Introduction
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
The purpose of protocols in the out-of-hospital setting is to assure safe and effective
intervention during the out-of-hospital phase of patient care. In consideration of the unique
resources, needs, population and geography of individual service programs, the physician
medical director may choose to enhance or omit portions in accordance with Iowa Code,
Chapter 147A. Medical directors are responsible to ensure that EMS personnel use protocols,
have the training and skills required, and perform Continuous Quality Improvement (CQI)
activities. According to Iowa Administrative Code 641 – 132.9(2)”a” individual physician
medical directors duties include “developing, approving, and updating protocols to be used by
service program personnel that meet or exceed the minimum standard protocols developed by
the department.”
Use of skills in the out-of-hospital setting are limited to the EMS provider’s scope of practice
and EMS service program’s level of authorization as approved by the physician medical director.
The service program medical director must determine what skills within the level of service
authorization and provider scope of practice are to be included or not included for individual
EMS services. The Iowa EMS Scope of Practice document outlines skills by certification level.
Additionally, according to 641 – 132.8(3)”b,” service program shall “utilize department
protocols as the standard of care. The service program medical director may make changes to
the department protocols provided the changes are within the EMS provider’s scope of practice
and within acceptable medical practice. A copy of the changes shall be filed with the
department.”
Any changes or revisions made by the EMS service medical director must be on file with the
State EMS Regional Coordinator.
1
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Authorization
According to Iowa Code, Chapter 147A, emergency medical personnel may only deliver emergency care under the
direction of a physician medical director who is licensed in Iowa. The medical practice of out-of-hospital personnel
is an extension of the medical director’s license.
Protocols shall be approved, signed and dated by the EMS service medical director prior to implementation. Staff
training must be documented and on file. Any changes must be on file with your EMS Regional Coordinator. Skills
must be within the level of service authorization and EMS provider’s scope of practice.
The Service Physician Medical Director Must Approve the Protocols in Accordance with the
Authorized Level of Service
Lee County EMS Ambulance, Inc.
Transport Ambulance: Staffed 24 / 7
Level of Authorization: PS / Paramedic / Critical Care Transport (protocols attached)
These protocols are to be considered a standing order. Radio communications are not required prior to
performing any protocol action. EMT’s / Paramedic’s should call in for further direction, confirmation, or
consultation of orders whenever the situation warrants or protocol requires. __X___ YES ______ NO
The emergency medical care provider present with the highest level of certification (on the transporting service)
shall determine, based upon patient care needs, the appropriate level of provider to attend the patient during
transport. ___X__ YES ______ NO
Approval of Skills and Training Level (Physician Medical Director must approve skills based on
providers scope of practice & service authorization level).
Emergency Medical Technician:
King Airway
IV Maintenance
Glucose Monitor
Epinephrine Auto Injector
CPAP
ECG / EKG accusation / transmission
Paramedic Only:
Esophageal / tracheal double lumen airway
Gastric tube OG / NG
Needle Thoracostomy
Oral / Nasal Tracheal Intubation
RSI (attach protocol)
EKG Interpretation (multi-lead or 12 lead)
_x_
_x_
_x_
___
_x_
_x_
_x_
___
_x_
_x_
_x_
_x_
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
___
___
___
_x_
___
___
___
_x_
___
___
___
___
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Paramedic Only:
Thrombolytics (attach protocol) ___
Assessment-based SMR
_x_
Needle Cricothyrotomy
_x_
Urinary Catheterization
___
Intraosseous Insertion
_x_
YES
YES
YES
YES
YES
_x_
___
___
_x_
___
NO
NO
NO
NO
NO
I understand I am responsible for providing appropriate medical direction and overall supervision of the medical
aspects of the service program and I have reviewed this document and Iowa EMS Scope of Practice which is
defined by Iowa Administrative Code 641 – 132.
Dr. David C. Wenger-Keller M.D. ______________________________________
Physician Medical Director Signature
2
Date: ________________
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Authorized Medication List
Medications listed on this page are those referenced in the protocols. Medical directors may add, delete, and/or
substitute medications as appropriate for their service program. Additional Medications, such as those from
current AHA / ACLS guidelines, may be added by the service program medical director. Staff training must be
documented and on file.
Quantity
(6)
(1)
(2)
(X)
(1)
(2)
(1)
(1)
(4)
(2)
(2)
(6)
(1)
(2)
(1)
(1)
(2)
(1)
(2)
(2)
(4)
(2)
(1)
(2)
(2)
(4)
(2)
(2)
(3)
(1)
(2)
Medication
Albuterol
Aspirin
Glucose Paste
Oxygen
Glucagon
Amiodarone
Diphenhydramine
Epinephrine
Epinephrine
Promethazine
Atropine
Adenosine
Magnesium Sulfate
Narcan
Sodium Bicarbonate
NTG Tablets
Dextrose 50 %
Dopamine
Morphine
Fentanyl
Midazolam
Diazepam
Succinylcholine
Vecuronium
Etomidate
Rocuronium
Lactated Ringers
Normal Saline
Normal Saline
Normal Saline
Normal Saline
Concentration
Supplied
2.5 mg / 3 ml NS
Prefilled
80 mg / tablet
Bottle
15 mg / tube
Tube
Not Applicable
Tank
1 mg / 1 ml
Vial
450 mg / 9 ml
Vial
50 mg / 1 ml
Vial
1:1,000 1 mg / 1 ml
Ampule
1:10,000 1 mg / 10 ml
Prefilled
25 mg / 1 ml
Ampule
1 mg / 10 ml
Prefilled
6 mg / 2 ml
Prefilled
5 gm / 10 ml = 500 mg / 1 ml
Vial
2 mg / 2 ml
Prefilled
50 mEq / 50 ml
Prefilled
0.4 mg per tablet
Bottle
25 gm / 50 ml = 0.5 gm / 1 ml
Prefilled
400 mg / 250 ml = 1600 mcg / 1 ml Prefilled
10 mg / 1 ml
Vial
100 mcg / 2 ml = 50 mcg / 1 ml
Ampule
5 mg / 5 ml
Vial
10 mg / 2 ml = 5 mg / 1 ml
Prefilled
200 mg / 10 ml = 20 mg / 1 ml
Vial
10 mg / 10 ml
Vial
20 mg / 10 ml = 2 mg / 1 ml
Vial
50 mg / 5 ml = 10 mg / 1 ml
Vial
1000 ml
Bag
1000 ml
Bag
500 ml
Bag
250 ml
Bag
50 ml
Bag
Dr. David C. Wenger-Keller M.D. _______________________________ Date:______________
3
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Routine Care Protocol
Perform scene size up. As you approach assure safety of yourself, other rescuers and the
patient. Consider need for additional resources and communicate with dispatch.
Utilize necessary Body Substance Isolation techniques.
Remove patient from hazardous environment.
Perform Initial Assessment: Perform initially on every patient to form a general impression
of needs and priorities, treating life threatening conditions immediately.
Assess the Patient’s Airway Status:
 Responsive patient – assess for adequacy of breathing
 Unresponsive patient – maintain open airway
Assess the Patient’s Breathing:
 Adequate oxygenation and ventilation
 Assess lung sounds
 Apply oxygen via nasal cannula at 2 – 6 lpm, titrate oxygen to SpO2 of 94 – 99 %
 Apply high flow oxygen when patient clinical condition warrants, consider titrating
SpO2 to maintain 94 – 99 %
 Utilize SpO2 and ETCO2 as patient clinical condition warrants.
Assess the Patient’s Circulation:
 Check perfusion by evaluating skin condition, color, temperature
 Compare peripheral to center pulses
 Check capillary refill
 Check for and control any major hemorrhage
Assess the patient and determine if the patient has a life threatening condition.
Identify Priority Patients:
a. Poor general impression
b. Unresponsive patients
c. Responsive, not following commands
d. Breathing difficulty
e. Shock (hypoperfusion)
f. Complicated childbirth
g. Acute Coronary Syndrome
4
h. Uncontrolled bleeding
i. Syncope
j. Acute Brain Attack (CVA)
k. Multi-System Trauma
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Routine Care Protocol
Perform systematic secondary assessment of patient as indicated and treat per
appropriate protocol.
Check and record vital signs, obtain medical history, current medications, and allergies.
Check for medical alert tags including universal sign for out of hospital DNR.
If indicated, establish IV at TKO. Administer 250 ml to 500 ml fluid boluses as needed, if signs /
symptoms of dehydration are present or as patient’s clinical condition warrants.
Reassure and calm patient, providing continuous emotional support.
Position patient as indicated by condition or situation and maintain body temperature.
Monitor ECG and treat dysrhythmias if indicated following appropriate protocol.
Obtain 12-lead EKG and interpret, if patient’s condition warrants, document findings.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
All patients riding in the ambulance will be placed on the ambulance cot and secured
properly with all rails and straps (including the shoulder harness). This is the safest place
for the patient to ride in the ambulance and will be explained to them. If they continue
to refuse, they will be required to sign a refusal waiver.
Establish communications with receiving facility giving patient report as soon as possible.
Transport as soon as feasible to appropriate destination. Every attempt will be made to limit
scene time to 20 minutes except in extenuating circumstances (i.e. vehicle extrication). If
extenuating circumstances exist and scene time is over 20 minutes, documentation of
reasoning for extended scene time must be included in the PCR.
Complete written patient care report and provide a copy as soon as possible for the receiving
facility to assure continuity of patient care.
Clean, restock and check vehicle and equipment to prepare for next assignment.
You may need to use more than one protocol for any single patient.
5
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocol
Airway
Follow routine care protocol.
Breathing spontaneously, adequate oxygenation and ventilation:
 Maintain oxygenation with appropriate adjuncts, titrate SpO2 to maintain 94 – 99 %
Breathing spontaneously, without adequate oxygenation and ventilation:
 Check airway for obstruction, proceed to steps 2 or 3 as needed
 After airway is clear, assist ventilation as needed with appropriate adjuncts, high flow
oxygen
 If adequate oxygenation and ventilation is not maintained, proceed to advanced
airway
Not breathing:
 Open the airway, ventilate as needed with appropriate adjuncts and high flow oxygen
 Ventilate at appropriate rate and depth for patients clinical condition
 If adequate oxygenation and ventilation cannot be maintained, proceed to advanced
airway management
Partially obstructed (conscious patient able to talk or cough):
 Do not assist patient in dislodging obstruction.
 Give patient reassurance and encourage them to cough.
 Administer oxygen as clinical condition warrants.
 Provide immediate transport.
Completely Obstructed Airway:
 Perform American Heart Association maneuvers for airway obstruction.
 If unsuccessful, utilize laryngoscope to visualize and magill- forceps to remove
obstruction.
 If the airway remains obstructed, perform needle cricothyrotomy.
 With obstruction removed, assess lung sounds for bilateral air movement.
 Secure and maintain patient’s airway, including advanced airway if necessary.
 Apply ETCO2 monitoring for all advanced airway management procedures.
 Establish an IV when patient clinical condition warrants.
Special Considerations For Pediatric Patients:
REMEMBER THE PRIMARY CAUSE OF CARDIAC ARREST IN PEDIATRIC
PATIENTS IS THE OBSTRUCTED AIRWAY
6
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiac Arrhythmias
General Cardiac Arrest Guidelines:
Follow the American Heart Association guidelines for Basic Cardiac Life Support. Perform high
quality CPR immediately; avoid unnecessary interruptions in chest compressions. Apply cardiac
monitor and check rhythm as soon as possible.
If cardiac arrest is witnessed by EMS, or CPR is being performed adequately prior to arrival of
EMS defibrillate immediately if patient clinical condition warrants.
Defibrillate at 150 joules, first attempt, 200 joules all other attempts, when patient clinical
condition warrants.
If cardiac arrest is not witnessed by EMS, or no or inadequate CPR is being performed on EMS
arrival, perform high quality CPR for two minutes (approximately 5 cycles) prior to any
defibrillation.
When defibrillation is administered, CPR is begun immediately post shock, without pausing for a
pulse check or rhythm analysis. Perform two minutes (approximately 5 cycles) of CPR before
subsequent defibrillations.
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
For a patient in cardiac arrest ventilations should not exceed 8 – 10 bpm with high flow oxygen.
Avoid hyperventilating or over ventilating the patient. Ventilations should be administered low
and slow.
When medications are administered peripherally the medication should be flushed with 20 – 30
ml of normal saline and the extremity elevated when possible.
7
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiac Arrhythmias
Ventricular Fibrillation or Pulseless Ventricular Tachycardia:
Defibrillate at 150 joules, first attempt, 200 joules all subsequent attempts as patient clinical
condition warrants.
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
Evaluate for treatable causes.
Administer epinephrine 1:10,000 1.0 mg IV / IO / ETT, repeat every 3 – 5 minutes as patients
clinical condition warrants.
Administer amiodarone 300 mg (6 ml) IV / IO, repeat an additional 150 mg (3 ml) in 5 minutes
if persistent VF / pulseless VT.
At any time the patient converts to another rhythm, follow the appropriate protocol.
If patient has ROSC post amiodarone administration, mix 360 mg (7.2 ml) of amiodarone in 250
ml of normal saline and infuse at 40 ml / hr.
Torsades De Pointes:
Administer magnesium sulfate, 2 gm (4 ml) IV / IO, diluted in 50 ml of normal saline infuse at
300 ml / hr (also consider for know hypomagnesic state).
Asystole / PEA:
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
Evaluate for treatable causes:
Hypovolemia
Hypoxia
Acidosis
Hypo – Hyperkalemia
Hypothermia
Tension Pneumothorax
Cardiac Tamponade
Toxins
Thrombosis (pulmonary / coronary)
Administer epinephrine 1:10,000 1.0 mg IV / IO / ETT, repeat every 3 – 5 minutes as patients
clinical condition warrants.
8
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiac Arrhythmias
Perfusing Cardiac Arrhythmias:
Bradycardia:
Symptomatic bradycardia may include one of the following S/S:
Chest Pain
Pulmonary Congestion / Edema
Dyspnea
Congestive Heart Failure
Altered Mental Status
Acute Coronary Syndrome
Hypotension
Acute Myocardial Infarction
If symptomatic, administer atropine 0.5 mg IV / IO every 3 – 5 minutes as patients clinical
condition warrants, maximum dose 3.0 mg.
Consider transcutaneous pacing. (consider sedation)
OR
Consider administering dopamine infusion (see below for dosing).
OR
Consider administering epinephrine infusion (see below for dosing).
Sedation / Analgesia: administer 2 mg versed IV / IO, may repeat 2 mg prn until desired
sedation is achieved. Administer fentanyl 50 – 100 mcg for analgesia; repeat half the initial dose
every 5 minutes until sufficient analgesia is achieved. End point for administration of sedation
or analgesia is achieved when patient is comfortable, maintaining adequate blood pressure and
respiratory drive.
Dopamine: infuse premixed dopamine 400 mg in 250 ml (1600 mcg / ml), administer starting at
5 mcg / kg / min. increasing prn (titrate to life), max dose 20 mcg / kg / min. without medical
direction.
(patient weight in kilograms)
Mcg/kg/
Min.
2 mcg
5 mcg
10 mcg
15 mcg
20 mcg
2.5
**
**
1
2
2
5
**
1
2
3
4
10
**
2
4
6
8
20
1.5
4
8
11
15
30
2
6
11
17
23
40
3
8
15
23
30
50
4
9
19
28
38
60
5
11
23
34
45
70
5
13
26
39
53
80
6
15
30
45
60
90
7
17
34
51
68
100
8
19
36
56
75
110
8
21
41
62
83
120
9
23
45
68
90
130
10
24
49
73
98
140
11
26
53
79
105
150
11
28
56
84
113
160
12
30
60
90
120
Epinephrine: infusion, mix 1 mg epinephrine in 250 ml normal saline, start infusion at
2 mcg / min. Increase prn to obtain a ventricular rate of 60 bpm or greater or a blood pressure of
90 mm/Hg systolic or greater up to a maximum dose of 10 mcg / min.
2 mcg = 30 ml / hr.
4 mcg = 60 ml / hr.
9
6 mcg = 90 ml / hr. 10 mcg = 150 / hr.
8 mcg = 120 ml / hr.
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiac Arrhythmias
Perfusing Cardiac Arrhythmias:
Tachycardia:
If patient is unstable with a heart rate greater than 150 bpm:
Perform synchronized cardioversion starting at 100 joules and increasing to 150, 200 prn.
Consider sedation:
Sedation / Analgesia: administer 2 mg versed IV / IO, may repeat 2 mg prn until desired
sedation is achieved. Administer fentanyl 50 – 100 mcg for analgesia; repeat half the initial dose
every 5 minutes until sufficient analgesia is achieved. End point for administration of sedation
or analgesia is achieved when patient is comfortable, maintaining adequate blood pressure and
respiratory drive.
If the tachycardia converts to another rhythm, follow the appropriate protocol.
Monitor level of consciousness, respiratory status, and vital signs very closely.
Note: Synchronized cardioversion MAY NOT be performed on patients with a heart rate
less than 150 bpm without an on-line physician order.
Stable Wide QRS Tachycardia:
Pharmaceutical or electrical therapies for tachycardias with rates less than 150 bpm are generally
not indicated and on-line physician consultation is required.
Patient stable with wide QRS tachycardia:
If regular and monomorphic, consider administration of adenosine 12 mg rapid IV / IO, repeat in
2 minutes at 12 mg IV / IO.
Consider administration of amiodarone 150 mg (3 ml), mix in 50 ml of normal saline and infuse
at 300 ml / hr.
If tachycardia fails to resolve, or returns after initial termination, consider repeat administration
of amiodarone 150 mg (3 ml), mix in 50 ml of normal saline and infuse at 300 ml / hr.
Consult medical control for further dosage of amiodarone.
Maintenance infusion: mix 360 mg (7.2 ml) amiodarone in 250 ml normal saline and infuse at
40 ml / hr.
10
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiac Arrhythmias
Stable Wide QRS Tachycardia:
If Torsades De Pointes is suspected, urge patient to cough deeply and / or bear down.
Consider administration of magnesium sulfate, 2 gm (4 ml) IV / IO, diluted in 50 ml of normal
saline infuse at 300 ml / hr (also consider for know hypomagnesic state).
May repeat 1 gm (2 ml), IV / IO diluted in 50 ml of normal saline at 300 ml / hr.
Consult medical control for further treatment or maintenance infusions.
Stable Narrow QRS Tachycardia:
Pharmaceutical or electrical therapy for tachycardia with rates less than 150 bpm are generally
not indicated.
Patient stable with narrow complex tachycardia:
Have patient attempt vagal maneuvers.
Consider administration of adenosine 12 mg rapid IV / IO, may repeat adenosine 12 mg rapid
IV / IO after 1 minute. May consider third dose of adenosine 12 mg rapid IV / IO after 1 minute.
Use of adenosine is contraindicated in the management of patients with Wolff-ParkinsonWhite syndrome. Inquire if the patient has a history of WPW before administering
adenosine.
11
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Post Resuscitation with ROSC
Follow routine care protocol.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Consider the need for advanced airway and / or intubation, if not already performed.
Monitor wave form capnography, maintaining ETCO2 35 – 40 mmHg, (avoid hyperventilation).
Consider treatment of hypotension (SBP < 90 mmHg)
 Administer fluid boluses 500ml as needed up to 1 to 2 liters may be required
 Administer dopamine 5 mcg / kg / min. (titrate as needed)
 If bradycardic, consider administration of epinephrine drip
Note: See below for dopamine and epinephrine administration instructions.
If patient is unable to follow commands, consider induced hypothermia if it can be maintained by
the receiving facility. May need to consult with on-line medical control.
Obtain a 12-lead EKG for interpretation and documentation, initial management goal should be
to identify STEMI and transport the patient to the facility most appropriate for their needs.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
Monitor ECG and VS closely, treat arrhythmias per appropriate protocol.
Dopamine: infuse premixed dopamine 400 mg in 250 ml (1600 mcg / ml), administer starting at
5 mcg / kg / min. increasing prn (titrate to life), max dose 20 mcg / kg / min. without medical
direction.
(patient weight in kilograms)
Mcg/kg/
Min.
2 mcg
5 mcg
10 mcg
15 mcg
20 mcg
2.5
**
**
1
2
2
5
**
1
2
3
4
10
**
2
4
6
8
20
1.5
4
8
11
15
30
2
6
11
17
23
40
3
8
15
23
30
50
4
9
19
28
38
60
5
11
23
34
45
70
5
13
26
39
53
80
6
15
30
45
60
90
7
17
34
51
68
100
8
19
36
56
75
110
8
21
41
62
83
120
9
23
45
68
90
130
10
24
49
73
98
140
11
26
53
79
105
150
11
28
56
84
113
160
12
30
60
90
120
Epinephrine: infusion, mix 1 mg epinephrine in 250 ml normal saline, start infusion at
2 mcg / min. Increase prn to obtain a ventricular rate of 60 bpm or greater or a blood pressure of
90 mm/Hg systolic or greater up to a maximum dose of 10 mcg / min.
2 mcg = 30 ml / hr.
4 mcg = 60 ml / hr.
12
6 mcg = 90 ml / hr. 10 mcg = 150 / hr.
8 mcg = 120 ml / hr.
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Pediatric Cardiac Arrest:
General Cardiac Arrest Guidelines:
Follow the American Heart Association guidelines for Basic Cardiac Life Support. Perform high
quality CPR immediately; avoid unnecessary interruptions in chest compressions. Apply cardiac
monitor and check rhythm as soon as possible.
If cardiac arrest is witnessed by EMS, or CPR is being performed adequately prior to arrival of
EMS defibrillate immediately if patient clinical condition warrants.
Defibrillate at 2J/KG initial attempt, 4J/Kg all other attempts, when patient clinical condition
warrants.
If cardiac arrest is not witnessed by EMS, or no or inadequate CPR is being performed on EMS
arrival, perform high quality CPR for two minutes (approximately 5 cycles) prior to any
defibrillation.
When defibrillation is administered, CPR is begun immediately post shock, without pausing for a
pulse check or rhythm analysis. Perform two minutes (approximately 5 cycles) of CPR before
subsequent defibrillations.
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
For a patient in cardiac arrest ventilations should not exceed 10 – 12 bpm with high flow oxygen.
Avoid hyperventilating or over ventilating the patient. Ventilations should be administered low
and slow.
When medications are administered peripherally the medication should be flushed with 20 – 30
ml of normal saline and the extremity elevated when possible.
Ventricular Fibrillation or Pulseless Ventricular Tachycardia:
Defibrillate at 2J/Kg, immediately resume CPR for 2 minutes
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
 Second defibrillation at 4J/Kg.
 Subsequent defibrillations increasing by 2J/Kg, to a max of 10J/Kg, not to exceed
max adult dose.
13
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Pediatric Cardiac Arrest:
Ventricular Fibrillation or Pulseless Ventricular Tachycardia:
Evaluate for treatable causes:
Hypovolemia
Hypoxia
Acidosis
Hypo – Hyperkalemia
Hypothermia
Tension Pneumothorax
Cardiac Tamponade
Toxins
Thrombosis (pulmonary / coronary)
Administer epinephrine 1:10,000 according to length / weight based tape every 3 – 5 minutes.
(epinephrine 1:10,000 0.1 ml / kg IV / IO, every 3 – 5 minutes)
Administer amiodarone according to length / weight based tape every 5 minutes, may repeat
twice.
(amiodarone 5 mg / kg IV / IO, may repeat x 1, max single dose 300 mg)
If at any time the patient converts to another rhythm, follow the appropriate protocol.
Consider administration of magnesium sulfate, 50 mg / kg IV / IO, diluted in 50 ml of normal
saline infuse at 300 ml / hr. for Torsades De Pointes or known hypomagnesic state. Max
single dose is 2 grams.
Upon conversion to a perfusing rhythm, consult medical control for antiarrythmic therapy.
If VF / Pulseless VT returns after being temporarily defibrillated to another rhythm, return to the
last successful energy level for subsequent defibrillation.
Asystole / PEA:
Organize therapies such as rhythm and pulse checks, defibrillation, IV / IO access, medication
administration and airway management procedures around two minute cycles of high quality
CPR.
Evaluate for treatable causes:
Hypovolemia
Tension Pneumothorax
Hypoxia
Cardiac Tamponade
Acidosis
Toxins
Hypo – Hyperkalemia
Thrombosis (pulmonary / coronary)
Hypothermia
Administer epinephrine 1:10,000 according to length / weight based tape every 3 – 5 minutes.
(epinephrine 1:10,000 0.1 ml / kg IV / IO, every 3 – 5 minutes)
14
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Pediatric Cardiac Arrest:
Cardiac Arrhythmias With Pulse:
Stable patient with a pulse:
Maintain oxygenation and ventilation with adjuncts as needed, titrate SpO2 94 – 99 %.
Evaluate treatable causes.
Bradycardia With Signs Of Poor Perfusion Despite Oxygenation & Ventilation:
Start immediate high quality CPR if pulse is less than 60 bpm and altered mental status.
Administer epinephrine 1:10,000 according to length / weight based tape every 3 – 5 minutes.
(epinephrine 1:10,000 0.1 ml / kg IV / IO, every 3 – 5 minutes)
Consider administration of atropine according to length / weight based tape.
(atropine 0.02 mg / kg IV / IO, minimum dose 0.1 mg, max dose 0.5 mg)
Tachycardia:
Pharmaceutical or electrical therapy for tachycardia with rates less than 180 bpm in children or
210 bpm in infants are generally not indicated.
Patient unstable:
Perform synchronized cardioversion according to length / weight based tape immediately.
Patient stable:
Sinus Tachycardia (rate < 180 child or < 210 infant):
Observe, supportive care, rapid transport.
Stable SVT (rate > 180 child or > 210 infant):
Administer adenosine according to length / weight based tape.
(adenosine 0.1 mg / kg, if no effect double dose x 1, max dose 12 mg)
Stable Wide QRS (rate >180 child or > 210 infant):
Administer amiodarone according to length / weight based tape.
(amiodarone 5 mg / kg IV /IO, mix in 50 ml of normal saline, run at 150 ml / hr.)
Note: consider consultation with medical control for pediatric emergency arrhythmias.
15
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Newborn Resuscitation & Care:
Follow routine care protocol.
Suction the airway using a bulb syringe as soon as the head is delivered and before delivery of
the body. Suction first the mouth and then the nose.
Once the baby is delivered, (note date, time, place), dry the baby, replace wet towels with dry
towels. Wrap the baby in towels or blankets to maintain body temperature, cover the scalp to
preserve warmth.
Open and position the airway. Suction the airway again using the bulb syringe. Suction first the
mouth and then the nose.
If baby does not have spontaneously vigorous cry, dry, warm, position, suction, tactile
stimulation is performed.
Assess breathing and adequacy of ventilation.
If ventilation is inadequate, stimulate by gently rubbing the back and flicking the soles of the
feet.
If ventilation is still inadequate after brief stimulation, begin assisted ventilation at 40 – 60 bpm
using a infant BVM with room air. If no improvement after 30 – 60 seconds, apply high flow
oxygen to BVM.
If ventilation is adequate and the infant displays central cyanosis, administer oxygen at 5 lpm
via blow-by. Hold the tubing ½ inch from the infant’s nose.
If the heart rate is slower than 60 bpm after 30 seconds of assisted ventilation with high
flow oxygen, initiate the following actions:
 Begin high quality chest compressions at a combined rate of 120 / minute (three
compressions to each ventilation).
 If there is no improvement in the heart rate after 30 seconds, consider upgrading to
advanced airway (perform endotracheal intubation), apply and continuously monitor
capnography.
 If no improvement in heart rate after intubation and ventilation, administer:
- Reference length / weight based tape for equipment / medication dosages
- Epinephrine 1:10,000 0.01 mg / kg IV / IO, max dose 1 mg
- Repeat epinephrine at the same dose every 3 – 5 minutes prn
Initiate rapid transport; reassess heart rate and respiratory status en route.
16
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Newborn Resuscitation & Care (continued):
If the heart rate is between 60 and 80 bpm, initiate the following actions:
 Continue assisted ventilations with high flow oxygen.
 If no improvement after 30 seconds, initiate management outlined above.
 Initiate rapid transport; reassess heart rate and respiratory status en route.
If the heart rate is between 80 and 100 bpm, initiate the following actions:
 Continue assisted ventilations with high flow oxygen.
 Stimulate using tactile stimulation as previously described.
 Initiate rapid transport; reassess heart rate and respiratory status en route.
If the heart rate is greater than 100 bpm, initiate the following actions:
 Assess skin color, if central cyanosis remains present, continue blow by oxygen.
 Initiate rapid transport; reassess heart rate and respiratory status en route.
If at any time VF, pulseless VT is present defibrillate at 2J/Kg.
 Continue treatment per PALS resuscitation procedures
 Consult with medical control
 Consider narcan administration 0.1 mg / kg IV / IO if maternal narcotic use suspected
 Initiate rapid transport; reassess en route
If thick meconium is present:
Initiate endotracheal intubation before the infant takes a first breath if possible. Suction with
meconium aspirator, while withdrawing the ETT. Repeat this procedure until the ETT is clear of
meconium. If the infant’s heart rate slows, discontinue suctioning immediately and provide
ventilation until the infant recovers.
Note: If the infant is already breathing and crying this step should be omitted.
17
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Acute Coronary Syndrome
Follow routine care protocol.
Place patient in position of comfort, loosen tight clothing and provide reassurance.
If the patient complains of SOB / respiratory distress, and / or SpO2 is < 94 % administer
supplemental oxygen titrating SpO2 to maintain 94 – 99 %.
Obtain a 12-lead EKG for interpretation and documentation, initial management goal should be
to identify STEMI and transport the patient to the facility most appropriate for their needs.
12-lead EKG’s should be performed on patients with any of the following complaints:
 Chest pain, pressure, discomfort
 Syncopal episode in any patient over 25 years of age
 Unexpected respiratory distress
 Atypical cardiac pain, (shoulder, arm, jaw) especially in females, elderly patients, and
diabetic patients
 Unexplained sudden weakness, nausea, or flu-like symptoms in the elderly
 Any patient with ACS symptoms with a positive history of illicit drug use
Administer (4) 81 mg chewable aspirin, if no contraindications exist (allergies).
Establish IV access at TKO rate. Consider second IV access en route if time permits. Do not
delay scene time.
Administer nitroglycerin (tab or spray) 0.4 mg sublingually if systolic blood pressure 90 mmHg
or above for S/S of chest pain or atypical cardiac pain. Repeat one dose every 5 minutes as
needed, monitoring VS maintaining systolic blood pressure above 90 mmHg. Max (3) doses.
 Contact on-line medical control for additional nitroglycerin administration
 Patients taking erectile dysfunction medications, Viagra (sildenafil citrate), Cialis
(tadalafil), Levitra (vardenafil), acquire time of last dose and contact on-line medical
control for consultation on administration of nitroglycerin.
 Remember female patients may also use Viagra (sildenafil citrate) for pulmonary
hypertension. These medications are prescribed for other conditions.
Administer morphine sulfate 2 – 4 mg IV / IO, repeat as needed to achieve desired clinical effect.
Monitor patients LOC, respiratory status, vital signs for maximum dosage.
If patient is allergic to morphine sulfate, may administer fentanyl 50 – 100 mcg IV /IO, repeat at
half the initial dose as needed to achieve the desired clinical effect. Monitor patients LOC,
respiratory status, vital signs for maximum dosage.
18
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Congestive Heart Failure
Follow routine care protocol.
Place the patient in position of comfort, typically sitting up, loosen tight clothing and reassure
the patient with continuous emotional support.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Obtain a 12-lead EKG for interpretation and documentation.
Establish IV access at TKO rate, unless otherwise indicated by patient’s clinical condition.
Be prepared to aggressively manage the airway.
Monitor ECG and treat arrhythmias following appropriate protocols.
If capability exists, apply CPAP:
Administer nitroglycerin (tab or spray) 0.4 mg sublingually if systolic blood pressure 90 mmHg
or above for S/S of chest pain or atypical cardiac pain. Repeat one dose every 5 minutes as
needed, monitoring VS maintaining systolic blood pressure above 90 mmHg. Max (3) doses.

Contact on-line medical control for additional nitroglycerin administration

Patients taking erectile dysfunction medications, Viagra (sildenafil citrate), Cialis
(tadalafil), Levitra (vardenafil), acquire time of last dose and contact on-line medical
control for consultation on administration of nitroglycerin.

Remember female patients may also use Viagra (sildenafil citrate) for pulmonary
hypertension. These medications are prescribed for other conditions.
May consider administration of morphine sulfate 1 – 2 mg prn for pain / anxiety, monitor
respiratory status closely when administering narcotics to any patient with difficulty breathing.
19
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cardiogenic Shock
Follow routine care protocol
Place patient in supine position if possible and maintain body heat.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Establish IV at TKO rate, administer calculated / calibrated 250 ml to 500 ml fluid boluses as
patients clinical condition warrants.
Obtain a 12-lead EKG for interpretation and documentation.
Dopamine: infuse premixed dopamine 400 mg in 250 ml (1600 mcg / ml), administer starting at
5 mcg / kg / min. increasing prn (titrate to life), max dose 20 mcg / kg / min. without medical
direction.
(patient weight in kilograms)
Mcg/kg/
Min.
2 mcg
5 mcg
10 mcg
15 mcg
20 mcg
2.5
**
**
1
2
2
5
**
1
2
3
4
10
**
2
4
6
8
20
1.5
4
8
11
15
30
2
6
11
17
23
40
3
8
15
23
30
50
4
9
19
28
38
60
5
11
23
34
45
70
5
13
26
39
53
80
6
15
30
45
60
90
7
17
34
51
68
100
8
19
36
56
75
110
8
21
41
62
83
120
9
23
45
68
90
130
10
24
49
73
98
140
11
26
53
79
105
150
11
28
56
84
113
160
12
30
60
90
120
Epinephrine: infusion, mix 1 mg epinephrine in 250 ml normal saline, start infusion at
2 mcg / min. Increase prn to obtain a ventricular rate of 60 bpm or greater or a blood pressure of
90 mm/Hg systolic or greater up to a maximum dose of 10 mcg / min.
2 mcg = 30 ml / hr.
4 mcg = 60 ml / hr.
6 mcg = 90 ml / hr. 10 mcg = 150 / hr.
8 mcg = 120 ml / hr.
Special Consideration for Pediatric Patients:
 Consult on-line medical control for pediatric treatment options for cardiogenic shock.
20
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Altered Mental Status
Follow routine care protocol.
PRESENTATION: Patients may exhibit confusion, focal motor sensory deficit, unusual
behavior, unresponsiveness to pain.
Seizures, hypoxia, hypoglycemia, hypoperfusion, head injury, CVA, and alcohol or drug abuse
can be causes of altered mental status. Consider recent history of possible illness, infection,
fever, or stiff neck.
ALCOHOL CAN CAUSE ALTERED MENTAL STATUS BUT IS NOT COMMONLY A
CAUSE OF TOTAL UNRESPONSIVENESS TO PAIN.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
Establish IV at TKO rate, administer calculated / calibrated fluid boluses as patients clinical
condition warrants.
IF PATIENT HAS CONSTRICTED PUPILS AND / OR RESPIRATORY DEPRESSION
OR IS UNRESPONSIVE AND THE PROVIDER STRONGLY SUSPECTS A NARCOTIC
OVERDOSE,

Administer narcan: 2 mg slow IV / IO until respiratory status improves, may repeat
as needed. When IV / IO access not readily available may administer 2 mg IM.
Special Considerations For Pediatric Patients:
If age-related vital signs and patient’s condition indicate hypoperfusion, administer initial fluid
bolus of 20 ml / kg IV / IO. If patient’s condition does not improve, administer second bolus of
fluid 20 ml / kg IV / IO.
For volume-sensitive children administer initial fluid bolus of 10 ml / kg IV / IO. If patient’s
condition does not improve, administer the second bolus of fluid at 10 ml / kg IV / IO. Volumesensitive children include: neonates (0-28 days), children with congenital heart disease, chronic
lung disease, or chronic renal failure.
Hypoglycemia:
 Dextrose 0.5 g / kg IV / IO up to 25 grams
 Glucagon 0.025 mg / kg IM max dose 1 mg
21
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Allergic Reaction / Anaphylaxis / Anaphylactic Shock
Follow routine care protocol.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Be prepared to aggressively manage the airway if needed, evaluate the need for intubation and
notify the receiving facility as soon as possible if RSI may be required.
Look for medical alert tags and medication that might assist in making treatment decisions.
Evaluate the need for epinephrine 1:1,000
 Adult epinephrine 1:1,000 0.5 mg IM
 Child epinephrine 1:1,000 0.3 mg IM
Establish IV at TKO rate; administer calculated / calibrated fluid boluses as patients clinical
condition warrants.
Evaluate the need for diphenhydramine 25 mg IV / IO or 50 mg IM.
Evaluate the need for administration of albuterol 2.5 mg in 3 ml NS by nebulizer mask.
For cases of severe anaphylaxis (laryngeal edema, hypotension) consider administration of
epinephrine 1:10,000 0.5 mg IV / IO slowly over 3 minutes.
Special Consideration for Pediatric Patients:
 Dosage for epinephrine 1:1,000 0.3 mg IM, repeat as needed
 Dosage for diphenhydramine 1 mg / kg IV / IO (max 25 mg IV / IO, max 50 mg IM)
 Dosage for epinephrine 1:10,000 0.01 mg / kg IV / IO for profound shock, max dose
of 0.5 mg
22
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Asthma
Follow routine care protocol.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Administer albuterol 2.5 mg in 3 ml normal saline via nebulizer mask with supplemental oxygen.
Evaluate the need for epinephrine 1:1,000
 Adult epinephrine 1:1,000 0.5 mg IM
 Child epinephrine 1:1,000 0.3 mg IM
If capability exists, evaluate the need for CPAP
Be prepared to aggressively manage the airway if needed, evaluate the need for intubation and
notify the receiving facility as soon as possible if RSI may be required.
Establish IV at TKO rate, administer calculated / calibrated fluid boluses as patients clinical
condition warrants.
Consider administration of magnesium sulfate for bronchospasm in acute asthma, usually
administered with continuous albuterol nebulizer treatments.
 Magnesium sulfate 2 gm (4 ml) IV / IO, mix in 50 ml of NS run at 150 ml / hr.
23
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Abdominal Pain
Follow routine care protocol.
Rule out physical or organic causes providing additional patient care from appropriate protocols
if indicated.
Allow patient to assume position of comfort.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
BE ALERT for vomiting.
Give nothing by mouth.
Save any stool, urine or emesis to be taken to receiving hospital.
Establish an IV infuse at TKO, unless hypotensive. If hypotensive, administer calculated /
calibrated fluid boluses as the patient’s condition warrants.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
Consider monitoring cardiac rhythm if patient’s clinical condition warrants.
Evaluate the need for pain control and follow appropriate protocol
 fentanyl preferable due to short half life
 consider consultation with on-line medical control for pain control
Evaluate the need for nausea / vomiting medications and follow appropriate protocol.
Special Considerations for Pediatric Patient:
Children experience blunt trauma to the abdomen more often than adults. In fact, this is often a
site of hidden injury. Keep in mind the possibility of a serious abdominal injury when treating
children.
24
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Abuse / Neglect
Follow routine care protocol.
ALL HEALTH CARE PROVIDERS ARE OBLIGATED BY LAW TO REPORT CASES
OF SUSPECTED CHILD OR VULNERABLE ADULT ABUSE OR NEGLECT TO
EITHER THE LOCAL POLICE, PYSICIAN IN THE EMERGENCY DEPARTMENT
OR SOCIAL SERVICE AGENCIES. DO NOT INITIATE REPORT IN FRONT OF THE
PATIENT, PARENTS, OR CAREGIVERS.
DO NOT CONFRONT OR BECOME HOSTILE TO THE PARENTS OR CAREGIVERS.
Presentation:
The patient may present with patterned burns or injuries suggesting intentional infliction,
such as: injuries in varying stages of healing, injuries scattered over multiple areas of the
body, fractures or injuries inconsistent with stated cause of injury. The patient, parent, or
caregiver may respond inappropriately to the situation. Malnutrition or extreme lack of
cleanliness of the patient or environment may indicate neglect. Signs of increased
intracranial pressure (bulging fontanels and altered mental status in an infant) may also be
seen.
Stabilize injuries according to protocol.
Discourage patient from washing if sexual abuse is suspected.
Treat injuries according to appropriate protocols.
Document the following information on the PCR:
All verbatim statements made by the patient, the parents, or caregivers shall be
placed in quotation marks, including statements made about the manner of the
injuries.
Any abnormal behavior of the patient, parents, or caregivers must be
documented.
Document the condition of the environment and other residents present.
Document the time the police, ERP, welfare agency were notified, include name and
title of person contacted.
Document the name of the receiving health care provider (RN, PA, MD) and any
statements made.
25
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Alcohol Emergencies
Follow routine care protocol.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Consider ventilation with BVM and appropriate adjuncts as patient clinical condition requires.
Consider intubation for patients with the inability to maintain a patient airway, no intact gag
reflex, or a GCS < 8.
All intubated patients require continuous monitoring (ECG, NIBP, SpO2, ETCO2).
Establish an IV infuse at TKO, unless hypotensive. If hypotensive, administer calculated /
calibrated fluid boluses as the patient’s condition warrants.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
Administer narcan: 2 mg slow IV / IO until respiratory status improves, may repeat as needed.
Provide continuous reassessment and interventions as required per appropriated protocol.
26
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Amputated Part
Follow routine care protocol.
Control Bleeding, see tourniquet protocol as first line hemorrhage control if patient clinical
condition requires.
Treat for shock as patient clinical condition requires.
Follow appropriate trauma protocols as patient clinical condition requires.
Care of Amputated part:

Locate and preserve the amputated part.

Place the part in an empty plastic bag.

Place the plastic bag containing the part in a larger bag or container with ice and
water. Use cold packs if necessary.

Do not use ice alone.

Do not use dry ice.

Label with name, date and time and transport with patient.
Consider pain control, follow appropriate protocol as patient clinical condition requires.
Special Considerations:
Most extremity parts can be reattached, such as arms, ears, fingers, feet, toes, hands, legs, nose,
penis and scalp. Optimal results are obtained when implantation occurs within a few hours of
the injury.
27
Lee County EMS Ambulance, Inc.
Standing Operating Procedures / Protocols
Apparent Death
Follow routine care protocol.
Determination of Apparent Death:
 Apparent death indications are as follows:
 Signs of trauma are conclusively incompatible with life.
 There is physical decomposition of the body.
 Rigor Mortis or Lividity
 May use cardiac monitor to document asystole (two leads).
If apparent death is confirmed, then continue as follows:
 Contact law enforcement and the county Medical Examiner.
 Where possible contact Iowa Donor Network at 1-800-831-4131.
 At least one EMS provider should remain at the scene until the appropriate
authority is present, i.e. law enforcement.
 Provide psychological support for grieving survivors.
 Document reason no resuscitation was initiated.
If any suspicious circumstances are apparent, preserve the crime scene:
 Limit entry into or around the scene.
 Move nothing not required to confirm death.
 Document everyone who has entered or been around the crime scene and provide
law enforcement with this information.
In all other circumstances (except where “NO CPR / DNR protocol applies) full resuscitation
must be initiated.
Special Considerations for Pediatric Patients:
Complete section for Out-Of-Hospital Responders on the Infant Death Scene Investigation
Report.
This is at times completed per the Medical Examiner or Death Scene Investigator.
28
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Behavioral Emergencies
Follow routine care protocol.
(BE ALERT FOR YOUR OWN SAFETY)
Evidence of immediate danger; protect yourself and others by summoning law enforcement.
Consider the need for law enforcement presence before approaching the scene.
Use law enforcements presence when necessary to enable you to render care.
Establish a secure environment.
Remove all potential weapons from your uniform.
Rule out physical or organic causes providing additional patient care from appropriate
protocols when patient’s clinical condition warrants.
Do not leave the patient with behavioral emergency alone.
Use one responder to assume control of the situation and establish contact with the patient
to reduce confusion and minimize stress. Only the responder assuming control should be
within reach of the patient. Always leave someone far enough away to get help if needed.
Use a calm, quiet voice, and talk to the patient. Be honest, direct, and non-threatening.
move slowly, and explain what you are doing. Avoid remarks that could be perceived to be
judgmental. Keep your own emotions in check.
Use physical restraint only if necessary for the protection of yourself or your patient.
 Obtain law enforcement assistance if needed.
If transport of patient is not indicated, ensure that patient disposition is appropriate.
 Documentation / release information must be completed thoroughly.
For the severely agitated / anxious patient causing a threat to self / others, or requiring physical
restraint consider administration of a sedative
 A sedative should be strongly considered anytime the patient continues to struggle
against required physical restraints (i.e. excited delirium).
 Consider diazepam (Valium) 2 mg IV / IO, titrate for desired clinical effect, max dose
10 mg.
 If unable to establish IV / IO diazepam (Valium) 5 to 10 mg IM may be administered.
 Consider administration of midazolam (Versed) 2 mg IV / IO, titrated for desired
clinical effect, max dose 5 mg.
 If unable to establish IV / IO midazolam (Versed) 5 mg IM may be administered, may
repeat second dose midazolam (Versed) 5 mg IM to achieve desired clinical effect.
29
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Burns
Follow routine care protocol.
Additional routine care for ALL burn patients:
 Remove patient from source of injury
 Immediately stop the burning process, when possible
 Secure and maintain patient’s airway, consider advanced airway if patient’s clinical
condition warrants
 Administer high flow oxygen as patient’s clinical condition warrants
 Remove rings, bracelets, or any other potentially constricting items as soon as
possible, expose area
 Estimate percent of body surface area injured and depth of injury
 Establish an IV / IO of LR or NS, for severe burns, administer 500 ml fluid bolus
 May establish a second IV / IO if time allow, do not delay scene time
 Utilize plastic wrap as a dressing on painful burn sites, or wrap in clean dry drsg.
 Consider pain control, administer morphine sulfate 2 – 4 mg IV / IO, repeat as needed
to achieve desired clinical effect. Monitor patients LOC, respiratory status, vital
signs for maximum dosage
 May consider administration of fentanyl 50 – 100 mcg IV /IO, repeat at half the initial
dose as needed to achieve the desired clinical effect. Monitor patients LOC,
respiratory status, vital signs for maximum dosage
Thermal Burns:
 Remove smoldering clothes if not adhering to the skin, and any objects that may
retain heat
 Initially stop the burning process with water or saline
 Estimate percent of body surface area injured and depth of injury
 If wound is less than 10 % Body Surface Area, cool down burn with water or saline
 Cover the burned area with plastic wrap or clean dry drsg.
 Do not break blisters
 Do not use any type of ointments, lotion, or antiseptic
 Maintain the patient’s body heat
Chemical Burns:
 Brush off powders prior to flushing
 Immediately flush the exposed areas with water after 5 minutes, remove the patient’s
clothing and continue flushing with water for up to 20 minutes
 Do not use extremely cold water in order to minimize the chance of hypothermia
 Flush eyes with copious amounts of water or saline if they are exposed, and remove
any contact lenses if possible
 Attempt to identify the chemical
30
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Burns
Electrical Burns:
 Be sure all electrical hazards have been eliminated before rendering any care
 Cover all burns sites with dry, clean drsg.
 Immobilize any suspected fractures
 Follow appropriate arrhythmia protocols as patient’s clinical condition warrants
Toxin In Eyes:
 Flush eye(s) with copious amounts of water or saline, use caution not to contaminate
the other eye
 Remove contact lens
 Flush for at least 20 minutes
 Have the patient blink frequently
 Attempt to identify the contaminant
Special Considerations for Pediatric Patients:
 Burns pose greater risks to infants and children.
 This is because their body surface area is greater in relation to their total body size.
 This results in greater fluid and heat loss than would be found in an adult patient.
 Consider the possibility of child abuse. Iowa Child Abuse Reporting Number is
1-800-362-2178
 Establish an IV / IO of LR or NS, for severe burns, administer 20 ml / kg, not to
exceed 500 ml
 Contact medical control for further fluid administration
 Treat pain per pain protocol
Note:
To estimate percent of body surface area injured you can also use the “Rule of Palm”. The
patient’s palm equals approximately 1 percent of the body surface area
31
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Cerebrovascular Accident (CVA)
Paralysis
Acute Brain Attack
Follow routine care protocol.
Calm and reassure the patient, even if not conscious.
Monitor and maintain patient airway, including intubation in necessary.
Maintain oxygenation with supplemental oxygen, titrate SpO2 to 94 – 99 %.
Position patient with head elevated.
Attempt to obtain a history, evaluate for time of onset, including the exact time the patient was
last seen as “normal”.
Perform a “ FAST” Cincinnati Prehospital Stroke Scale – checking facial droop, arm drift,
speech.
Notify receiving facility as soon as possible if stroke is suspected
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
Establish an IV infuse at TKO, unless hypotensive. If hypotensive, administer calculated /
calibrated fluid boluses as the patient’s condition warrants.
Monitor the patient’s level of consciousness and blood pressure every five minutes, keep the
patient as calm as possible.
Protect affected limbs from injury during transport, and take care to maintain body heat.
Special Considerations:
Timely recognition of acute neurological deficit and early transport / notification to the receiving
hospital can increase the chance to reverse acute stroke through early intervention.
While stroke patients may not be able to speak, they are usually acutely aware of their
surroundings and are anxious. Talk to your patient and keep the patient informed about the
treatment being rendered.
32
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Obstetrical Emergencies
Follow routine care protocol.
Normal Delivery:
 If delivery is imminent with crowning, commit to delivery on site and establish
contact with on-line medical control.
 BSI and infection control precautions should be taken
 Mother should be positioned with knees drawn up and spread apart
 When the baby’s head appears during crowning, place fingers on bony part of skull
and exert very gentle pressure to prevent explosive delivery
 Use caution to avoid the fontanelle
 If the amniotic sac does not break, puncture the sac and push it away from the baby’s
face and mouth as they appear
 As the head is delivered, determine if the umbilical cord is around the baby’s neck;
slip over the shoulder or clamp, cut and unwrap
 After the head is delivered, support the head and suction the mouth and then the nose
with a bulb syringe
 As the torso and full body is delivered, support the head and hold the infant securely
with both hands
 See neonatal resuscitation care protocol for infant support
 Keep the infant level with the vagina until the cord is cut
 Double clamp, tie and cut umbilical cord as pulsations cease approximately 4 inches
from the infant
 Observe for delivery of the placenta while preparing mother and infant for transport
 When delivered, place the placenta in a plastic bag for transport to the receiving
facility
 Use uterine message if bleeding is heavy until the abdomen becomes firm
 Place a sterile pad over the vaginal opening, lower the mother’s legs
 Record exact time, date and place of delivery
 Do not delay transport for delivery of the placenta
 Assess Apgar Score at 1 – 5 – 10 minutes
Multiple Births:
 Always ask the mother if she knows if she is having multiple infants prior to
beginning delivery
 Deliver as you would normally deliver one infant
 Expect increased complications in infants due to probable low birth weight
33
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Obstetrical Emergencies
Apgar Score
Features Evaluated
0 Points
1 Point
Heart Rate
Absent
Breathing
Absent
< 100 bpm
Irregular, shallow, or
gasping breaths,
weak cry
Full breaths
strong cry
Weak, some
movement
Actively moving arms
and legs
Grimace
Cry or active
avoidance
Pale or blue in
hands and feet
Completely pink
Muscle Tone
Reflexes /Irritability
Skin Color
Limp
No reflexes
Pale or blue all over
2 points
 100 bpm
Breech Delivery:
Buttocks Presentation:
 Allow spontaneous delivery
 Support infant’s body as it delivers
 If head delivers spontaneously, proceed as in normal delivery
 If head does not deliver within 3 minutes, insert gloved hand into the vagina, keeping
your palm toward baby’s face; form a V with your fingers and push the wall of the
vagina away from the baby’s face, thereby creating an airway for the baby
 Transport immediately for emergent cesarean section, do not remove your hand until
relieved by hospital staff.
 Notify receiving facility of situation as soon as possible
Limb Presentation:
 Place mother in Trendelenberg position
 Administer high flow oxygen
 Transport immediately for emergent cesarean section
 Notify receiving facility of situation as soon as possible
34
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Obstetrical Emergencies
Prolapsed Cord:
 Place mother in Trendelenberg position
 Administer high flow oxygen
 Insert gloved hand into the vagina and gently push up on the baby’s head to take
pressure off the umbilical cord
 Do not remove your hand until relieved by hospital staff
 Transport immediately
 Notify the receiving facility of the situation as soon as possible
Miscarriage:
 May result in profuse vaginal bleeding
 Provide emotional support to mother
 Treat for shock and maintain body temperature
 Follow other appropriate protocols as patient clinical condition warrants
 Save all expelled tissues and transport with patient
 Immediate transport without delay, notify receiving facility of situation as soon as
possible
Eclampsia:
 Follow routine care protocol
 Eclamptic patient who is actively seizing, administer 4 gm (8 ml) magnesium sulfate
IV, dilute in 50 ml of NS and run at 300 ml / hr.
 If seizure continues or reoccurs consult on-line medical control for administration of
benzodiazepines
Third Trimester Hemorrhage:
 Estimate blood loss and suspect placenta previa or abruptio placenta
 Follow appropriate protocols as patient’s clinical condition warrants
 Place patient in Trendelenberg position
 Try to auscultate or doppler fetal heat tones and document findings
 Visualize perineal area for tissue loss
 Establish an IV infuse at TKO, unless hypotensive. If hypotensive, administer
calculated / calibrated fluid boluses as the patient’s condition warrants.
35
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Heat Emergencies
Follow routine care protocol.
Remove the patient from the hot environment and place in a cool environment.
Loosen or remove clothing.
Place in a recovery position when possible.
Initially cool patient with fanning and additionally cool patient with cold packs to neck, groin,
axilla. Note rapid cooling of patient may cause vomiting.
Establish an IV infuse at TKO, unless hypotensive. If hypotensive, administer calculated /
calibrated fluid boluses as the patient’s condition warrants.
If the patient is alert, stable and not nauseated, have the patient slowly drink small sips of water.
If the patient has AMS, N/V the patient should be NPO.
Consider monitoring ECG as patient clinical condition warrants.
Consider obtaining 12-lead EKG as patients clinical condition warrants.
Special Considerations:
 Not all heat emergencies are environmental in nature. They may occur from febrile
or neurological etiology
 High body temperature may cause seizures
 Rapid cooling may cause vomiting
Special Considerations for the Pediatric Patient:
 Be prepared to treat febrile seizures in children
 Consider sponging with ONLY COOL water during transport
 DO NOT induce shivering
36
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Hypothermia
Follow routine care protocol.
Hypothermia:
 Handle the patient gently.
 Remove wet clothing, keep dry and maintain body temperature.
 Do not message or allow patient to message extremities
 Do not delay transport for any advanced procedures prior to the patient being
rewarmed.
 Obtain temperature if capability exists, core temperature is preferred.
 Establish an IV with warm fluids if available, do not administer cold fluids.
Local Cold Injuries (Frostbite):
 Remove the patient from the cold environment.
 Protect the cold injured extremity from further injury (manual stabilization).
 Remove wet or restrictive clothing.
 Do not rub or message.
 Do not re-expose to cold.
 Remove jewelry.
 Cover with dry clothing or drsg.
 Establish IV access at TKO, use warmed fluid if possible.
 Refer to pain control protocol as patient clinical condition warrants.
Special Considerations:
 Do not allow the patient to eat or drink stimulants, coffee, tea, smoking, etc. may
worsen the condition.
 Unwarmed high flow oxygen may cause further hypothermia.
 The hypothermic heart may be unresponsive to defibrillation.
37
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Hypovolemic Shock
Follow routine care protocol.
Control all external bleeding as soon as possible.
Tourniquet should be used as first line treatment for extremity hemorrhage, see appropriate
protocols.
Have an increased index of suspicion of internal bleeding if MOI suggests.
Compensated Shock:
 Pale, cool, clammy skin / poor capillary refill / tachycardia / weak distal pulses.
 Assess for further life threatening injuries.
 Maintain body temperature (heat the ambulance).
 Do not delay scene times, initiate rapid transport to appropriate facility.
 Establish IV access at TKO rate, use warm fluids when possible.
 Consider aeromedical transport to a trauma center when patients clinical condition
warrants.
Uncompensated Shock:
 Pale, cool, clammy skin / delayed capillary refill / tachycardia / absent distal pulses.
 Assess for further life threatening injuries.
 Maintain body temperature (heat the ambulance).
 Do not delay scene times, initiate rapid transport to appropriate facility.
 Consider aeromedical transport to a trauma center when patient’s clinical condition
warrants.
 Establish IV access using warm fluids when possible.
 Administer calculated / controlled 250 ml fluid boluses if SBP < 80 - 90 mmHg to
maintain a SBP of > than 80 mmHg.
 Consider permissive hypotension resuscitation when patient’s clinical condition
warrants.
Note: refer to appropriate protocols as patient clinical condition warrants (Trauma
Protocol).
Special Considerations for the Pediatric Patient:
If age-related vital signs and patient’s condition indicate hypoperfusion, administer initial fluid
bolus of 20 ml / kg IV / IO. If patient’s condition does not improve, administer second bolus of
fluid 20 ml / kg IV / IO.
For volume-sensitive children administer initial fluid bolus of 10 ml / kg or IV / IO. If patient’s
condition does not improve, administer the second bolus of fluid at 10 ml / kg IV / IO. Volumesensitive children include: neonates (0-28 days), children with congenital heart disease, chronic
lung disease, or chronic renal failure.
Note: Permissive hypotension resuscitation should not be considered in patients <12 yo.
38
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Pain Control
Follow routine care protocol.
First, attempt to manage painful conditions:
 Splint extremity injuries
 Place patient in position of comfort if clinical condition allows.
 Cold packs applied as patient clinical condition warrants.
Consider administration of pain medications for patients that have significant pain that are
hemodynamicly stable and maintaining SpO2 > 94 %.
Consider administration of fentanyl 50 to 100 mcg IV / IO, repeat at half the initial dose as
needed to achieve the desired clinical effect. Monitor patients LOC, respiratory status, vital
signs for maximum dosage.
Consider administration of morphine 2 – 4 mg IV / IO, repeat as needed to achieve desired
clinical effect. Monitor patients LOC, respiratory status, vital signs for maximum dosage.
May administer morphine IM when IV / IO access is not available
Note: Administer narcan: 2 mg slow IV / IO until respiratory status improves, for
respiratory depression, may repeat as needed. If IV / IO access not readily available may
administer 2 mg IM.
Note: For severe pains consider addition of anxiolytic medications, using caution as
anxiolytic medications can potentiate the effects of narcotics.
Consider administration of versed 1 – 2 mg IV / IO / IM, repeat as needed to achieve desired
clinical effect. Monitor patients LOC, respiratory status, vital signs for maximum dosage.
Consider administration of valium 1 – 5 mg IV / IO / IM, report as needed to achieve desired
clinical effect. Monitor patients LOC, respiratory status, vital signs for maximum dosage.
Note: When administering significant pain control medications you must monitor patients
ECG, SpO2, ETCO2 and vital signs continuously.
Special Considerations for the Pediatric Patient:
Fentanyl 1.0 mcg / kg IV, may repeat as needed to achieve desired clinical effect, max dose 100
mcg.
Morphine 0.1 mg / kg IV /IO / IM, may repeat as needed to achieve desired clinical effect, max
dose 10 mg.
39
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Nausea & Vomiting
Follow routine care protocol.
Keep patient NPO.
Consider calculated / calibrated IV / IO fluid boluses if patient clinical condition warrants.
Consider advanced airway management including intubation for patients with AMS who are
vomiting and cannot protect their airway.
Contact receiving facility as soon as possible if need for RSI exists.
If patient is nauseated or vomiting, consider administration of phenergan 12.5 – 25 mg IV / IO
slow push, dilute in 10 ml NS and administer from the IV port closest to the IV bag and furthest
from the patient through a rapidly flowing patent line. Slow flow rate to achieve desired effect
per patient’s clinical condition after administration.
Alternate administration: phenergan 25 mg diluted in 50 ml bag of NS and run at 300 ml / hr.
May also administer phenergan 25 – 50 mg IM.
Note: Due to phenergan sedative side effects, which are potentiated when administered
with narcotics or benzodiazepines be diligent and cautious with administration.
Consider continuous monitoring of ECG, SpO2, ETCO2 and vital signs when administering
phenergan, especially when combined with narcotics or benzodiazepines.
Note: Extra caution should be exercised with dosing of pediatric and elderly patients.
Note: Phenergan administration may not exceed 25 mg IV / IO or 50 mg IM without
consent from on-line medical control.
40
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Poisoning
Follow routine care protocol.
Identify contaminate, notify Poison Control following directions given: 1-800-222-1222.
Contact / coordinate with on-line medical control as soon as possible with information provided
by Poison Control.
Ingested Poisons:
 Identify and estimate amount and time of ingestion.
Inhaled Poisons:
 Use extreme caution, if possible hazard exists to responders; notify additional
resources (fire service / hazardous materials team).
 Remove patient to fresh air.
 Be alert for respiratory difficulties.
 Administer high flow oxygen as patient’s clinical condition warrants.
 Identify inhaled substance.
 Estimate time and duration of exposure to inhaled substance.
Absorbed Poisons:
 Use extreme caution, if possible hazard exists to responders; notify additional
resources (fire service / hazardous materials team).
 Identify contaminate.
 Protective clothing and extreme caution.
Injected Poisons:
 Be alert for respiratory difficulties.
 Administer high flow oxygen as patient’s clinical condition warrants.
 Expose and examine for marks, punctures, stings, rashes, welts.
 Attempt to identify the source of the injected poison.
41
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Seizures
Follow routine care protocol.
Presentation: Seizures are a neuromuscular response to an underlying cause such as: Epilepsy,
hypoxia, hypoglycemia, hypoperfusion, head injury, CVA, alcohol / drug abuse, neurological
injury. Consider recent history of possible illness, infection, fever, or stiff neck.
Maintain / protect a patent airway as required including advanced airway management if
patient’s clinical condition warrants.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
If the patient is seizing on arrival:
 Do not restrain the patient.
 Protect the patient from further injury.
 Place the patient in the recovery position if possible.
 Monitor type and duration of seizure activity.
Note: Status epilepticus is a true life-threatening emergency and requires immediate
intervention.
Establish IV access at TKO rate, unless otherwise indicated by patient’s clinical condition.
Actively seizing patients administer 2 – 5 mg diazepam IV / IO / IM, repeat as patients clinical
condition warrants.
Diazepam Chart:
 1 mg = 0.2 ml
 2 mg = 0.4 ml
 3 mg = 0.6 ml
 4 mg = 0.8 ml
 5 mg = 1 ml
May consider versed 2 – 5 mg IV / IO / IM, repeat as patients clinical condition warrants.
Post Seizure: it is common to find the patient in a postical state.
Maintain / protect a patent airway as required including advanced airway management if
patient’s clinical condition warrants.
Obtain blood glucose level if patient’s clinical condition warrants.
Treat adults: < 70ml/dl / Treat infants & children: < 40 ml/dl
42
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Sexual Assault
BE SURE THE SCENE IS SAFE FOR APPROACH, if not already on scene call for law
enforcement.
Follow routine care protocol.
Identify yourself to the patient, assure patient that they are safe, and are in no further danger.
When possible crewmembers of the same sex may relate better to the patient in times of such
emotional crisis. Accurately record your observations and conversations with the patient.
Administer continuous emotional support as required to patient, family, etc.
DO NOT burden the patient with questions about the details of the crime; you are there to
provide emergency medical care only.
DO NOT allow the patient to bathe, douche, change clothes, or go to the bathroom.
BE alert to immediate scene and document what you see. Touch only what you need to touch at
the scene. Remember to preserve the crime scene.
Do not disturb any evidence unless necessary for treatment of the patient. If necessary to disturb
evidence or move anything, DOCUMENT WHY AND HOW IT WAS DISTURBED.
Treat any other injuries / problems per appropriate protocols.
Preserve evidence, such as clothing you may have had to remove for treatment, and make sure
that it is NEVER left unattended at any time, to preserve the “chain of evidence”.
Special Considerations for the Pediatric Patient:
Follow initial treatment protocols. Gather information from the parents or care giver away from
the child without expression of disbelief or judgment.
Talk with the child separately about how the injury occurred.
If you are suspicious about the mechanism of injury, contact law enforcement and consider
transport even though the severity of injury may not warrant such action.
Report your suspicions to law enforcement and the emergency department staff in accordance
with local policies.
43
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
TASER Dart Removal and Care
EMS personnel have seen an increase in the number of patients who have been subdued with
TASER stun guns by law enforcement officers. The following guidelines address evaluation and
treatment of these patients.
A TASER works by firing two wire-attached darts that can strike a suspect from up to 15 or
more feet away. It delivers up to 50,000 volts of electricity to the recipient. This jolt of
electricity is not harmful to vital body functions such as heart rhythm, pacemaker function or
respirations. However, it will instantaneously incapacitate the person. Each electric discharge
lasts a total of 5 seconds and is controlled by the officer who fires the device.
The TASER dart usually penetrates the skin only a few millimeters. EMT’s can safely remove a
dart simply by pulling it out. The only exception is involvement of the eye, face, neck, breast, or
groin. In this case, leave the dart in place and transport the patient to the hospital for dart
removal.
Strongly consider scene safety and measures to protect yourself and others from a potentially
violent patient in situations when a TASER gun has been used. You do not need to transport a
person to the hospital based solely on TASER dart exposure. If a patient has no need for further
medical evaluation, you can leave him or her in police custody.
This skill may be performed by BLS or ALS providers.
ALS Indicators:
 Compromise in ABC’s requires ALS intervention and transport.
 Use law enforcement as needed to assist with restraint or accompany EMS with
transport.
BLS Indicators:
 Taser dart imbedded in skin.
BLS Care:
 Assure scene safety.
 Wear PPE including gloves and eye protection – consider mask and gown if blood is
present.
 Remove TASER cartridge from gun or cut wires before removing darts.
 Darts are a sharps hazard – treat as contaminated needle.
 Check with law enforcement, sometimes darts and wires are required as evidence.
 Dispose of darts in sharps container or TASER cartridge.
44
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
TASER Dart Removal and Care
Removal Procedure:
 Do Not Remove Darts if:
 Patient is not under control
 Eye, face, neck, breast or groin are involved – patient must be transported to
hospital for dart removal in this case.
 Grasp firmly with one hand, while holding other hand firmly against skin around
entrance wound, pull to remove one dart at a time.
 Reassess patient.
 Consider medical and behavioral problems as the original cause of violent behavior.
 Drug / Alcohol Intoxication
 Behavioral / Psychiatric Problems
 Head Trauma
 Bandage wounds as appropriate.
Document Situation and Patient Contact Thoroughly
Patient Disposition:
 Release to law enforcement if indicated.
 Transport with law enforcement support if:
Eye, Face, Neck, Breast, or Groin are involved.
ALS is indicated.
Law enforcement officer requires medical evaluation, law enforcement
protocol may require transport. This may be by law enforcement or
ambulance.
Burn Hazard:
When a TASER is used in the presence of pepper spray propellant, there is a burn hazard.
Electrical arcing from imperfect (but effective) dart contact can ignite the propellant. The
resulting combustion may not be visible, but can lead to complaints of heat and burning. If a
patient complains of heat or burning, evaluate for possible minor burns.
45
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Trauma
Follow routine care protocol.
Follow the Out-of-Hospital Trauma Triage Destination Decision Protocol for the identification
of time-critical injuries, method of transport and destination decision for treatment of those
injuries.
The goal should be to minimize scene time with time critical injuries, including establishing IV’s
en route.
Hemorrhage Control:
 Control external hemorrhage with direct pressure.
 Large gaping wounds may need application of bulky drsg. and direct pressure by
hand.
 Consider use of tourniquets as first line hemorrhage control for extremity injuries.
 Refer to tourniquet protocols as needed.
Establish IV access and administer IV fluids as follows:
 Establish IV access using warm fluids when possible.
 Administer calculated / controlled 250 ml fluid boluses if SBP < 80 - 90 mmHg to
maintain a SBP of > than 80 mmHg.
 Consider permissive hypotension resuscitation when patient’s clinical condition
warrants.
 Refer to hypovolemic shock protocol as patients clinical condition warrants.
Chest Trauma:
 Seal open chest wounds immediately using occlusive drsg.
 If breathing becomes worse, loosen one side of the drsg. to release pressure and then
reseal wound.
 Impaled objects must be left in place and should be stabilized with bulky drsg.
 Use caution that the penetrating object is not allowed to cause further harm.
 Diligently assess breath sounds often.
Abdominal Trauma:
 Control external bleeding, drsg. applied to open wounds.
 Evisceration should be covered with sterile saline soaked drsg.
 Impaled objects should be stabilized with bulky drsg. for transport.
46
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Trauma
Head & Neck Trauma:
 Establish and maintain manual stabilization.
 Place the head in a neutral in-line position unless the patient complains of pain or
the head does not easily move into position.
 Apply cervical collar and SMR when patients clinical condition warrants.
 Closely monitor the airway, provide suction as needed.
 Be prepared to log roll the patient, provide manual spinal stabilization if the patient
requires log roll.
 Impaled objects in the cheek may be removed if causing airway problems, or you are
having trouble controlling bleeding. Use direct pressure on injury after removal to
control any bleeding.
 Reassess vital signs and GCS frequently.
 Consider advanced airway management when patient clinical condition warrants.
Extremity Injuries:
 Assess extent of injury including presence or absence of pulse.
 Establish and maintain manual stabilization of injured extremity by supporting above
and below the injury.
 Remove or cut away clothing and jewelry.
 Cover open wounds with a sterile drsg.
 Do not intentionally replace any protruding bones.
 Apply cold pack to area of swelling or pain.
 If severe deformity and the distal extremity is cyanotic or lacks pulses, align with
gentle traction before splinting, and transport immediately.
 Consider administration of pain control per pain control protocol as patient
condition warrants.
47
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Tourniquet Application
Follow routine care protocol.
If unable to control bleeding with direct pressure, apply tourniquet to extremity approximately 2
inches proximal to the wound. The tourniquet is tightened until bleeding has ceased.
An additional tourniquet can be placed just proximal to the first if bleeding control is inadequate
following placement of the first tourniquet. (studies have shown that the addition of a second
tourniquet, rather than continuing to tighten the first tourniquet is beneficial to patient outcomes).
Research has show that tourniquets should now be considered as first line use of severe
hemorrhage of extremities
The time of tourniquet application should be documented and relayed to the trauma team upon
arrival at the receiving facility.
Consideration should be given to rapid transport to a facility with immediate surgical capabilities
whenever possible.
Studies show tourniquets have few, if any, significant complications attributed to tourniquet use.
They are a safe procedure and should be performed by all EMS providers when control of
hemorrhage with direct pressure is inadequate or not possible due to access, environment,
visualization, extrication, or the need to perform other interventions.
Tourniquets should be placed as soon as possible in the pre-hospital setting for severe
hemorrhage, prior to transport, there is a clear survival advantage if placement is done prior to
the onset of shock.
If patient condition stabilizes during transport time permitting, and hemorrhage control can be
maintained with a pressure drsg. You may attempt to loosen the tourniquet after the pressure
drsg. is in place. Do not remove the tourniquet, retighten if hemorrhage reoccurs.
After one attempt has been made to control hemorrhage with a pressure drsg. with the tourniquet
loosened and the attempt has failed with hemorrhage reoccurring and the tourniquet retightened;
no further attempt to loosen or remove the tourniquet should be attempted pre-hospital.
Research shows tourniquets can remain in place for at least 90 minutes with little consequence.
Refer to hypovolemia protocol as patients clinical condition warrants.
48
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transport – Certified
Only personnel currently certified at the Paramedic level who have completed the Lee County
EMS Ambulance, Inc. Critical Care Transport – Certified education and training may utilize
the following protocols/procedures.
When transporting critical care patients, orders for medications / procedures not identified
herein will be obtained from a physician prior to departure or by radio / cell phone during
transport. These orders shall be documented in the PCR narrative with the physicians name for
reference.
All medication required, (or possibly required) for CCT; that we do not regularly stock in our
medication module, narcotics kit or CCT kit should be obtained from the transferring facility
prior to loading the patient.
Minimum staffing for a critical transport will be a Critical Care Transfer – Certified Paramedic
with EMT-B / Paramedic driver. If the patient is on a ventilator, minimum staffing is a Critical
Care Transfer – Certified Paramedic with additional attendant and a driver.
Obtain additional staff by calling communications to locate a third person, please notify them
as soon as possible as locating and travel for the third person may delay transport of the
patient.
While preparing for transfer, ready required equipment:
For transfers requiring a ventilator:
 On-board oxygen filled to at least 1000 psi.
 Portable oxygen filled to capacity.
 CCT and ventilator equipment as stored at base
Ensure that sufficient oxygen is sent with all patients for the expected duration of the trip
including possible delays due to weather, road construction or other circumstances.
Prior to departure, the attending Critical Care Transfer - Certified Paramedic will check all
equipment for function and completeness. Confirm all orders with attending physician / CRNA.
Follow all LCEMSA / CCT - C protocols unless otherwise specified by attending physician /
CRNA.
Upon return to county, stop in Donnellson to replace CCT supplies as needed. It is the
responsibility of the attending staff to ready all equipment for additional transfers, i.e. fill oxygen
tanks, restock supplies, and return supplemental equipment.
49
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Continuation of Paralysis / Sedation of the Intubated Patient:
Confirm correct placement of endotracheal tube clinically (auscultation over epigastrium and of
breath sounds bilaterally, etc.). Document tube placement by noting cm of insertion at the corner
of the mouth or tube holder (whichever is clearly seen).
All intubated patients require continuous ECG, SpO2, ETCO2 monitoring.
Confirm order for paralytic/sedative agents with physician and/or CRNA when required.
May administer sedation / paralytics as patients clinical condition warrants:
Medication
Vecuronium
Norcuron
Rocuronium
Zemuron
Nimbex
Cisatracurium
Succinylcholine
Anectine
Etomidate
Amidate
Midazolam
Versed
Propofol
Diprivan
Supplied
Concentration
Dosage
Duration
10 mg / 10 ml
1 mg / ml (reconstituted)
0.1 mg / kg
30 – 45 Minutes
50 mg / 5 ml
10 mg / ml
1.0 mg / kg
20 – 30 Minutes
20 mg / 10 ml
2 mg / ml
0.3 mg / kg
30 – 40 Minutes
200 mg / 10 ml
20 mg / ml
1 mg / kg
4 – 6 Minutes
20 mg / 10 ml
2 mg / ml
0.3mg / kg
3 – 10 Minutes
5 mg / 5 ml
1 mg / ml
0.1 ,g / kg
5 – 15 Minutes
20 mg / 2 ml
10 mg / ml
2 mg / kg
5 – 10 Minutes
Consider analgesia as patient condition warrants:
 Fentanyl 50 to 100 mcg IV / IO, repeat at half the initial dose as needed to achieve the
desired clinical effect. Monitor patients LOC, respiratory status, vital signs for
maximum dosage.
 Morphine 2 – 4 mg IV / IO, repeat as needed to achieve desired clinical effect.
Monitor patients LOC, respiratory status, vital signs for maximum dosage.
Note: Never administer a paralytic agent without first administering a sedative agent.
50
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer - Certified
Management of a Patient Utilizing Automatic Transport Ventilator:
Note clinical parameters of patient for baseline status.
Initial settings should be an attempt to emulate the in hospital ventilator settings the patient has
been maintained on. Ideal settings are 6-10 ml/kg of ideal body weight for tidal volume and 812 breaths/minute. Use Table to obtain ideal body weight. Use clinically appropriate PEEP as
necessary. Obtain order from medical staff, CRNA, or respiratory staff, if in doubt on
appropriate ventilator settings.
Select appropriate settings and activate all alarms.
Ensure placement and adequacy of patient’s artificial airway.
All intubated patients require continuous ECG, SpO2, ETCO2 monitoring.
Ensure an alternative airway is available for use prior to departure.
Confirm orders for paralysis, sedation, and analgesia prior to departure. Obtain all maintenance
medication required from transferring hospital prior to loading the patient.
Prior to departure from the originating hospital, perform a 5 - 10 minute trial with the transport
ventilator to ensure patient tolerance. Be prepared to resume ventilating with the in hospital
ventilator as needed. If time allows, a repeat set of ABG’s may be ordered by the attending
physician to verify adequacy of ventilation.
Have alternative ventilation equipment available prior to departure in case of equipment failure.
51
Tidal Volume Settings for a Male Patient
Height (in)
IBW (kg)
Tidal Volume (mL/kg)
6
7
8
9
10
60
52.0
312.0
364.0
416.0
468.0
520.0
61
53.9
323.4
377.3
431.2
485.1
539.0
62
55.8
334.8
390.6
446.4
502.2
558.0
63
57.7
346.2
403.9
461.6
519.3
577.0
64
59.6
357.6
417.2
476.8
536.4
596.0
65
61.5
369.0
430.5
492.0
553.5
615.0
66
63.4
380.4
443.8
507.2
570.6
634.0
67
65.3
391.8
457.1
522.4
587.7
653.0
68
67.2
403.2
470.4
537.6
604.8
672.0
69
69.1
414.6
483.7
552.8
621.9
691.0
70
71.0
426.0
497.0
568.0
639.0
710.0
71
72.9
437.4
510.3
583.2
656.1
729.0
72
74.8
448.8
523.6
598.4
673.2
748.0
73
76.7
460.2
536.9
613.6
690.3
767.0
74
78.6
471.6
550.2
628.8
707.4
786.0
75
80.5
483.0
563.5
644.0
724.5
805.0
76
82.4
494.4
576.8
659.2
741.6
824.0
Tidal Volume Settings for a Female Patient
Height (in)
52
IBW (kg)
Tidal Volume (mL/kg)
6
7
8
9
10
60
49.0
294.0
343.0
392.0
441.0
490.0
61
50.7
304.2
354.9
405.6
456.3
507.0
62
52.4
314.4
366.8
419.2
471.6
524.0
63
54.1
324.6
378.7
432.8
486.9
541.0
64
55.8
334.8
390.6
446.4
502.2
558.0
65
57.5
345.0
402.5
460.0
517.5
575.0
66
59.2
355.2
414.4
473.6
532.8
592.0
67
60.9
365.4
426.3
487.2
548.1
609.0
68
62.6
375.6
438.2
500.8
563.4
626.0
69
64.3
385.8
450.1
514.4
578.7
643.0
70
66.0
396.0
462.0
528.0
594.0
660.0
71
67.7
406.2
473.9
541.6
609.3
677.0
72
69.4
416.4
485.8
555.2
624.6
694.0
73
71.1
426.6
497.7
568.8
639.9
711.0
74
72.8
436.8
509.6
582.4
655.2
728.0
75
74.5
447.0
521.5
596.0
670.5
745.0
76
76.2
457.2
533.4
609.6
685.8
762.0
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer - Certified
Management of Chest Drainage Systems:
Note clinical parameters of patient for baseline status.
Note tidaling of water in system.
Check functionality of system.

If suction is being utilized, turn suction off.

Wait for bubbling to stop in fluid chamber. If bubbling does not stop, an air leak is
present.

Clamp tubing proximal to the patient.

If bubbling stops, consult medical control or attending physician to check tube
patency and occlusive drsg. Minor amounts of bubbling may be normal for the
patient. Check with attending staff.

Progressively isolate segments of the system to find the leak. Correct when found.
Closed chest drainage systems require that the pressure within the chest be greater than that
within the system. Keep the drainage unit at least one foot below the chest tube insertion site.
All connections must remain airtight.
The addition of a suction source may facilitate removal of large amounts of air/fluid.
53
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Rapid Sequence Induction:
Overview:
Rapid sequence induction (RSI) is a method of emergency airway management in patients who
have a gag reflex who would otherwise be impossible to secure and control the patient’s airway
adequately.
Because of the nature of RSI, not all paramedics are eligible and close scrutiny is required.
Training places the utmost emphasis on skills and decision making (who should receive RSI and
who should not receive RSI). All paramedics who complete the initial Critical Care Transport –
Certified (CCT – C) training presented by Lee County EMS Ambulance, Inc. (LCEMSA) may
perform RSI when necessary or indicated on interfacility transports.
Continuous quality improvement (CQI) is critical to the success of RSI. Cases will be reviewed
as soon as possible following the RSI by the Training Coordinator or EMS Director, and the
Medical Director with feedback provided to the paramedic. Those paramedics making poor
decisions, having difficulty with intubation rates will be identified and remediated by the
Training Coordinator quickly. If improvement is not seen, they must be removed from the CCT
– C approved paramedics.
An email will be sent to the Training Coordinator immediately following the case, notifying
management that RSI was performed and indicating the PCR number of the response.
All RSI cases should also be reviewed through the normal CQI process.
In the instance that RSI is performed inappropriately, the EMS Director, Training Coordinator
and Medical Director will make recommendations as to whether remediation is necessary or if
the paramedic should be removed from the Critical Care Transport – Certified program.
Outline of Initial Critical Care Transport – Certified Training:
Critical Care Transport Monitoring:
0.5 hour
Capnography The Vital Sign of Life:
1.5 hour
Critical Care Transport, Central Lines
:
0.5 hour
Critical Care Transport Pharmacology Review:
1.5 hour
Rapid Sequence Induction
1 hour
Critical Care Transport Ventilator
1 hour
Critical Care Transport Labs & ABG’s
1 hour
Critical Care Transport Documentation
0.5 hour
Critical Care Transport EMTALA & Ethical / Moral Issues 0.5 hour
54
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Rapid Sequence Induction:
Maintenance of RSI Certification:
RSI recertification will be documented during yearly skills evaluations.
Practical demonstration / scenarios
May include pharmacology written test
May include required reading and review
Contents of Critical Care Transport – Certified Medication Kit:
(1)
Succinylcholine
200 mg / 10 ml
(2)
Vecuronium
10 mg / 10 ml
(4)
Rocuronium
50 mg / 5 ml
(4)
Etomidate
20 mg / 10 ml
Note: may vary according to medication availability (always use caution)
Indications for RSI: (RSI may be done under standing orders if required)
Age over 18 unless specific permission given prior to procedure by medical direction.
Need for intubation:
Acute or impending airway loss (including inability to protect airway), RR < 10 or > 30
Respiratory failure (asthma, CHF, COPD) with hypoxia
Respiratory fatigue with impending respiratory failure
Need to decrease myocardial oxygen demand
GCS < 8 with intact gag reflex
Multi-system trauma with need for airway control
Trauma with the inability to provide proper SMR due to combativeness
Severe head injury with need for airway control
Severe head injury or major stroke with unconsciousness
Burn patients with airway involvement or possible airway loss during transport
Overdose with altered mental status with need for airway control
Uncontrolled seizure activity (to provide airway control)
Contraindications (relative or absolute):
Patients who would be difficult / impossible to ventilate / intubate
Patients in whom Needle Cricothyroidotomy would be difficult or impossible
Patients < 18 years of age unless with prior approval of medical control
Massive neck swelling or injury
Acute epiglottitis
Known hypersensitivity to the medications
Hyperkalemia (elevated potassium such as end-stage renal disease)
Penetrating eye injuries
History of malignant hyperthermia
Unstable facture (secondary to muscle fasciculation)
55
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Rapid Sequence Induction:
Note: The benefit of obtaining airway control must always be weighed against the risk of
complications in RSI procedure for all patients.
Note: In an emergency airway situation there are no absolute contraindications to
succinylcholine.
Complications:
Increased intragastric pressure (emesis)
Bradycardia / Asystole
Malignant hyperthermia
Prolonged apnea (hypoxia)
Inability to ventilate / intubate
Hypotension
Aspiration
Increased intracranial pressure
Increased intraocular pressure
Preparation:
Monitoring (continuous ECG, SpO2, ETCO2, NIBP pre & post RSI)
Assess oropharynx and neck anatomy to anticipate difficult intubation (LEMON)
Estimate patient’s weight and calculate mediation dosages
Medications drawn up and labeled
Patent IV’s (two if possible)
Assemble & ready all equipment (scopes, blades, ETT’s, BVM, oxygen source, etc.)
Suction equipment assembled, (on and working)
Alternate airway procedures (bougie, King LT, Needle Cric.) immediately available
Tube confirmation equipment readily available
Ventilator set-up complete and readily available
Oxygenation:
The goal of RSI is to facilitate a controlled intubation without positive pressure ventilation (an
adequately preoxygenated pt. can remain apneic for 2 – 3 minutes without serious hypoxia).
It is ideal to allow the pt. to spontaneously breathe 100 % oxygen for 4 – 5 minutes to “wash
out” the nitrogen reservoir and establish an oxygen reservoir.
If the pt. is not adequately breathing and positive pressure ventilation is required, preoxygenated
with 100 % oxygen and a BVM for 1 -2 minutes (ventilations should be administered low and
slow to minimize gastric distention).
56
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Rapid Sequence Induction:
Procedure:
Consider pre-treatment with lidocaine and atropine when necessary.
Lidocaine 1 mg / kg 2 – 3 minutes prior to intubation for increased ICP
Atropine 0.5 mg IVP for adults exhibiting bradycardia.
(pediatric dose 0.01 mg / kg, should be considered in all pediatrics < 3 yo)
Analgesia: consider administration of fentanyl or morphine prn for pain control.
Defasciculation: for increased ICP, penetrating eye injury Vecuronium 1 mg SIVP.
Induction: Etomidate 0.3 mg / kg SIVP for sedation and induction
Note: sedation must always be administered prior to paralysis.
Paralysis: Succinylcholine 1 mg / kg IVP
Note: wait for paralysis to occur prior to intubation attempt.
Intubate: Perform controlled endotracheal intubation.
Discontinue attempt and ventilate with 100 % oxygen via BVM if:
Intubation attempt fails after 30 – 60 seconds.
SpO2 falls below 92 %.
Heart rate falls below 60.
Once intubation is complete immediately confirm placement with at least three methods:
Bilateral breath sounds
Absence of gastric sounds
Symmetrical chest wall rise
Condensation on the inside of the ETT
Visualization of the ETT passing through the vocal cords
Wave form capnography
Continued and sustained SpO2 readings in the high 90’s (if this is consistent with the
patients baseline).
Secure the ETT with the tube holder
Note: size of tube, confirmations, depth of tube, medications administered for documentation.
Ventilator: attach and adjust ventilator setting as the patient’s clinical condition warrants.
If prolonged paralysis is required, administer:
Vecuronium 0.1 mg / kg IVP every 30 – 45 minutes
Rocuronium 1.0 mg / kg IVP every 20 – 30 minutes
57
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Critical Care Transfer – Certified
Rapid Sequence Induction:
Failure to Intubate:
If you are unable to intubate the patient after two attempts consider:
Allowing another qualified health care provider attempt intubation.
Using difficult airway maneuvers such as the BURP technique, the bougie, etc.
Attempt repositioning the patient.
Consider use of back up airway devices such as the King LT.
Consider NPA, OPA and BVM ventilation until paralytics ware off.
Consider use of the needle cricothyrotomy procedure.
Considerations:
Remember sedation and analgesia requires re-dosing when paralytics are administered.
Once a paralytic is administered you assume complete responsibility for maintaining an adequate
airway and ventilations.
Remember the Number 1 Rule of EMS
First Do No Harm!
58
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
EMS Out-Of-Hospital Do-Not-Resuscitate Protocol
Purpose: This protocol is intended to avoid unwarranted resuscitation by emergency care
providers in the out-of-hospital setting for a qualified patient. There must be a valid Out-OfHospital Do-Not-Resuscitate (OOH DNR) order signed by the qualified patient’s attending
physician or the presence of the OOH DNR identifier indicating the existence of a valid OOH
DNR order.
No Resuscitation: Means withholding any medical intervention that utilizes mechanical or
artificial means to sustain, restore, or supplant a spontaneous vital function, including but not
limited to:
 Chest Compressions
 Defibrillation
 Esophageal/tracheal/double-lumen airway; endotracheal intubation
 Emergency drugs to alter cardiac or respiratory function or otherwise sustain life
Patient Criteria: These patients are recognized as qualified patients to receive no resuscitation:
 The presence of the uniform OOH DNR order or uniform OOH DNR identifier
 The presence of the attending physician to provide direct verbal orders for care
The presence of a signed physician order on a form other than the uniform OOH DNR order
form approved by the department may be honored if approved by the service program EMS
medical director. However, the immunities provided by law apply only in the presence of the
uniform OOH DNR order or uniform OOH DNR identifier. When the uniform OOH DNR order
or uniform OOH DNR identifier is not present contact must be made with on-line medical
control and on-line medical control must concur that no resuscitation is appropriate.
Revocation: An OOH DNR order is deemed revoked at any time that a patient, or an individual
authorized to act on the patient’s behalf as listed on the OOH DNR order, is able to communicate
in any manner the intent that the order be revoked. The personal wishes of family members or
other individuals who are not authorized in the order to act on the patient’s behalf shall not
supersede a valid OOH DNR order.
Comfort Care: When a patient has met the criteria for no resuscitation under the foregoing
information, the emergency care provider should continue to provide that care which is intended
to make the patient comfortable, (a.k.a. Comfort Care). Whether other types of care are
indicated will depend upon individual circumstances for which medical control may be contacted
by or through the responding ambulance service personnel.
Comfort Care: may include, but is not limited to:
 Pain medication
 Fluid therapy
 Respiratory assistance (oxygen and suctioning)
Qualified Patients means an adult patient determined by an attending physician to be in a terminal condition for which the attending physician has
issued an Out of Hospital DNR order in accordance with the law. Iowa Administrative Code 641 – 142.1 (144A) Definitions.
59
Lee County EMS Ambulance, Inc.
Standard Operation Procedures / Protocols
Out of Hospital Trauma Triage Destination Decision Protocol
Adult
IOWA’S TRAUMA SYSTEM
The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries,
method of transport and trauma care facility resources necessary for treatment of those injuries.
Step 1 – Assess for Time Critical Injuries: Level of Consciousness & Vital Signs:
Glasgow Coma Score < 14
Respiratory Difficulty / Rate <10 or >29
Heart Rate >120
Systolic Blood Pressure < 90
If ground transport time to a Resource (Level I) or Regional (Level II) TCF is less than 30
minutes, Transport to the nearest Resource (Level I) or Regional (Level II) TCF.
If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II)
Transport to the nearest appropriate TCF.
If time can be saved or level of care needs exist, tier with ground or air ALS service program
If step 1 does not apply, move to step 2
Step 2 – Assess for Anatomy of an Injury:
All penetrating injury to head, neck, torso, and extremities proximal to elbow and knee
Partial or full thickness Burns >10 % TBSA or involving face / airway
Amputation proximal to wrist or ankle
Crushed, degloved, or mangled extremity
Paralysis or Parasthesia
Flail Chest
Suspected two or more long bone fractures
Any open long bone fractures
Suspected pelvic fracture
Open or depressed skull fracture
EMS provider judgment for possible abdominal or thoracic injuries
If ground transport time to a Resource (Level I) or Regional (Level II) TCF is less than 30
minutes, Transport to the nearest Resource (Level I) or Regional (Level II) TCF.
If greater than 30 minutes ground transport time to Resource (Level I) or Regional (Level II)
Transport to the nearest appropriate TCF.
If time can be saved or level of care needs exist, tier with ground or air ALS service program
If step 1 does not apply, move to step 3
Step 3 – Consider Mechanism of Injury & High Energy Transfer:
Falls – Adult: .20 ft. (1 story = 10 ft)
High-risk auto crash:
Intrusion: > 12 in, occupant site; 18 in, any site
Ejection (partial or complete)
Death in same passenger compartment, Vehicle telemetry data consistent with high risk of injury
Auto vs Pedestrian / Bicyclist thrown, run over, or with significant (>20 mph) impact
Motorcycle crash >20 mph, Rollover (unrestrained occupant) Bicyclist into handlebars
Transport to the nearest appropriate TCF, need not be the highest level trauma care facility.
If step 3 does not apply, move on to step 4
60
Lee County EMS Ambulance, Inc.
Standard Operation Procedures / Protocols
Out of Hospital Trauma Triage Destination Decision Protocol
Adult
IOWA’S TRAUMA SYSTEM
Step 4 – Consider risk factors:
Age > 55 yrs (Risk of injury / death increases)
Time – sensitive extremity injury
EMS provider judgment
Anticoagulation and bleeding disorders
Pregnancy >20 weeks
Transport to the nearest appropriate TCF, need not be the highest level TCF.
If none of the criteria in the above 4 steps are met, follow local protocol for patient disposition.
When in doubt, transport to nearest TCF for evaluation.
For all Transported Trauma Patients
Contact receiving TCF:
 Give patient report to include MOI, injuries, VS, GCS, Treatment, Age, Gender, ETA
 Obtain further orders from Medical Control as needed.
61
Lee County EMS Ambulance, Inc.
Standard Operation Procedures / Protocols
Out of Hospital Trauma Triage Destination Decision Protocol
Pediatric
IOWA’S TRAUMA SYSTEM
The following criteria shall be utilized to assist the EMS provider in the identification of time critical injuries,
method of transport and trauma care facility resources necessary for treatment of those injuries.
Step 1 – Assess for Time Critical Injuries: Level of Consciousness & Vital Signs:
Abnormal Responsiveness: abnormal or absent cry or speech. Decreased response to parents
or environmental stimuli. Floppy or rigid muscle tone or not moving. Verbal, Pain,
Unresponsive on AVPU Scale.
OR
Airway / Breathing Compromise: obstruction to airflow, gurgling, stridor or noisy breathing.
Increased / excessive retractions or abdominal muscle use, nasal flaring, stridor, wheezes,
grunting, gasping, or gurgling. Decreased / absent respiratory effort or noisy breathing.
Respiratory rate outside normal range.
OR
Circulatory Compromise: cyanosis, mottling, paleness / pallor or obvious significant bleeding.
Absent or weak peripheral or central pulses; pulse or systolic BP outside normal range.
Capillary refill >2 seconds with other abnormal findings.
If ground transport time to a Resource (Level I) or Regional (Level II) TCF is less than 30
minutes, Transport to the nearest Resource (Level I) or Regional (Level II) TCF.
If time can be saved or level of care needs exist, tier with ground or air ALS service program
If step 1 does not apply, move on to step 2
Step 2 – Assess for Anatomy or an Injury:
All Penetrating injury to head, neck, torso, and extremities proximal to elbow and knee
Partial or full thickness burns >10% TBSA or involving face / airway
Amputation proximal to wrist or ankle, Crushed, degloved, or mangled extremity
Paralysis or Parasthesia
Flail chest
Suspected two or more long bone fractures
Any open long bone fractures
Suspected pelvic fracture
Open or depressed skull fracture
EMS provider judgment for possible abdominal or thoracic injuries
Step 3 – Consider Mechanism or Injury & High Energy Transfer:
Falls - >10 feet or Pediatric: > 2 – 3 times the victims height
High-risk auto crash
Intrusion: > 12 in, occupant site; > 18 in any site
Ejection (partial or complete)
Death in same passenger compartment
Bicyclist into handlebars
Auto vs Pedestrian / bicyclist thrown, run over, or with significant (>20 mph) impact
62
Lee County EMS Ambulance, Inc.
Standard Operation Procedures / Protocols
Out of Hospital Trauma Triage Destination Decision Protocol
Pediatric
IOWA’S TRAUMA SYSTEM
Transport to the nearest (Any Level) TCF
If step 3 does not apply, move onto step 4
Step 4 – Consider risk factors:
Age <5 yrs (Risk of injury / death increases)
ETOH / Drugs
Time – sensitive extremity injury
Transport to the nearest (Any Level) TCF
For all Transported Trauma Patients
Contact Medical Control:
 Patient report to include: MOI, Injuries, VS, GCS, Treatment, Age, Gender, ETA
 Obtain further orders as needed
63
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Physician on Scene
Your offer of assistance is appreciated. However, this EMS service, under law and in
accordance with nationally recognized standards of care in Emergency Medicine, operates under
the direct authority of a Physician Medical Director. Our Medical Director and physician
designees have already established a physician-patient relationship with this patient. To ensure
the best possible patient care, and to prevent inadvertent patient abandonment or interference
with an established physician-patient relationship, please comply with our established protocols.
Please review the following if you wish to assume responsibility for this patient:





64
You must be recognized or indentify yourself as a qualified physician.
You must be able to provide proof of licensure and identify your specialty.
If requested, you must speak directly with the on-line medical control physician to
verify transfer of responsibility for the patient from that physician to you.
EMS personnel, in accordance with state law, can only follow orders that are
consistent with the approved protocols.
You must accompany this patient to the hospital, unless the on-line medical control
physician agrees to re-assume responsibility for this patient prior to transport.
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
AIR MEDICAL TRANSPORT
Utilization guidelines for Scene Response
These guidelines have been developed to assist with the decision making for use of air medical
transport by the emergency medical services community. The goal is to match the patient’s
needs to the patient’s needs to the timely availability of resources in order to improve the care
and outcome of the patient from injury or illness.
Clinical Indicators:

Advanced level of care need (skills or medications) exists that could be made
available more promptly with as air medical tier versus transport by ALS ground
service, and further delay would likely jeopardize the outcome of the patient.

Transport time to definitive care hospital can be significantly reduced for a critically
ill or injured patient where saving time is in the best interest of the patient.

Multiple critically ill or injured patients at the scene where the needs exceeds the
means available.

EMS Provider ‘ index of suspicion ‘ based upon mechanism of injury and patient
assessment.
Difficult Access Situations:

Wilderness or water rescue assistance needed.

Road conditions impaired due to weather, traffic, or road construction / repair.

Other locations difficult to access.
The local EMS providers must have a good understanding of regional EMS resources and strive
to integrate resources to assure that ground and air services cooperate as efficiently and
effectively as possible in the best interest of the patient.
Medical directors for ambulance services should assure that EMS providers are aware of their
own service’s abilities and limitations given the level of care and geographic response area being
served. Audits should be conducted on ongoing basis to assure that utilization of regional
resources (ground and air) is appropriate in order to provide the level of care needed on a
timely basis.
65
Lee County EMS Ambulance, Inc
Standard Operating Procedures / Protocols
Procedure for Photographic Documentation of Mechanism of Injury
PURPOSE:
To obtain photographic documentation of mechanism of injury to assist the attending physician
in determining possible underlying injury.
INDICATIONS:
 Any traumatic injury where the attending paramedic believes that obtaining pictures
of the accident scene and mechanism of injury will aid the attending physician in
patient care.
CONTRAINDICATIONS:
 Do not delay transport to the receiving facility to obtain photographs.
 If the patient or patient’s family object to taking photographs of the patient, exclude
the patient from the photographs while still attempting to provide documentation of
the mechanism of injury.
PROCEDURE:
 Obtaining photographs should in no way compromise patient care.
 Provide care based on the appropriate protocol.
 Obtain 1-2 photographs of the mechanism of injury.
 If a motor vehicle accident is involved, pictures of the area of impact to the exterior
of the vehicle and damage to the patient compartment can be obtained.
 Wherever possible, photographs should be obtained by law enforcement or fire
department personnel.
 Pictures are obtained for the use of receiving facility Medical staff only. They may
be viewed by other members of the healthcare team (i.e. aeromedical staff), but they
are to remain in the ED and become part of the patient’s permanent medical record.
66
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Fatal Illness / Injury
Discontinuation of Resuscitation
Determine Death:
If a patient appears dead, the following protocol should be used.
Initial patient assessment.
If appropriate, determine if the patient has expire by:
 Identification of All Presumptive signs of death.
Unresponsiveness
Apnea
Pulselessness
Fixed dilated pupils, plus;
It is permissible to identify the absence of productive electrical activity in the heart by applying
the cardiac monitor to document asystole in at least two leads.
Identification of at least one conclusive sign of death:
 lividity and/or generalized cyanosis
 fully established rigor mortis
 complete partition or destruction of the body incompatible with life
 generalized body putrefaction
Once it has been determined that the patient has expired and resuscitation will not be attempted,
cover the body with a sheet or other suitable item. Immediately notify dispatch to contact the
Medical Examiner or his/her designee. Notify the appropriate law enforcement agency, if not
already done.
When making decisions regarding resuscitation vs. no resuscitation, remember to identify special
circumstances which may affect your decision:
 Drowning
 Hypothermia
 Suspected Drug or Toxin Ingestion
The above may benefit from continued resuscitation efforts.
******** WHEN IN DOUBT, RESUSCITATE ********
67
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Fatal Illness / Injury
Discontinuation of Resuscitation
Indications to consider termination of resuscitation in the field:
 Patient is in full arrest with no signs of life present.
 Patient is considered an adult.
 Full ACLS has been instituted (Paramedic Level) to include rhythm analysis and
defibrillation if indicated, advanced airway management, and drugs given per
appropriate protocol.
 No return of circulation or shockable rhythm exists.
 Correctable causes or special resuscitation circumstances have been considered and
addressed.
Termination of resuscitation:
 Patient meets all five criteria under indications above, or patient is terminally ill /
DNR where CPR was started prior to knowledge of resuscitation status.
 Physician on-line medical direction is contacted (while ACLS continues) to discuss
any appropriate actions.
 Resuscitation may be discontinued if on-line medical direction authorizes.
Other considerations:
 Documentation must reflect that the decision to terminate resuscitation was
determined by on-line medical direction.
 An EMS / health care provider must attend the deceased until the appropriate
authorities arrive.
 All IV’s, tubes, etc. should be left in place until the medical examiner authorizes their
removal.
 Implement survivor support plans related to coroner notification, funeral home
transfer, leaving the body at the scene, and death notification / grief counseling for
survivors.
Physician on-line medical control / direction includes either of the following:
 Hospital based physician contact via phone or radio.
 Patient’s primary care physician or on call physician contact via phone or radio.
Special Considerations:
 Patients with profound hypothermia or drug or toxin overdose may benefit from
continued resuscitation.
68
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Guidelines for EMS Providers initiating Organ & Tissue Donation
At the scene of the Deceased

All appropriate patient care protocols will be enacted to assure patient care is
provided according to prevailing standards.

If resuscitation efforts are unsuccessful, or if upon arrival the patient is deceased and
without indications to initiate resuscitation, then on-line medical direction will be
contacted to confirm that no further medical care is to be given. Also see fatal
illness/injury discontinuation of resuscitation protocol.

As per Iowa Code 142C.7 a medical examiner or a medical examiner’s designee,
peace officer fire fighter, or emergency medical care provider may release an
individual’s information to an organ procurement organization, donor registry, or
bank or storage organization to determine if the individual is a donor.

As per Iowa Code 142C.7 Any information regarding a patient, including the
patient’s identity, however, constitutes confidential medical information and under
any other circumstances is prohibited from disclosure without the written consent of
the patient or the patient’s legal representative.

At least one EMS provider should remain at the scene until the appropriate authority
(law enforcement, medical examiner, funeral home, etc.) is present.

Contact IOWA DONOR NETWORK at 1-800-831-4131.
69
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Guidelines for EMS Providers responding to a patient with special needs
(This protocol is not intended for inter-facility transfers.)
These guidelines should be used when an EMS provider, responding to a call, is confronted with
a patient using specialized medical equipment that the EMS provider has not been trained to use,
and the operation of that equipment is outside of the EMS provider’s scope of practice. The
EMS provider may treat and transport the patient, as long as the EMS provider doesn’t monitor
or operate the equipment in any way while providing care.
When providing care to patients with special needs, EMS personnel should provide the level of
care necessary, within their level of training and certification. When possible, the EMS provider
should consider utilizing a family member or caregiver who has been using this equipment to
help with monitoring and operating the special medical equipment if necessary during transport.
Some examples of special medical devices:
PCA (patient controlled analgesic)
Chest Tubes
Ventilators
Feeding Tubes and Pumps
Etc.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Instructions For Completing The Report Of Suspected Child Or Dependent Adult Abuse
All EMS personnel are mandatory reporters of child / dependant adult abuse. The initial oral
report must be made to 1-800-367-2178 within 24 hours. As soon as your response duties are
completed and you return to quarters; this would be the best time to make the call. Follow the
menu on the phone system and be prepared for a long wait. Again the oral report must be
made within 24 hours or as soon as possible. If the child / adult is in immediate danger
deal directly with local law enforcement.
The report of suspected child abuse form must be completed and submitted within 48 hours.
This form is prepared by the Mandatory Reporter who has made the initial oral report to the
Department of Human Services. This report can be obtained by contacting management or with
the use of the internet. Go to www.dhs.state.ia.us, locate the search all of Iowa.gov in the upper
right hand corner, type child abuse report form, the results will take you to a printable version of
the report.
Submit this form within 48 hours to the Centralized Intake Unit.
Centralized Intake Unit
401 SW 7th Street, Suite G
Des Moines, IA 50309-3574
It may be faxed to 1-515-564-4011.
If the oral report was not accepted for investigation, this form is not necessary.
Use the space on the back side of the form if there is not enough space for all pertinent
information on the front of this form. Collateral reports or other information may be
attached to the form.
Note: During these situations management should be consulted immediately should you
have any questions or difficulty with completing the above.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
START Triage
The following are guidelines for initial tactical triage using the START method. START is most
useful in initially clearing the disaster zone where there are numerous casualties. It focuses on
respiration rate, perfusion, and mental status and takes under one minute to complete.
Once the patient moves toward a higher level of care (evacuation), a more detailed approach to
triage may be needed.
Respirations
Perfusion
Mental Status
72
Green = Minor / Ambulatory
Yellow = Delayed
Red = Immediate
Black = Deceased / Expectant
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Jump START Triage
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Assessment Based Spinal Management
Mechanism of Injury
Positive
Uncertain
Negative
Apply Spinal Motion
Restriction
Does the patient have spine pain or tenderness?
YES
Apply Spinal Motion
Restriction
NO
Is the motor / sensory exam abnormal?
YES
NO
Apply Spinal Motion
Restriction
Is the exam reliable?
YES
NO
Apply Spinal Motion
Restriction
74
Spinal Motion Restriction
Unnecessary
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Blood Glucose Monitoring
Procedure:

Remove a new test strip from the vial.

Insert the test strip into the test strip slot on the meter.

The meter turns on automatically.

A flashing blood drop symbol will appear and the meter is ready to perform a test.

Obtain a small amount of venous or capillary blood.

With the strip in the meter, touch and hold the drop of blood to the edge of the strip.

The blood will be drawn automatically into the strip. Do not press the tip against the
skin or place the blood on top of the test strip.

After a beep, you will see the meter count down 5 seconds.

Withdraw strip and dispose of strip and sharp appropriately. The meter will
automatically turn off upon removing the strip. Clean meter as needed.

Restock meter supplies as needed. These meters require no coding.
Glucose Control Testing:

Perform Control Testing as appropriate. Control Testing is performed once a week
during inventory.

The paramedic feels an inappropriate reading was obtained

Insert Strip into the meter. Apply a drop of test solution.

Normal control solution range is 105 – 145 mg/dL.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Needle Cricothyroidotomy
Indications:
A patient in respiratory arrest or near arrest in whom an airway cannot be secured with
intubation or other advanced airway management procedures.
Situations in which standard endotracheal intubations cannot be done such as:
 Excessive oropharyngeal hemorrhage
 Massive traumatic or congenital deformities
 Complete airway obstruction precluding ET tube placement
Severe cervical spine injury with respiratory compromise in patients who cannot be
endotracheally intubated.
Unsuccessful attempts at endotracheal intubation in situations where delays would result in
hypoxic injury.
Procedure:
 Place the patient in the supine position.
 Palpate the cricothyroid membrane between the thyroid and cricoids cartilages.
 Prep the area with betadine swabs.
 Attach a 14 gauge IV catheter to a 10 cc syringe.
 Puncture the skin midline, directly over the cricothyroid membrane.
 Direct the needle at a 45 degree angle.
 Carefully insert the needle through the lower half of the membrane, aspirating as the
needle is advanced.
 Aspiration of air signifies entry into the tracheal lumen.
 Withdraw the stylet while carefully advancing downward into position, being careful
to avoid the posterior tracheal wall.
 Attach catheter needle hub to a 3.0 mm EET adapter and ventilate with 100 % oxygen
via BVM.
 Adequate PaO2 can be maintained for only a short period of time.
 Rapid transport to a facility capable of a Surgical Cricothyroidotomy is immediately
required.
 Notify the receiving facility of the situation with an estimated time of arrival.
 Observe lung inflation and auscultate for adequate ventilation.
 Secure as necessary to the neck.
 Document and record responses (ECG, SpO2, ETCO2).
Complications:
 Exsanguinating hematoma.
 Subcutaneous and/or mediastinal emphysema.
 Inadequate ventilations resulting in hypoxia and death.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Needle Thoracentesis
After identifying a tension pneumothorax: (as characterized by extreme anxiety, dyspnea, and
tachypnea, diminished or absent breath sounds on one side, tachycardia, narrow pulse pressure,
hypotension, and tracheal deviation) Note tracheal deviation is a late sign; its absence should not
be used to rule out this possibility.
Identify the second or third intercostal space in the mid-clavicular line on the side of the
pneumothorax.
Prep the site with alcohol or betadine.
Insert a Safety Fluid Drainage System Needle 8 Fr. into the skin (2nd or 3rd ICS-MCL) and direct
the needle into the pleural space above the underlying rib. Needle should not be introduced
underneath the rib. Watch for the indicator to turn green, indicating you’re placement is
confirmed.
Remove the stylette
Cover and stabilize with dry bulky dressing.
Continue to assess patient’s vital signs, level of consciousness, and respiratory status.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Guidelines
Protocol Revision Authorization
List all changes made by the physician medical director. According to Iowa Administrative Code 641-132.8(3)”b”
service programs shall, “utilize department protocols as the standard of care. The service program medical director
may make changes to the department protocols provided the changes are within the EMS provider’s scope of
practice. A copy of the changes shall be filed with the department.” Include a copy of any additional protocols if
approved for use. Submit a revised copy of the drug list if additions or deletions apply.
Protocol:
Routine Care Protocol
Changes Made (all protocols on file):______________________
Revised to provide complete ALS assessment/treatment of all
initial out-of-hospital patient contacts.
Cardiac Arrhythmias
Post Resuscitation (ROSC)
Ped. Cardiac Arrest
Newborn Resuscitation
ACS
CHF
Cardiogenic Shock
Revised to provide all cardiac care using AHA/BLS/ACLS/PALS
standards/guidelines with consultation with medical director,
pharmacy staff, and referring cardiology groups (see protocols).
Abdominal Pain
Initial out-of-hospital care for ALS providers.
Alcohol Emergencies
Initial out-of-hospital care for ALS providers to include
medications.
Allergic Reaction
Anaphylaxis
Anaphylactic Shock
Initial out-of-hospital care for ALS providers to include
medications.
Asthma
Initial out-of-hospital care for ALS providers to include
medications.
Altered Mental Status
Initial out-of-hospital care for ALS providers to include
medications.
Behavioral Emergencies
Initial out-of- hospital care for ALS providers to include
medications.
Burns:
Initial out-of-hospital care for ALS providers to include
fluid administration and medications.
Hypovolemic Shock
Initial out-of-hospital care for ALS providers to include
fluid administration and permissive hypotension for appropriate
age groups.
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Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Guidelines
Protocol Revision Authorization
Protocol:
Pain Control
Changes Made (all protocols on file):______________________
Initial out-of-hospital pain control for ALS providers to include
medications (morphine, fentanyl).
Nausea / Vomiting
Initial out-of-hospital care for ALS providers to include
medications (phenergan).
Sexual Assault
Initial out-of-hospital care and assessment of the victim of sexual
assault for the ALS provider.
Taser Dart Removal
Initial out-of-hospital and assessment of the patient subdued by use
of a taser for the ALS provider to include removal, care & release.
Trauma
Initial out-of-hospital care for ALS providers to include
tourniquets, permissive hypotension.
Tourniquet Application
Initial use of CAT tourniquets for hemorrhage control.
CCT SOP’s & Protocols
Guidelines for critical care transport to be utilized by staff
paramedics that have completed the LCEMSA CCT-C
education or have a CCP endorsement; including SOP’s
and protocols for continued sedation/paralysis, RSI,
automatic transport ventilator operation, chest drainage
management, RSI, see protocols.
All other SOP’s & Protocols are guidelines for specific incidents or procedures. These include but are not limited to
specific manufactures directions and/or guidelines for use of equipment. State required or suggested guidelines of
incidents, triage, etc. Included is a list of service approved abbreviations. All protocols are drafted to include adult
and pediatric patients, special considerations and situations. These SOP’s & Protocols are not to replace the
providers knowledge, training and medical control should be consulted whenever any incident or situation requires
further consult or explanation. Providers may use multiple protocols to care for any one patient. All SOP’s &
Protocols were drafted with consultation of multiple references to include consultation with the
service medical director, pharmacy staff, etc. All SOP’s & Protocols are on file with the IDPH
bureau of EMS.
Dr. David C. Wenger-Keller M.D.
79
_____________________________
Service medical director signature
____________
Date
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Guidelines
Approved Abbreviations
ABC
Afib
ALOC
ALS
AMI
amps
ASA
AT
AV
bicarb
BID
BLS
BP
BS
CAD
CC
cc
CCU
CHB
CHF
CID
cm
CNS
c/o
CO
C02
COPD
CPR
CSF
CVA
D/C
DOA
D5W
DM
Dx
ED
EKG, ECG
Epi
ER
80
airway, breathing, circulation
atrial fibrillation
altered level of consciousness
advanced life support
acute myocardial infarction
ampules
aspirin
atrial tachycardia
atrioventricular
sodium bicarbonate
twice a day
basic life support
blood pressure
blood sugar
coronary artery disease
chief complaint
cubic centimeter
coronary care unit
complete heart block
congestive heart failure
cervical immobilization device
centimeter
central nervous system
complains of
carbon monoxide
carbon dioxide
chronic obstructive pulmonary disease
cardiopulmonary resuscitation
cerebral spinal fluid
cerebral vascular accident
discontinue
dead on arrival
5% dextrose in water
diabetes mellitus
diagnosis
emergency department
electrocardiogram
epinephrine
emergency room
Lee County EMS Ambulance, Inc.
Standard Operating Procedure / Protocols
Approved Abbreviations
ERP
ET
ETT
ETOH
fib
fl
fx
GI
gm
gr
gtt
hr
hx
ICU
IM
IV
Kg
KVO
L
LOC
LR
LSB
mgtt
MD
mEq
mg
MI
min
ml
mm
MSo4
NaCI
NG
NTG
NPO
NS
NSR
NVM
O2
81
emergency room physician
endotracheal
endotracheal tube
alcohol
fibrillation
fluid
fracture
gastrointestinal
gram
grain
drop(s)
hour
history
intensive care unit
intramuscular
intravenous
kilogram
keep vein open
liter
level of consciousness
lactated ringers
long spine board
micro drop
medical doctor
millequivalents
milligram
myocardial infarction
minute
milliliter
millimeter
morphine sulfate
sodium chloride
nasogastric
nitroglycerine
nothing by mouth
normal saline
normal sinus rhythm
Neurological / Vascular / Motor
oxygen
Lee County EMS Ambulance, Inc.
Standard Operating Procedures / Protocols
Approved Abbreviations
OB
OD
OR
P
PAC
PAT
PCR
PE
ped
PERRL
PJC
po
prn
PVC
QID
R
R/O
RN
Tx
SMR
SQ
Sec
SL
SOB
STAT
s/s
SVT
Sx
TIA
TID
TKO
VF
w/s
x
y/o
MAEW
82
obstetrics
overdose
operating room
pulse
premature atrial contraction
paroxysmal atrial tachycardia
patient care report
physical exam / pulmonary edema / pulmonary embolism
pediatric
pupils equal, round, reactive to light
premature junctional contraction
by mouth
as needed
premature ventricular contraction
four times a day
respirations
rule out
registered nurse
treatment
spinal motion restriction
subcutaneous
second
sublingual
shortness of breath
immediately
signs & symptoms
supraventricular tachycardia
symptoms
transient ischemic attack
three times a day
to keep open
ventricular fibrillation
watt second setting
times
years old
moves all extremities well