotic Overdose Naloxone Narcan may be given intranasal until IV access is available e Symptomatic Hypoglycemia Blood sugar less than 80 mg dl Glucagon may be given intranasal until IV access is available Medications administered via the IN route require a higher concentration of drug in a smaller volume of fluid than typically used in the IV route In general no more than 1 milliliter of volume can be administered during a single administration event Contraindications e Bleeding from the nose or excessive nasal discharge e Mucosal Destruction e Nasal trauma e Less than 6 months of age Technique e Draw proper dosage see below e Expel air from syringe e Attach the MAD device via LuerLock Device e Briskly compress the syringe plunger Complications e Gently pushing the plunger will_not result in atomization e Fluid may escape from the naries e IntraNasal Dosing is less effective than IV dosing Slower onset incomplete absorption e Current patient use of nasal vasoconstrictors Neosynephrine Cocaine will significantly reduce the effectiveness of IN medications Absorption is delayed peak drug level is reduced and time of drug onset is delayed Procedure Intranasal Me
55. on site for approximately 10 seconds 6 Remove the DuoDote Auto Injector from the thigh and look at Green Tip If the needle is visible the drug has been administered If the needle is not visible check to be sure the Gray Safety Release has been removed and then repeat above steps beginning with Step 4 but push harder in Step 5 Needle visible Needle not visible 7 After the drug has been administered push the needle against a hard surface to bend the needle back against the DuoDote Auto injector 8 Put the used DuoDote Auto Injector back into the plastic pouch if available Leave used DuoDote Auto Injector s with the patient to allow other medical personnel to see the number of DuoDote Auto Injector s administered 9 Immediately move yourself and the patient away from the contaminated area and seek definitive medical care for the patient DuoDote is a trademark of Meridian Medical Technologies Inc Columbia MD 21046 A subsidiary of King Pharmaceuticals Inc 1 800 776 3637 Procedure Duodote Page 2 of 2 l 14 Wilson County Emergency Management Agency Protocol Manual Procedures Electrical Therapy Guidelines Paramedic Standing Order The Zoll monitor defibrillator maximum charge is 200 Joules Zoll utilizes biphasic rectilinear technology and the following settings should be used This is a guideline on the amount of electrical therapy refer to AHA guidelines when to apply the treatment These recomm
56. ondary IV clamp 15 Unclamp all clamps on the secondary line 16 The infusion should be completed in about ten 10 minutes 17 Once the 50 ml bag is empty let the medication pass by the gravity flow controller since there is a significant amount of medication in the IV tubing be extremely careful and monitor do not allow any air to enter into the circulatory system 18 Clamp the secondary IV line off and remove it from the main IV line discard accordingly 19 Open main line to an appropriate rate Se Oe a a E O NOTE These calculations are based on the 20 gtts ml gravity flow controller Procedure Magnesium Sulfate Mixture Page 1 of 1 22 Wilson County Emergency Management Agency Protocol Manual Procedures Magnesium Sulfate Mixture Pediatric Paramedic Standing Order Assessment indications This medication may be utilized for cardiac emergencies as indicated Procedure Main Line Prep 1 Obtain and setup equipment for vascular access set up according to manufacturer recommendations The IV tubing should always be 10 drop ml 2 Obtain Vascular access and ensure no side effects and the rate is set at TKO unless otherwise indicated Secondary Line Prep 1 Prepare a 100 ml bag of an IV solution 2 Invert the IV bag clean the injection port with alcohol and inject 2000 mg 2 Grams of Magnesium Sulfate 3 Gently rotate the IV bag to mix medication 4 Attach a Buretrol set to the
57. ost common use is Valium administration for pediatric patients Procedure 1 Gather and prepare equipment a 14 gauge IV catheter filter straw or 2 5 endotracheal tube b Medication to be administered c IV catheter Remove the needle from the catheter dispose properly and apply the catheter to the needleless syringe d Endotracheal tube Remove the stylet and the 15 22mm BVM adaptor lubricate the ETT with water soluble jelly 2 Place the child in a side lying position Insert the syringe about 1 inch into the rectum 4 Administer the correct amount of medication for the patient scenario and slowly remove the syringe As you remove the syringe hold the child s buttocks together Hold or tape them together for 10 minutes Special Notes e Be careful when utilizing the entire amount of a medication when the entire amount is not going to be administered For example Valium is packaged 10mg 2ml if you are planning to administer 5 mg 1ml be sure you are in a situation where nothing happens accidentally and the entire amount is pushed e Ifthe ETT is utilized the length should be shortened or normal saline added to the syringe to the extra space within the ETT e The 2 5 ETT has a 2 5 ml air space and the 14 ga IV catheter and filter straw have about 0 25mi of air space these must be taken into account Procedures Rectal Medication Administration Page 1 of 2 29 on Wilson County Emergency Management Age
58. play EtCO2 waveform Attach the capnography sensor to endotracheal tube or supraglottic airway This can still be done while the unit is warming up Push the wave 2 soft key on the Zoll monitor defibrillator to display the ETCO2 waveform You can still get a waveform during the warmup cycle Monitor ETCO2 level and waveform changes Capnography shall remain in place and be monitored throughout the pre hospital care and transport Any loss of ETCO2 detection or waveform may indicate an airway problem and should be treated accordingly Normal ETCO2 reading should be 35 45 mmHg Document the procedure and results in the Patient Care Report PCR End Tidal C02 Detectors Color Metric Style These devices should be used as initial confirmation when a patient is intubated orally nasally or a supraglottic airway such as the King LT is utilized Refer to Reference section End Tidal CO2 User Manual J 13 Adult amp J 14 Pediatric Procedure Capnography Page 1 of 1 l 4 Wilson County Emergency Management Agency Protocol Manual Procedures Cardioversion Paramedic Standing Order Assessment Indications Unstable patient with a tachydysrhythmia rapid atrial fibrillation supraventricular tachycardia Or ventricular tachycardia with a pulse Procedure 1 Attached the four 4 lead EKG cables 2 Apply correct size multifunction pads to patient s bare chest ensure they are pushed firmly against the c
59. prove helpful 1 Laterally by twisting the tube or 2 Anteriorly by extending the neck or 3 Posteriorly by lifting the jaw and extending the neck non trauma patients 6 Once tube placement has been confirmed the BAAM should be removed and an proper size BVM should be attached Since the aperture diameter is only 4 mm it precludes long term ventilation through the device 7 Confirm placement and document results refer to the Basic Assessment and Management A 3 page 5 Special Notes The BAAM is designed for single use only and should be disposed of following use to prevent cross infection in patients The BAAM will whistle if the ET tube is in the right mainstem or the pharynx additional confirmation must be done to confirm placement at the carina 3 minimum Procedure BAAM Page 1 of 1 l 3 Wilson County Emergency Management Agency Protocol Manual Procedures Bleeding Control EMR EMT AEMT amp Paramedic Standing Order Assessment Indications Active bleeding should be treated by the EMS provider Depending on the severity of the bleeding dictates the treatment that should be administered In recent years the tourniquet and hemostatic agents have proven to save lives in major bleeding in the US military Aggressive treatment must be applied to severe uncontrolled bleeding Basic Wound Care e Direct pressure and elevation will stop most bleeding e Once bleeding has been controlled a sterile dressing should be
60. r Assessment Indications This procedure may be utilized for respiratory emergencies as indicated within the Wilson County Emergency Management Agency protocols Procedure 1 Gather all necessary equipment nebulizer and normal saline flush 2 Inject 5 mls of normal saline into the nebulizer 3 Run oxygen at 6 10 LPM 4 This may be applied by any acceptable device approved for administration a few would include oxygen mask BVM amp blow by method Procedures Humidified Saline Page 1 of 1 20 Wilson County Emergency Management Agency Protocol Manual Procedure Intranasal Medication AEMT PARAMEDIC Medication administration in a certain subgroup of patients can be a very difficult endeavor For example an actively seizing or medically restrained patient may make attempting to establish an IV almost impossible which can delay effective drug administration Moreover the paramedic or other member of the medical team may be more likely to suffer a needle stick injury while caring for these patients In order to improve pre hospital care and to reduce the risks of accidental needle stick the use of the Mucosal Atomizer Device MAD is authorized in certain patients The MAD allows certain IV medications to be administered into the nose The device creates a medication mist which lands on the mucosal surfaces and is absorbed directly into the bloodstream Assessment Indications Emergent need for medication administrati
61. rocedure any complications and fluids medications administered in the Patient Care Report PCR Special Notes e Only access these central venous access lines if the patient needs it for critical medications e DONOT access these lines as precautionary access e You MUST have received training to be able to utilize central venous access Procedure Central Venous Access Page 1 of 1 l 6 Wilson County Emergency Management Agency Protocol Manual Procedures Chest Decompression Kits Paramedic Standing Order Assessment Indications Patient with hypotension clinical signs of shock and at least one of the following signs Jugular vein distention Tracheal deviation away from the side of injury often a late sign Absent of decreased breath sounds on the affected side Hyper resonance to percussion on the affected side Increased resistance when ventilating a patient Decreased level of consciousness Rapid shallow respirations Weak thready pulses possibly no radial pulses Cook Pneumothorax Kit Procedure At 2 3 gt A HOON Administer high flow oxygen Prepare all equipment apply and secure with supplied wire tie blue safety disk to catheter just below hub make sure the flat side is to the patient s chest wall Identify and prep site with Betadine and or alcohol e 2 or 3 intercostal space at the mid clavicular line anterior chest e 4 or 5 intercostal space at the mid axillary line n
62. rocedure I 15 Charge the defibrillator to the selected energy level Continue chest compressions while the defibrillator is charging Hold compressions assertively state CLEAR and visualize that no one including yourself is in contact with the patient Deliver the shock by depressing the shock button for hands free operation Immediately resume chest compressions and ventilations for 2 minutes After 2 minutes of CPR analyze rhythm and check for pulse only if appropriate for rhythm Repeat the procedure every two 2 minutes as indicated by patient response and ECG rhythm Keep interruption of CPR compressions as brief as possible Adequate CPR is a key to successful resuscitation Procedure Manual Defibrillation Page 1 of 1 a4 Wilson County Emergency Management Agency Protocol Manual Procedures Deviation for Protocols Protocols EMR EMT AEMT or Paramedic e NEVER simply disregard a protocol e These protocols have been established so that the EMR EMT AEMT and Paramedic may provide the best care possible to patients e Most patients will be covered by a single protocol However some patients may have signs and symptoms of illness and or injury that are covered by more than one protocol or in rare cases following a protocol may not be in the best interest of the patient e n these cases you must be aware that combining protocols may lead to medication errors overdose and medication incompatibi
63. s by squeezing the specified time container firmly If leaks are found discard unit 1 Attach a Buretrol set to the 100 ml bag 2 Place the amount of ML recommended in the Dose Medic reference manual in the Buretrol chamber 25 mg is the MAX dose 3 Close the chamber to not allow any more medication into the Buretrol set 4 Open the gravity flow controller package extension set remove the protective cover Set the volume selector to the open and ensure the clamp is open 5 Bleed all air from the IV tubing and the gravity control extension set Once all air is bled from the tubing clamp the IV tubing Note The volume selector is very hard to move for the first time do not be afraid to use slight force to open the volume selector Invert the gravity flow controller and tap to dislodge any trapped air while flushing the tubing 6 Clean the medication port on the main line with alcohol 7 Attach the secondary line with the gravity flow controller extension set to your main line tubing 8 Clamp turn off the main IV line make sure secondary line drip is higher than main line 9 Ensure the gravity flow controller is set to the desired amount see below for calculation and open your secondary IV clamp 10 The infusion should be completed in ten 10 minutes 0 16 is used in your calculation below 11 Once the Buretrol is empty let the medication pass by the gravity flow controller since there is a significant amount of m
64. sult in trauma to the airway or esophagus 9 Documentation Document the size and depth in cm s of the King airway Document any complications of intubation attempts or King airway insertion Document all methods used to ensure appropriate placement of the King airway including lung sounds absence of epigastric sounds waveform capnography reading and misting of the King airway Assess and document placement verification of the King airway after every patient move and frequently during care and transportation 10 Transport Considerations Contact the intended receiving hospital as early as possible during the course of patient treatment for respiratory and or cardiac arrest Notify the hospital during the verbal report that the airway has been maintained using a King airway Ensure that the resuscitation team including the receiving physician and respiratory therapist are aware that the King airway is in place on arrival to the receiving hospital and familiarize them as needed with the equipment Procedure King LT S D Page 3 of 3 21 1 Wilson County Emergency Management Agency Protocol Manual Procedures Magnesium Sulfate Mixture Adult Paramedic Standing Order Assessment Indications This medication may be utilized for respiratory emergencies as indicated Procedure Main Line Prep 1 Obtain and setup equipment for vascular access set up according to manufacturer recommendations The IV tubing should al
65. to suspected spinal injury e With the King airway rotated laterally 45 90 degrees such that the blue orientation line is touching the corner of the mouth introduce the tip of the tube into the mouth and advance behind base of the tongue Never force the tube into position e As the tube tip passes under the tongue rotate the tube back to midline blue orientation line faces the chin e Without exerting excessive force advance the King airway until the base of the connector aligns with the teeth or gums e Fully inflate the cuffs using the maximum volume of the syringe included in the EMS kit see chart e Attach the bag valve mask device to the 15 mm connector of the King and gently bag start bagging the patient to assess ventilation simultaneously withdraw the airway until ventilation is easy and free flowing large tidal volume with minimal airway pressure e Note the depth markings to give an approximate distance in cm s to the vocal cords e Confirm proper position by auscultation chest movement and verification of CO2 using waveform capnography Paramedic only e Readjust cuff inflation to just seal the airway e Secure the King airway to the patient using an accepted method and bite block oral airway Use care not to place tape over the proximal opening of the gastric access device Procedure King LT S D Page 2 of 3 21 1 Wilson County Emergency Management Agency Protocol Manual Procedures 7 Removal of th
66. trap Do not use the ResQPOD s timing lights during CPR utilizing a facemask for ventilation Perform ACLS interventions as appropriate Prepare for endotracheal intubation C Using the ResQPOD on an endotracheal tube or Supraglottic Airway Endotracheal intubation is the preferred method of managing the airway when using the ResQPOD Place endotracheal tube or Double Lumen Airway and confirm placement Secure the tube with a Comfit for adults and per Pediatric Endotracheal Tube Securing Protocol Move the ResQPOD from the facemask to the advanced airway and turn on timing assist lights remove clear tab 4 Continue CPR with minimal interruptions a Provide continuous no pauses chest compressions approximately 10 per light flash and ventilate asynchronously over 1 second when light flashes 10 min 5 Perform ACLS interventions as appropriate 6 Ifa pulse is obtained remove the ResQPOD and assist ventilations as needed Se Sol See Special Notes Always place ETCO gt detector between the ResQPOD and ventilation source Administer endotracheal medications directly into endotracheal tube Do not interrupt CPR unless absolutely necessary If a pulse returns discontinue CPR and the ResQPOD If the patient rearrests resume CPR with the ResQPOD Do not delay compressions if the ResQPOD is not readily available VOW m Procedures ResQPOD Page 1 of 1 29 1 Wilson County Emergency Management Agency Protocol Manual
67. ture while at maximum current output stop pacing immediately If capture is observed on monitor check for corresponding pulse and assess vital signs Consider the use of sedation or analgesia if patient is uncomfortable refer to the Cardioversion and Pacing Sedation Protocol G 2 10 Document the dysrhythmia and the response to external pacing with ECG strips in the PCR Special Notes 1 2 The Zoll monitor will not pick up an EKG tracing while pacing if the 4 lead patient cable is not attached and monitoring in lead The Zoll will generally start capture at 40 60 milliamps but may require more Procedure External Pacing Page 1 of 1 27 Wilson County Emergency Management Agency Protocols amp Standing Orders Manual Procedures Pulse Oximeter EMT AEMT amp Paramedic Standing Order Assessment Indications Patients with suspected hypoxemia however it is common practice to apply to most patients and document as a vital sign Procedure 1 Apply probe to patient s finger or any other digit as recommended by the device manufacturer Younger pediatric patients may need a pediatric probe or disposable flexible probe to read accurately and stay in place Allow machine to register saturation level Record time and initial saturation percent on room air if possible on with the patient care report PCR Verify pulse rate on machine with actual pulse of the patient O A O N Monitor
68. ve it from the main IV line discard accordingly 16 Open main line to an appropriate rate NOTE Calculations are based on the 20 gtts ml gravity flow controller The rate is based on 20 minute infusion Calculations Volume 100 per Dosemedic book divided by time hour ml per hr on controller EXAMPLE 10 kg pt 25 ml DIVIDE by 0 33 hr 40 kg pt 100 ml DIVIDE by 0 33 hr 75 ml hr on gravity flow device 300 ml hr on gravity flow device Procedure Magnesium Sulfate Mixture Page 1 of 1 22 1 Wilson County Emergency Management Agency Protocol Manual Procedures Meconium Suctioning Paramedic Standing Order Assessment Indications 1 Meconium noted during birth Precautions Be cautious to prevent hypoxia Technique 1 Suction oral airway 2 Gather equipment a Correct sized endotracheal tube b Meconium aspirator c Suction set to a maximum of 80 mmHg Connect the meconium aspirator to the suction tubing Intubate newborn Apply the meconium aspirator to the endotracheal tube 15 mm adaptor Place thumb over the suction control port to regulate suction and remove meconium Suctioning should be done while the endotracheal tube is being removed Sy oh Special Notes e The newborn may have to be intubated and suctioned more than once to clear all Meconium e Refer to the Meconium Aspirator J 28 Procedures Meconium Suctioning Page 1 of 1 23 Wilson County Emergency Manag
69. ways be 10 drop ml 2 Obtain Vascular access and ensure no side effects and the rate is set at TKO unless otherwise indicated Secondary Line Prep Prepare a 50 ml bag of an IV solution Prepare the Magnesium Sulfate with sterile practices Clean the injection port on the IV solution Invert the IV bag and inject 2 Grams 4 ml of Magnesium Sulfate into the IV solution Insert the Magnesium Sulfate into the medication port of the IV solution Gently rotate the IV bag to mix medication Attach 10 drop IV tubing to the 50 ml bag Attach the gravity flow controller to the IV tubing Open the gravity flow controller package extension set remove the protective cover Set the volume selector to the 300 ml hr and ensure the clamp is open Bleed all air from the IV tubing and the gravity control extension set Once all air is bled from the tubing clamp the IV tubing Note The volume selector is very hard to move for the first time do not be afraid to use slight force to open the volume selector Invert the gravity flow controller and tap to dislodge any trapped air while flushing the tubing 11 Clean the medication port on the main line with alcohol 12 Attach the secondary line with the gravity flow controller extension set to your main line 10 drop tubing 13 Clamp turn off the main IV line make sure main secondary line drip is higher than main IV line 14 Ensure the gravity flow controller is set to 300 ml hr and open your sec

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