BEMS Protocols

EMT-Basic [B] Authorized for Clinical Practice in accordance with policy CLI-003 and guidance within this Patient Care Protocols manual and the scope of practice as outline by his/her current EMT-B certification issued by the TxDSHS. EMT-B do not have authorization from the Medical Director to perform any of the following tasks: 1. Any EMT-I restrictions 2. Assume primary care of Priority 3 acuity with ALS interventions, except for the following: a. Patient with IV access without medication administration. b. Patient who requires the following medication(s): i. Dextrose 50% or 25% ii. Oral Glucose iii. Glucagon iv. Albuterol v. Ipratropium Bromide (Atrovent) vi. Diphenhydramine (Benadryl) vii. NARCAN viii. Zofran ix. Phenergan x. Nitroglycerin Spray - stable angina xi. ASA

1. Treat the problem that is more life-threatening first. Evaluate the problem against the "ABC's", and intervene in the one(s) which affect the airway first, then the one(s) that affect breathing, and last the one(s) that affect circulation. For example, if you have a patient who is suffering from cardiac ischemia and pulmonary edema, treat the pulmonary edema ("B") first, then the cardiac ischemia ("C"). 2. If the above test does not resolve the conflict, treat the problem that is more underlying first. For example, if assessment of the present history indicates that hypertensive crisis caused pulmonary edema, then treat the hypertension first.

BEMS embraces as fundamental components of its standard of care the following concepts: The emergent patient benefits from early medical interventions, especially the early and aggressive application of airway establishment and maintenance, early administration of oxygen, early protection of the cervical spine, and early initiation of definitive therapies. The patient defines the emergency. As EMS personnel we are often called upon to assist with social or psychological problems, and we must respond as professionally and thoroughly to these as we do for medical or surgical problems. We must understand and embrace that we are officers of both public health and public safety, and we must successfully balance the demands of each. EMS is truly an extension of definitive medical care into the field, not merely a mode of transportation to the hospital. To be successful at this requires that we educate ourselves beyond first aid procedures and dedicate ourselves to being an integral part of the total health care team.

All employees are expected to adhere to the standards established in this document, unless a reasonable deviation is required in the patient's best interest. BEMS personnel's first priority in the field should be safety for themselves, patients, and the public. This includes the use of appropriate personal protective equipment. Standard of Care is dynamic, changing and improving on a regular basis. It is not possible to produce a written document; that addresses every clinical situation or that is perpetually up to date. It is therefore necessary for BEMS personnel to continuously update their own knowledge and, at times, to rely upon clinical judgment not discussed in written policy. Compassion for the patient tempered by intellectual honesty should direct BEMS personnel when applying these protocols to patient care.

Asystole Adult INDICATIONS Any patient presenting as: Pulseless Apneic WITH Asystole in two or more leads OBJECTIVES Early and effective CPR Correct any existing hypoxia Return of spontaneous circulation Correct treatable causes STANDING ORDERS CABC's CPR ECG "quick look" Intubation ECG monitoring IV Access Epinephrine 1 mg IV/IO OR Epinephrine 2 mg (1:1000) ET Epinephrine Infusion can be substituted for Epinephrine 1 mg every 3 - 5 minute single dosing. NG intubation Sodium Bicarbonate 1 mEq/kg IV, IF o Preexisting metabolic acidosis o Hyperkalemia o Tricyclic antidepressant overdose SPECIAL CONSIDERATIONS Early and effective CPR is crucial. Use Quick Combo pads for initial ECG reading Confirm rhythm in 2 or more leads. Epinephrine is indicated if intubation is accomplished prior to IV access. Repeat Epinephrine doses every 3 - 5 minutes OR Epinephrine Infusion (mix 24 mg of Epi (1:1000) into 500 mL of NS, 10-gtt drip set, infusation rate of 60 gtts/min (1 gtt/sec). Place NG tube as soon as possible for gastric distention Sodium Bicarbonate is indicated for any suspected acidosis.

Asystole Adult RATIONALE IV fluid must be NS and of the largest bore possible. IV sites must be no more peripheral than the antecubital (AC) fossa. IV's may be placed in the AC, the upper humerus arm area, or the external jugular (EJ). It is imperative that Asystole be confirmed in 2 leads, as VF can easily masquerade as Asystole in any lead. Should the patient develop spontaneous circulation, use the Post-Resuscitation Protocol. Rapid administration of epinephrine most significantly affects outcome in cardiopulmonary arrest. Therefore, it must be administered as early as possible. As ET medications are generally not effective as those given IV, IV access should be given a high priority and obtained as early as possible. Epinephrine, when given via endotracheal route in the (1:1000) concentration, needs to be diluted with NS to a total volume of 8 - 10 cc prior to administration. NG intubation should be used to decompress the stomach in all CPR patients, as gastric insufflation will inhibit effective ventilations and may exacerbate brady-asystolic dysrhythmias by pressing directly on the vagus nerve. H's Hypoxia- Oxygen and ventilation Hypovolemia- Fluid challenge Hydrogen ion (acidosis) -Sodium bicarbonate Hypo-/hyperkalemia- Cardiac Arrest Special Consideration Hypothermia -Warm fluid T's Toxins- Poisoning/Overdose Protocols Tamponade (cardiac)- Rapid Transport Tension pneumothorax- Needle Chest Decompression Thrombosis, pulmonary -Rapid Transport - PE Thrombosis, coronary- Rapid Transport - STEMI 2010 AHA Recommendations: o High-quality CPR o Minimize interruption of chest compression, no more than 10 seconds.

Rapid Transport Occasionally, EMS personnel will encounter a patient whose injury can only be treated definitively with surgery. When confronted with such a patient, the attending EMS personnel shall institute the basic interventions noted here and begin transport to an appropriate facility AS SOON AS POSSIBLE. ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INITIATING TRANSPORT: 1. Spinal motion restriction. 2. BLS airway and ventilation procedures (oxygen administration, OPA, BVM, etc.) 3. Defibrillation (only the initial three shocks) 4. Intubation IF it can be accomplished rapidly (two attempts) 5. Surgical airway (Paramedic 1 or Higher) 6. Occlusion of open chest wounds 7. Vital signs (may use peripheral pulses to estimate--see "Diagnostic Tools and Procedures" rationale) 8. Freeing patient from entrapment. All other interventions are to be done once en route to the hospital. The following represent patients for whom rapid transport is required: 1. Adult and Pediatric Critical Trauma as defined in "Transport Destination" protocol 2. Head Injury or CVA with evidence of increasing ICP 3. Suspected aortic aneurysm 4. Suspected ectopic pregnancy, abruptio placenta, or uterine rupture 5. All abdominal pain patients with unstable vital signs (tachycardia with normotension, hypotension) 6. Obstetrical emergencies resulting in possible fetal distress, such as limb presentation, breech delivery, or prolapsed cord 7. GI bleeding with unstable vital signs (tachycardia with normotension or hypotension) 8. Any other patient requiring urgent surgical intervention.

Cardiac Alert Patient Assessment Initial Assessment - Identify & manage life-threaten emergencies Obtain the chief complaint and history of present illness Acquire, analysis, and transmit 12-Lead ECG on ALL patients with chest pain or equivalent. 12-Lead ECG Interpretation Diagnosis of Acute MI Negative QRS in aVR, No LBBB ST Elevation 1 mm in 2 limb leads, or ST Elevation 2 mm in 2 chest leads Reciprocal changes o II, III, aVF <> I, aVL, V1-V6 Location of AMI: ST elevation pattern Septal MI: V1 & V2 Anterior MI: V3 & V4 Lateral MI: I, aVL; V5, V6 Inferior MI: II, III, aVF Posterior MI: ST depression (V1-V3) Interventions Establish IV access Draw blood: green, red, purple, & blue (if available) Cardiac Ischemia Protocol o Oxygen o ASA 325 mg/day o NTG spray o Morphine o NTG drip Facility Radio Report o Age/Sex o Chief complaint o Duration of symptoms o Vital Signs o Any changes 2nd IV if time permits Repeat 12-Lead ECG Transportation Ground transport if 30 minutes or less to PCI facility. Consider Air Medical Transport if > 45 minutes Cath Lab BEMS personnel will remain with the patient so long as the patient is on BEMS stretcher.

ET Medication Administration Medications may be given via the endotracheal tube IF: 1. IV access is delayed and intubation is accomplished AND 2. Auscultation reveals clear lung fields Medications given via the ET tube are not picked up as well as IV meds, require higher doses and dilution and are very susceptible to bronchial/alveolar infiltrates and alveolar wall disturbances. Medications which may be given via ET are: o Lidocaine, Atropine, Naloxone, Epinephrine The unit or "bolus" dose of any medication given via ET is to be doubled from the standard IV dose. Any medication given via the ET tube is to be diluted with NS to achieve a total volume of 10 ml.

Cardiac Arrest Medications In addition to those therapies expressly listed in the protocol as standing orders, the following medications are available for use on standing order in any cardiac arrest situation where there is evidence that they are indicated: o D50% 25-50 G o Naloxone 2-8 mg o Flumazenil 0.2-3 mg

Cardiac Arrest Special Consideration - Hyperkalemia Adult Medical - Cardiac INDICATIONS Cardiac arrest in the setting of known or suspected hyperkalemia evidenced by a history of one of the following conditions: Chronic / Acute Renal Failure Rhabdomyolysis (crush injury) Tumor Lysis Syndrome STANDING ORDERS Sodium Bicarbonate 1 mEq/kg IV Calcium Chloride 1 G IVP D50% 25 G IVP Treat dysrhythmias by their specific protocol OBJECTIVES Temporarily reduce the net circulating levels of potassium Terminate lethal arrhythmia Restore perfusing rhythm SPECIAL CONSIDERATIONS This protocol is designed to be used as an adjunct only. The medications herein are to be administered in addition to those listed in the individual protocols for the arrhythmia being treated.

Cardiac Arrest Special Consideration - Hypothermia Adult Medical - Cardiac Protect from environment o Remove any wet clothing. o Cover patient to provide / conserve warmth o Warm all oxygen and IV fluids IF temp is less than 85 F (30 C) o Do NOT attempt further defibrillations o Do NOT administer any medications o Contact medical control for further orders IF temp is greater than 85F (30 C) o Follow appropriate protocol for treatment

Chemical Restraint INDICATIONS Physical restraint is inadequate or unsuccessful in achieving the objectives of restraint EMS personnel believe that the physical restraint cannot be initiated or maintained safely and effectively without first inducing sedation CONTRAINDICATIONS Any situation in which restraint will result in harm to the patient or the EMS personnel

Chemical restraint STANDING ORDERS [P] Ketamine 1-2 mg/kg IV OR [P] Midazolam 0.5 mg IV Administer in 0.5 mg increments Maximum IV dose is 5 mg. o PEDIATRICS [P] Midazolam 0.05 mg/kg IV Administer in 0.05 mg/kg Maximum IV dose is 2 mg IF IV access is not obtainable o [P] Ketatmine 2-4 mg/kg IM OR o [P] Midazolam 0.1 mg/kg IM May repeat once in 5 minutes IF IV access can be (has already been ) ON-LINE MEDICAL CONTROL OPTIONS IF Midazolam reversal is indicated: o Flumazenil 0.2 - 3 mg IV Flumazenil dosing regimen is as follows: -0.2 mg initial dose -Repeat in 1 minute as 0.3 mg -After 1 minute, repeat as 0.5 mg -Repeat as 0.5 mg every 1 minute as needed to maximum of 3 mg. obtained:

EMT-Paramedic [P] Authorized for Clinical Practice in accordance with policy CLI-003 and guidance within this Patient Care Protocols manual and the scope of practice as outlined by his/her current EMT-P or LP certification issued by the Texas Department of State Health Services (TxDSHS).

EMT-Intermediate [I] Authorized for Clinical Practice in accordance with policy CLI-003 and guidance within this Patient Care Protocols manual and the scope of practice as outline by his/her current EMT-I certification issued by the TxDSHS. EMT-I do not have authorization from the Medical Director to perform any of the following tasks: 1. Administer narcotics1 2. Administer the sedation protocol† 3. Administer RSII medications† 4. Perform surgical airway procedures 5. Chest decompression 6. Assume primary care of Priority 1 or 2 acuity patients.

IV Starts and fluid resuscitation Unless specifically limited or prohibited by the particular protocol, medics may initiate an IV on any patient at their discretion. Patients suffering from burns, trauma or hypothermia should receive warmed IV fluids. In general, IV fluid infusion should be titrated to attain and maintain a systolic pressure of 90 - 100 mm Hg.

Endotracheal Intubation Medics may secure the airway via endotracheal intubation of any patient whom they believe is at risk for airway compromise or who requires positive pressure ventilation. Lidocaine 1 mg/kg should be administered prior to intubation attempts in any patient who is at risk for fasciculation and increased intracranial pressure. Such patients include victims of CVA's and closed head injuries.

General Therapies

General Therapies •Thiamine -100mg •Dextrose •Zofran- 4mg slow IV push for adult, 1mg slow IV (1 - 4 year of age), and 2mg slow IV push (5 - 12 year of age). •Promethazine may be given either IM or IV when ondansetron is contraindicated or refractory. Dosage is 6.25 mg - 12.5 mg for adults and 0.5 mg/kg up to 6.25 mg for pediatric patients (over 2 year of age). •IV resuscitation •ET Intubation •ET medication administration (Lidocaine, Atropine, Naloxone, Epinephrine) The unit or "bolus" dose of any medication given via ET is to be doubled from the standard IV dose. Any medication given via the ET tube is to be diluted with NS to achieve a total volume of 10 ml. •Cardiac Arrest Medications (D50% 25-50 G, Naloxone 2-8 mg, Flumazenil 0.2-3 mg) •Acetaminophen 15mg/kg if temperature is 100.5F or higher, max dose 1500mg •Sedation - (Paramedic 2 or higher) a. Etomidate 0.3mg/kg IV (20mg maximum dose) OR b. Midazolam 1-2mg OR c. Ketamine1-2mg/kgIV (200mgmaximumsingledose) •Pain Management - (Paramedic 2 or Higher) o [P] Fentanyl 1 mcg/kg IV over 2 minutes Fentanyl maximum single dose 100 mcg. Maximum total dose of Fentanyl is 200 mcg. Pediatrics: 0.5 mcg/kg, maximum dose 50 mcg (100 mcg for Burns) OR o [P] Ketamine 0.2 mg/kg IV over 60 seconds Ketamine maximum single dose 20 mg OR o [P] Morphine IV/IM Adults: 2-10 mg, given in 2 mg increments Pediatrics: 0.1-0.2 mg/kg, maximum single dose is 2 mg

Determination of Patient's Capacity To determine if a patient is competent, that is, has present mental capacity to make an informed decision to accept or refuse care. Procedures: 1. Determine scene safety. 2. If the patient is suicidal or homicidal contact police immediately. 3. In order to have decision making capacity the patient must be 18 years of age or if a minor, be emancipated, must not be suicideal or homicidal or have had their decision making capacity removed by determination of a court of law. 4. If the above criteria in #3 have been met the patient must be assessed for their ability to demonstrate the following: a. Does the patient understand their illness or injury and the benefits of treatment and/or evaluation AND b. Does the patient understand consequences (including death) or not seeking treatment and/or evaluation far their illness or injury AND c. Does the patient understand the alternatives to immediate care by EMS AND d. Can the patient describe, in his own words, the above components and provide and defend a reason for their decision not to submit to treatment or transportation? 5. A patient with any of the following MAY lack decision making capacity and should be carefully assessed for their ability to perform #4. a. Orientation to person, place or time that differs from baseline b. History of drug/alcohol ingestion with appreciable impairment such a slurred speech or unsteady gait c. Head injury with LOC, amnesia, repetitive questioning d. Medical condition such as hypovolemia, hypoxia, metabolic emergencies (e.g., diabetic issues); hypothermia, hyperthermia, etc. 6. If there is any uncertainty about the patient's present mental capacity contact Medical Control. 7. If it is determined that a patient who wishes to refuse care lacks the present mental capacity to do so contact Medical Control (on-duty Shift Commander or his/her designee) to assist with the process. 8. Document any allowed history and exam, the absence of suicidal or homicidal ideation, the components of the capacity assessment and contact with Medical Control

Informed Consent In Texas the general rule of law is that before a person may receive medical treatement they must give informed consent for that treatment. Without consent the medical treatment is unlawful. This is true regardless of whether the person receiving the treatment is a minor or has reached the age of majority (18 years of age). Informed consent is based on an individual's appreciation and understanding of the facts, implications and future consequences of an action. In order to provide informed consent or refusal a patient must have adequate reasoning faculties (capacity) and be provided with information (risks/benefits) relevant to the decision making process. They should also be aware of the options available to them if they choose not to accept evaluation and/or treatment.

Multi-Casualty Incident Management In the event of a multi-casualty incident (MCI) the following triage protocol will be used. A multi-casualty incident is defined as an incident in which the immediate medical needs ("CABC's") of all patients cannot be met by the EMS resources available at that time. BEMS EMS units will employ the Simple Triage and Rapid Treatment (START) system as part of our procedure for managing multi-casualty events. The first arriving medical personnel will clear the area of "walking wounded" by instructing them to move to a designated area. These walking wounded patients will be evaluated (using the parameters described below) once the remaining patients have been assessed. Those patients that remain after "clearing out" the walking wounded will immediately be evaluated using the following system. All patients are initially evaluated using three parameters: 1. Respiration (Ventilation) 2. Perfusion 3. Mental (Neurological) status. Assessment of these parameters will result in the patient being assigned to one of three preliminary categories: 1. Dead/non-salvageable 2. Critical/immediate 3. Delayed. This initial assessment of each patient should take no longer than 60 seconds. The assessment of these parameters should be performed as follows. 1. Respiration: If adequate, proceed to the next assessment. If inadequate, attempt to improve ventilation using basic maneuvers such as removal of debris and positioning. The patient is then classified as follows: o No respiratory effort = dead/non-salvageable. o Respiratory rate > 30 OR requires airway assistance = critical/immediate. o Respiratory rate < 30 = delayed. 2. Perfusion: The paramedic may use either capillary refill (CR) for pediatrics or the radial pulse for adults to evaluate this component. The patient is classified as follows: o CR > 2 seconds OR no radial pulse present = critical/immediate. o CR < 2 seconds OR palpable radial pulse = proceed to next assessment. 3. Neurological: The assessment of the patient's level of consciousness will result in classification as follows. o Unconscious = critical/immediate. o Altered level of consciousness = critical/immediate. o Normal level of consciousness = delayed. Once patients have been initially categorized as immediate, delayed or dead the medic responsible for triage shall complete a second, more detailed assessment of the patients and assign individual, numeric priorities to each patient. These individual priorities must be constantly updated (the patients re- assessed) by the triage officer. Resources will be allocated per these priority designations. During multi-patient incidents that involve lightning strike or electrocution, the patients who present in cardiopulmonary arrest should receive first priority. Survival rates with rapid ACLS intervention for theses injury types are high enough to warrant directing resources to these patients.

Multi-Casualty Incident Management INITIAL RESPONSE AND ASSESSMENT OF AN EVENT/INCIDENT Use IMS/ICS span of control when assigning specific the following Medical Branch positions: Establish IC-EMS/Medical Branch Director STAGING MANAGER SAFETY OFFICER(s) -Implement accountability system: o Collect vehicle tags, personnel identifiers o Conduct periodic personnel checks -Survey the area and personnel for unsafe situations or practices; correct or report them to IC or corrective action. -Observe rehab area for fatigued personnel, those displaying signs of critical incident stress or illness/injury. TRIAGE OFFICER(s) -Obtain triage ribbon/tag kits/tags -Assign staff to each triage priority location -Assign litter carriers -Triage Officer: regularly notify IC-EMS/Medical Branch of patient count and severity -Indicate patient priority -Mark clearly locations/cars that have been searched. TREATMENT OFFICER(s) -Collect equipment and supplies -Locate large, open and protected patient care division: report location to IC-EMS Branch -Assign staff to each division/group o One division officer per triage category o One Paramedic/one EMT provider per two critical patients o One EMT per five non-critical patients -Establish and clearly identify entrances and exits -Set out sector locations using tarps or flags -Coordinate patient activity with Triage Officer -Re-triage patients at entrance to the treatment sector -Ensure patients are neatly organized in the designated area: -Three feet around each patient -Heads placed in one direction -Non-ambulatory patients on backboards -Reassess patient in designated sector -Treat injuries and indicate findings on triage tag or patient log -Prepare patients fro transport ASAP -Report staffing, medical equipment, pharmaceutical and supply needs to IC-EMS Branch -Coordinate evacuation with Transport Officer

Determination of a Patient: The definition of a patient is any human being that: o Has a complaint suggestive of potential illness or injury o Requests evaluation for potential illness or injury o Has obvious evidence of illness or injury o Has experience an acute event that could reasonably lead to illness or injury o Is in a circumstance or situation that could reasonably lead to illness or injury All individuals meeting any of the above criteria are considered "patients" in the BEMS System. These criteria are intended to be considered in the broadest sense. The determination of an individual's status as a patient requires the input of both the individual and EMS personnel as well as an assessment of the circumstances that led to the 9-1-1 call. If there are any questions or doubts, the individual should be considered a patient.

NO PATIENT 1. EMS may consider a "No Patient" under the following situation: o Unable to locate a patient o Unable to physically make contact with a patient (CAD notes documentation required) o Anyone that does not fit the definition of a patient as defined above does not require an evaluation or completion of a Patient Care Report upon notification and approval of Medical Control. Where applicable, certain scene dynamic and/or situation should be documented via CAD Notes. 1. All appropriate operational information (date, time, unit, crew, etc.) 2. A narrative clearly indicating that criteria for "No Patient" were met. In other words, description or history of the event or incident. 3. Name of Medical Control authorizing the "No Patient." 4. Digital signature of the attending EMS personnel. o If there is any doubt, an individual should be deemed a patient and appropriate evaluation should be provided and documented in the PCR.

TRANSPORT OFFICER(s) Locate appropriate large area with easy access and egress in proximity to Treatment Sector; announce location to IC-EMS Branch and Staging Manager Prepare travel path and mark with ribbon/traffic cones Determine vehicle transport needs Arrange for arrival of needed vehicles with Staging Manager via assigned channel/phone Communicate with hospital coordinating center: o Determine the number of hospitals to use and their receiving capability/capacity o Record data on Tranport Log Have arriving vehicles put 'BLS' or 'ALS' in front windshield using sign or one-inch tape Organize arriving vehicles to lead adequate space between them; if located close to patients, turn engines off or relocate transport division Assign arriving patients to each vehicle: 2-3 priority patietns to each ambulance, ensuring availability of adequate transport crew. The severity of patients should be mixed if multiple are assigned to a single vehicle. Collect a designated portion of the triage tag or ID number for every patient and record data on Transport/Patient Log. Assign a hospital destination to each vehicle; provide verbal/written instructions Alert hospital coordination center with patient information (# of patients, treatment, ETA) Coordinate air evacuation: o Assign LZ safety team; air evacuation should not be used with chemical or biological patients. o Designate LZ; announce location through IC o Communicate LZ assignment with incoming aircraft via radio o Assign patients; collect patient transport tags o Notify hospital coordination center of patient information Use non-traditional vehicles to transport walking wounded patients: City of Beaumont Public Health - EMS 60 Patient Care Protocols o o o Secure buses through IC and/or Staging Manager Assign transport staff: one provider per 5- 10 patients Notify hospital coordination center of patient information

Non-EMS Certified & Licensed Medical Personnel Under no circumstance is a non-EMS licensed or certified member of the health care profession, such as a nurse or respiratory therapist, allowed to assume primary care of a patient in an ambulance operated by the City of Beaumont Public Health - EMS when they accompany a patient to the hospital during an emergency and/or non-emergency transfer. Primary care is to remain with the City of Beaumont Public Health - EMS personnel at all times. The health care provider is allowed to perform specialized care to, and for, the patient according to their individual level of expertise upon the direct/indirect orders from a physician only. The only exception to this rule is when a physician assumes direct responsibility for the patient and accompanies the patient to the hospital on board the City of Beaumont Public Health - EMS ambulance.

Dextrose Dextrose may be administered to any patient if the EMS personnel suspect hypoglycemia. In the hypoglycemic (or suspected hypoglycemic) patient with an intact gag reflex in whom an IV cannot be established, dextrose may be given orally. Oral dextrose may be administered as PO D50% or glucose paste.

Ondansetron or Promethazine Ondansetron is the drug of choice and may be given to any patient complaining of nausea and/or vomiting and do not have any contraindications to the medication. The dosage for Ondansetron is 4mg slow IV push for adult, 1mg slow IV (1 - 4 year of age), and 2mg slow IV push (5 - 12 year of age). Promethazine may be given either IM or IV when ondansetron is contraindicated or refractory. Dosage is 6.25 mg - 12.5 mg for adults and 0.5 mg/kg up to 6.25 mg for pediatric patients (over 2 year of age).

General therapies Etomidate and/or midazolam may not be used to chemically "restrain" unintubated patients, except as specifically permitted in the chemical restraint procedure protocol. Etomidate and/or midazolam may be used in any situation as described above in which the medication is not contraindicated (see the applicable drug reference page).

Pain Management - (Paramedic 2 or Higher) Unless specifically contraindicated, morphine sulfate may be administered IV/IM, fentanyl and/or Ketamine may be administered IV only in this setting for the control of pain (see drug reference and/or specific protocols for dosage regimen.) Rationale Administration of ketamine should be accompanied by midazolam to reduce the effect of emergence phenomenon, commonly associated with ketamine administration. Administration of midazolam in this setting are as followed: o Adult: 2 mg IV o Pediatric 0.05 mg/kg (Max dose 2 mg)

REFUSALS 1. All patients refusing assessment, treatment, and/or transport must: a. Be at least 18 years of age or an Emancipated minor; b. Be able to demonstrate present mental capacity in accordance with the Determination of Patient's Capacity procedure. c. NOT have been declared legally incompetent by a court of law. If a patient has been declared legally incompetent, his/her court appointed guardian has the right to consent to, or refuse, assessment, treatment, and/or transportation for the patient. d. NOT be suicidal or homicidal. 2. Patients meeting the above criteria who demonstrate present mental capacity retain the right to refuse any or all assessment, treatment, and/or transport. All patients should be encouraged to seek care. Additional resources may be employed including but not limited to involving the patients physician, additional providers such as on-duty Shift Commander, Supervisors and/or Medical Control. 3. Under no circumstances will BEMS personnel refuse or deny assessment, treatment or EMS transportation to any patient (or legal patient representative) who requests medical assistance from the provider. The initiation of assessment and/or treatment should not be dependent on the patient's willingness to accept transport. (e.g., Hypoglycemia, Ashtma, etc.) This does NOT include the administration of narcotic pain medications or sedative agents. 4. BEMS personnel shall not discourage any patient (or legal patient representative) from seeking medical care form a physician or from accepting EMS transport to a hospital. 5. When a patient with present mental capacity wishes to refuse care: a. The patient will be instructed that the evaluation and/or treatment is incomplete due to the limitations of the pre-hospital care environment; b. BEMS personnel will attempt to identify any patient perceived obstacles to treatment/transport and make reasonable efforts to address these obstacles. This includes but is not limited to the offer of transportation without treatment, or the offer of transportation to a facility not recommended by protocol. These should be offered only for the purpose of facilitating additional evaluation and/or treatment which would otherwise be refused - documentation on Destination Authorization Form. c. BEMS personnel will inform the patient of the risks of refusal and benefits of treatment/transport in accordance with their presenting complaint. It should be explained that the risks described are not comprehensive due to the diagnostic limitations of the pre- hospital environment and that their refusal may result in worsening of their condition, serious disability or death. d. The patient will be advised that they should seek immediate medical care at an Emergency Department or with their own physician and that they may call 9-1-1 again at ANY time if they wish to be transported to the hospital or if their condition changes or worsens. 6. Documentation: a. BEMS personnel must document facts sufficient to demonstrate the patient's present mental capacity and understanding of his/her condition and the consequences of refusing treatment and/or transport to include those mentioned above on the PCR. b. If a patient wishes to refuse assessment, treatment and/or transport, have the patient sign the Refusal Form relating to the refusal of specific assessment, treatment, destination recommendation, and/or transport and signature of witness, in the following priority: i. A relative of the patient ii. An independent third-party (bystander, etc.) iii. A police officer iv. A firefighter (or other first responder) v. Another EMS provider vi. Your partner as a last resort. c. If the patient refuses to sign the refusal form, BEMS personnel will document the circumstances under which the patient refused to sign.

Patient Restraint INDICATIONS *Patients in whom mental status or age (pediatric patients unable to comply with directions) makes restraint necessary for their own protection or the protection of EMS personnel *To facility assessment, treatment, & transport CONTRAINDICATIONS *Any situation in which restraint will result in harm to the patient or the EMS personnel

Patient restraint STANDING ORDERS BEMS personnel are authorized and required to use minimal reasonable force necessary to: o Impose appropriate assessment and treatment modalities o Effect transport of patients who are unable to refuse assessment, treatment or transport (as described in the patient consent/refusal policy). o Use of physical restraint is specifically authorized by standing order in cases involving a disoriented or pediatric patient in whom appropriate medical assessment, treatment, and transportation: *Is required (absence of such assessment, treatment, and transport will likely result in harm to the patient) AND *Cannot be effected without restraint. ON-LINE MEDICAL CONTROL OPTIONS *Chemical restraint, as described in the procedure below.

Patient Restraint EQUIPMENT AND SUPPLIES Physical Restraint: -Minimum of three (3) EMS personnel trained in physical restraint procedure -Triangular bandages (4) -Backboard, KED, or other such device (if indicated). -Injection lock -Stretcher Chemical Restraint: -All items for physical restraint, as listed to the left. -Midazolam (Versed) -All supplies for intramuscular (IM) and/or intravenous (IV) medication administration.

Patient restraint a. EMS personnel may not defer transport of a disoriented patient to any other entity, including law enforcement. b. Only triangular bandages (or, if available, commercial patient restraints) may be used to physically restrain patients. c. All crew members must agree on the need before applying restraint. d. BEMS personnel may not utilize restraints in a punitive or unnecessary fashion, and will enlist the assistance of law enforcement personnel as needed. Restraints must not inflict any harm on the patient or worsen pre-existing conditions. e. Chemical sedation, used in compliance with the "General Therapies" protocol, is not considered chemical restraint and is not captured by this protocol. f. The biggest threat involved with both physical and chemical restraint is compromise to the patient's airway and/or ventilatory status. EMS personnel must be extremely vigilant to protect the patient's airway and respiratory status.

Patient restraint PROCEDURE 1. Don appropriate PPE. 2. Ensure adequate manpower. a. Physical "takedown" of a potentially combative adult will generally require at least five (5) personnel, three of whom should be trained in physical restraint techniques. 3. If it is likely that restraint for the patient will result in harm to the EMS personnel (e.g., dangerous patients), defer initial control and restraint of the patient to law enforcement personnel. a. BEMS personnel will then work in conjunction with law enforcement to ensure that the patient is safely and effectively restrained in such a manner as to permit necessary medical assessment and procedures. b. The BEMS paramedic is responsible for ensuring that the patient is restrained in an appropriate manner for EMS assessment, treatment, and transport. 4. To a. One rescuer is assigned to control each of the patient's extremities b. One rescuer will remain in front of the patient, in eye contact, to act as verbal and visual physically "takedown" a potentially combative adult patient, position rescuers as follows: "decoy" c. If available, a sixth rescuer should be positioned behind the patient to help control the patient's descent to the ground. 5. When all personnel are position and ready; a. The rescuers (excluding the "decoy") should approach the patient quietly and from out of his/her line of sight b. The "decoy" should maintain communication and eye contact with the patient and continuously attempt to sooth and distract the patient. c. All four rescuers assigned to the extremities should take the patient simultaneously and lower the patient to the ground as smoothly and softly as possible. 6. All restrained patients should be secured as follows: a. Patients may be secured to the cot, to a backboard, or to another device as needed. In general, securing to the cot only is the most appropriate for adults and large children. Small children may require the "Papoose" board or KED. b. When securing a patient to the cot or backboard, the first option is to secure the patient in a supine position. The ankles and wrists should be independently tied to the cot frame (or backboard) with triangular bandages. The wrists should be tied in such a way that one arm is in normal anatomic position at the patient's side, while the other arm is secured above the patient's head. A sheet should be tied across the patient's legs, above the knees. A second sheet may be added across the patient's chest, so long as it does not impede respiratory effort. c. For patients who cannot be adequately controlled with the above procedure, the second option is to secure the patient to a cot (not a backboard) in the supine position. Secure the ankles and legs as described above. Secure the arms by tying the wrists (using triangular bandages) across the body, to the opposite side of the cot frame. Then raise the head of the cot up slightly, so that the patient's arms are pulled securely across the chest. Make certain the positioning does not inhibit respiratory effort. d. For patients who cannot be adequately controlled by the procedure in "c", the third option is to secure the patient to a cot (not a backboard) in the prone position. Secure the patient's ankles as described above. Tie the patient's wrists to the cot frame with triangular bandages, with both arms in the "down" position at the patient's sides. Then raise the head of the cot up slightly. Make certain the positioning does not inhibit respiratory effort.

Pre-hospital Termination of Resuscitation Efforts Rationale Termination of resuscitation in the out-of-hospital setting is endorsed and recommended by the American Heart Association Emergency Cardiac Care Committee (2010), the American College of Emergency Physicians EMS Section (2010) and the National Association of EMS Physicians (2010). A compilation of research has provided us with indicators as to when resuscitation efforts are futile. Continued utilization of precious EMS resources for cardiac arrest cases that are clearly futile is associated with significant costs and risks for the involved EMS personnel, the EMS system and the community as a whole. It is now clear that the most appropriate approach in certain cases of cardiac arrest which do not respond to EMS care is to discontinue resuscitative measures on the scen

Pre-hospital Termination of Resuscitation Efforts INDICATIONS Discontinuation of resuscitative measures with on-line medical control authorization for cases other than those specifically listed under standing orders on page 1 of the Resuscitation and DNR protocol CONTRAINDICATIONS -Pediatric patient (< 13 years of age) -Hypothermia -Cold water drowning -Inability to intubate or obtain IV access Persistent VF or VT -ROSC at any time during the resuscitation Family wishes resuscitation efforts to continue (does not approve discontinuation) STANDING ORDERS Resuscitation efforts may be discontinued in the adult medical (non-traumatic) patient under the following circumstances: o Age18ORfamilyofaminoris agreeable o Adequate CPR has been administered o Intubated and IV/IO access accomplished o ALS treatments in progress for >25 minutes (time starts with intubation) o Asystole/PEA continuously for >25 minutes o No ROSC at any time o ALL paramedic providers agree with decision to cease efforts o Family or patient's representative agrees to discontinuation of efforts ON-LINE MEDICAL CONTROL OPTIONS Discontinuation of resuscitative measures for patients meeting any of the criteria listed to the left.

Resuscitation & DNR SPECIAL NOTES Adult Trauma: As BEMS initiates resuscitative measures on pulseless trauma patients only in very limited cases (see protocol "Traumatic Cardiac Arrest"), we will not discontinue resuscitative measures in trauma cases. Resuscitation may be discontinued at any time in all cases regardless of the status of resuscitative measures when the following criteria are identified/found: o Multi-casualty incidents, per MCI Triage protocol o Decapitation o Decomposition or incineration o Rigor mortis o Dependent lividity o Visible trauma to the head or cardio-vascular system clearly incompatible with life o Valid "Do Not Resuscitate" directives as defined in the "Resuscitation and DNAR" rationale Consideration should be given to family or patient representative's wishes. If the family or patient representative wishes efforts to be continued or the family/patient representative's wishes remain unclear, in the informed setting, resuscitative efforts should continue. If there is no family or patient representative present, resuscitative efforts should continue. Consideration should be given to logistic factors including patient location (e.g. public place), weather and/or the safety of the crew and/or public. Chaplain services contact should be considered early in the resuscitation if termination is anticipated. Having pastoral care on scene prior to termination of efforts is optimal.

Procedure for Pre-Hospital Termination of Resuscitative Measures *As soon as it becomes apparent that the patient is a potential candidate for resuscitation termination, the medic shall: o Advise the on-duty Shift Commander o Discuss the situation with the family or patient's representative and ensure that they understand that the EMS personnel may approach them later for a decision regarding the discontinuation of resuscitative measures. *Contact pastoral care representative, if desired by the family or patient's representative. *Ensure that all indications are met and there are no contraindications for discontinuation of resuscitative measures (use the approved "checklist"). *Contact on-line medical control for authorization. *If approved, terminate resuscitative efforts. Document the time at which resuscitation is discontinued. *Notify law enforcement. *Remove all medical/clinical devices and materials from the patient except invasive devices (IV catheters, IO, ET tubes, NG tubes, etc.). Invasive devices should be capped/secured and left in place. For IV/IO's, the IV tubing may be disconnected and the catheter capped (using an injection lock or J-loop) and left in place. *Prepare the patient for viewing by the family, if they so desire. This should include cleaning the patient of blood or other material (as can be reasonably accomplished) and covering the patient's body. *Offer the opportunity to view the patient to the patient's family. Answer any questions they may have regarding the medical care given. *Complete the PCR as soon as possible. Ask law enforcement if they need a copy of the PCR faxed to them once it is complete. Obtain fax number for later use if necessary. *Release the scene to law enforcement.

ECG Monitoring ECG should be assessed and continuously monitored on ALL patients on whom ALS interventions are performed. ECG must be assessed on ALL patients complaining of chest pain (or other possible myocardial ischemia pain), shortness of breath, syncope or dizziness, or nausea/vomiting, or who display tachycardia, hypotension, or altered mental status. ECG must also be assessed on all patients who have suffered a convulsion or syncopal episode prior to EMS arrival. ECG should be assessed within 5 minutes of patient contact. Stable patients presenting in rhythms thought to be either SVT or VT MUST have a 12-Lead or multi-lead ECG (if 12-lead monitor is NOT available) obtained and recorded. See the "ECG" procedure and the "12-Lead ECG" and "Multi-Lead ECG Interpretation" references.

Pulse Oximetry Pulse oximetry shall be used to evaluate the oxygen saturation status of all patients in whom hypoxia or ischemia is suspected. Pulse oximetry may be used to titrate oxygen delivery, and will permit the EMS personnel to utilize delivery devices or flow rates other than those dictated in the protocols. Pulse oximetry readings are accurate only if: 1. The probe is able to "see" the arterial blood flow 2. The patient is reasonably well perfused peripherally This means that the probe must be firmly attached to a clean finger or toe. Nail polish may occlude the probe's light beam, so un-polished nails are preferred. Additionally, hypotensive, hypoperfused, or peripherally vasoconstricted patients are generally not good candidates for pulse oximetry. Be sure the pulse oximeter's heart rate matches the patient's palpable pulse rate, that the waveform is peaked sharply or the light is green, and that the light is flashing in concert with the patient's pulse before accepting the SaO2 value. Pulse oximeter values are reported as % SaO2 (saturation of oxygen).

Pulseless Electrical Activity INDICATIONS Any patient presenting as: Pulseless Apneic WITH Any ECG rhythm except V-Fib, V-Tach, or Asystole OBJECTIVES Early and effective CPR Correct any existing hypoxia Return of spontaneous circulation Correct treatable causes STANDING ORDERS CABC's CPR ECG "quick look" Intubation ECG monitoring IV Access [P] IF indicated, Surgical Airway IF surgical problem/injury, TRANSPORT NOW IF tension pneumothorax, Needle Chest Decompression Epinephrine 1 mg IV/IO OR Epinephrine 2 mg (1:1000) ET Epinephrine Infusion can be substituted for Epinephrine 1 mg every 3 - 5 minute single dosing. NG intubation Sodium Bicarbonate 1 mEq/kg IV, IF o Preexisting metabolic acidosis o Hyperkalemia o Tricyclic antidepressant overdose SPECIAL CONSIDERATIONS Early and effective CPR is crucial. Use Quick Combo pads for initial ECG reading Confirm rhythm in 2 or more leads. Epinephrine is indicated if intubation is accomplished prior to IV access. Repeat Epinephrine doses every 3 - 5 minutes OR Epinephrine Infusion (mix 24 mg of Epi (1:1000) into 500 mL of NS, 10-gtt drip set, infusation rate of 60 gtts/min (1 gtt/sec). Place NG tube as soon as possible for gastric distention Sodium Bicarbonate is indicated for any suspected acidosis.

Pulseless Electrical Activity Adult Medical - Cardiac RATIONALE IV fluid must be NS and of the largest bore possible. IV sites must be no more peripheral than the antecubital (AC) fossa. IV's may be placed in the AC, the upper humerus arm area, or the external jugular (EJ). ALWAYS administer a 250-500 ml fluid bolus as soon as possible if PEA cause is unclear or believed to be hypovolemia. If the patient responds to the fluid challenge then additional fluid should be given PRN. The paramedic should treat this patient as hypovolemic and establish a second IV. DO NOT, however, delay epinephrine administration to manage the fluid challenge. If it is suspected that the PEA is a product of a surgical problem, such as hypovolemia, cardiac tamponade, tension pneumothorax or pulmonary embolism, transport ASAP as in critical trauma. If tension pneumothorax is suspected, perform needle chest decompression as soon as possible. Should the patient develop spontaneous circulation, use the Post-Resuscitation Protocol. Rapid administration of epinephrine most significantly affects outcome in cardiopulmonary arrest. Therefore, it must be administered as early as possible. As ET medications are generally not effective as those given IV, IV access should be given a high priority and obtained as early as possible. Epinephrine, when given via endotracheal route in the (1:1000) concentration, needs to be diluted with NS to a total volume of 8 - 10 cc prior to administration. NG intubation should be used to decompress the stomach in all CPR patients, as gastric insufflation will inhibit effective ventilations and may exacerbate brady-asystolic dysrhythmias by pressing directly on the vagus nerve.

Resuscitation & DNR 1. When assessing an apneic/Pulseless patient, the paramedic must be aware of the following facts: a. Patients presenting in any rhythm, including asystole, can potentially be resuscitated. b. "Downtime" is an inaccurate decision tool for resuscitation, as the patient may in fact have been perfusing the brain and simply unconscious for some of that time. c. Pupil size and reactivity are not accurate signs of brain injury or death as numerous factors affect them. 2. Rigor Mortis is defined as the stiffening of body parts that occurs generally 2 to 4 hours after death. 3. Dependent lividity is defined as skin discoloration which occurs in dependent (gravitationally lower) parts of the body after blood circulation has ceased. It generally presents as blue or bluish-black areas, and is caused by the degradation of red blood cells. 4. ECG evaluation is not a required parameter when assessing the possible DOS situation. As asystole is a potentially resuscitable rhythm, its presence or absence has very little bearing on the "viability" of a given patient. 5. DO NOT RESUSCITATE requests may be honored in the following circumstances: a. An inpatient resident of a medical facility, including a nursing home, whose chart includes a written DNR order signed by the patient's physician. b. An outpatient client of a home health service whose chart is at the residence and contains a written DNR order signed by the patient's physician. c. A patient whose family or representative request that no resuscitative measures be taken AND who presents a valid, original Texas Department of State Health Services Out-of- Hospital DNR form OR a valid, original "Directive to Physicians" which states the patient does not wish resuscitative measures. d. A patient who is wearing an official Texas Department of State Health Services Out-of- Hospital DNR identification device around the neck or on the wrist. e. Patients who present out-of-state DNAR orders or DNR identification device(s), if there is no reason to question the authenticity of the order. 6. EMS personnel must actually see the original authorizing document(s). If presented with a copy, the EMS personnel must obtain on-line Medical Control authorization to honor the request. 7. If there is any doubt, question, conflict, or missing component concerning the paperwork, identification device or situation, resuscitative measures must be started and on-line Medical Control contacted for further orders. 8. If the patient or the patient's representative (family or person holding a Durable Power of Attorney) verbally indicate they wish resuscitative measures to be initiated, the wishes of the patient or the patient's representative shall supersede the written directive(s). The patient's representative's identification, date, time, and place or revocation must be documented. 9. A directive to withhold resuscitative measures shall not prevent EMS from providing appropriate emergency care to ameliorate suffering, such as oxygen administration, airway suctioning, or authorized analgesia. 10. If there are any indications of unnatural or suspicious circumstances, the provider should begin resuscitation efforts and contact medical control for direction. 11. Resuscitation efforts may not be withheld from a person known by the health care professional to be pregnant

Resuscitation & DNR Documentation Requirements for Out-of-Hospital DNR Assessment of patient's physical condition. Type of device used to confirm DNR status including patient identification number. Any problems relating to the implementation of the DNR order. Patient's attending physician. Full name, address, telephone number and relationship to patient of any witnesses used to identify the patient. If the patient is transported, the original DNR order should be kept with the patient. If the DNR order is implemented, the original DNR order should be left with the concerned parties or health care facility.

Resuscitation & DNR INDICATIONS Pulseless/apneic patient in whom there is some question as to whether to initiate or continue resuscitative measures CONTRAINDICATIONS Any person presenting in cardiac arrest who does not meet the specific criteria defined within this protocol.

Resuscitation & DNR STANDING ORDERS Resuscitative measures may be withheld or discontinued in any of the following cases: o Multi-casualty incidents per MCI Triage Protocol o Decapitation o Decomposition or incineration o Rigor mortis o Dependent lividity o Visible trauma to head or cardio-vascular system clearly incompatible with life o Valid "Do Not Resuscitate" directives as defined in the "Resuscitation & DNR" rationale ON-LINE MEDICAL CONTROL OPTIONS Any person known to be pregnant Honoring an out-of-hospital DNR when a copy of the original paperwork is produced. Withholding or discontinuing resuscitation in all other cases.

Resuscitation & DNR SPECIAL CONSIDERATIONS Pediatric patients who meet DNR criteria *Focus should shift to the surviving parents/family members o The grieving process is usually better served if the patient is transported to the emergency department o The hospital is better equipped to meet the needs of the surviving family members. *If the decision is made to transport a patient that meets the DNR criteria o Move the body to the unit o NO resuscitation efforts should be started *Transport of the deceased child in this case should be accomplished as follows: o Cover the body with a sheet o Transport in non-emergency mode o Contact the receiving facility by cell phone. Do not use AHERN. *If the paramedic believes that the scene is a "crime scene" o Surviving family members should be removed from the immediate proximity of the patient o The body and scene should be left undisturbed o Secure area until turned over to a law enforcement representative *If you encounter surviving family members prepared for such an event (i.e. terminally ill child) o Some may demonstrate an understanding of the finality of the event o They often need to start the grieving process immediately o In this setting, the grieving process is best served when: *The body is left in place *Family is allowed direct contact

SPECIAL CONSIDERATIONS Request by Law Enforcement to remove a body due to scene dynamics *On rare occasions, the possibility of retaliation against EMS or other Public Safety Personnel may the dictate removal of a DOS patient from the scene. *If it is determined the on-scene personnel would be in danger by withholding or discontinuing resuscitation on scene: o Remove the body from the scene to the unit o Leave the scene immediately *Transport of the deceased patient under these circumstances is done as follows: o Cover body with a sheet o Transport in non-emergency mode o Contact receiving facility by cell phone. Do not use AHERN SPECIAL CONSIDERATIONS Death of EMS or Public Health Personnel *EMS and/or Public Safety Personnel who meet the DNR criteria should be removed from the scene via the med unit. *Transport of the deceased patient under these circumstances is done as follows: o Cover body with a sheet o Transport in non-emergency mode o Contact receiving facility by cell phone. Do not use AHERN

Acetaminophen Acetaminophen may be administered to any febrile patient (without contraindications to the medication) presenting with a temperature of 100.5° F or greater. The dose is 15 mg/kg either PO or PR with a maximum of dose of 1500 mg. Liquid Acetaminophen may also be given through a patent gastrostomy tube when encountered in a patient unable to tolerate medications by the PO route. It is imperative that the G-tube is flushed for patency prior to administration of Acetaminophen. A minimum flush of 50cc is indicated after the Acetaminophen is administered; this helps maintain patency and prevents clogging.

Sedation - (Paramedic 2 or higher) Etomidate and/or midazolam may be used as needed to sedate intubated patients whose agitation or combativeness is threatening the status of the patient's airway or venous access. Examples might include post-resuscitation patients or patients intubated utilizing the RSII procedure. Etomidate or Ketamine should be used for the sedation of surgical and obstetric patients, while Midazolam should be used for the sedation of medical patients or Ketamine for hypotensive patients.

Cardiac Arrest Special Consideration - Hypothermia Revision Date 11/22/2011 INDICATIONS Cardiac arrest in the setting of known or suspected hypothermia with evidence of an environmental cause. OBJECTIVES -Terminate lethal arrhythmia -Restore perfusing rhythm -Prevent further heat loss SPECIAL CONSIDERATIONS Much controversy exists as to the role of ALS procedures in the profoundly hypothermic patient. Therefore, the uses of medications or defibrillation in these patients are generally withheld, except where noted in the protocol. STANDING ORDERS CABC's CPR Oxygen / BVM Ventilations ECG "quick look" Use Quick Combo pads for initial ECG reading IF V-Fib o Defibrillation @ 360 J (bi-phasic) Intubation ECG monitoring Confirm rhythm in 2 or more leads. IV Access Measure tympanic or rectal temperature Protect from environment o Remove any wet clothing. o Cover patient to provide / conserve warmth o Warm all oxygen and IV fluids IF temp is less than 85°F (30°C) o Do NOT attempt further defibrillations o Do NOT administer any medications o Contact medical control for further orders IF temp is greater than 85°F (30° C) o Follow appropriate protocol for treatment NG intubation ON-LINE MEDICAL CONTROL OPTIONS IF temp is less or equal to 85°F(30°C) o Contact for medication and treatment orders o Contact for destination determination

Special Consideration - Hypothermia Section Adult Medical - Cardiac Revision Date 11/22/2011 RATIONALE Much controversy exists as to the role of ALS procedures in the profoundly hypothermic patient. Therefore, the use of medications or defibrillation in these patients are generally withheld, except were noted so in the protocol. Oxygen is to be 100% by BVM and warmed if possible. Oxygen can be warmed by applying chemical heat packs to the humidifier and/or O2 supply line. IV shall be NS at TKO. Catheters must be large bore and no more peripheral than the AC. NG intubation should be used to decompress the stomach in all CPR patients, as gastric insufflation will inhibit effective ventilations and may exacerbate brady-asystolic dysrhythmias by pressing directly on the vagus nerve. 2010 AHA Recommendations: o High-quality CPR o Minimize interruption of chest compression, no more than 10 seconds.

Implied Consent In potentially life-threatening emergency situtions where a patient is unable to give informed consent the law presumes that the patient would give consent if able. In potentially life- threatening emergency situations, consent for emergency care is implied if the individual is: o Unable to communicate because of an injury, accident, illness, or unconsciousness and suffering from what reasonably appears to be a life-threatening injury or illness OR o Suffering from impaired present mental capacity OR o A minor who is suffering from what reasonably appears to be a life-threatening injury or illness and whose parents, managing or possessory conservator, or guardian is not present.

Substituted (Surrogate) Consent In some circumstances an individual with legal standing may give consent for a patient when the patient does not have the ability to do so because they are a minor, incarcerated or have been determined by courts to be legally incompetent. Parents or guardians are entitled to provide permission because they have the legal responsibility, and in the absence of abuse or neglect, are assumed to act n the best interests of the child. The best way to think about this is not to view the minor as "refusing" treatment, but simply to ask: Has someone who is legally competent to do so given consent to treat this minor? Without this consent, medical treatment cannot begin.

Blood Glucose (BG) Blood glucose must be assessed on all patients with altered mental status. Those patients with altered mental status which appears to be secondary to trauma should also have their blood glucose assessed IF such assessment will not delay definitive interventions, such as airway management, cervical spine immobilization, bleeding control, or transport. Blood glucose must be assessed on all patients with a history of DM or glucose problems, regardless of complaints or findings. Blood glucose must be assessed on all newborn infants (1 month of age or less). Blood glucose must be assessed on all patients 1 year or less in distress, regardless of findings or complaints. Blood glucose must be assessed on all patients who experience a seizure prior to arrival of EMS or while in the care of EMS. The chemstrips and glucometers utilized by our service are accurate when used correctly. The technique used when obtaining blood glucose via chemstrip can dramatically affect the results. The blood glucose value will be inaccurate if: 1. Blood is not placed on the stick as a "drop" 2. Blood is left on the stick too long or too short a time 3. The blood is hemolyzed 4. The blood is drawn more than 30 seconds prior to being placed on the stick 5. Prescribed procedures for clearing and reading the stick are not followed. Permissible techniques for obtaining the "well drop" of blood for use in determining a BG are as follows: 1. Utilizing a finger stick. Be sure that the puncture is large enough to allow the blood to exit the tissue without any difficulty. 2. After starting an IV, attach a syringe to the catheter hub and gently draw a blood sample. The blood must not be utilized if the is any evidence of trauma to the red cells (difficult draw, "bubbling", etc.) 3. After starting an IV, remove the stylet and allow the patient's blood to drop directly from the catheter onto the glucometer stick. Blood for BG determination may not be obtained from the stylet of an IV catheter. Blood glucose values are reported or documented in terms of milligrams per deciliter (mg/dl). After administering D25% or D50%, the blood glucose value will remain falsely elevated for quite some time as the cells attempt to uptake the glucose. Therefore, repeat D-sticks may not be useful in determining accurate BG levels. The patient's clinical status should be used to determine whether or not to administer additional dextrose. If a repeat blood glucose evaluation is used, wait at least 10 minutes after dextrose administration before obtaining one.

Temperature Temperature must be assessed on all pediatric seizure patients, all suspected septic patients, and all patients whose complaints or findings indicate possible fever. Temperature also must be obtained on all patients suspected of either hypothermia or heat stroke, and all near drowning patients who present in cardiopulmonary arrest. Temperatures greater than 100.5°F require treatment with Acetaminophen. Low grade temperatures less than 100.5°F pose no threat to the patient and are often beneficial to the patient's disease fighting capabilities and should not be treated with Acetaminophen.

Trauma alert PROCEDURES 1. Notify the EMS Communications Specialist that you have a patient meeting trauma alert criteria. 2. When activating a Trauma Alert, the following information must be provided to 911-Dispatch: a. Patient's gender and approximate age b. The specific Trauma Alert Criterion that pertains to your patient c. Mechanism of injury d. Estimated time prior to arrival at the ED. (Include packaging and transport time) 3. 911-Dispatch will contact Christus St. Elizabeth Hospital Transfer Center, (409) 899-7888 and provide the above Trauma Alert information. 4. Cancellation of Trauma Alert: a. Beaumont EMS paramedic b. Cancellation must go through 911-Dispatch; dispatch will notify the hospital. c. Can ONLY be cancelled while on scene. 5. All Trauma Alerts including cancellation must be documented in the ePCR.

The Richmond Agitation-Sedation Scale (RASS) is to be used to assess the patient's level of consciousness for sedation. Description + 4 COMBATIVE —Combative, violent, immediate danger to staff + 3 VERY AGITATED —Pulls to remove tubes or catheters; aggressive + 2 AGITATED —Frequent non-purposeful movement, fights ventilator + 1 RESTLESS —Anxious, apprehensive, movements not aggressive 0 ALERT & CALM —Spontaneously pays attention to caregiver - 1 DROWSY —Not fully alert, but has sustained awakening to voice (eye opening & contact > 10 second) - 2 LIGHT SEDATION —Briefly awakens to voice (eyes open & contract < 10 second) - 3 MODERATE SEDATION —Movement or eye opening to voice (no eye contact) - 4 DEEP SEDATION —No response to voice, but movement or eye opening to physical stimulation - 5 UNAROUSABLE —No response to voice or physical stimulation If RASS is ≥ -3 Sedation recommended If RASS is -4 or -5 Sedation adequate (Reassess later)

If a dysrhythmia is to be treated, do so in the following order: First: Treat the Rate Second: Treat the Rhythm Third: Treat the Blood Pressure 1. If low blood pressure and dysrhythmias are due to low intravascular volume, normal saline bolus (rapid) should be administered first. 2. If a patient converts to another treatable rhythm after an intervention, refer to that appropriate protocol. 3. When a patient changes from one algorithm to another algorithm, do not administer more than the maximum total dose of a medication

Thiamine Thiamine may be administered to any adult patient in whom the medic has any reason to suspect malnutrition or alcohol abuse. Thiamine should be given as 50 mg IM and 50 mg IV, as this result in longer therapeutic levels. However, in the patient with inadequate muscle mass to receive IM injections, the entire 100 mg may be given IV. Conversely, if an IV cannot be established, the medic may administer the entire 100 mg IM.

Trauma alert ADULT CRITERIA -Airway o Any intubated trauma patient or airway obstruction -Breathing o Respiratory rate adult <10 or > 30 -Circulation o Systolic blood pressure < 90mmHg with evidence of hypo-perfusion o Pre-hospital CPR -Disability o Glasgow Coma Score (GCS) 10 o Paralysis post injury Event o Falls greater > 20 feet o Amputation proximal to ankle or wrist o Penetrating injury to the head, neck, torso, or extremities proximal to the elbow and knee o Burns > 20% BSA

Trauma alert PEDIATRIC CRITERIA o Airway o Any intubated trauma patient or airway obstruction Breathing o Respiratory rate < 10 Circulation o SBP < 80mmHg ages 6-13 years o SBP < 70mmHg ages 1-6 years o SBP < 60mmHg ages birth-1 year o Pre-hospital CPR o Bradycardia with significant injury mechanism o Persistent tachycardia with evidence of hypo-perfusion or compensated shock Disability o GCS≤10 o Paralysis post injury Event o Falls > than 2.5 times patient's height o Amputation proximal to ankle or wrist o Penetrating injury to head, neck, torso, or extremities proximal to the elbow and knee o Burns > 10% if patient < 6 yrs

Cardiac Alert INCLUSION CRITERIA *Continuous chest pain < 12 hours *ECG = STEMI *Patient will tolerate transport to PCI center *No exclusion criteria met EXCLUSION CRITERIA o Cardiac Arrest o DNR o Altered mental status/Head injury o Multi-system trauma o Cardiogenic shock > 85 y/o o Pt. weight > 350 lbs. o Patient refuses verbal consent for heart cath. PROCEDURES Field Paramedic Assessment & Activation 1. Field paramedic will perform 12-Lead ECG for cardiac related illnesses or at the discretion of the paramedic. 2. Field paramedic will interpret the 12-Lead ECG to determine if a STEMI exists. 3. Obtain and interpret information as it relates to inclusion and exclusion criteria AND determine if patient is a Cardiac Alert (CA) Candidate. 4. Paramedic will contact Fire Alarm via radio and transmit the following information: a. "Cardiac Alert", age, sex, location of STEMI, cardiologist (if known), facility (St. E or Baptist), and ETA. b. Fire Alarm will contact the appropriate facility and relay above information. 1. St. Elizabeth Hospital - Transfer Center: 409-880-3777 2. Baptist Hospital - Cardiac Line: 409-212-6655 (Must speak to a charge nurse or ER physician). 5. Transmit 12-Lead ECG to appropriate facility as soon as possible. Contacting Receiving Facility - ER Department 1. BEMS paramedic will contact the receiving facility via TXMED28 (AHERN) as soon as possible if the patient if the patient meets inclusion criteria to be a cardiac alert candidate. In addition to the routine radio traffic, the following information will be included: a. "Cardiac Alert candidate" b. Location (inferior, lateral, anterior, etc.) of the STEMI c. Patient's cardiologist if known 2. Receiving facility - ER Department: Acknowledgement of Cardiac Alert radio traffic Arrival at the Emergency Department 1. The 12-Lead ECG will be shown to the ER physician (EDP) and he/she will note the accuracy of the interpretation. 2. BEMS ECG will be copied and placed in the BEMS ECG box of the ED (St. Elizabeth Hospital ONLY).

Use of Air Medical Service Authorization: PARAMEDIC-2 or HIGHER This protocol provides guidelines and authorization for the use of helicopter ambulance (air medical service) to transport a patient directly from a scene. By standing order, EMS personnel are authorized to utilize helicopter ambulances to evacuate patients at their discretion. The following are guidelines for their use; however, these do not represent absolute rules. THE ATTENDING EMS PERSONNEL ARE PERSONALLY RESPONSIBLE FOR SELECTING THE MODE OF TRANSPORT MOST BENEFICIAL FOR THE PATIENT, AND WILL BE HELD ACCOUNTABLE BY THE BEMS MEDICAL DIRECTOR FOR THEIR DECISION. The primary indication for the use of a helicopter ambulance is when the helicopter can deliver the patient to definitive care (i.e., surgery) faster than the ground unit can. This usually means: 1. A critically ill or injured patient requiring care not available from local facilities in whom extrication, basic procedures, and transport time will exceed the total call-received to arrival at the hospital time for the helicopter. 2. A multi-patient scene including urgent or critical patients where the time for additional ground units to arrive and provide transport would exceed the total time for the helicopter.

Pulseless Electrical Activity Adult Medical - Cardiac RATIONALE IV fluid must be NS and of the largest bore possible. IV sites must be no more peripheral than the antecubital (AC) fossa. IV's may be placed in the AC, the upper humerus arm area, or the external jugular (EJ). ALWAYS administer a 250-500 ml fluid bolus as soon as possible if PEA cause is unclear or believed to be hypovolemia. If the patient responds to the fluid challenge then additional fluid should be given PRN. The paramedic should treat this patient as hypovolemic and establish a second IV. DO NOT, however, delay epinephrine administration to manage the fluid challenge. If it is suspected that the PEA is a product of a surgical problem, such as hypovolemia, cardiac tamponade, tension pneumothorax or pulmonary embolism, transport ASAP as in critical trauma. If tension pneumothorax is suspected, perform needle chest decompression as soon as possible. Should the patient develop spontaneous circulation, use the Post-Resuscitation Protocol. Rapid administration of epinephrine most significantly affects outcome in cardiopulmonary arrest. Therefore, it must be administered as early as possible. As ET medications are generally not effective as those given IV, IV access should be given a high priority and obtained as early as possible. Epinephrine, when given via endotracheal route in the (1:1000) concentration, needs to be diluted with NS to a total volume of 8 - 10 cc prior to administration. NG intubation should be used to decompress the stomach in all CPR patients, as gastric insufflation will inhibit effective ventilations and may exacerbate brady-asystolic dysrhythmias by pressing directly on the vagus nerve.

V-Fib / Pulseless V-Tach Adult Medical - Cardiac INDICATIONS Any patient presenting as: Pulseless Apneic WITH V-Fibrillation or V-Tachycardia on the ECG OBJECTIVES Early and effective CPR Early defibrillation Correct any existing hypoxia Return of spontaneous circulation STANDING ORDERS CABC's CPR Oxygen / BVM Ventilations ECG "quick look" Defibrillation @ 360 J (bi-phasic) Intubation ECG monitoring IV Access Epinephrine 1 mg IV/IO OR Epinephrine 2 mg (1:1000) ET Epinephrine Infusion can be substituted for Epinephrine 1 mg every 3 - 5 minute single dosing. Amiodarone 300 mg slow IVP o Repeat as 150 mg (once) Lidocaine 1.5 mg/kg IV or 3 mg/kg ET IF VF / VT refractory to above interventions: o Procainamide 30 mg/minute IF Torsades or persistent refractoriness: o Magnesium Sulfate 2 G IVP NG intubation SPECIAL CONSIDERATIONS Early and effective CPR is crucial. Use Quick Combo pads for initial ECG reading Defibrillation after each med administration Confirm rhythm in 2 or more leads. Epinephrine is indicated if intubation is accomplished prior to IV access. Repeat Epinephrine doses every 3 - 5 minutes OR Epinephrine Infusion (mix 24 mg of Epi (1:1000) into 500 mL of NS, 10-gtt drip set, infusation rate of 60 gtts/min (1 gtt/sec). Flush IV with 10 cc NS following Amiodarone Lidocaine cumulative maximum is 3 mg/kg Procainamide maximum dose is 17 mg/kg Give Magnesium at any time for suspected Torsades Place NG tube as soon as possible for gastric distention Sodium Bicarbonate is indicated for any suspected acidosis.

Intravenous Access All IV fluids shall be normal saline (NS). An injection lock or J-loop, in place of IV fluids, may be utilized for the following cases: 1. Any patient in whom IV fluid or IV medication administration is not anticipated 2. Any patient who will receive Adenosine (injection lock ONLY) Patients suffering from burns, trauma or hypothermia should receive warmed IV fluids. IV fluid infusion should be titrated to attain and maintain a systolic pressure of 90 - 100 mm Hg with a "normal" heart rate (considering the patient's size, age, etc.) IV's should always be of an appropriate size for the patient's condition. In the out-of-hospital setting, small gauge catheters (20 - 24 ga) should be avoided whenever possible. Small gauge catheters: 1. Do not increase IV success rates 2. Do not allow adequate fluid volume administration IV tubing and drip chamber selections should be according to the following guidelines: 1. Mini-drip set (60 gtts/ml) a. Most maintenance medication infusions b. Drug reference for individual medications will specify where otherwise indicated 2. Blood or "Y" set a. Patient requiring large volumes of fluid b. Patient who may require blood at the emergency department 3. Standard (macro-drip) sets (10 gtts/ml) a. All adult and pediatric IV's other than those specified above b. Most bolus medication infusions.

Vital Signs Complete vital signs are defined as respiratory rate, pulse or heart rate (indicate which), capillary refill (in the pediatric patient less than one year of age) and blood pressure (auscultated if possible with both systolic and diastolic). Capillary refill (CR) may be used as an adjunct to blood pressure in assessing/describing the perfusion status of any patient. CR is not an acceptable substitute for BP in the patient greater than 1 year of age. A systolic BP alone (palpated BP) is acceptable ONLY: 1. As an additional vital sign in the non-urgent patient in whom an auscultated BP has already been obtained and was within normal limits. 2. In a critical patient in whom serial palpated BP's are being obtained. 3. In the patient in whom an auscultated BP ABSOLUTELY can not be obtained. An initial set of complete vital signs is to be obtained within 5 minutes of patient contact. Patients refusing treatment/transport must have one complete set of vital signs taken and charted, if the patient allows. If the vitals are out of normal limits, at least a second set should be obtained, a minimum of 5 minutes after the first. All subsequent repeat vital signs should be at least 5 minutes apart. Patients transported to a hospital must have a minimum of two (2) complete sets of vital signs obtained and recorded. "Stable" patients with non life- or limb- threatening problems should have vitals repeated every 15 minutes. Urgent or critical patients must have vitals taken every 5 to 7 minutes. Respiratory rate, blood pressure, and pulse rate are to be obtained on all patients assessed, INCLUDING children and infants. DO NOT defer BP in pediatric patients unless absolutely unobtainable. Capillary refill and peripheral pulse quality may be substituted for blood pressure measurement in the infant less than 1 year of age. The accuracy of an obtained blood pressure is influenced by many factors, one of which is the size of the cuff used. It is important that the size of the cuff be correct for the patient. A cuff too small for the arm will yield a falsely elevated blood pressure; one too large will result in a falsely low reading. The cuff should easily go around the patient's upper arm, but the air bladder should not overlap itself. The cuff itself should be 2/3 the length of the patient's upper arm. It is imperative to note the difference between a heart rate and a pulse rate. The term "heart rate" refers most correctly to the rate of electrical depolarization (usually ventricular) noted on the ECG monitor. "Pulse rate" refers to the palpable rate of perfusion noted at a pulse point. While in most patients these are identical values, this is not always the case. When reporting the rate on the ECG monitor, use the term "heart rate". When reporting the rate derived by feeling the radial, brachial, femoral, or carotid pulse, use the term "pulse rate". When using the ECG monitor or an apical pulse to observe the patient's heart rate, one must be absolutely certain that this rate correlates with the perfusing or palpable pulse rate. In the critical patient for whom time is a factor, the EMS personnel may use palpable pulses to estimate and document blood pressure. The acceptable values are as follows: o Palpable radial pulse: systolic pressure of at least 80 mm Hg o Palpable brachial pulse: systolic pressure of at least 70 mm Hg o Palpable femoral pulse: systolic pressure of at least 60 mm Hg o Palpable carotid pulse: systolic pressure of at least 50 mm Hg

A patient must be properly evaluated by EMS personnel and appropriate treatment and transportation offered. If a patient wishes to refuse offered assessment, treatment and/or transport Against Medical Advice (AMA) refer to Patient Refusal Protocol. o The definition of an adult is a person who is 18 years of age or older o Competent (see Determination of Patient's Capacity) adults have the right to consent to or refuse three separate aspects of EMS care: Assessment (which includes visual observation, palpation, obtaining vitals signs, ECG evaluation or the blood glucose, etc.) Treatment (all therapies and inventions) Transport

o The definition of a minor is: o A person under the age of 18 who is not and has never been married or who has not had the disabilities of minority (emancipation) removed for general purposes by a court. Generally, minors can neither consent to, nor refuse, medical treatment. Some minors however, are considered to be emancipated and have the rights to conset/refusal affored an adult. o A minor is considered emancipated if he or she has obtained a court order of emancipation from a Texas court. Minors may petition the court for emancipation if s/he is: (i) A resident of Texas; (ii) 17 years of age or at least 16 years of age and living separate from this parents, managing conservator or guardian; (iii) Is self-supporting and managing his own financial affairs. o In certain situations, a minor may consent to medical treatment without involvement of a parent or legal guardian. A minor may consent to treatment if the minor: Is on active duty with the US armed services; Is 16 years or older residing separately from his parents or guardian and is managing his own financial affairs (regardless of the source of income); Consents to diagnosis and treatment of any infectious/communicable disease with a reporting requirement; Is unmarried and pregnant and consents to care related to the pregnancy, other than abortion; Consents to examination and treatment relating to drug or alcholol dependency; Is unmarried and has custody of their biological child, they may consent to treatment for the child.