Florence County Emergency Medical Service Advanced Life Support Protocols

 

The opinions, facts, techniques, methodologies, modalities and practices represented herein are solely those held and promoted by the authors of these pages and do not necessarily reflect the policies and practices endorsed by the Florence County Emergency Medical Service or Florence County Council in it's capacity as Florence County government. Readers are reminded to consult with local laws, medical control, regulations and protocols before adopting procedures described here in these pages, diagrams, and pictures. The following Protocols or Standing Orders are based on the Advanced Life Support Protocols published by the South Carolina Department of Health and Environmental Control (DHEC),  EMS Division. Those Protocols were designed to be a minimal guide to establish a framework to a more comprehensive set of Protocols, specific to each area and under the direction of the Medical Control Physician for the Service Provider. These Protocols are specific to Florence County EMS, Pamplico, Johnsonville, and Timmonsville Rescue Squads.  No other agency or agent  is authorized to utilize them to provide medical treatment within Florence County in the manner that they indicate.
Adult and selected Pediatric	Pediatric specific
Anaphylaxis Asthma/Reactive Airway Disease Asystole Blunt Trauma/Shock/Hypotension/Suspected GI Bleed Bradycardia / Third Degree Heart Block Burns - Major Coma or Altered Mental Status CVA/TIA - Suspected Diabetic Coma Dystonic Reactions EMT-D Defibrillation Field Resuscitation and Discontinuation of Resuscitation Head Injuries Hypertensive Crisis - Suspected Hyperthermia Hypoglycemia - Symptomatic Hypotension Hypothermia Intraosseous Fluids Isolated Fractures Nitrous Oxide Obstetric Patients Penetrating Trauma/Shock Pleural Decompression Poisoning/Overdose Premature Ventricular Contractions Pulmonary Edema Pulseless Electrical Activity (PEA) (Electromechanical Dissociation [EMD]) Respiratory Arrest Respiratory Distress Saline Locks Seizure/Post-ictal State Shock Supra-Ventricular Tachycardia Suspected Acute Myocardial Infarction Syncopal/Near Syncopal Episode Termination of Resuscitative Efforts Ventricular Fibrillation - Pulseless Ventricular Tachycardia Ventricular Tachycardia-  Pulse Present: Stable Ventricular Tachycardia - Pulse Present: Unstable	Pediatric Asthma/Reactive Airway Disease Pediatric Asystole Pediatric Bradycardia Pediatric Medical Cardiac Arrest Pediatric Dehydration/Hypovolemic Shock Pediatric EMD Pediatric Hypoglycemia Pediatric Major Trauma/Head Injury Pediatric Respiratory Distress Pediatric Seizures Pediatric SVT Pediatric Ventricular Fibrillation Pediatric Ventricular Tachycardia

 

Supra-Ventricular Tachycardia

Criteria: Heart rate greater than 150 BPM with a QRS greater than 0.12 sec Wide. If the QRS is greater than 0.12 sec - consider treating as Supra-Ventricular Tachycardia. Initial Treatment 1. Appropriate Airway Management. 2. Cardiac Monitor. 3. IV D5W at KVO. 4. Consider sedation with Valium 5-10mg IV push prior to Cardioversion (Must contact Medical Control for Valium Administration). 5. Start Synchronized cardioversion progression at 100J, 200J, 300J, 360J until cardioversion is successful or until 360J attempt fails. Contact Medical Control for Options 6. Administer 6mg Adenosine Rapid IV followed by 20cc fluid bolus. 7. If unsuccessful - administer 12mg Adenosine followed by 20cc fluid bolus. 8. If unsuccessful - administer 12mg Adenosine (second 12mg dose) followed by 20cc fluid bolus.

Suspected Acute Myocardial Infarction

Criteria: patient complains of chest discomfort, nausea, or any combination of events that may lead the Medic to believe a cardiac event is occurring. 1. Appropriate Airway Management with Oxygen. 2. Cardiac Monitor. 3. Start IV D5W for N.S. 4. 4 Baby Aspirin PO (bite chew and swallow) (Patient must be conscious and oriented). 5. Nitroglycerine 0.4mg - if B/P > 100 - give one tab (1:150) or metered dose 0.4mg Nitrospray. 6. Repeat NTG que 5 minutes until pain is resolved of B/P < 100 to a total of 3 administrations. (Consider number of Patient administered doses prior to your arrival). Contact Medical Control for the following options 7. Morphine Sulfate 2-10mg Slow IV push. 8. Continued 0.4gm NTG que 5 min for pain. 9. Lidocaine 1-1.5mg/kg slow IV for serious ectopy. If ectopy resolved, begin Lidocaine infusion at 2mg/min.

Anaphylaxis

1. Recognize history of insect sting, or recent ingestion of medicine, certain foods in susceptible individuals. 2. Perform BLS. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 4. Monitor cardiac activity. 5. If BP < 90 systolic, start IV of NS wide open titrating until BP > 90. Draw red and purple top tubes of blood while starting IV. 6. If BP > 90 systolic, run IV at 150 cc/hr. 7. If patient is hypotensive and/or wheezing, give Epinephrine 1:1000 SQ 0.2-0.5 ml SQ. 8. Contact Medical Control.

Asthma/Reactive Airway Disease - 2 Years Old or Older

1. Recognize the existence of reactive airway disease (asthma or COPD) as evidenced by history and bilateral wheezing. 2. Place patient on high flow oxygen as tolerated by patient. If the patient is on home oxygen, maintain the same oxygen concentration en route as ordered for home administration. 3. If patient is apneic, cyanotic, or in severe respiratory distress, perform intubation and assist respirations as needed. 4. Place patient on cardiac monitor. 5. Start IV of NS or D5W KVO or saline lock. 6. Patients age 2 and older: 5.0 mg (1.0 ml) Albuterol inhalation solution mixed with 2-3 ml sterile NS delivered via hand held nebulizer over 5-15 minutes. 7. Repeat treatments may be given with on-line medical control. 8. Contact Medical Control. 9. If needed with on-line Medical Control Order, the following may be given: I. Epinephrine up to 0.5 mg SQ (1:1000) Q 15-30 min. x 3 total doses in patients over 40. II. Epinephrine Pediatric dosage 0.01 mg/kg SQ up to 0.3 mg Q 15-30 minutes to 3 total doses. III. Terbutaline Sulfate - 0.25 mg (0.25 ml) SQ: Pediatric dosage 0.005 mg/kg.

Asystole

1. Establish unresponsiveness, start CPR, and place on monitor. 2. Confirm asystole in two leads. 3. Hyperventilate patient with bag valve mask and 100% oxygen. 4. Intubate patient. 5. Start IV Normal Saline at KVO rate. 6. Give Epinephrine 1:10,000; 0.5 -1.0 mg. IV push (may elect to give per ET tube if IV cannot be established). Repeat every 3-5 minutes. 7. Give Atropine 1.0 mg. IV push or per ET tube. Repeat every 3-5 minutes to a maximum of 0.04 mg/kg. 8. If no response, apply external cardiac pacer at lowest setting, titrating as necessary to obtain pacing. 9. Contact Medical Control - Be prepared to utilize Class IIb drugs. 10. If unable to contact Medical Control, Class IIb drugs may be utilized.

Blunt Trauma/Shock/Hypotension/Suspected GI Bleed

1. Perform BLS. Start high flow oxygen via mask. 2. Open and maintain airway as needed and immobilize C-spine if traumatic injury is suspected. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. Remember C-spine immobilization when intubating. 4. Monitor cardiac activity. Draw red and purple top tubes of blood. 5. If systolic BP > 90, start large bore IV with NS at 150 cc/hr. If systolic BP < 90, start two large bore IV lines with NS at wide open titrating to maintain BP above 90 systolic. 6. Apply MAST garment but do not inflate. Inflate only on orders of Medical Control. 7. Contact Medical Control. (In blunt trauma, contact Medical Control as soon as possible on arrival to scene with information including sites of injury, revised trauma score, age, and ETA.)

Bradycardia / Third Degree Heart Block

1. Oxygen by nasal cannula or mask. 2. Start IV at KVO rate. 3. If patient is unstable (BP less than 90 or decreased level of consciousness) administer 1 mg Atropine IV push. 4. Contact Medical Control. 5. If unable to contact Medical Control, proceed with transcutaneous pacing if available, starting at the lowest setting and titrating as necessary to obtain pacing.

Major Burns

1. Move patient away from danger into a well-ventilated area. 2. Recognize burn injury and assess its severity. Major burns are defined at 25% or greater second or third degree burns. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 4. Begin high flow oxygen by mask or cannula if not intubated. If intubated, place on flush rate. 5. Place two large bore IVs in unburned area if possible. Begin NS at wide open rate. 6. Monitor cardiac activity. 7. If possible, remove all clothing and restrictive articles such as rings and bracelets. 8. Wrap burned areas in sterile saline dressings or burn pack. Do not use ice or cold water. 9. Continue supportive measures and protect against hypothermia. 10. Contact Medical Control.

Coma or Altered Mental Status

1. Recognize coma and note any evidence of trauma. 2. Open and maintain the airway. If apneic, or rate less than ten, perform endotrachial intubation and assist respirations as needed. 3. Protect and immobilize the C-spine. 4. Monitor cardiac activity. 5. Administer O2 by mask at 12-15 L/min. 6. Draw red and purple top tubes and test for base line glucose. 7. Establish IV access and infuse D5W at a KVO rate. 8. If blood glucose < 80 give one amp D50 IV push. Give Narcan 2 mg IV push. 9. Contact Medical Control.

Suspected CVA/TIA

1. Recognize possible CVA/TIA syndrome. 2. Open airway and start oxygen at 6-10 L/min. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 4. Place on cardiac monitor. 5. Start IV line of NS at KVO. 6. Perform dextrostick. If dextrostick < 80, push one amp of D50 IV. 7. Contact Medical Control.

Diabetic Coma

1. Recognize possible diabetic coma state. 2. Open and maintain airway, administer O2 via mask or cannula. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist ventilation as necessary. 3. Place on cardiac monitor. 4. Perform dextrostick, draw red and purple top tubes and begin IV line of NS at 150cc/hr. 5. If systolic BP <90, give 300cc NS fluid bolus IV, then titrate IV rate to maintain a systolic BP of 90. 6. Contact Medical Control.

Dystonic Reactions

1. Obtain a history of the use of one of the following drugs: Haldol, Loxitane, Moban, Thorzine, Melleril, Prolixin 2. Recognize extrapyramidal effects. 3. Obtain IV access and start NS at KVO rate. 4. Oxygen via mask or cannula. 5. Administer Diphenhydramine (Benadryl) 50 mg slow IV push. 6. Contact Medical Control.

Isolated Fractures

1. Perform BLS. 2. Recognize fracture and splint extremity appropriately. 3. Check for distal pulse before and after splinting. 4. At paramedic's discretion, draw red and purple top tubes of blood and start IV NS at KVO, if BP < 90 systolic, give 300 cc fluid bolus and run IV at 150 cc/hr. 5. Allow patient to self administer Nitrous Oxide for severe pain relief. 6. Contact Medical Control.

Major Head Injuries

1. Recognize patient with major traumatic head injury, assess level of consciousness, and immobilize cervical spine. 2. Open airway and administer oxygen at 10 L/min by mask. Place patient on cardiac monitor. 3. If patient is apneic, cyanotic, or obvious respiratory distress is present, perform intubation and assist ventilations. 4. Hyperventilate patient with high flow oxygen. 5. Begin IV of NS at KVO rate. 6. If systolic BP < 90, give fluid bolus of 300 cc, then decrease IV rate to KVO. 7. Contact Medical Control.

Suspected Hypertensive Crisis

1. Recognize possible hypertensive crisis. 2. Open airway and start oxygen at 10 L/min. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 4. Place on cardiac monitor. 5. Start IV line with D5W at KVO. 6. Contact Medical Control. 7. Be prepared to give 20-40 mg Lasix IV.

Hyperthermia

1. Ensure airway; remove clothing. 2. Oxygen at 4-5 L/min. 3. Cool with water soaked sheets - ensure air flow over patient for evaporative loss. 4. Start IV D5W. 5. Do a dextrostick. If < 80, give D50 - one amp. 6. Monitor cardiac rhythm. 7. Contact Medical Control.

Symptomatic Hypoglycemia

1. Recognize hypoglycemic state. 2. Open and maintain airway. If apneic, cyanotic, or obvious respiratory distress is present, perform intubation and assist ventilation as necessary. 3. Place patient on cardiac monitor. 4. Draw red and purple top tubes and start IV of D5W. 5. Perform dextrostick. If dextrostick < 80, administer one amp of D50 IV push. 6. Contact Medical Control. 7. Be prepared to give Glucagon 1 mg IM if unable to obtain IV. Note: Glucagon should be used only if IV access is unobtainable after multiple attempts or if Dextrose is unavailable.

Hypothermia

1. Ensure airway. 2. If no pulse, proceed to approved protocol and contact Medical Control. Notify that patient is hypothermic and in cardiac arrest. 3. Oxygen at 4-5 L/min, warm and humidified if possible. 4. Avoid unnecessary suctioning or airway manipulation. 5. Remove wet or constrictive clothing. 6. Wrap in blankets and remove from exposed environment. 7. Start IV NS at KVO rate. Fluid should be warm if possible. Do not attempt to start IV until pt. is moved to a warm environment. 8. Draw red and purple top tubes and do a dextrostick, if < 80 give one amp D50. 9. Monitor cardiac rhythm. 10. Contact Medical Control.

Intraosseous Fluids

1. In comatose children, four years of age or younger, presenting with multiple systems injuries or cardiac arrest in whom 2 attempts at peripheral IV is unsuccessful (should take less than 90 seconds) the following procedure should be performed: 2. Prepare the aspiration syringe and IV adjuncts. 3. Locate an area on the tibia of the leg one to two finger widths below the tubercle (approximately 1 cm) on the anteromedial surface. 4. Cleanse the skin as for a normal IV with betadine and alcohol. 5. Insert the needle at a slightly downward angle with the point directed towards the foot and away from the epiphyseal plate. A boring or screwing motion is used until penetration into the marrow, noted by decreased resistance. 6. The stylet is then removed, leaving the hollow needle in place. 7. Marrow is aspirated into a saline filled syringe. If marrow cannot be aspirated, but saline can be flushed in easily without evidence of swelling around the site, the needle should be in place. If not, abandon the site. 8. Saline is infused by syringe to check placement and to clear the needle of any clot. 9. A standard IV tubing is attached and infusion of fluids or drugs is begun under gravity or pressure. 10. The skin guard is screwed flush to the skin. 11. The skin guard is then placed parallel to the tibia, flush with the skin. One-half inch strips of tape should be used to tape the skin guard down. Contraindications: 1. Skin infection at desired puncture site. 2. Fractured leg (use other leg). Remember: D50W and Sodium Bicarbonate must be diluted 1:1 with sterile water before being administered in the pediatric patient.

Nitrous Oxide

1. Indications for Use (age greater than 12):  a. Musculoskeletal Trauma  b. Fracture or Dislocation to Extremities  c. Blunt Crush Injury to Extremities  d. Traumatic Amputation  e. Burns  f. Kidney Stones  g. Painful Procedures at Scene 2. Patient will have O2, increase as needed. 3. Start an IV of NS at KVO rate and attach cardiac monitor. 4. Nitrous Oxide/Oxygen is to patient administered only. 5. Only Nitrous Oxide/Oxygen is to be used. Nitrous Oxide is never to be used alone. 6. Contact Medical Control. 7. Monitor patient closely. If level of arousal is depressed, stop Nitrous Oxide/Oxygen and continue transport.

Obstetric Patients

1. Recognize the pregnant patient and determine how many times she has been pregnant (gravida), how many children she has (para), how many miscarriages/abortions she has had (AB), and how far along she is in this pregnancy. (Reported as G,P,AB counting this pregnancy in the gravida part.) 2. Place patient on oxygen at 4-6 L/min via nasal cannula if stable, or high flow mask if unstable. 3. Place patient on cardiac monitor. 4. If patient is hypotensive, place patient on left side. 5. If hypotensive, heavy vaginal bleeding, severe abdominal pain, or delivery imminent, start IV NS. Titrate IV to maintain BP of 90 systolic or greater. 6. Code 4 returns will be considered in patients with hypotension, severe abdominal pain, heavy vaginal bleeding, or imminent delivery in the complicated patient. 7. Contact Medical Control. ** Be prepared for imminent delivery **

Penetrating Trauma/Shock

1. Perform BLS. Start high flow oxygen at 10 L/min. Monitor cardiac activity. 2. Open and maintain airway and immobilize C-spine if indicated. 3. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 4. All procedures are to be done enroute to the hospital. 5. Start a large bore IV NS at 150 cc/hr if systolic BP > 90. 6. If systolic BP < 90, then IV rate increases to wide open. Start a second large bore IV with NS as time permits at wide open rate. 7. Contact Medical Control as soon as possible upon arrival to scene with information including site of injury, revised trauma score, and ETA. ** Be prepared to treat tension pneumothorax **

Pleural Decompression

1. Recognize the existence of tension pneumothorax.  Significant Signs/Symptoms: a. Jugular vein distention.  b. Tracheal deviation away from the affected side.  c. Decreased or absent breath sounds on affected side.  d. Hyperressonance to percussion on affected side. 2. Contact Medical Control. · Anticipate orders for pleural decompression. 3. If unable to contact Medical Control:  a. Locate 2nd intercostal space, mid-clavicular line or 4th or 5th intercostal space mid axillary line on affected side.  b. Quickly prep the area with Betadine.  c. Attach a 14 g over-the-needle catheter to a 10 or 20 cc syringe partially filled with water or saline.  d. Insert needle into the skin over top of the third rib mid-clavicular line into the interspace.  e. Puncture the parietal pleura; look for air entering the syringe under pressure, and bubbling in the fluid.  f. If successful, remove syringe with needle, attach flutter valve to catheter.  g. Apply dressing and secure catheter. 4. Procedure may be repeated in alternate site if first attempt does not relieve the symptoms. 5. Monitor EKG and be alert for deterioration in patient that may result from reoccurring tension pneumothorax.

Poisoning/Overdose

1. Recognize poisoning: possible clues are history from family or friends, abnormal breath odor, constricted or dilated pupils, or altered state of consciousness. 2. Open and maintain airway. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. Place on cardiac monitor. 3. Obtain history from bystanders. If overdose is suspected, bring any containers along with patient. 4. If there is evidence of external contamination: a. Protect all EMS personnel. b. Remove contaminated clothing. c. Flush skin and eyes with copious amounts of water. 5. In cases with internal contamination, place IV line of NS at KVO rate and draw red and purple top tubes of blood. 6. If patient is comatose, proceed with Coma of Unknown Cause protocol. 7. Continue supportive measures during transport. 8. Contact Medical Control. 9. Be prepared to give Ipecac if patient is alert, has a gag reflex, and ingestion does not contraindicate its use. Dosage: 30 cc / adult, 15 cc / child. 10. Be alert for possible tricyclic overdoses evidenced by wide complexes on EKG, dilated pupils, and hypotension. Be prepared to give Sodium Bicarbonate IV push.

Premature Ventricular Contractions

1. Recognize presence of malignant PVC's in a symptomatic patient:  a. More than six PVC's/min.  b. Bigeminy lasting greater than thirty seconds.  c. Multifocal PVC's.  d. Salvos: two or more PVC's in a row.  e. R-on-T pattern. 2. Place pt. on high flow O2, obtain IV access and start NS or D5W at KVO rate. 3. If after two to three min. on O2, with no change in the status of symptoms and continued malignant PVC's, then administer Lidocaine 1-1.5 mg/kg rapid IV push. 4. Contact Medical Control.

Pulmonary Edema

Criteria: Presence of dyspnea with crackles present or any symptoms felt to resemble Pulmonay Edema. Peripheral Edema without dyspnea DOES NOT always constitute a need for treatment in the pre-hospital setting. Appropriate Airway Management with Oxygen. 1. Cardiac Monitor. 2. IV D5W at KVO. 3. If B/P > 100 Nitroglycerin 0.4mg SL or Spray que 5 min until arrival at the hospital (IV does not need to be established prior to NTG administration if B/P > 100). 4. If B/P > 200 - 0.4mg NTG que 3 min until arrival at the hospital - if B/P drops under 200 que 5 min as above. 5. Give Lasix 40 mg IV (over 2-3 min). Contact Medical Control for the following options 6. Morphine Sulfate 2-10mg slow IV for anxiety. 7. Additional Lasix slow IV up to 200mg. Document Vitals between Drug Administrations

Pulseless Electrical Activity (PEA) (Electromechanical Dissociation [EMD])

1. Oxygenate and ventilate, CPR, obtain IV access and start NS at KVO rate. 2. Give Epinephrine 1:10,000, 1mg - 3mg - 5mg IV push 3 min. apart (may be given per ET tube if unable to start an IV). 3. Consider Atropine 1 mg IV if rate is bradycardic. Repeat every 3-5 min. to a total of 0.04 mg/kg. 4. Consider etiology and possible therapies and treatments. * 5. Contact Medical Control. Possible Causes Of PEA and Treatment Hypovolemia Volume Infusion Hypoxia Ventilation Cardiac Tamponade  Rapid Transport  Tension Pneumothorax Needle Decompression Hypothermia  See Hypothermia Protocol Massive Pulmonary Embolism Rapid Transport Drug Overdose See Overdose Protocol Hyperkalemia Sodium Bicarbonate 1 mEq/kg Acidosis Sodium Bicarbonate 1 mEq/kg Massive Acute Myocardial Infarction Rapid Transport

Respiratory Arrest

1. Recognize respiratory arrest: Apneic or gasping respiration, unconsciousness. 2. Open the airway. 3. Assist ventilation:  a. Mouth to face mask.  b. Bag-valve-mask with supplemental Oxygen at 10-15 L/min. 4. If unable to ventilate, consider obstruction and do the following in sequence:  a. Apply 6-10 subdiaphragmatic abdominal thrusts b. Apply the finger sweep. c. Directly visualize the upper airway, remove obstruction, and reattempt ventilation. d. If still unable to ventilate, continue steps 4A, 4B, and 4C, transport and continue with the remainder of the protocol. 5. Suction the airway as needed. 6. Check peripheral pulse. If absent, proceed with cardiac arrest protocols. If present, continue with the remainder of the protocol. 7. Intubate if necessary. 8. Establish IV access: Infuse D5W or NS at KVO rate. 9. Monitor cardiac activity. 10. Contact Medical Control. 11. Continue airway maintenance and ventilation assistance until transport is complete.

Respiratory Distress

1. Open airway and start oxygen at 10 L/min. 2. If apneic, cyanotic, or obvious respiratory distress is present perform intubation and assist respirations. 3. Place on cardiac monitor. 4. Start IV of NS at KVO rate and draw red and purple top tubes of blood. 5. Contact Medical Control.

Saline Locks

Alternate method for keeping the vein open. The saline lock is used in lieu of IV fluids when fluids are not needed for therapeutic measure. Saline lock will not be used in cardiac arrest for any reason or in trauma of any type. They will not be used when hypovolemic shock is present. If the patient needs fluid therapy, then do not start a saline lock. The saline lock is used as a route to deliver medications when fluids are not needed. 1. Start 18 or 20 gauge Jelco. 2. Place lock in place on hub of Jelco. 3. Flush with 3-5 cc sterile saline. 4. Tape in place. If the need to push a drug arises, clean lock with alcohol prep. Push drug. Flush with 3-5 cc of NS.

Seizure/Post-ictal State

1. Recognize post-ictal state or evidence of seizures. 2. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 3. Place on cardiac monitor. 4. Draw red and purple top tubes of blood and begin IV line of NS at KVO rate. 5. Perform dextrostick. If dextrostick < 80, push one amp of D50 IV. 6. Contact Medical Control. 7. Be prepared to give 5 mg Valium IV push if patient continues in status epilepticus or experiences repeated seizure activity after receiving orders from Medical Control.

Syncopal/Near Syncopal Episode

1. Recognize near-syncopal or syncopal episode. 2. Open and maintain airway. If apneic, cyanotic, or obvious signs of respiratory distress are present, perform intubation and assist respirations as needed. 3. Place on cardiac monitor. 4. Draw red and purple top tubes of blood and begin IV line of NS at KVO. 5. Perform dextrostick. If dextrostick < 80, push one amp of D50 IV push. 6. If patient has systolic BP < 90, give 300 cc bolus of NS and titrate to maintain systolic BP of 90. 7. Contact Medical Control.

Ventricular Fibrillation - Pulseless Ventricular Tachycardia

1. Check pulse, if no pulse begin CPR until defibrillator available. 2. Check monitor for VF. 3. If VF, defibrillate at 200 joules. 4. If no response, defibrillate at 300 joules. 5. If no response, defibrillate at 360 joules. 6. If no pulse, initiate CPR. 7. Intubate and ventilate with 100% oxygen. 8. Start an IV of NS at KVO rate. 9. Epinephrine 1:10,000, 1mg - 3mg - 5mg IV push 3-5 min. apart (may be given per ET tube if unable to start an IV). 10. Defibrillate at 360 joules. 11. If no response, Lidocaine 1.5 mg/kg per ET tube or IV bolus. Repeat every 3-5 min. to a loading dose of 3 mg/kg. 12. Defibrillate at 360 joules. 13. Contact Medical Control. 14. Be prepared to administer any Class IIa drug See Attachment). 15. If unable to contact Medical Control, Class IIb drugs may be utilized. 16. Defibrillate at 360 joules, 30-60 seconds after each dose of medication. Pattern should be drug-shock, drug-shock. (See attachment for Drug Classification)

Ventricular Tachycardia Pulse Present: Stable

1. Oxygen by cannula or mask. 2. Initiate IV NS at KVO rate. 3. Contact Medical Control. 4. Be prepared to give Lidocaine 1.5 mg/kg IV push.

Ventricular Tachycardia Pulse Present: Unstable

1. Oxygen by cannula or mask, protect the airway as needed. 2. Initiate IV NS at KVO rate. 3. Contact Medical Control. 4. Be prepared to sedate patient with Valium 5-10 mg Iv push, and cardiovert at 100 joules.

Pediatric Asthma/Reactive Airway Disease

1. Assess patient and determine the presence of wheezing consistent with asthma/reactive airway disease. 2. If patient is in severe respiratory distress, follow respiratory distress protocol. 3. Place patient on oxygen as tolerated. Obtain IV access and start NS. 4. Place patient on cardiac monitor. 5. Contact Medical Control. 6. Be prepared to administer Epinephrine 1:1000 at 0.01 ml/kg dose.

Pediatric Asystole

1. Oxygenate and ventilate, begin CPR, and intubate. Obtain IV access and start NS. 2. Give appropriate dose of Epinephrine (repeat every 5 minutes. Second dose is to be 2-3 times initial dose). 3. Give appropriate dose of Atropine. 4. Consider Etiology. 5. Contact Medical Control.

Pediatric Bradycardia

1. Oxygenate and ventilate, CPR, obtain IV access and start NS at KVO rate. 2. For a neonate (2 months and under): Give appropriate dose of Epinephrine and consider Epinephrine drip. 3. For a child (over 2 months): Give appropriate dose of Atropine. 4. Contact Medical Control.

Pediatric Medical Cardiac Arrest

Drug Doses:  Epinephrine 0.1 cc/kg or 0.01 mg/kg  Atropine 0.2 cc/kg or 0.02 mg/kg Lidocaine 1 mg/kg Bretylium 5 mg/kg Defibrillation 2-4 joules/kg  Cardioversion 0.5-1 joule/kg

Pediatric Dehydration/Hypovolemic Shock

1. Determine that dehydration/hypovolemic shock exists by patient assessment. 2. Place on high flow oxygen by mask. 3. Place on cardiac monitor. 4. If respiratory distress, cyanosis, or airway compromise exists, assist respirations with bag-valve-mask. (Be alert for development of tension pneumothorax. Be sure to listen for axillary breath sounds when assessing ET tube placement.) 5. Perform intubation as needed (See Pediatric Respiratory Distress Protocol). 6. Begin IV line NS with a large bore needle. (If unable to start peripheral IV after 2 attempts, contact Medical Control for intraosseous orders.) 7. Give 20 cc/kg fluid bolus and reassess capillary refill and lung sounds. 8. Do dextrostick. Consult Pediatric Hypoglycemia Protocol if dextrostick <80. 9. If time permits, up to 4 fluid bolus of 20 cc/kg may be given, but capillary refill, lung sounds, and abdominal palpation for liver edge must occur between each bolus. 10. If capillary refill approaches 2 seconds, lungs sound wet, or liver is palpated, reduce IV rate to 50 cc/hr. 11. Contact Medical Control.

Pediatric EMD

1. Oxygenate and ventilate, CPR, obtain IV access and start NS at KVO rate. 2. Give appropriate dose of Epinephrine (repeat every 5 minutes. Second dose is to be 2-3 times initial dose). 3. Consider Atropine if rate is bradycardia. 4. Consider etiology (hypovolemia, hypoxia, tension pneumothorax, cardiac tamponade, acidosis) 5. Contact Medical Control.

Pediatric Hypoglycemia

1. Determine that hypoglycemia exists by performing dextrostick. 2. If dextrostick <80, begin IV line with D51/2NS. If possible, draw red and purple top tubes of blood. 3. Give 1 gm/kg of Dextrose 25 IV. (4cc D25 equals 1 gm of Dextrose) (Alternatively, if patient is also dehydrated, hypoglycemia may be treated with 20 cc/kg fluid bolus of D5NS. This may be prepared by adding 2 amps of D50 to a one liter bag of NS) 4. Contact Medical Control. ** 2cc of Dextrose 50 equals 1 gm of glucose. So alternatively, the total dosage may be calculated in grams, draw up from D50 and then dilute to D25. Pediatric Body Weight Estimation Guidelines Age Weight (kg)   Term Infant  3.5 Birth Weight (BW) 6 Months  7  2 x BW  1 Year  10  3 x BW  4 Years 16  1/4 Adult Wt. (Adult is 70 kg)  10 Years   35 1/2 Adult Wt.

Pediatric Major Trauma/Head Injury

1. Perform BLS. Start high flow oxygen via mask. 2. Open and maintain airway as needed and immobilize C-spine if indicated. 3. If apneic, cyanotic, or obvious respiratory distress is present, perform intubation and assist respirations with 100% oxygen. Remember C-spine immobilization when intubating. 4. All procedures to be done enroute to the hospital. 5. Monitor cardiac activity. 6. Start large bore IV with NS at KVO. 7. If patient is hypotensive, give 20 cc/kg fluid bolus.* If time permits, up to 4 fluid bolus of 20 cc/kg may be given if patient remains hypotensive, but capillary refill and lung sounds must be checked between each bolus. 8. Contact Medical Control as soon as possible upon arrival to scene with information including sites of injury, revised trauma score, age, and ETA. * Normal Blood Pressure Limits: 1. Less than 1 year: 70 systolic. 2. 1 year and older: calculate at 70 plus 2 times age in years. Acceptable Upper Limits of Normal Respiratory and Pulse rates Age Respiratory  Rate Pulse Infant 40 160 Toddler 30 140 School-age child 25 120  Adolescent  20 110

Pediatric Respiratory Distress

1. Assess patient for signs of respiratory distress. 1. Nasal Flaring       2. Intercostal Retractions 3. Altered Mental Status 4. Bradycardia 5. Grunting 6. Head Bobbing 7. Cyanosis 2. Place patient on high flow oxygen by mask or assist respirations with bag-valve-mask if needed. (Be alert for development of tension pneumothorax.) 3. Place patient on cardiac monitor. 4. If unable to maintain adequate ventilation with bag-valve-mask, or prolonged transport, intubate as needed. Consult the following estimated ET tube size chart for appropriate selection of tube size. Obtain IV access and start NS. 5. Contact Medical Control. Suggested Sizes for Endotrachial Tubes Age Internal Diameter of Tube (mm)  Newborn 3.0 6 Months 3.5 3 Years 4.5 5 Years 5.0 6 Years 5.5 8 Years 6.0 12 Years 6.5  16 Years 7.0

Pediatric Seizures

1. Recognize seizure or post-ictal state. 2. Place patient on high flow oxygen as tolerated and protect airway as needed. 3. Place patient on cardiac monitor. 4. Perform dextrostick. If dextrostick < 80, follow hypoglycemia protocol. 5. If patient is actively experiencing seizure activity, establish an IV NS at KVO rate. (Contact Medical Control after two failed peripheral attempts for possible intraosseous orders.) 6. Contact Medical Control. * * Be prepared to give Valium if patient continues in status epilepticus or experiences repeated seizure activity.

Pediatric SVT

1. Oxygenate and ventilate. Obtain IV access and start NS. 2. If patient is stable - Observe and continue transport. 3. If patient is unstable with pulse - DC synchronized cardioversion. 4. Contact Medical Control.

Pediatric Ventricular Fibrillation

1. Recognize Ventricular Fibrillation. 2. Defibrillate 2-4 joules/kg (repeat x 1 if necessary). 3. Ventilate and oxygenate and start CPR. Obtain IV access and start NS. 4. Epinephrine (repeat every 5 minutes, 2nd dose is to be 2-3 times the original dose). 5. Lidocaine 6. Bretylium - Currently not in supply use. Medical Control has acknowledged supply issue with it, and issued a letter remanding it from regular use. 7. Contact Medical Control.

Pediatric Ventricular Tachycardia

1. Oxygenate and Ventilate. Obtain IV access and start NS. 2. If patient is stable - give appropriate dose of Lidocaine. 3. If patient is unstable with a pulse - DC synchronized cardioversion. 4. If patient is in cardiovascular collapse - Begin CPR and unsynchronized cardioversion/defibrillation. 5. Contact Medical Control.

EMT-D Defibrillation

1. Determine unresponsiveness. 2. Provide appropriate BLS. 3. Turn monitor/defibrillator on. 4. Place electrodes appropriately. 5. Verify rhythm Ventricular Fibrillation (VF) or pulseless Ventricular Tachycardia (VT). 6. Verify absence of pulse and spontaneous respirations. 7. Charge semi-automatic defibrillator to appropriate power (200 joules). 8. Assure all clear. 9. Verify VF or pulseless VT. 10. Appropriately discharge defibrillator. 11. Evaluate patient - pulse, respirations, rhythm. 12. If VF or pulseless VT persists, repeat steps 5-11. If a pulse is palpable, go to step 13. NOTE: The second defibrillation energy level is 200 joules, the third energy level is 360 joules. 13. If a life threatening rhythm occurs, appropriate supportive care is instituted.

Field Resuscitation and Discontinuation of Resuscitation (based on State Approved EMS Protocol)

1. Resuscitation need not be attempted in the field if any of the following conditions are met: a) There is visual evidence of massive trauma that is absolutely incompatible with life, such as - decapitation, severe crush injury of the skull, incineration, etc. b) Rigor Mortis, profound lividity, or bodily decomposition are present. c) The patient has already been pronounced dead by an authorized official, such as the Medical Examiner, Coroner, or by a physician who is licensed to practice medicine in South Carolina. d) A valid EMS DNR is found by or presented to the EMS crew. 2. If the above conditions are not met, and there is any possibility that life exists or can be restored, every effort should be made to resuscitate the patient - Once resuscitation is initiated, it is to be continued until one of the following occurs: a) Effective spontaneous circulation and ventilation are restored. b) Resuscitation efforts are transferred to others of at least equal skill, training, and experience. c) The rescuers are exhausted and are physically unable to continue resuscitation efforts. d) Online Medical Control issues an order to discontinue resuscitation on a pulseless and apneic patient. 3. Medical Control Order to Discontinue Resuscitation a) Paramedics are permitted to accept an order in person, by radio or by telephone from a licensed South Carolina Physician to discontinue resuscitation in a pulseless and apneic patient. b) When such an order is issued by telephone or radio, a second crewmember must confirm the order to avoid any chance of misunderstanding. The second crewmember (confirming member) does not have to be a certified Paramedic. c) Should resuscitation be terminated before the patient is placed in the ambulance, disposition will be the same as if the patient were found dead at the scene. d) When resuscitation is discontinued after the patient has been placed in the ambulance, the deceased will be transported to the Medical Control Hospital for disposition. e) The signature of the Physician who orders the termination of resuscitation must be obtained on the Patient Care Form. The Crew Chief may elect to continue resuscitation at his or her discretion and transport to the hospital in response to mitigating circumstances. Effective date 2-22-2001