Emr Protocols

Monroe County Ambulance Service
Emergency Medical Responder Protocols

2011

1

Introduction:

These standing orders were developed and approved by Monroe
County Ambulance Service, Medical Director to provide
standardization of basic life support interventions delivered to
patients by EMR (Emergency Medical Responder) within Monroe
County. These standing orders are subject to revision and additions
as determined necessary by the EMS Medical Director.
No set of standing orders can cover every possible situation.
EMRs are expected to use common sense and provide care that is in
the best interest of the patient. Progression through the Standing
Order should be to the point of resolution of the medical or traumatic
condition and then cease further standing order treatments. Unusual
situations or any perceived need to deviate from these standing
orders should be discussed with a Medical Control Physician. Any
deviation from the established standard should be thoroughly
documented on the patient care report.
The standing orders contained within are those basic life support
measures that may be instituted prior to voice contact with a Medical
Control Physician. Initiation of these orders should be on the basis of
patient need an indication. If at any time the EMR has a question or is
uncomfortable with instituting any standing order, he/she should
consult with a Medical Control Physician.

2011

2

Table of Contest
Universal Care Patient Standing Orders-.....3
Initial Assessment-...3
Trauma Assessment-..4
Medical Assessment- .5
Ongoing Assessment-....6
Patient Hand off Report-.6
Calling for Medical Direction-.6
CPR and AED-..7
Combi-Tube.43
Choking-....8
Shock-9
Abdominal Pain-.18
Abdominal (open) Injury-...30
Altered Mental Status (unknown)-14
Anaphylactic Shock-..10
Behavioral Emergencies-..26
Burns-...32
BSA Chart-..44
Chest Pain-..12
Flail Chest-..33
Sucking Chest Wound-.29
Childbirth-34
Complicated-...35
Cutting the Umbilical Cord-...36
Caring for the Newborn-....36
External Bleeding-..27
Extremity Injuries-...28
Heat Related Emergencies-..23
Hyperglycemia-...16
Hypoglycemia-17
Hypothermia-...24
Localized Cold Injuries-.25
Impaled Objects-.31
Poisons-..
Absorbed-21
Inhaled-20
Ingested-..19
Injected-22
Respiratory Emergencies-.13
Seizures-..15
Stroke-.........11

Pharmacology Index-.37
2011

3

Universal Care Patient Standing Orders
Personal Protective Equipment:
Gloves, Eye Protection, Mask, Gown
Scene Size Up:
Scene Safety
MOI/ Nature of Illness
Number of Patients
Request Additional Resources if Necessary (using dispatch)
Extra Man Power, Extra EMS Units, Utilities, Hazmat
Consider Stabilization of CSpine
Initial Assessment:
Determine LOC (Level of Consciousness)
AVPU (Alert, Verbal, Painful, Unresponsiveness)

ABCs (Airway, Breathing, Circulation)

Airway/Breathing:
Initiate appropriate oxygen therapy
Assure adequate ventilation
Injury management

Circulation:
Assess/Control major bleeding
Assess pulse
Assess skin (color, temperature and condition)
Trauma Assessment ..page 4
Medical Assessment . page 5
2011

4

Trauma
Rapid Trauma Assessment
Head to Toe Exam
Noting DCAPBTLS (Deformities, Contusions,
Abrasions, Punctures, Burses,
Tenderness, Lacerations, Swelling)
Controlling life threats
Baseline Vital Signs
Pulse, Respirations, BP, SPO2

Obtain S.A.M.P.L.E. History
Signs/Symptoms
Allergies
Medications
Pertinent History
Last Oral Intake
Events leading up to Incident

Detailed Physical Exam
Performing a Head to Toe Exam with more Detail

Manage Secondary Injuries/Wounds

Perform On Going Assessment & Pt Hand Off:
Page: 6

2011

5

Medical
Focused History, Physical Exam and Rapid Assessment

Rapid Head to Toe Assessment
Note any DCAPBTLS (Deformities, Contusions, Abrasions,
Punctures/Penetrations, Burns,
Tenderness, Lacerations, Swelling)
Controlling life threats

Obtain S.A.M.P.L.E.
Signs and Symptoms
OPQRST
Onset- Ex: What time did it start?
Provokes- Ex: Is there anything that makes the pain
worse or better?
Quality- Ex: Describe to me what it feels like.
Radiates- Ex: Does the pain move around any where?
Severity-Ex: On a scale of 1-10, 10 being the worse pain
you ever had what number would you give
this pain?
Time- Ex: What time/day did this start?
Interventions- Ex: Have you done anything for (complaint)
and has this helped or made it worse?
Allergies
Medications
Past Pertinent History
Last Oral Intake
Event leading to resent illness (rule out trauma)

Focused Physical Exam
Assess affected body part/system or if indicated follow rapid trauma
assessment on page 3.

Obtain Baseline Vital Signs

Interventions
Follow standing order for signs & symptoms.
Obtain medical direction (if needed)

Perform On Going Assessment & Pt Hand Off :
Page 6
2011

6

Ongoing Assessment

Continuing Vital Signs and Treatment Every:
5 mins-Unstable
10 mins-Stable

Patient Hand Off Report

Only to be given to someone with the same level of care or
higher. Information to be given:
Patients Mental Status
Age and Sex
Chief Complaint
ABC Status
Physical Findings
SAMPLE History
Interventions Applied and Patients Response

Calling For Medical Direction

Medical Direction can be the unit responding
(contacting them by radio) or Sweetwater ER.
(423)337-6172
(865)213-8524

When calling for Medical Direction information needed:
Who You Are/ Who You Are With
Patients info
Age, Chief Complaint, Vital Signs (what you have on
hand), and interventions that have been done
Why you are calling

2011

7

CPR and Automated External Defibrillator (AED)
Chain of Survival
Early Access
Early CPR
Early Defibrillation
Early Advanced Life Support
When to Begin CPR
Perform Initial Assessment (pg 3)
Note: When assessing and opening Airway
Non-trauma: Head tilt method
Trauma: Jaw Thrust, as appropriate (document)
When assessing Breathing
Look and Listen (no more than 10 seconds)
Not Breathing- Check Circulation
Breathing- Take necessary precautions and follow
Difficulty Breathing protocol.
When assessing Circulation
Take no longer then 10 seconds to assess for a pulse OR
any other signs of circulation AND breathing.
Adult/Child (1 yr & older)- Check the Carotid pulse
Infant (1mo- 1 yr)- Check the Brachial pulse
Neonate (birth- 1mo)- Check the Apical pulse
Newborn (just delivered)- Check Umbilical cord
YOU MAY CHECK BREATHING AND CIRCULATION AT THE SAME TIME
REMEMBER: DO NOT CHECK ANY LONGER THAN 10 SECONDS WHEN CHECKING BOTH
BREATHING AND CIRCULATION TOGETHER!!!!!
Negative findings on ABCs
1. Notify Dispatch of findings.
2. Place patient on firm hard surface in the supine position.
3. Follow American Heart Association (AHA) instruction on CPR for
appropriate per age group.
4. Retrieve AED
Note: Adult Place AED as soon as possible.
Child If witnessed (by rescuer) give five cycles/2 mins of
CPR before placing AED.
Not witnessed- Place AED as soon as possible.
Use the pads ADULT Pads for ADULT Patients!!!
Use Pediatric pads for infant/pediatric patients when available otherwise Adult
pads maybe used
5. Continue CPR until- EMS arrives to relieve rescuer, if patient recovers
or if all rescuers are too exhausted to continue.
6. Combi-Tube may need to be placed (pg 43)
Follow patient Hand Off Report: Page 6
2011

8

Choking Patient

Signs/Symptoms: (but not limited to)
Mild Airway Obstruction :
Good air exchange
Responsive and can cough forcefully
May wheeze in between coughs
Severe Airway Obstruction :
Poor or no air exchange
Clutching the neck making the universal choking sign
Weak, ineffective or no cough at all
High pitch noise while inhaling or no noise at all
Increased respiratory difficulty
Possible cyanosis
Unable to speak
Unable to move air

Perform Initial Assessment: pg 3

Mild Airway Obstruction:
- Encourage the patient to cough until obstruction relieved, complete airway
obstruction occurs or EMS arrives on scene.

- Obstruction Relieved continue Assessment:
Pg 4 Trauma
Pg 5 Medical

-COMPLETE AIRWAY OBSTRUCTION OCCURS-
Follow Severe Airway Obstruction Protocol

Severe Airway Obstruction:
-Adult Patients-
Provide abdominal thrust until object is relieved, patient becomes
unresponsive or EMS arrives on scene.
(If patient is to large and/or pregnant provide chest thrust)
-Pediatric Patients-
Provide Five (5) chest thrusts and Five (5) Back blows until object is relieved,
patient becomes unresponsive or EMS arrives on scene.

-Obstruction Relieved continue to
Pg 4 Trauma
Pg 5 Medical

-PATIENT IS UNRESPONSIVE-
Follow CPR and AED protocol (pg 7) assessing airway before every
ventilation.

Follow patient Hand Off Report: Page 6
2011

9

Shock
Altered Mental Status
Restlessness/combative, Unresponsive, Anxiety
Breathing
Rapid and Shallow
Skin
Pale, cool, clammy, diaphoretic
Pulse
Rapid and Weak
Profuse Bleeding
Nausea and/or Vomiting
Shaking and/or Trembling
Dizziness
Fear


Treat Life Threats:
Provide Oxygen:
15 LPM of Oxygen by Non re-breather

Control External Bleeding:
Control Life Threatening bleeding as soon as possible

Keep Patient at Rest:
Place patient in position of comfort (as long as trauma is not
suspected)

Keep Patient Warm:
Maintain Patients body heat

Place Patient in Trendelenberg:
Unless Airway is compromised

GIVE PATIENT NOTHING BY MOUTH

Follow On Going Assessment and Patient Hand Off Report Pg 6
2011

10

Anaphylactic Shock
Restlessness/combative, Unresponsive, Anxiety
Breathing
Wheezing, Rapid and Shallow
Skin
Pale, cool, clammy, diaphoretic
Pulse
Rapid, Weak, or Not Detected
Swelling to Face, Tongue and Airway


Treat Life Threats:
Provide Oxygen:

Epinephrine Auto-injector (Epi-Pen) pg 42
Patient is having a known Anaphylactic Reaction
Must be prescribed to patient

Check for the 5 Rs
Right patient, Right medication, Right dose, Right route, and Right time

. Call for medical direction for further orders: pg 6

Steps for Assisting Patient After Orders Have Been Obtained

-Remove cap from autoinjector
-Place tip of injector against patients lateral thigh, midway between hip and knee
-Push the injector firmly against thigh until injector activates
-Hold injector in place for 10 seconds/until medication is administered
-Record time
-Dispose injector in proper container

Place patient in position of comfort, reassure patient and treat patient for
shock (Treating for shock- pg 9)

Obtain Base line Vitals:

2011

11

Follow On Going Assessment and Patient Hand Off Report Pg6
Stroke

Headache
Syncope (fainting)
Numbness/Paralysis
Difficulty with speech
Difficulty with vision
Dizziness
Seizures
Altered Breathing Patterns
Hypertension (High Blood Pressure)


Provide Oxygen:



Perform the Cincinnati Pre-hospital Stroke Scale (CPSS)

Facial Droop: Have the patient smile or show their teeth.
Observe for facial droop or non- symmetrical movement.

Arm Drift: Have the patient hold their arms out in front of them and
close their eyes.
Observe for arm drift or if patient cannot bring both arms up
together.

Abnormal Speech: Observe for slurred speech, inappropriate words
or unable to respond verbally

2011

12

Chest Pain
Chest / Upper Abdominal Pain
Chest/Upper Abdominal Pressure
Chest/Upper Abdominal Burning
Pain behind the Sternum
Pain radiating to either arm, shoulder, jaw, upper back, upper and middle
abdomen.
Shortness of Breath
Nausea
Sweating
Weakness
Increased/ Irregular pulse


Provide Oxygen:



Nitroglycerin: pg 41
If patient is prescribed nitroglycerin, blood pressure is over 100 systolic
and has not taking more than 3 tabs for this initial chest pain, assist
patient in taking 1nitroglycerin tab sublingual.
Reassess patient after 3-5 mins.

Check for the 5 Rs

. Call for medical direction for further orders: pg 6

Contraindications- Systolic pressure less 100,
Head injury
Patient has already taken max dose prescribed
IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg6

2011

13

Respiratory Emergencies

Signs and symptoms: (but not limited to)
Absent or shallow rise and fall of the chest
No air heard or felt at the nose and mouth
Noisy breathing or gasping sounds
Irregular, rapid, slow, and /or labored breathing
Use of accessory muscles and/or nasal flare
Skin pale or cyanotic
Patient in tripod position


Provide Oxygen:

Place patient in position of comfort, (preferably sitting up) reassure patient
and treat patient for shock. (Treating for shock on pg 9)


Metered- Dose Inhaler: pg 40
If patient is prescribed a metered-dose inhaler

Call for medical direction: pg 6

Check for the 5 Rs

Contraindications- Altered Mental Status
(Ex: patient unable to use device properly)
Permission was not given
Patient has already taken maximum prescribed dose
Not patients prescription

IF IN DOUBT CALL FOR MEDICAL DIRECTION
Pg6

Follow On Going Assessment and Patient Hand Off Report
Page 6

2011

14

Unknown Altered Mental Status

Decrease in Patients Alertness
Decrease in Patients Responsiveness
Decrease in Patients Responsiveness to Surrounds


MAINTAIN C SPINE UNTIL PROVEN NONE IS NEEDED

Provide Oxygen:

Treat Patient for Shock:
Pg: 9


Pg6

Page 6

2011

15

Seizure

Sudden Loss of Responsiveness
Convulsions
Loss of Bladder and/or Bowel Control
Labored Breathing/ Frothing at the Mouth
After Seizure
Patient body is relaxed/ combative
May have headache (before/after)


Protect Patient from Injury:
Do not Restrain patient
Do not place anything in Patients Mouth
Loosen Restrictive Clothing
Watch for Vomiting (suction maybe needed)


Provide Oxygen:

Place patient in position of comfort, (preferably recovery position) reassure
patient and treat patient for shock. (Treating for shock on pg 9)


Look for Underlining Cause of Seizure:
A seizure is not a disease, but a sign of an underlying condition.

Pg6

Page 6

2011

16

Hyperglycemia

Signs and symptoms (but not limited to)
Gradual onset
Over hours/days
Unresponsive, Restlessness and/or Stupor
Breathing
Difficulty, Abnormal, Deep and Rapid
Pulse
Rapid, Weak
Skin
Warm, Dry, may have a Red appearance
Extreme Thirst
Abdominal Pain
Ketone Breath
Sweet fruit smell
Dry Mouth


Provide Oxygen:



Pg6

Page 6

2011

17

Hypoglycemia
Rapid Onset
Minutes
Abnormal, Hostile/Aggressive Behavior (May appear Intoxicated)
Convulsions, Fainting, occasionally coma
Pulse
Full Rapid, or Weak Rapid
Skin
Pale, Cool, Clammy, Diaphoretic
Dizziness
Headache
Intensely Hungry; Drooling


Provide Oxygen:



KNOWN HISTORY OF DIABETES, PATIENT IS ALERT AND ABLE TO SWALLOW

Oral Glucose: pg 39
Administer one (1) tube of Oral Glucose
Place Glucose into mouth (preferable between cheek and
gum).

Pg6

Page 6

2011

18

Abdominal Pain
Signs of Shock
Abdominal Pain
Back Pain
Nausea/Vomiting
Breathing
Rapid and Shallow
Pulse
Rapid
Bleeding
Rectal, urine and vaginal
Fever
Pulsating Mass
Rigidity
Distension
Tenderness


Provide Oxygen:

shock. (Treating for shock on pg 9)


GIVE PATIENT NOTHING BY MOUTH
Collect any vomitus/body fluids in bio-hazard bag.
To be transported with patient to hospital.

Page 6

2011

19

Ingested Poison

Altered Mental Status/ Unresponsive
Dilated/Constricted Pupils
Burns/Stains around/in patients mouth/throat
Excessive saliva
Breathing
Abnormal
Pulse
Abnormal rate and rhythm
Skin
Diaphoretic
Unusual Breath odor, Body odor
Abdominal Pain
Nausea/Vomiting
Convulsions


Provide Oxygen:



GIVE PATIENT NOTHING BY MOUTH (unless
Medical Direction Orders) Activated Charcoal (pg38)
Collect any vomitus/body fluids in bio-hazard bag.
To be transported with patient to hospital.

Contact Medical Direction/Poison Control for Further Instruction
Pg 6 (800)-2221222

Page 6

2011

20

Inhaled Poison

Breathing
Shortness of Breath, coughing
Pulse
Rapid/Slow
Eyes will appear irrigated

1
ST
PRIORITY IS EMR

Remove Patient from Source
Patient May Need to be Decontaminated
Hazmat May Need to be Contacted


Provide Oxygen:



Pg 6 (800)-2221222

Page 6

2011

21

Absorbed Poison

Anaphylactic Shock (pg 10)
Skin
Mild Irritation/Severe Burns, Itching, Increase Tempature
Eye Irritation

1
ST
PRIORITY IS EMR

Remove Patient from Source
Patient May Need to be Decontaminated
Hazmat May Need to be Contacted


Provide Oxygen:



Pg 6 (800)-2221222

Page 6

2011

22

Injected Poison
Weakness, Dizziness, Syncope
Anaphylactic Shock (pg 10 )
Breathing
Abnormal/Difficult
Pulse
Abnormal
Skin
Itching, Pain around Wound Site, Puncture Marks, Swelling,
Discoloration
Nausea/Vomit
Vision Problems


Provide Oxygen:



DO NOT FORGET TO REMOVE ANY CONSTRICTING ITEMS

For Snake Bites
Clean Site with Soap and Water
Immobilize Bitten Extremities
Keep Bitten Extremity level with or below heart level

Pg 6 (800)-2221222

Page 6

2011

23

Heat-Related Emergency

Breathing
Rapid, Shallow, Abnormal
Pulse
Rapid, Weak/Strong
Skin
Normal, Pale, Hot, Heavy/None Perspiration
Muscles
Cramps, Twitching
Seizure


Remove Patient from Environment
Cool Patient but Do Not Allow Patient to Become Chilled

Provide Oxygen:



If Patient is Alert and Able to Maintain own Airway Sips of Water Maybe Given

Page 6

2011

24

Hypothermia

Decreased, Lack of Coordination, Impaired Judgment
Pulse
Initially rapid then slow
Skin
Shivering, Cool/Cold, Muscle rigidity/stiffness, Joint Stiffness


On Unresponsive Patients Check for a pulse for at least 30-40 seconds
IF NONE IS FELT INITIALLY

Handle Patient Very Carefully


Provide Oxygen:



REMEMBER DO NOT GIVE PATIENT ANYTHING BY MOUTH

Pg6

Page 6

2011

25

Localized Cold Injury

Early
Blanching of the skin
Feeling cold, pain, or loss of feeling/sensation to injured area
Skin remains soft
If thawed, tingling sensation is present
Late
White, waxy skin
Firm to frozen feeling on palpation
Swelling
Blisters
If thawed, may appear flushed with areas of purple/blanching


Handle Patient Very Carefully

Provide Oxygen:



Early:
Manually stabilize the extremity; Cover the extremity, DO NOT
rub/massage injury, and DO NOT re-expose injury to cold.
Late:
Remove restrictive items, Cover injury with sterile dressings, DO NOT
break blisters, DO NOT rub/massage injury, DO NOT apply heat, DO NOT rewarm and
DO NOT allow patient to use effected site.

Pg6

Page 6
2011

26

Behavioral Emergencies

Abnormal behavior that is unacceptable or intolerable to the
patient, family or community.
Experiencing Extreme emotions
Psychological/ Mental Condition
Under the influence


Provide O2 if needed:
15 LPM of Oxygen by Non re-breather / BVM



IN SURE SCENE SAFETY AT ALL TIME!

Pg6

Page 6

2011

27

External Bleeding
Arterial Bleeding:
Blood spurting with each heart beat. (Bright Red)
Venous Bleeding:
Blood flows steadily from injury. (Dark Red)
Capillary Bleeding:
Blood oozes from injury. (Bright/Neutral Red)

DO NOT FORGET PPE!




Control Bleeding:
1) Direct pressure (if bleeding continues)
2) Elevation with Direct pressure (if bleeding continues)
3) Pressure Points are Applied (if bleeding continues)
4) Use Tourniquet!
Use tourniquet as last resort! DO NOT remove once placed!
Remember to write on patient time tourniquet was placed!

Remember: that impaled objects must be stabilized and are not removed
unless; it is in the cheek or effecting chest compressions.



Amputated Injuries:
Cover Amputated injury (that has been removed from body) in sterile
dressing place in a baggy that can be sealed in placed baggy in ice
water. NEVER place amputated injury directly on ice.
Transport with Patient.

Pg 6

Page 6
2011

28

Extremity Injuries

Bruising/Contusing
Deformity
Pain
Swelling
Discoloration
Inability to move joint/limb
Numbness/Tingling Sensation
Slow Capillary Refill
Sound of Breaking at time of Injury
Exposed Bone or Punctured Skin






Expose Injury
If you cant see it you cant treat it!
Remove jewelry from injured extremity

Immobilize Injury
ONLY if Pulse is present (if not notify EMS of findings)
Use proper splint for suspected injury site
Splint one (1) joint above and below injury site
Recheck distal PMS

Apply Cold Pack
Do Not Place Ice Pack Directly on Exposed Skin

Pg 6

Page 6

2011

29

Sucking Chest Wounds

Open Chest wound
Torn/Punctured
Sucking Sound
Bubbling at Injury Site
Coughing of Red Bright, Frothy Blood






Expose Injury

Treatment:
1. Seal the patients wound with the palm of your gloved hand as the
patient exhales. (DO NOT unseal wound to prepare dressing).
2. Place occlusive under your hand while patient exhales.
-Tape three (3) sides
3. Monitor patient!

Pg 6

Page 6

2011

30

Open Abdominal Injury

Deep Cut/Puncture Wound
Exposure of Organs

DO NOT FORGET PPE!






Expose Injury

Treatment:
1. Have patient lie on back
-Flex the patients legs and support them with a pillow/blanket.
- If signs if pelvic, lower limb, or back injury DO NOT flex legs.
2. Be alert for VOMITING.
3. Do NOT touch exposed internal organs
4. Cover them with occlusive Dressing
- Tape four (4) sides
5. Maintain Warmth
-Place bulky dressing/towel over occlusive dressing.

Pg 6

Page 6

2011

31

Impaled Objects

Object Protruding From Patient






Expose Injury

Treatment:
1. DO NOT Remove object
-Object must be stabilized UNLESS affecting airway/chest
compressions.
2. Stabilize object with bulky dressing/pads
-Place material on opposite sides of object (long axel)
- Second 2
nd
layer opposite direction to the first (1
st
)
- Use tape or triangle dressing to secure dressing/pads in place
Abdominal injury leave patient in position found to minimize injury.
Cheek injury make sure suction is available.
Eye DO NOT forget to cover both eyes.

Pg 6

Page 6

2011

32

Burns
Superficial (1
st
Degree)
Top layer of skin (epidermis)
Reddening of Skin
Pain at Site
Partial-Thickness (2
nd
Degree)
Top two (2) layers of skin (epidermis & dermis)
Intense Pain
Skin-Moist, Mottled, White/Red, Blisters
Full-Thickness (3
rd
Degree)
All layers of skin
May involve subcutaneous layers, muscle and/or bone
Skin-Dry, Leathery, White, Dark Brown/ Charred
Little to No Pain at initial Site
(Remember that around site will be partial, superficial burns
which are painful)


Treatment:
1. Stop Burning Process
Extinguish Flames, (Caution in Hazmat Situations, Pt may need decontaminated
before treatment can start)
(Chemical- Wash away chemical, flush for at least 20 mins)
2. Flush Burn
Only if burn is less than 9% of total BSA (body surface area) Pg 44
Flush with cool water for several minutes
DO NOT allow patient to becomes chilled
3. Remove Clothing and Jewelry (DO NOT remove clothing that has melted to skin)
4. Cover Burned area with sterile dry dressing and bandage.
Eyes- Moisten sterile dressing cover both eyes.





Pg 6

Page 6

2011

33

Flail Chest
Pain and Tenderness
At site, moving, breathing
Deformity
May swell or have obvious rib deformity
Guarding
Patient may splint affected side for stabilization
Movement
When the patient is breathing a section of chest wall moves in the
opposite direction to the rest of the chest wall.






Expose Injury

Treatment:
1. Locate flail section by gently feeling the injury site.
2. Apply bulky dressing/pillow (small & lightweight)
3. Use large strips of tape to secure pad in place.
DO NOT tape entirely around patients chest.

Pg 6

Page 6

2011

34

Childbirth
Having Laboring Pains
Less than five (5) minutes part
Watery/Bloody Discharge
Feeling Strain in Pelvis/Lower Abdomen
Need to Move Bowels
Feel Baby at Vaginal Opening/Moving to




Prepare Mother for Delivery:
1. Extra BSI
Proper gloves, mask with eye shield, gown
2. Prepare Patient for Delivery
Remove clothing from waist down. Place patient on back, knees
bent feet flat on floor, legs spread a part. Use clean sheets, towels
to cover patient.
3. Check for Crowning
Look for normal presentation, (head first)
-If normal continue with delivery
-NOT NORMAL go to pg 35
Normal & Crowning
1. Support Head
2. Check for cord around infants neck
If cord is around neck attempt to remove
UNABLE to remove cord clamp twice and cut in between clamps
3. Suction Mouth and Nose
4. Assist in the Head and Shoulders (DO NOT PULL)
5. Support Head, Trunk and Legs
6. Keep infant at level with vagina until umbilical cord is cut.
(DO NOT move infant from location until cord has been cut,
MUST call for Medical Direction to cut umbilical cord).
If ALLOWED to cut cord go to pg 36.
7. Keep Infant Warm & Note time of Birth
8. Monitor and Record Infants (and go to pg 36) and Mothers Vital Signs
9. Prepare for Delivery of Placenta
If placenta is delivered, place remains in a doubled bagged bio-hazard bag.
(Should be transported with patient to receiving hospital)
10. Place sanitary pad over vaginal opening, lower and place legs together.

Keep Mother at Rest:
Place mother in position of comfort, reassure patient and treat patient for

IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6
2011

35

Complicated Childbirth
Meconium Staining
Breech Birth
Presenting Limb
Prolapsed cord
Seizures
Spontaneous Abortion
Multiple Births
Premature Birth




Meconium Staining- (black/green discharge) is noted in newborns airway; suction repeatedly
Call for Medical Direction pg 6
Continue Care pg 34

Breech Birth- Newborn can be delivered without complication
Insure newborns airway by performing the V technique around newborns nose & mouth.
Call for Medical Direction (pg 6) if complication pursue.
Continue Care pg 34

Presenting Limb- Place patient in knee-chest position
Notify EMS/Medical Direction (pg 6)

Prolapsed Cord- Place patient in knee-chest position
Place moist dressing over cord
Notify EMS/Medical Direction (pg 6)
You may need to insert two (2) fingers in patients vagina to take pressure
off the umbilical cord. (Push gently up on the infants head. You should
feel in cord pulsating at that point). Once done DO NOT remove fingers.
You will be going with patient to Hospital.

Seizures- Contact Medical Control/EMS (pg 6)
Go to Page 15

Spontaneous Abortion- Contact Medical Control/EMS (pg 6)
Having Patients Information before Contacting EMS is Vital!

Premature Birth- Follow AHA guidelines if Patient needs assistance with
Breathing/Circulation.
Contact Medical Control/ EMS (pg 6)

IF IN DOUBT CALL FOR MEDICAL DIRECTION Pg 6
Follow On Going Assessment and Patient Hand Off Report Page 6

2011

36

Cutting Umbilical Cord

Must Contact Medical Direction Prior to Doing Skill!

1. Wait for the cord to stop pulsating. (Unless Medical Direction has advised other wise).
2. Use sterile clamps- Apply 1
st
clamp 10 inches from newborns belly.
Apply 2
nd
clamp 3 inches closer to newborn.
3. Cut between the two clamps.
4. Check for BLEEDING.
If bleeding continues place another clamp as close to the original as possible.

Caring For Newborn

REMEMBER THESE THINGS SHOULD BE DONE EVEN BEFORE THE
UMBILICAL CORD IS CUT!!!




-Insure ABCs

-Follow AHA guidelines if newborn needs assistance with Breathing/Circulation
Heart Rate- Less than 100 but more then 60
Assist in ventilations for 30 seconds then revaluate
Continue until Heart rate is above 100, EMS arrives or heart
rate falls below 60.
Heart Rate- Less than 60
Start CPR, Follow AHA guidelines

-Maintain newborns body temperature!

Page 6

2011

37

Pharmacology

Drugs that EMR may ASSIST With

Activated Charcoal- Page 38

Oral Glucose- Page 39

Metered-Dose Inhaler- Page 40

Nitroglycerin- Page 41

Epinephrine Autoinjectors- Page 42

2011

38

-Activated Charcoal-

Indication-
Poisoning by Mouth (Ingestion)

Contraindications-
Ingestion of Acid/ Alkalis
Unable to Swallow
Dosage-
1gram activated charcoal/kg of body weight.
(Adult: 25-50 grams, Pediatric: 12.5-25 grams)

Administration-
1. Contact Medical Direction
2. Shake Container Vigorously
3. Encourage patient to take recommended dose
4. Record
Name, Dose, Route, and Time administered

Side Effects-
Black Stools
May cause nausea/vomiting

2011

39

-Oral Glucose-

Indications-
Patient with altered mental status with known history of diabetes
Patient has taken insulin with no food/has been physically active.

Contraindications-
Unresponsiveness/unable to swallow
Unable to maintain own airway
Known diabetic that hasnt taken insulin for days.

Dosage-
One (1) tube/15g of glucose

Administration-
1. Ensure patient is alert enough to swallow/maintain own airway
2. Assist in administration
- administer into mouth (preferably under patients tongue) and have
patient swallow gel until gel is gone. Administering small
amounts at one time.
3. Perform on going assessment.

Side Effect-
None when given properly.

2011

40

-Metered-Dose Inhaler-

Indications- Meets all of the Following Criteria:
1. Authorized by Medical Direction
2. Signs and Symptoms Respiratory Difficulty
3. Patient is Prescribed Medication

Contraindications-
- Altered Mental Status (unable to assist with device properly)
- No permission given
- Patient has taken Maximum Dose Prior to EMR Arrival

Dose-
Number of inhalations based on Medical Directions/Physician Order.

Administration-
1. Obtain order from Medical Direction.
2. Confirm patient is alert enough to use inhaler.
3. Ensure it is the patients own prescription.
4. Check expiration date.
5. Check if patient has already taken any doses.
6. Shake inhaler several times.
7. Have patient exhale deeply.
8. Have patient put lips around the opening of the inhaler.
9. Have patient depress the handheld inhaler when beginning to inhale
10. Instruct patient to hold breath for as long as possible
11. Allow patient to breathe a few time and repeat dose if ordered.
12. Provide oxygen as appropriate.

Side Effects-
- Increased Pulse Rate.
- Anxiety.
- Nervousness.

2011

41

-Nitroglycerin-

Indications- All of the Following Must is Met:
1. Patient Complains of Chest Pain.
2. Patient has a History Cardiac Problems.
3. Patients Physician has Prescribed Nitroglycerin.
4. Systolic Blood Pressure is Greater than 100.
5. Medical Direction must Authorize 2
nd
/3
rd
dose.

Contraindications-
- Patient has a systolic blood pressure below 100.
- Patient has a head Injury.
- Patient has already taken maximum prescribed dose.

Dose-
- One dose is = to 0.4mg.
- Repeat in 3 5 minutes as long as systolic remains above 100.
- Maximum 3 doses
(Spray is typically prescribed for one metered spray followed by second in 15 mins).

Administration-
1. Must meet indication.
2. Ensure Right medication, Right Patient, Right Dose, Right Route
3. Check Expiration Date
4. Ensure patient is Alert.
5. Ask Patient when last dose was taken and how it was taken.
6. Ask patient to lift tongue and place tablet or spray under tongue.
7. Recheck blood pressure in 2 3 minutes.
8. Record administration, route and time.
9. If systolic pressure is still above 100, Call For Medical Direction.

Side Effect-
- Hypotension (lowers blood pressure)
- Headache
- Pulse Rate Changes
- Dizziness, Lightheadedness

2011

42

-Epinephrine Autoinjectors-

Indications- Must Meet the Following Three Criteria:
1. Patient exhibits signs of severe allergic reaction,
Including Respiratory Distress/Shock.
2. Medication is prescribed to patient
3. Authorized by Medical Direction.

Contraindications-
None in lfe-threating situation!

Dosage-
Adult- One adult autoinjector (0.3mg)
Infant/Child- One infant/child autoinjector (0.15mg)

Administration-
1. Obtain patients prescribed autoinjector.
Ensure- Its patient prescription
Medication is not expired/discolored
2. Obtain order from Medical Direction
3. Remove cap from autoinjector
4. Place tip of autoinjector against patients lateral thigh
Midway between hip and knee
5. Holding injector tightly, push firmly against thigh
Until the injector activates
6. Hold the injector in place until the medication is injected
At least 10 seconds
7. Record activity and time
8. Dispose of injector in biohazard container

Side Effects-
- Increased heart rate
- Dizziness
- Chest Pain
- Headache
- Nausea/Vomiting
- Excitability, Anxiety
- Pale Skin

2011

43

-Combi-Tube-

Indications- Must meet all of the Following Criteria:
1. Patient must be unresponsive.
2. Patient must be Pulse less and Apneic (not breathing).
3. Patient must be between 5 to 7 feet tall.
4. Patient must not have a Gag Reflex.
Must have placed a oral airway prior to the use of this device!
5. Patient must not have Esophageal Varices.

Contraindications-
-Patient Does Not Meet all the Indications List Above!

Administration-
1. With oral air way in place have partner hyperventilate patient.
2. Prepare and Check Equipment.
-Check Comi-Tube for any defects
-Check/Inflate bulbs properly
Blue (1)-100 ml of air
White (2)- 15 ml of air
-Deflate bulbs and Lubricate(water soluble).
3. Remove oral airway and have partner prepare BVM.
4. Place Combi-tube (DO NOT FORCE DEVICE).
-Insert Combi-tube until teeth are in between the two (2) black lines.
5. Place 100 ml of air in the blue (1) pilot balloon. (Remove syringe from
pilot balloon).
- DO NOT HOLD COMBI-TUBE AT THIS TIME
6. Place 15 ml of air in the white (2) pilot balloon. (Remove syringe from
pilot balloon).
7. Ventilate through the blue (1) tube 1
st
. Check for placement.
-If no chest rise is noted and ventilation not heard in lungs go to
white (2) tube and reassess.
8. Keep equipment together in case tube becomes displaced or is needed
in the future for this patient.

If patient becomes alert deflate bulbs and remove
Combi-tube be prepare for VOMITUS!

Pg6

2011

44

Body Surface Area Chart

Emr Protocols

Încărcat de

Informații document

Titlu original

Drepturi de autor

Formate disponibile

Partajați acest document

Partajați sau inserați document

Opțiuni de partajare

Vi se pare util acest document?

Este necorespunzător acest conținut?

Drepturi de autor:

Formate disponibile

Emr Protocols

Încărcat de

Drepturi de autor:

Formate disponibile

Monroe County Ambulance Service

Emergency Medical Responder Protocols

S-ar putea să vă placă și