2015 Laems Protocols

Lodi Area Emergency Medical Service
EMT BASIC and EMT INTERMEDIATE

TECHNICIAN PROTOCOLS
Updated 03/2015
EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS
Table of Contents
Table of Contents......................................................................................................................................... 2
Homeland Security...................................................................................................................................... 5
EMT Intermediate Technician Scope of Practice......................................................................................... 6
EMT Basic and EMT Intermediate Technician Level of Practice..................................................................7
Physician at the Scene.............................................................................................................................. 10
Patients Who Decline Treatment or Transport........................................................................................... 11
DNR and Termination of Resuscitation in the Field....................................................................................12
Body Substance Precautions..................................................................................................................... 13
Airborne Precautions................................................................................................................................. 14
Standard of Care for Transporting an Infectious Patient............................................................................15
Standard of Care for Latex Sensitive/Allergic Patients..............................................................................16
Procedure Initial Patient Assessment (Medical Patient)..........................................................................17
Procedure Initial Patient Assessment (Trauma Patient)..........................................................................19
Procedure Intravenous Therapy............................................................................................................. 21
Procedure Intraosseous Therapy............................................................................................................ 23
Procedure Multi-Trauma Patient Assessment.........................................................................................24
Procedure Tourniquet............................................................................................................................. 25
Procedure Triage Guidelines for Major Trauma......................................................................................26
Glasgow Coma Scale................................................................................................................................ 27
ALS Equipment Used by the EMT Basic and Intermediate Technician......................................................28
General Guidelines for the EMT Intermediate Technician..........................................................................29
General Patient Care Guidelines............................................................................................................... 30
Airway Management and Oxygen Therapy Guidelines..............................................................................31
Protocol for Use of the Combitube /King LTS-D Non-Visualized Airway...................................................32
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KING LTS-D Laryngeal Tube Airway (LTA)................................................................................................34
Procedure Cardiac Monitoring by the EMT Basic or EMT Intermediate Technician................................36
Treatment Protocol Congestive Heart Failure (Pulmonary Edema)........................................................37
Treatment Protocol Abdominal Injury...................................................................................................... 38
Treatment Protocol Abdominal Pain....................................................................................................... 39
Treatment Protocol Altered Level of Consciousness...............................................................................40
Treatment Protocol Amputated Part........................................................................................................ 41
Treatment Protocol Anaphylaxis............................................................................................................. 42
Treatment Protocol Asthma, Chronic Lung Disease (COPD)..................................................................44
Treatment Protocol Behavioral Emergencies.......................................................................................... 45
Treatment Protocol Bleeding (External).................................................................................................. 46
Treatment Protocol Burn Injury-Severe (Chemical or Thermal)..............................................................47
Treatment Protocol Carbon Monoxide Poisoning...................................................................................48
Treatment Protocol Cardiac Arrest.......................................................................................................... 49
Treatment Protocol Cardiac Arrest due to Trauma or Hypovolemia........................................................51
Treatment Protocol Indications for Withholding Resuscitation in Traumatic and Cardiopulmonary Arrest
................................................................................................................................................................... 52
Treatment Protocol Cardiac Ischemia (Chest Pain)................................................................................53
Treatment Protocol Cardiogenic Shock.................................................................................................. 55
Treatment Protocol Chest Trauma.......................................................................................................... 56
Treatment Protocol Child Abuse............................................................................................................. 59
Treatment Protocol Continuous Positive Airway Pressure (CPAP).........................................................60
Treatment Protocol - Cyclic Antidepressant Overdose...............................................................................62
Treatment Protocol Diabetic Emergencies.............................................................................................. 63
Treatment Protocol Eye Irrigation........................................................................................................... 65
Treatment Protocol - Fractures & Dislocations..........................................................................................66
Treatment Protocol Gas & Smoke Inhalation..........................................................................................67
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Treatment Protocol Gynecological Emergencies....................................................................................68
Treatment Protocol Heat Illnesses/Hyperthermia (Heat Exposure)........................................................69
Hypothermia General Information.............................................................................................................. 70
Treatment Protocol Hypothermia (Low Body Temperature)....................................................................71
Treatment Protocol Medication/Drug Overdose/Poisioning (Ingestion of drug or toxin)..........................72
Treatment Protocol Neonatal Emergency............................................................................................... 74
Treatment Protocol Obsterics/Childbirth................................................................................................. 75
Treatment Protocol Pediatric Respiratory Distress Croup/Epiglotitis in Infant/Child...............................77
Treatment Protocol Respiratory Arrest.................................................................................................... 78
Treatment Protocol - Seizures................................................................................................................... 79
Treatment Protocol Sexual Assault......................................................................................................... 80
Treatment Protocol Shock, Hypotension, and Hemorrhage....................................................................81
Treatment Protocol Spinal/Neurological Injury........................................................................................ 82
Treatment Protocol Stroke/Cerebral Vascular Accident..........................................................................83
Treatment Protocol Upper Airway Obstruction........................................................................................ 84
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Homeland Security
The Lodi Area Emergency Medical Service will follow the guidelines as set forth by the Department of
Homeland Securitys Incident Command Systems (ICS).
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EMT Intermediate Technician Scope of Practice

The EMT Intermediate Technician is an advanced level EMT who has completed an approved EMT
Intermediate Technician course and is authorized by the Wisconsin State Statutes and defined in and
regulated by Administrative Rules HFS 111, to perform selected advance procedures under physician
direction. The following Basic Life Support (BLS) and Advanced Life Support (ALS) skills are approved by
Sauk Prairie Memorial Hospital for use by an EMT Intermediate Technician under their direction, with
direct physician order.
EMT Intermediate Technician skills

1.
2.
3.
4.
5.
6.
Advanced procedures used by the EMT Basic

Starting and maintenance of intravenous lines.
Starting and maintenance of intraosseous lines.
Administration of Normal Saline Solution, 5% Dextrose in Water, Ringers Lactate
Administration of intravenous Naloxone/nasal Naloxone and 50% Dextrose solution
Administration of sublingual Nitro (service carried)
Advanced Procedures (used by both EMT Basics and EMT Intermediate

Technicians)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Advanced Airways (Combitube,King)

Defibrillation
Epinephrine by EpiPen Auto-Injector
Administration of subcutaneous/intramuscular Epinephrine by filtered syringe
Hemorrhage control by use of tourniquet.
Assisting patient with their own medications (NTG, Inhalers)
Field measurement of blood glucose
Administration of Albuterol and Atrovent by nebulizer
Administration of baby aspirin
Administration of Glucagon
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EMT Basic and EMT Intermediate Technician Level of Practice

Skill
EMT Basic
EMT Intermediate Technician
AIRWAY/VENTILATION/OXYGENATION
Airway Lumen (Non-Visualized)
Airway Nasal (Nasopharyngeal)
Airway Oral (Oropharyngeal)
Bag-Valve-Mask (BVM)
CPAP
Cricoid Pressure (Sellick)
Manual Airway Maneuvers
Obstruction Forceps & Laryngoscope

(Direct Visual)
Obstruction Manual
Oxygen Therapy Nasal Cannula
Oxygen Therapy Non-rebreather mask
Oxygen Therapy Nebilizer
Pulse Oxymetry/Capnometry/Rad57
Suctioning Upper Airway (soft & rigid)
Medication Administration Routes

Aerosol/Nebulizer
Auto-Injector
Intramuscular (IM)
(X)
Intranasal (IN)
Intravenous (IV) Push
Oral
Subcutaneous (SQ)
Sub-Lingual (SL)
Assisted Medications Patients Own

Auto-Injected Epinephrine
Revised: 03/2015
X
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Medicated Inhaler Prescribed Albuterol
Medicated Inhaler Prescribed Atrovent
Approved Medication by Protocol

Albuterol (Nebulized Unit Dose)
Atrovent (Nebulized Unit Dose)
Aspirin (ASA) for Chest Pain
Dextrose 50%
Epinephrine for Anaphylaxis (Unit Dose)
Glucagon
Mark I Auto-Injector (for Self and Crew)
Narcan
Nitroglycerin (SL only, Service Carried)
Oral Glucose
IV Initiation/Maintenance/Fluids
IV Solutions D5W, Normal Saline,
Lactated Ringers
Maintenance Non-Medicated IV Fluids
(D5W, NS, LR)
X
X
Peripheral Initiation
X
Cardiovascular/Circulation
ECG Monitor (non-interpretive)
12-Lead ECG (acquire but non-interpretive)
Hemorrhage Control Direct Pressure
Hemorrhage Control Pressure Point
Hemorrhage Control Tourniquet
Trendelenberg Positioning
Cardiopulmonary Resuscitation
(CPR/CCR)
Defibrillation Automated/Semi-Automated
(AED)
Immobilization
Spinal Immobilization Cervical Collar
Spinal Immobilization Long Board
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Spinal Immobilization Manual
Stabilization
Spinal Immobilization Seated Patient
(KED, etc.)
Splinting Manual
Splinting Pelvic Wrap
Splinting Rigid
Splinting Soft
Splinting Traction
Miscellaneous
Assisted Delivery (Childbirth)
Blood Glucose Monitoring
Blood Pressure Automated
Eye Irrigation
Vital Signs
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Physician at the Scene
Ask the physician to identify themselves and area of expertise (ask to show proof if possible.)
Allow the physician to assist if they do not interfere with, or attempt to alter, your protocol or
procedure.
If an on-scene physician attempts to alter your field procedure in any unacceptable way, explain that
you are operating under specific EMT Protocol and under medical control. Present the on-scene
physician with a form that states the following:
The Emergency Medical Service team has responded to an emergency call for help and is operating
under specific Protocol. In addition, this team is in direct communication with a medical control physician.
In the event you wish to assume full responsibility for the care of this patient, the EMS team and medical
control physician require you to:
1. Properly identify yourself as a physician licensed to practice medicine.
2. Sign this form accepting Full Responsibility for pre-hospital patient care. Remain with the patient at
all times at the scene, during transport, and until relieved by the Medical Control Physician.
Otherwise, we appreciate your offer for assistance, but must proceed according to protocol.
I _______________________, a physician licensed to practice medicine, hereby accept full responsibility
for pre-hospital care of the patient and agree to comply with the above stipulations.
Signature
Date
No physician may intercede in patient care without the medical control physician relinquishing
responsibility of care via radio or telephone. If the responsibility is transferred to a physician at the scene,
that physician is responsible for any and all patient care given at the scene and en route to the hospital.
They must sign the medical record. The physician MUST accompany the patient in the ambulance to the
hospital.
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Patients Who Decline Treatment or Transport

Any patient who refuses treatment, transport, or both must be asked to sign a Refusal of treatment and
Conveyance Form. The form should also have the signature of two witnesses in the spaces provided for
on the form. If the patient is a minor child, one who is under the age of 18 years, a parent or legal
guardian must sign the refusal form. The order of signature preference on the release form is:
1. Police Officer
2. Family Member
3. Crew Member
A. Attempt to assess the patient as you would any other.
B. Explain to the patient the possible risks involved in not seeking medical evaluation and care.
C. If you feel the patients judgment is impaired by drugs, alcohol, illness or obvious psychiatric
defect, get the police involved to assist you in placing the patient in protective custody.
D. Document carefully:
1) The reason you were called, for example: The patients chief complaint or reported problem.
2) Whether the patient allowed assessment.
3) That you explained the possible consequences of not seeking medical care.
4) Your assessment of the patient based on exam if done, background or bystander information,
mechanism of injury.
E. Have the patient sign declination of care form.
Minor Patients - Strictly speaking, persons under the age of 18, are not considered legally competent
and therefore cannot refuse care. All minors should be transported when possible. Exceptions are:
Minor is emancipated
Minor is married
Minor is in armed forces
When EMTs have questions or problems, Medical Control must be contacted for a final decision.
Note: These cases present high risk for the patient and high liability risk for the EMTs and the
system. You must document these cases thoroughly.
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DNR and Termination of Resuscitation in the Field

Most pulseless non-breathing patients should have full resuscitative efforts, consisting of CPR,
defibrillation when applicable, Advanced Life Support tiered response, and transport to the hospital.
There are exceptions to this general policy in which resuscitation can be waived or terminated. These
situations are outlined below.
Emergency Medical Technicians shall not waive (except under #1 below) or cease resuscitation without a
direct order from a Medical Control physician, the patients private physician, or other recognized
physician. The ordering physician assumes full responsibility for this order.
Upon order from a physician as described above, resuscitation attempts shall be waived or discontinued if
started in any of the following situations:
1. Obvious signs of death: A patient with obvious signs of death such as rigor mortis, dependent
lividity, decomposition, decapitation, or transected torso. (With rigor mortis and/or dependent lividity,
acquire a 4-Lead rhythm strip to determine asystole, leave the strip with the medical examiner.
2. A qualified physician orders that resuscitation be waived or stopped: The patients personal
physician is available in person and personally directs rescuers not to resuscitate based on his/her
knowledge of the patients medical condition.
3. The patient has a Wisconsin DNR bracelet: The patient has a Do Not Resuscitate order or
bracelet that is verifiable and clearly states a desire not to have CPR or other resuscitation measures
done in the even of a cardiac arrest.(DNR bracelets only apply to adults)
4. The patient has cardiac arrest due to severe blunt trauma, has no signs of life, is in asystole, and NO
CPR has been started.
5. Other conditions as determined by a Medical Control physician.
If any of the above apply, do not begin resuscitative measures, request the Public Safety Communications
Center to notify appropriate law enforcement and the Medical Examiner. Remain at the scene until
relieved by a law enforcement officer or the Medical Examiner. Provide support to family members as
needed until law enforcement or others can assume this role.
If none of the above are present, and both EMTs believe resuscitations should not be attempted, contact
medical control and explain the circumstance. It is inappropriate for the EMTs to decide on their own
volition not to resuscitate when the above conditions are not present. If medical control is unavailable,
perform all resuscitative efforts and transport to the hospital.
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Body Substance Precautions

1. Gloves shall be worn by all personnel at all times.
2. Eye protection must be worn by all personnel under the following circumstances:
A. Non-visualized airway
B. Suctioning
C. Other situations where body fluids could be splashed into the eyes
3. Masks should be worn when suctioning a patient
4. Pocket masks, bag-mask, or a demand valve must be used for airway ventilation.
5. IV cannula and needles should not be recapped. All cannula and needles should be immediately
placed into an approved sharps container after use.
6. An alcohol-based foam or liquid hand cleaner should immediately be used if contamination occurs in
the field.
7. Thorough hand washing with soap and water is mandatory after every patient contact.
8. A gown should be worn when splashes of blood or body fluids are likely.
9. Clothes contaminated with blood or body fluids should be removed and placed in a bio-hazard bag as
soon as possible. Contaminated clothes should be appropriately laundered or discarded at the
station.
10. All significant exposures must be reported to the service director.
11. All personnel significantly exposed, should be checked into the ER as a patient and examined,
decontaminated, and treated by hospital staff. Significant exposure forms are available in the
emergency department and should be completed for all parental and mucocutaneous exposures. If
possible, source patient and attending EMT should be tested for Hepatitis B and C, and HIV.
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Airborne Precautions
Patients with the following signs and symptoms will be treated as potential suspects for TB:
1.
2.
3.
4.
5.
6.
7.
8.
Persistent cough (greater than 3 weeks duration)

Coughing up blood
Weight Loss (greater than 20 pounds)
Loss of Appetite
Lethargy or Weakness
Night Sweats
Fever
People who tell you they have Active TB
All crew members will use a HEPA mask if they suspect they are transporting a person with TB.
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Standard of Care for Transporting an Infectious Patient

1.
2.
3.
4.
Mask the patient if he/she shows signs or has symptoms of TB

Mask self using your personal HEPA respirator
Gloves must be worn. Use PPE as needed.
Make sure all cupboards and doors (including the door between the ambulance cab and rear
compartment) are closed on the he ambulance. If the need arises, you will need to cover the walls
with plastic covering and hold it in place with duct tape. If the person is coughing and they do not
tolerate a mask, this must be done.
5. If the infected person coughs and the above was not done, then when cleaning the ambulance, you
must take everything out of the cupboards and clean them thoroughly with an EPA approved
Tuberculocidal /Germicidal disinfectant.
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Standard of Care for Latex Sensitive/Allergic Patients

The following guidelines are to be used providing emergency medical care to a patient with a known
sensitivity or allergy to latex products.
1. STANDARD OF CARE for the patient identified as being sensitive /allergic to latex:
A.
B.
C.
D.
Observe standard body substance isolation (BSI) procedures

Latex-free gloves will be worn by all crew members when in contact with patient
Remove latex agents/sources if possible
Provide emergency care as needed, but providing critical emergency medical care should not be
delayed to modify latex containing equipment
E. As possible, products that are known to be latex-free are to be used during patient care and
transport
F. If a product is required for emergency patient care and contains or contains latex, cover all latex
sites with gauze, or latex free tape to prevent direct patient contact.
G. If a patient has a latex-free treatment kit in the home or on their person, the contents should be
used as needed
2. STANDARD EQUIPMENT: Ambulance(s) and emergency care kits will carry latex-free kits for caring
for latex sensitive/allergic patients. These kits are to be stocked with items of known content only.
The latex-free kits will be identified by blue bag and will contain the following items:
A.
B.
C.
D.
E.
A copy of this protocol

One roll clear non-latex tape
Two 4x4 gauze pads
One latex-free nasal cannula
One modified non-rebreather oxygen mask (modified by removing the two latex valves in the
mask. Note: This will reduce the masks efficiency.)
F. Three pairs nitrile (or other latex-free examination gloves)
G. Two sets of non-latex electrodes
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Procedure Initial Patient Assessment (Medical Patient)

EMT Basic and Intermediate Technician
1. Scene size up
A.
B.
C.
D.
E.
Is the scene safe?

PPE/BSI
Number of patients and are all the victims accounted for?
Note mechanism of injury.
Request additional resources as needed
1)
2)
3)
4)
5)
Additional ambulances
Fire suppression
HAZMAT team
Extrication
ALS intercept or Aero medical evacuation
2.
3. Primary Assessment
A. Verbalizes general impression age, gender, race, level of distress, overall appearance,
environmental clues.
B. Determines mental status AVPU
C. Determines chief complaint
D. Check for patency of airway: interventions (c-spine, positioning, suction, adjuncts)
E. Assess breathing/respiratory quality/depth; interventions (O2, assist)
F. Assess circulation (rate and quality of pulse, skin temperature, capillary refill, control life
threatening bleeding, interventions)
G. Evaluates disability- patient affect; neurological (pupils, GCS, pain)
H. Exposes as needed.
I. Creates a field impression (leading to differential diagnosis)
J. Performs a Rapid Scan (if patient is unresponsive)
K. Determines transport priority and destination (stable vs. unstable)
Note: If patient is found to be critically ill during the initial patient assessment, contact Medical
Control as needed and initiate treatment and/or transport immediately. Consider ALS.
4. HISTORY TAKING, VITAL SIGNS AND MONITORING DEVICES
1) Investigate Chief complaint (history of current problem) O-P-Q-R-S-T
2) SAMPLE
3) Baseline Vital Signs
5. SECONDARY ASSESSMENT
A.
B.
C.
D.
E.
F.
UNRESPONSIVE PATIENT
Head-to-toe exam with attention to common signs of medical problems.
General appearances, skin color, skin temperature, level of consciousness.

Head. Pupils, facial asymmetry, jaundice.
Neck. Tracheal deviation, neck vein distention.
Chest and lungs. Breath sounds (normal, wheezes, crackles).
Heart exam. Regularity of rhythm.
Abdomen. Distention, tenderness.
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G. Extremities. Edema, distal pulses, tenderness.
H. Neurologic. Paralysis, distal sensation. (Cincinnati Stroke Scale).
Establishes a Differential Diagnosis (reevaluates field impression)

Initiates management plan
Reevaluates interventions and transport
RESPONSIVE PATIENT
Conducts Focused Assessment (physical exam based upon chief complaint)
Establishes a Differential Diagnosis (reevaluates field impression)
Initiates management plan.
Reevaluates interventions and transport.
REASSESSMENT
Repeats primary assessment

Reassess Vital Signs
Reassess secondary assessment
Evaluates patient response to treatment/interventions
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Procedure Initial Patient Assessment (Trauma Patient)

EMT Basic and EMT Intermediate Technician
1. Scene size up
A.
B.
C.
D.
E.
Is the scene safe?

PPE/BSI
Number of patients and are all the victims accounted for?
Note mechanism of injury.
Request additional resources as needed
1)
2)
3)
4)
5)
Additional ambulances
Fire suppression
HAZMAT team
Extrication
ALS intercept or Aero medical evacuation
F. Is C-spine a consideration?
2. Primary Assessment
A. Verbalizes general impression age, gender, race, level of distress, overall appearance,
environmental clues.
B. Determine mental status AVPU
C. Determines chief complaint.
D. Assesses Airway patency; interventions (c-spine, positioning, suction, adjuncts)
E. Assesses breathing/respiratory quality/depth; interventions (O2, assist)
F. Assesses circulation: pulses, skin condition, color, temperature, control life threatening bleeding;
interventions
G. Evaluates disability patient affect; neurological (pupils, GCS, pain)
H. Exposes patient (as needed).
I. Creates a field impression (leading to differential diagnosis)
J. Performs a Rapid Scan (if patient has sustained significant MOI or is unresponsive)
K. Determines transport priority and destination (unstable or stable)
3. History Taking, Vital Signs and Monitoring Devices (order may vary)
A. Investigate Chief Complaint (history of current problem) O-P-Q-R-S-T (as applicable to MOI)
B. Obtain SAMPLE history (Signs and Symptoms, Allergies, Medications, Past history, Last meal,
and Events of injury).
C. Obtains Baseline Vital Signs.
D. Utilizes monitoring device(s); pulse oximetry, cardiac monitoring, BGL
4. Secondary Assessment SIGNIFICANT MOI
A. Conducts a Full-Body Scan (DCAP-BTLS)
1) Head. Examine for contusions, lacerations. Check pupils. Look for drainage from ears nose,
intra-oral injuries, facial fractures.
2) Neck. Check for deformity, tenderness, tracheal deviation. Assess neck veins.
3) Chest. Inspection for flail, contusion, wounds, palpation for crepitation, rib fractures,
auscultation for bilateral breath sounds.
4) Abdomen. Examine for contusion, wounds, evisceration, distention. Palpate for tenderness.
5) Pelvis. Examine and palpate (gently) for pain, instability.
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6) Lower extremities. Examine for wounds, contusions, signs of fracture, ability to move, distal
circulation, sensation.
7) Upper extremities. Palpate clavicles. Check extremities for wounds, contusions, signs of
fracture, ability to move, distal circulation, sensation.
8) Back. Examine for wounds. Palpate spine for deformity, tenderness.
9) Neurologic. Reassess level of consciousness, distal movement, and sensation.
B. Establishes a Differential Diagnosis (reevaluates field impression)
C. Initiates management plan.
D. Reevaluates interventions and transport.
5.
NON-SIGNIFICANT MOI
A. Conducts Focused Assessment (DCAP-BTLS) physical exam of injury.
B. Establishes a differential diagnosis (reevaluates field impression)
C. Initiates management plan
D. Reevaluates interventions and transport.
6. Reassessment
A. Repeats Primary Assessment
B. Reassess Vital Signs
C. Reassess Secondary Assessment
D. Evaluates patient response to treatment/interventions

1.
2.
3.
4.
Start a large bore IV NS wide open to maintain a SBP > 90.

If possible, start a second IV LR TKO.
If multi system trauma, consider starting first IV with LR and second IV with NS.
IVs should be started en route to the hospital, unless transportation is delayed by extrication or
unusual circumstances.
CONTACT MEDICAL CONTROL as soon as possible to prepare the receiving hospital and obtain any
additional orders.
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Procedure Intravenous Therapy

1. Initial Assessment
Standing orders for IV therapy:
Patients with indicated need for fluid replacement for:
Dehydration
Hemorrhagic shock
Burns
Major trauma
Any hypotensive state, provided the lungs
are clear
Life threatening cardiac, respiratory or
neurological condition
Diabetic reactions
Abdominal Pain
Cardiac Arrest
Respiratory Distress/Arrest
Seizures
To establish route for future medication
administration
1. Normal saline IV solution should be started on all patients falling within this list of standing protocols.
2. The most distal extremity site for infusion is preferred in all cases except severe trauma or cardiac
arrest (antecubital/intraosseous).
3. If more than two attempts are required for the initiation of an IV, the patient should be transported with
further attempts done en route.
4. Start a second IV when appropriate.
5. IVs in unstable patients should be started en route to the hospital rather than at the scene.
6. Where indicated to maintain a certain blood pressure it is implied that the IV infusion rate will be wide
open until the parameter is reached, then the rate will be reduced to TKO. Vital signs will be repeated
according to EMT standards of care and IV rate adjusted, as noted above, to maintain adequate vital
signs.
7. Methods:
A. Assemble equipment
1)
2)
3)
4)
5)
Skin prep
IV catheter
IV fluids
IV tubing
Tape
B. Select site
1) Do not use injured, disabled, mastectomy, or paralyzed side
2) Evaluate all options
3) Unstable patient distal site is preferable (once a vein is blown, you can go above but not
below)
C. Select catheter size
1) 20 gauge or smaller for patient needing only IV medications or keep open access only.
2) 18 gauge or larger for patient requiring fluid replacement (hypovolemia, trauma, drug
overdose).
D. Select flow rate
1) Rates of IV Fluids.
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a) TKO (To keep vein open). Slow 30 ml/hr (5 drops/minute) unless rate specified by
specific protocol.
b) Wide Open. As fast as possible to infuse volume. Start with an initial fluid challenge of
200ml, recheck the BP, then titrate to patients condition.
When this procedure is performed, it is the responsibility of the EMT Intermediate Technician to monitor
the patient for changes and adjust the flow rate (titrate) to the patients blood pressure and general
condition. In general, decrease the flow rate if the patients BP is greater than 100 systolic and
maintained.
2) Other rates as directed by Medical Control
8. Complications:
A. Infection at the site
B. Catheter fracture
9. Caveats:
A. Only 2 attempts at an IV stick unless directed by Medical Control
B. Do not delay transport for IV attempts.
Note: Intravenous fluid given rapidly, to bring blood pressure to 90-100 systolic, is appropriate for
all forms of shock except heart failure shock. Breath sounds should be evaluated before rapid IV
fluid is given. Any abnormality in the breath sounds, e.g., wheezes or rales (crackles) is an
indication that heart failure shock may be present and the IV rate should be TKO. Contact Medical
Control if in doubt.
10. IV Sites:
A. Note type and gauge of needle used, date, and time.
B. Give verbal report of catheter gauge to emergency department personnel.
11. Record on the ambulance report form:
A. Note type and name of fluid and rate.
B. Catheter type and gauge, date and time
C. Name of person attempting IV.
D. Record total volume infused.
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Procedure Intraosseous Therapy

Clinical Indications:
Patients where rapid, regular IV access if unavailable with any of the following:
Cardiac Arrest
CCR IO is preferable
Multisystem trauma with severe hypovolemia
Severe dehydration with vascular collapse and/or loss of consciousness
Respiratory failure/respiratory arrest
Contraindications:
Fracture proximal to proposed intraosseous site
History of Osteogenesis Imperfecta
Current or prior infection at proposed intraosseous site
Previous intraosseous insertion or joint replacement at the selected site.
Procedure:
1. Identify anteromedial aspect of the proximal tibia (bony prominence below the knee cap). The
insertion location will be 1-2 cm (2 finger widths) below this.
2. Or the proximal humerus directly on the prominent aspect of the greater tubercle. Slide thumb up
the anterior shaft until you feel the greater tubercle, this is the surgical neck. Approximately 1 cm
above the surgical neck is the insertion site.
3. Or the distal tibia. Place one finger directly over medial malleolus; move approximately 2 cm
proximal and palpate the anterior and posterior borders of the tibia to assure that your insertion
site is on the flat center aspect of the bone.
4. Cleanse the site.
5. For the EZ-IO intraosseous device, hold the intraosseous needle at a 60-90 degree angle, aimed
away from the nearby joint and epiphyseal plate, power the driver until a pop or give is felt
indicating loss of resistance. Do not advance the needle any further.
6. Remove the stylette and place in an approved sharps container.
7. Attach a 12cc syringe filled with 5cc of NS; aspirate bone marrow to verify correct placement,
then inject 5cc of NS to clear the lumen of the needle.
8. Attach the IV line. Use a pressure bag,
9. Stabilize and secure the needle with dressings and tape.
10. Following the administration of IO medications, flush the IO line with 10CC of IV fluid to expedite
medication absorption.
11. Document the procedure, time, and result (success) on/with the PCR.
Revised: 03/2015
Page 23 of 83
Procedure Multi-Trauma Patient Assessment

EMT BASIC
1. Perform initial patient assessment. Treat life-threatening problems as they are discovered.
2. If patient is critical (shock, respiratory distress, or head injury with decreased level of consciousness),
package the patient with the spine immobilized. Transport immediately.
EMT INTERMEDIATE TECHNICIAN

3. Start a large bore IV LR wide open to maintain a SBP > 90. If possible, start a second IV NS TKO.
(IVs should be started en route to the hospital, unless transportation is delayed by extrication or
unusual circumstances.) Titrate to patients condition.
CONTACT MEDICAL CONTROL to prepare the receiving hospital and obtain any additional orders.
Refer to Triage Guidelines for Major Trauma
4. Perform focused history and physical exam. (This may be done earlier at the scene and before
transport in stable patients.
5. Dress external wounds.
6. Splint fractures.
7. Monitor patients condition en route to the hospital and report any changes to the Medical Control
Physician.
Revised: 03/2015
Page 24 of 83
Procedure Tourniquet
Clinical Indications:
Extremity injury/amputation with uncontrollable hemorrhage despite aggressive direct pressure
Procedure:
Apply tourniquet device as proximal on extremity as possible, minimum of 2 proximal to
hemorrhage site.
Secure in place and expedite transport to Level 1 Trauma Center.
Document time placed in PCR and on device if possible.
Notify receiving center of presence, time placed and location of tourniquet.
Directions:
1. Route the Self-Adhering Band around the extremity and pass the free-running end of the band
through the inside slit of the friction adaptor buckle.
2. Pass the band through the outside slit of the buckle, utilizing the friction adaptor buckle which will
lock the band in place.
3. Pull the Self-Adhering Band and tight and securely fasten the band back on itself.
4. Twist the rod until bright red bleeding has stopped.
5. Lock the rod in place with the Windlass Clip
6. Hemorrhaging is now controlled. Secure the rod with the strap: Grasp the Windlass Strap, pull it
tight and adhere it to the opposite hood on the Windlass Clip.
7. **If needed a second tourniquet can be added more proximal.
Revised: 03/2015
Page 25 of 83
Procedure Triage Guidelines for Major Trauma

The following are guidelines for Emergency Medical Services for the triage of major trauma patients to the
trauma center.
Patients with major trauma, with one or more of the following conditions, should be transported to the
trauma center:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Patient unresponsive to voice

Systolic blood pressure <90
Respiratory rate <10, or >30
Penetrating injuries to head, neck, torso, or extremities proximal to the elbow or knee.
Flail chest
Trauma with significant burns
Two or more proximal long bone fractures (humerus ,femur)
Unstable pelvic fractures
New onset paralysis
Amputation injuries proximal to the wrist or ankle
Consider transport to the trauma center for patients with the following mechanisms of injury or
concomitant medical conditions:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Ejection from an automobile during a motor vehicle crash

Death of another patient in the same auto
Extrication time >20 minutes.
Falls >20 feet
Victim of a rollover auto crash
Victim of a high-speed crash (Impact speed >40mph, major auto deformity, intrusion of auto damage
into the passenger compartment)
Auto-pedestrian or auto-bicycle injury with significant impact
Pedestrian thrown or run over
Motorcycle crash >20mph, or separation of rider from bike
Patient with major trauma and age <5 or >55
Patient with major trauma who has cardiac or respiratory disease
Pregnant patient with major trauma or unstable vital signs
Major trauma patient with immunosuppression
Major trauma patient with bleeding disorder, or an anticoagulant medication.
If unsure, contact MECIAL CONTROL. The decision will be made by Medical Control.
Revised: 03/2015
Page 26 of 83
Glasgow Coma Scale
Adults
Pediatric ( 2 years)
Score
Spontaneous
Spontaneous
To Voice
To Voice
To Pain
To Pain
None
None
Eye Opening
Total
Oriented
Coos, Babbles
Confused
Irritable Cry
Inappropriate Words
Cries to Pain
Incomprehensible Words
Moans to Pain
None
None
Verbal Response
Total
Motor Response
Obeys Commands
Normal Spontaneous Movement
Localizes Pain
Withdraws from Touch
Withdraws from Pain
Withdraws from Pain
Flexion to Pain
Abnormal Flexion
Extension to Pain
Abnormal Extension
None
None
1
Total
Total of all sections (3-15)
Normal
Mild
Moderate
Severe
Revised: 03/2015
15
13 15
9 12
38
Page 27 of 83
ALS Equipment Used by the EMT Basic and Intermediate Technician

1. Parenteral Fluids (EMT Intermediate Technician only)
A. 1,000 ml bags of Normal Saline (NS)
B. 250 ml bags of 5% Dextrose in Water (D5W)
C. 1,000 ml bags of Lactated Ringers
2. IV Equipment (EMT Intermediate Technician only)
A. IV catheters in #14, #16, #18, #20, #22 gauge sizes.
B. IV administration sets of Macro Drip and Micro Drip
C. Accessory IV equipment: appropriate disposable gloves, absorbent sheets, face shields,
provodine iodine swabs, alcohol swabs, tape, tourniquet, arm boards, sterile dressings,
3. Non-Visualized Airway equipment (EMT Basic and EMT Intermediate Technician)
A. Combitube
B. King LTS-D
C. Bag-valve-mask
D. Suctioning equipment
4. Drugs (EMT Basic and EMT Intermediate Technician unless noted)
A.
B.
C.
D.
E.
F.
G.
H.
5.
6.
7.
8.
9.
10.
Epinephrine (1:1000) in 1ml vial with filtered needle and syringe

Dextrose 25 gm (50% solution) in 50 ml pre-filled syringes
Naloxone (Narcan) 2mg injection or IV push
Albuterol inhalation solution (2.5 ml/3ml) for nebulization
Nitroglycerin 0.4 mg per spray (EMT Intermediate Technician only)
Aspirin 81 mg chewable tablets a total of four tablets (unit dose)
Glucagon 1 mg Emergency Administration Kit for injection
Atrovent (0.5 mg/2.5 ml) for nebulization
Pulse oximeter (EMT Basic and EMT Intermediate Technician)

Rad57 pulse oximeter/CO meter (EMT Basic and EMT Intermediate Technician)
Blood Glucose Monitor (EMT Basic and EMT Intermediate Technician)
Nebulizer (EMT Basic and EMT Intermediate Technician)
Continuous Positive Airway Pressure (CPAP) (EMT Basic and EMT Intermediate Technician)
Capnometry
Revised: 03/2015
Page 28 of 83
General Guidelines for the EMT Intermediate Technician

The EMT-Intermediate Technician is an advanced level EMT-B who has completed additional training
beyond that of an EMT-Basic, and is authorized under Wis. Stats. 1460.50 (5) and Wis. Admin. Rule 110
to perform selected advanced procedures under physician direction. Patient assessment and critical
decision-making is heavily emphasized in the EMT-Intermediate Technician training.
1. Apply a process of decision making to use the assessment findings to form a field impression of the
patients condition.
2. Don Personal Protective Equipment (PPE) as indicated.
3. Follow EMT Intermediate Technician Protocols
4. Make radio contact with Medical Control as soon as needed/possible.
5. Report assessment.
A.
B.
C.
D.
Age and gender of patient

Problem or chief complaint Brief history of illness or injury
Level of consciousness, general appearance, degree of distress, skin temperature and color.
Vital signs including pulse oximetry
1) Check quality of central and peripheral pulses
2) Cardiac monitoring as needed using monitoring electrodes.
E. Physical exam findings

F. Other pertinent information (past medical history, medications, allergies).
G. Report any EMT Intermediate Technician actions taken by protocol
6.
7.
8.
9.
Request and/or receive any orders for ALS procedures requiring voice Medical Control
After receiving order from Medical Control, verify it with Medical Control and initiate procedure.
Document all orders and have the physician in the ED sign the ambulance report form.
On all critical patients, particularly those n whom ALS procedures are done monitor vital signs often
and report significant changes to Medical Control. Always get at least one set of vital signs after an
ALS intervention, if time allows (5 minutes for trauma; ten minutes for medical incidents).
10. Consider ALS level tiered response for critical patients if not already sent.
11. Record on the ambulance report form:
A. Results of patient assessment
B. Treatment performed/medications or fluids administered with dose and route
C. Name of EMT Intermediate Technician performing treatments.
12. Review performance by performing a run critique with other team members.
Revised: 03/2015
Page 29 of 83
General Patient Care Guidelines

The following are general guidelines for patient management. Refer to additional protocols as
appropriate for treatment of specific conditions.
1. Ensure scene safety.
A. Perform a scene survey to assess environmental conditions and mechanism of illness or injury. If
hazardous conditions are present (such as swift water, hazardous materials, electrical hazards, or
confined space), contact an appropriate agency before approaching the patient. Wait for the
designated specialist to secure the scene and patient as necessary.
B. Observe Body Substance Isolation.
2. Approach the patient and identify self. Establish patient responsiveness. If cervical spine trauma is
suspected, manually stabilize the spine.
3. Assess the patients airway for patency, protective reflexes and the possible need for advanced
airway management.
Assess for possible airway obstruction. Administer high-flow, 100%
concentration oxygen if needed. Use a non-rebreather mask or blow-by as tolerated for the pediatric
patient.
4. Assess patients breathing, including rate, auscultation, inspiration effort, and adequacy of ventilation
as indicated by chest rise. Obtain pulse oximeter reading. If signs of respiratory distress, failure or
arrest, refer to the appropriate protocol for treatment options.
5. Control hemorrhage using direct pressure or a pressure dressing.
6. Assess circulation and perfusion by measuring heart rate and observing skin color and temperature;
capillary refill time, and the quality of central and peripheral pulses.
A. Initiate CPR/CCR for a pulseless patient.
7. Initiate cardiac monitoring
A. At no time should defibrillation pads be applied to a patient with a palpable pulse.
B. Even if familiar with EKG rhythms, the EMT must always treat the patient, not the monitor. DO
NOT INTERPRET RHYTHMS
C. Specific emergencies that should include 12 Lead EKG monitoring are: cardiac emergencies,
altered level of consciousness, abnormal vital signs, pulse rate below 60 and above 120,
respiratory distress, seizures and arrhythmias. 4 Lead monitoring should be used for chest
trauma and major multi-system trauma.
D. Monitoring must not delay transportation of the patient.
8. Evaluate mental status, including pupillary reaction, distal function and sensation and AVPU
assessment.
9. If spinal trauma is suspected, continue manual stabilization, place a rigid cervical collar and
immobilize the patient on long backboard or similar device.
10. Initiate transport, if the patients condition is critical or unstable
A. Perform focused history and detailed physical examination en route to the hospital if patient
status and management of resources permit.
B. If the patients condition is stable, perform focused history and detailed physical examination on
scene, and then initiate transport.
11. Reassess vital signs as follows; trauma every 5 minutes, medical emergencies every 10 minutes
unless patients condition changes or deteriorates.
CONTACT MEDICAL CONTROL for additional instructions as indicated.
Revised: 03/2015
Page 30 of 83
Airway Management and Oxygen Therapy Guidelines

Regardless of the nature of the response, the EMT Basic and Intermediate Technician shall always insure
via the Primary Survey that the patient has an adequate airway. The steps below shall be followed as
necessary.

1. All patients shall be assessed immediately as to the patency and adequacy of the airway. Follow the
AHA guidelines.
2. Aggressive airway management is indicated if any of the following exist:
A.
B.
C.
D.
Cardiac or respiratory arrest.

Any form of airway obstruction.
Any unconscious patient
Any patient with labored, shallow, or rapid respirations.
3. When breathing is inadequate, but an advanced airway is not (yet) needed, the EMT-Basic and
Intermediate Technician assist the patients ventilation via:
A. Pocket mask with supplemental oxygen orB. Bag-valve-mask with 100% oxygen
C. Airway adjuncts (oral or nasal airways). Never use an oral airway in a patient with intact gag
reflex.
D. Consider a non-visualized airway (refer to Combitube/King Airway Protocol) in patient without a
gag reflex.
4. If aggressive management is not indicated and airway is intact, administer supplemental oxygen
following a pulse oximeter reading to any patient who exhibits any of the following:
A.
B.
C.
D.
E.
F.
Symptomatic cardio/respiratory problems

Altered mental status
Seizures
Severe trauma
Signs of shock
Signs of stroke regardless of SaO2 reading
5. Supplemental oxygen is supplied by:

A. Nasal cannula at 2-6 liters per minute (oxygen concentration 24-44%)
B. Nonrebreather mask at 8-15 liters per minute (oxygen concentration 80-95%)
6. Oxygen should not be withheld from patients with chronic lung disease who are dyspneic. Use pulse
oximeter and titrate to condition.
7. Always give 100% oxygen to suspected carbon monoxide poisoning victims. Pulse oximeter reading
may be misleading. Consider use of RAD 57 Pulse Oximeter/CO Monitor.
8. A saturation value of 92% or greater is usually considered adequate, though many patients should
have supplemental oxygen regardless of oximetry readings.
9. A saturation value less than 92% is low. Troubleshoot for technical problems, and give higher
concentrations of oxygen. Consider assisting ventilations.
If in doubt, CONSULT MEDICAL CONTROL.
Revised: 03/2015
Page 31 of 83
Protocol for Use of the Combitube /King LTS-D Non-Visualized Airway

Combitube /King LTS-D placement to establish control of the patients airway may be performed by any
trained, certified and licensed EMT affiliated with an ambulance service approved to use this advanced
airway procedure.
Indications
1. Cardiac arrest from any cause
2. Respiratory arrest
3. Unconscious patient with inadequate respirations and no gag reflex.
Contraindications (Do Not Use on patient if:)
1. Patient is less than five (5) feet tall.
2. Patient is less than sixteen (16) years of age.
3. Patient has an active gag reflex
4. Patient has known or suspected esophageal disease
5. Patient has ingested caustic substance
6. Patient has a laryngectomy or trachestomy stoma.
7. Patient has a foreign body obstruction (remove first)
Prepare for Insertion
1. Take appropriate body substance isolation precautions
2. Determine cuff integrity per manufacturers directions
3. Lubricate as necessary
4. Insure all necessary components and accessories are at hand.
5. Prepare the patient
A. Reconfirm original assessment
B. Inspect upper airway for visual obstructions (patients dentures, bridge work/plates, broken teeth,
etc.) and remove.
C. Position the patients head in a neutral position
Conbitube Insertion
1. Grasp the tongue and lower jaw between the index finger and thumb and lift upward (jaw-lift
maneuver).
2. Insert the Combitube gently but firmly until black rings on the tube are positioned between the
patients teeth. Insert with the curvature of the Combitube in the same direction as natural curvature
of pharynx
A. DO NOT USE FORCE- if tube doesnt insert easily, withdraw and reattempt
B. Maximum of three thirty (30) second attempts with pre-oxygenation between each attempt
C. Inflate pharyngeal cuff through line #1 (blue) with 100ml of air and distal cuff through line #2
(white) with 15ml air
D. Check inflation of both cuffs by gently squeezing the pilot balloons at the free ends of the tubing
of both cuffs. These balloons should feel firm.
E. Ventilate through primary (blue) tube (tube #1)
Stop compressions for a moment in order to auscultate both lungs and the stomach and observe for chest
rise. (continued on next page)
Revised: 03/2015
Page 32 of 83

3. Confirm tube placement by auscultating breath sounds (high axillary and bilaterally) and auscultating
over the stomach
A. Esophageal placement breath sounds are present bilaterally with absent epigastric sounds.
1) Continue to ventilate through primary (blue) tube
2) The clear tube may be used for the removal of gastric fluids or gas with the catheter provided
in the airway kit
B. Tracheal placement breath sounds absent and epigastric sounds present
1) Ventilate through secondary (clear) tube
2) Reassess placement by auscultation and , if confirmed
3) Continue to ventilate through secondary (clear) tube
C. Unknown placement breath and epigastric sound absent
1)
2)
3)
4)
Immediately deflate cuffs (blue then white)

Slightly withdraw tube then reinflate cuffs (blue then white)
Ventilate and reassess placement
If breath sounds and epigastric sounds are still absent, immediately deflate cuffs and remove
Combitube
a) Suction as necessary
b) Insert oropharyngeal and/or nasopharyngeal airway
c) Ventilate patient one breath every 5 seconds
4. Continue ongoing respiratory assessment and treatment.

Combitube Removal
Indications
1. Patient regains consciousness
2. Protective gag reflex returns
3. Ventilation is inadequate
Procedure
1. Position patient on side (use spinal injury precautions as necessary)
2. Deflate cuffs (blue then white) and withdraw airway
3. Remove in smooth, steady motion suctioning as needed
4. Monitor airway and respirations closely, suction as needed
5. Place patient on high-flow oxygen. Assist ventilation with a bag-valve-mask as required.
Revised: 03/2015
Page 33 of 83
KING LTS-D
Laryngeal Tube Airway (LTA)
Purpose:
To establish control of the patients airway and to facilitate ventilation for the listed indications.
Indications:
When an alternative airway device is needed in the management of respiratory failure in patients
4 feet tall or greater.
Contraindications:
Intact gag reflex
Patients who have known esophageal disease
Patients who have ingested caustic substances
Patient with known tracheal obstruction
Patient with tracheostomy or laryngectomy
Patients less than 4 feet tall
Equipment:
Correct size LTA (see chart below)
Bag valve mask
Oxygen reservoir
Suction device
Bite block and/or endotracheal tube holder (if available)
Appropriately sized syringes for expanding cuff.
End Tidal CO2 and oxygen saturation monitoring devices.
King LTS-D Airway Sizes
Airway Size
3
4
5
Connector
Color
Yellow
Red
Purple
Patient Height
OD/ID (mm)
4-5 Feet
5-6 Feet
>6 Feet
18/10 mm
18/10 mm
18/10 mm
Cuff Volume
(ml)
45-60 ml
60-90 ml
70-90 ml
Gastric Tube
(Fr.)
Up to 18
Up to 18
Up to 18
Procedure:
1. Pre-oxygenate patient with 100% Oxygen via Bag Valve Mask or spontaneous ventilation to
achieve O2 saturation of <93% if possible
2. Check the integrity of the cuff inflation system and pilot balloon
3. Tightly deflate the cuff with the syringe
4. Lubricate the posterior distal tip of the LTA with a water soluble lubricant
5. Place patient in neutral sniffing position (if no c-spine/spinal injury suspected)
For patients with suspected c-spine injury, perform two-person insertion technique
o One person maintains manual in-line cervical spine stabilization while the other
person proceeds with the procedure
6. Pull mandible down to open mouth
7. Insert uninflated LTA into oral cavity with midline or lateral technique
8. Advance the tip behind the base of the tongue while rotating the tube back to midline so that the
blue orientation line faces the chin of the patient
9. Without exerting excessive force, advance the tube until the base of the colored connector is
aligned with teeth or gums
Revised: 03/2015
Page 34 of 83

Procedure (Continued):
10. Inflate the King with the appropriate volume:
If uninflated King Airway insertion is difficult, perform a jaw thrust, pulling the tongue
forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate
insertion
11. Attach the BVM to the King LTS-D
12. While bagging the patient, gently withdraw the tube until ventilation becomes easy and free
flowing (large tidal volume with minimal airway pressure)
13. Adjust cuff inflation if necessary to obtain a seal of the airway at the peak ventilator pressure
employed
14. Obtain end-tidal CO2 (waveform), listen for lung sounds bilaterally, look for chest excursion, and
check oxygen saturation
15. Secure in the midline to help maintain a good seal over the larynx
16. Place bite block, oral airway or endotracheal tube holder (if available) between teeth to prevent
biting tube
17. Place orogastric tube and attach to low continuous suction as directed in the applicable
procedure to assist in gastric decompression
18. Ensure c-spine is still immobilized
19. If repeated attempts are made, oxygenate with 100% O2 for 2 minutes between attempts
20. **Follow manufacturers suggested guidelines at all times**
Revised: 03/2015
Page 35 of 83
Procedure Cardiac Monitoring by the EMT Basic or EMT Intermediate

Technician
Cardiac monitoring by the EMT will be allowed only by persons trained in the use of the semiautomatic
defibrillator that not only has the ability to defibrillate, but also the capability to record or print a hard copy
of the patients rhythm for further analysis by a higher medical authority.
Patients with a Pulse:
Either the 4-lead or 12-lead patient cables will be allowed for cardiac monitoring.
Patients who are Pulseless and Apneic:
The hands off defibrillator patches will be used, and the EMT algorithm followed.

1. Perform patient assessment
2. Follow appropriate patient care protocol
3. The Biphasic Defibrillator 4 lead or 12 lead patient monitor cables may be attached for the following
patients:
A.
B.
C.
D.
E.
F.
Chest Pain
Shortness of Breath
Unresponsiveness
Drug Overdose
Altered Mental Status
Syncope
4. If the 4 lead cables are attached, run a rhythm strip for approximately 10 seconds.
5. If the 12 lead cables are attached, acquire a 12 Lead tracing following procedures set forth by the
manufacturer and transmit to destination hospital.
6. Upon arriving at the receiving hospital run a patient summary strip and record the patients name for
EMS records.
7. If there should be a change in the patients condition, as above repeat step 5.
8. Additional tracings should be acquired after any treatments or medication administration.
9. At any time a higher medical authority may request that either the 4-lead or 12-lead patient monitor
cables be attached or a rhythm strip be run on a patient.
Revised: 03/2015
Page 36 of 83
Treatment Protocol Congestive Heart Failure

(Pulmonary Edema)
Signs & Symptoms:
shortness of breath, cough, foamy or watery sputum, wheezing, dusky or cyanotic skin. History may
include recent weight gain and/or swelling of extremities.
EMT Basic
1. Administer high flow oxygen by mask.
2. Maintain head of stretcher in upright position with the legs of the patient dependent.
3. Calm and reassure patient. Give clear form directions.
4. Cardiac monitor, pulse oximeter
5. If patients blood pressure is >100 mm hg systolic, assist patient in taking their nitroglycerin 0.4 mg
sublingual every 5 minutes x 3.
6. Consider advanced airway. (see Airway Management and Oxygen Therapy Guidelines) nonvisualized airway
7. Transport

8. IV NS TKO (restrict IV fluid volume unless hypotensive).
9. Consider nitro after IV established following the same rules as #5 above.
10. Consider an advanced airway. (see #6 above) for severe respiratory distress or apnea.
11. Consider Albuterol or Atrovent PER MEDICAL CONTROL only if evidence of wheezing, since these
medications my increase pulse rate and increase work of heart.
Revised: 03/2015
Page 37 of 83
Treatment Protocol Abdominal Injury

EMT BASIC
1.
2.
3.
4.
5.
Perform patient assessment

Oxygen Therapy Protocol
Cardiac Monitor, pulse oximeter
Give nothing by mouth
Follow Shock Protocol as needed
SPECIAL PROBLEMS
Open Abdominal Injury
A. Seal puncture wounds with sterile occlusive dressing
B. Stabilize impaled objects
C. Limit patient movement during transport
Evisceration
A.
B.
C.
D.
E.
Cover exposed or protruding organs with a sterile dressing moistened with sterile saline
Cover with an occlusive dressing to prevent moisture loss
Cover with bulky dressings
Secure dressing loosely in place
Transport patient in supine or lateral recumbent position with knees flexed

1. IV NS WO to maintain blood pressure >90.
2. Proceed with shock protocol as applicable
3. Contact Medical Control for further orders
Revised: 03/2015
Page 38 of 83
Treatment Protocol Abdominal Pain

EMT Basic
2. Airway and Oxygen Therapy Protocol
3. Cardiac monitor, pulse oximeter
4. Give nothing by mouth
5. Follow Shock Protocol as needed
6. Position patient for comfort

7. IV NS at TKO
* Note: In suspected abdominal aortic aneurysm do no increase BP above 100 mm Hg systolic.
Proceed with shock protocol as applicable
Revised: 03/2015
Page 39 of 83
Treatment Protocol Altered Level of Consciousness

This protocol includes patients with altered consciousness of unknown cause. Patients with head injuries,
know diabetics, and known drug ingestions are covered in other specific protocols.
1. Perform initial patient assessment. Assess for trauma, drugs, diabetes, breath odor or medical alert
tags.
2. Protect the airway. Use protected side position if spine trauma not suspected. Use airway adjuncts
and assist ventilations if needed.
3. Administer oxygen.
4. Apply cardiac monitor, apply 12 Lead EKG monitor once en route to the hospital.
5. Check blood glucose using blood glucose monitor.

If Blood glucose is less than 60, be prepared to start IV of either D5W or NS and administer 50%
Dextrose in the IV solution. Or, administer Glucagon I.M. 1mg. for adult, 0.5mg for child less than 1 year
old. Recheck blood glucose in 10 to 15 minutes. If blood glucose is 60 or more, start IV NS. If systolic
BP under 90, give a 200ml bolus of NS, recheck BP, then titrate IV rate to patients condition (see
discussion of Rates of IV fluids in the Intravenous Lines protocol.)
If there is reason to suspect a narcotic overdose (and assuming patients altered consciousness was not
due to hypoglycemia and improved by glucose administration), consider administration of Naloxone.
Administer Naloxone in small, titrated doses of 0.5ml. If IV access not available and Naloxone is to be
given, give all 2ml IM at once in anterolateral thigh.
Revised: 03/2015
Page 40 of 83
Treatment Protocol Amputated Part

EMT Basic
1.
2.
3.
4.
5.

Shock Protocol as needed
Oxygen Therapy Protocol as needed
Patient: gently cover stump with sterile dressing saturated with sterile saline; cover this with dry bulky
dressing and elevate.
6. Severed Part: Preserve Part! Wrap in Saline Moistened Sterile Gauze. Place in plastic bag or
specimen cup; seal. Place container on ice. DO NOT FREEZE. Transport with patient.

1. As per BASIC
2. Shock Protocol as needed
3. IV NS WO if in shock, to maintain blood pressure >90 systolic.
Revised: 03/2015
Page 41 of 83
Treatment Protocol Anaphylaxis

Patient has come in contact with substance that caused past severe allergic reaction and complains of
respiratory distress or exhibits signs and symptoms of shock (hypoperfusion)
EMT -Basic
1. Perform initial assessment
2. Obtain patient history and perform physical exam
A.
B.
C.
D.
History of Allergies?
What was patient exposed to and how exposed?
Effects and progression?
Interventions (previous injection?)
3. Secure airway. Ventilate if necessary. Administer high flow oxygen.

4. Epinephrine, 0.3-0.15mg 1:1000 drawn up by ampule (Adult) Sub-Q or IM through a filtered syringe,
then discarding filtered needle and replaced with a non-filtered needle. Or by EpiPen auto injector.
In children an EpiPen Jr. (containing 0.15 mg. 1:1000) auto-injector is to be used. If in severe
respiratory distress (need to contact medical control).
5. Describe procedure to patient and obtain consent (if possible)
6. Verify that the Epinephrine has not expired, is clear and not discolored
7. If the patient has their own EpiPen assist them in using it
8. Administer EpiPen (0.3 mg 1:1000 IM) or EpiPen Jr. (0.15 mg 1:1000 IM)
9. Dispose of injector properly
10. Record actions and reassess patient in two minutes
11. Transport immediately
12. Dose may be repeated if conditions appear to be life threatening
13. Monitor ECG
Note: This protocol may be used by properly trained and licensed EMTs who are certified in the treatment
of anaphylactic shock.

1. Same as EMT- Basic
2. Epinephrine, 0.3-0.15mg 1:1000 drawn up by ampule (Adult) Sub-Q or IM through a filtered syringe,
then discarding filtered needle and replaced with a non-filtered needle. Or by EpiPen auto injector.
In children an EpiPen Jr. (containing 0.15 mg. 1:1000) auto-injector is to be used. If in severe
respiratory distress (need to contact medical control).
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3. IV NS TKO (with large angiocath) if systolic BP less than 90, Infuse NSS wide open and titrate to
maintain systolic BP at 90.
4. Cardiac Monitor, pulse oximeter
5. May repeat 0.3 to 0.15 mg Epinephrine of 1:1000 SQ or IM, if no improvement after 5 minutes.
6. If Epinephrine is ineffective in relieving bronchospasm, administer unit dose Albuterol with unit dose
Atrovent by nebulizer.
Pearls:
Use caution prior to administering Epinephrine in patients who are >50 years of age, have a
history of cardiac disease, or if the patients heart rate is >150. Epinephrine may precipitate
cardiac ischemia. These patients should receive a 12-Lead ECG.
The shorter the onset from symptoms to contact, the more severe the reaction.
For a patient that has had contact with a substance that causes allergic reactions without signs of
respiratory distress or shock (hypoperfusion):

1. Continue with focused assessment
2. A patient not wheezing and/or without signs of respiratory compromise or hypotension should not
receive Epinephrine (remember, patients with severe asthma or brochospasm may not have audible
wheezing)
3. Transport, perform on going assessment and record actions
4. Report any changes to medical control
DOSAGE OF EPINEPHRINE
Adults (>60 pounds) 0.3-0.15 cc 1:1000 sub-Q or one EpiPen
Children (<60 pounds) 0.15 cc 1:1000 IM (one EpiPen Jr.)
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Treatment Protocol Asthma, Chronic Lung Disease (COPD)

This protocol is applicable to patients who have respiratory distress, have known asthma or chronic lung
disease (chronic bronchitis and/or emphysema) and who are wheezing. Any patient who uses an inhaler
as a prescribed medication is an appropriate candidate for treatment with Albuterol/Atrovent.
Signs and Symptoms: history of asthma, orthopnea, labored or difficult respirations, wheezes, decreased
breath sounds
EMT Basics
1. Perform initial assessment; respiratory rate, use of accessory muscles, color and temperature of skin,
color of nail beds and around mouth (circumoral), lung sounds, VS, presence of diaphoresis
2. Administer oxygen (if not done previously) and assist with ventilations
3. Obtain history including:
A. History of Asthma?
B. Onset and progression since onset?
C. Interventions (previous inhaler or injection)?
D. Whats the worst your asthma has ever been.
E. How has it been treated in the past.
F. What medications have you taken in the past?
5. Albuterol with Atrovent 2.5 mg/3ml (unit dose) by nebulizer (6 L 02) for wheezing
6. Use supplemental Oxygen via nasal cannula during treatment
7. Consider use of CPAP if patient meets CPAP criteria.
8. May repeat Albuterol and Atrovent nebulizer (per orders of Medical Control) then Albuterol only to
repeat
9. Bring in all medications to the hospital.

1. As per BASIC
2. IV NS TKO
3. If the patient is in extremis and under the age of 65 years, consider the use of Epinephrine 1:1000
(per orders of Medical Control)
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Treatment Protocol Behavioral Emergencies

General principles:
Treat all calls with caution and respect. Speak in a low and calm tone; do not yell. Focus on feelings
more than the situation. Do not judge the patient. At least one EMT should try to stay with the patient
at all times. You may want to separate the patient from family or companions.
EVALUATE HAZARD TO EMS PERSONNEL

Call law enforcement if there is any indication that help is needed.
DO NOT DEAL with an armed person.
Approach combative patients with extreme caution. DO NOT turn your back to the patient.
EMT BASIC and INTERMEDIATE TECHNICIAN

1. Perform initial assessment
A. Protect patient from hazard to him/her self
B. Monitor patient for unexpected movement
2. Approach the patient with a calm, but firm demeanor
3. Assess for medical problems. Treat as appropriate
4. Observe for signs/symptoms of substance abuse
A. Attempt to identify substance, amount and time ingested/injected/inhaled
5. For the protection of yourself or the patient use restraint only with the order from Medical Control
and the presence of Law Enforcement.
6. Oxygen Therapy as needed
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Treatment Protocol Bleeding

(External)
EMT BASIC
1.
2.
3.
4.
5.

Control Bleeding:
Apply dressing with direct pressure and elevate
If bleeding persists control with appropriate arterial pressure point.
needed
A. Immobilize affected area if possible
B. Immobilize any impaled objects
Apply pressure dressing as
6. Cardiac Monitor, pulse oximeter as needed

7. Shock protocol if indicated
NOTE: Impaled objects in the cheek may be removed only if necessary to assure a patent airway

1. As per BASIC
2. IV NS TKO with large bore catheter (wide open if BP < 90mm HG systolic)
3. Proceed with shock protocol as applicable
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Treatment Protocol Burn Injury-Severe (Chemical or Thermal)

Severe burn injury includes patients with second-degree burns greater than 20% of body surface, thirddegree burns greater than 10%, significant electrical burns, chemical burns and burns associated with
multiple traumas.
1. Ensure rescuer safety.
2. Move patient to a safe environment. Remove burned or smoldering clothing from the patient, if
possible.
3. Perform patient assessment. Stabilize any spinal injuries.
4. Administer 100% oxygen via non-rebreather mask (away from fire and after smoldering clothes
removed).
5. Cool acute burns (including chemical burns) using profuse irrigation with sterile water.
hypothermia. Maintain patients body temperature.
Prevent
6. Estimate Body Surface Area (BSA) using the Rule of Nines. Determine type and thickness of burns.
EMT Intermediate Technician may start IV of Lactated Ringers or NS using large

bore needle at wide open rate. If there is time, establish a second sight with
a large bore needle with NS. Titrate IV rate to patients condition to maintain
BP greater then 90-100 systolic.
7. Apply dry sterile dressings and bandages or burn sheet.
8. Apply cardiac monitor.
9. Monitor pulse oximeter.
10. CONTACT MEDICAL CONTROL and report as early as possible.
11. Consider ALS intercept when the patient has:
A.
B.
C.
D.
Second or third degree burns 20% BSA (>10% BSA in patients <12 or >60 years)
Facial burns
Respiratory compromise
Pain management.
Note: Burn patients with the following should be transported to the University Hospitals Burn Center:
1) Burns associated with significant traumatic injury
2) Burns involving complex body areas:
a) Hands
b) Face with nasal or oropharyngeal burns with possible respiratory compromise
c) Feet
d) Genitalia
3) Second and third degree burns involved greater than 20% BSA
4) All significant chemical or electrical burns
5) All significant pediatric burns.
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Treatment Protocol Carbon Monoxide Poisoning

1. Remove the patient from the toxic environment (be aware of danger to yourself and your crew.)
2. Perform patient assessment. If patient is comatose and has no gag reflex, consider insertion of a nonvisualized airway.
3. Place Rad57 on patient and assess patients oxygen and carbon monoxide levels.
4. Administer 100% oxygen via a non-rebreather mask.
5. If altered mental status, check blood sugar with blood glucose monitor. If blood sugar is less than 60,
treat for hypoglycemia according to Altered Level of Consciousness Protocol.
EMT Intermediate Technician May start IV of NS. Titrate IV rate to patients

condition to maintain BP greater than 90-100 systolic.
6. Perform cardiac monitoring and transport.
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Treatment Protocol Cardiac Arrest
Considerations:
Consider ALS backup and/or All Page.

Preparation for transport of patient should begin immediately as staffing allows.
Assuming no on-scene ALS, the patient should be transported when one of the following
occurs:
a. The patient regains a pulse.
b. Special circumstances ie; pediatric patient and scene safety
For adult patients if no bystander CPR has been started and EMS arrival is greater than 3
minutes since collapse, EMS personnel should provide two minutes of CPR chest compression
only (100/min) before defibrillation, If GOOD bystander CPR is being performed, one (1) full
energy shock may be given followed by two (2) minutes of CCR before reanalyzing regardless of
whether or not CPR is in progress prior to arrival. For pediatric patients. Two (2) minutes of CPR
should be performed before defibrillation.
All contact with patient must be avoided during analysis of rhythm and/or delivery of shock(s).
Assign roles while responding to the call. (Code Commander, Pumpers, Airway, IV/IO)
Use of Defibrillation during Resuscitation Attempts

1.
Operational Steps multi rescuer resuscitation of a pulseless non-breathing (PNB) patient.

Take body substance isolation precautions enroute to the scene.
Have pumper initiate compressions and airway apply NRB of 15L O2 with an oral airway.
If Public Access Defibrillation (PAD) is utilized prior to your arrival, switch from PAD to EMS
defibrillator.
Complete two (2) minutes of CCR/CPR if it has been >3 minutes since collapse and not GOOD
CPR was initiated. Turn on defibrillator, attach pads, go to manual mode and press confirm.
Clear patient - make sure defibrillator is charged prior to analysis.
Initiate a quick <3 second analysis of rhythm.
o
o
o
o
o
o
Deliver shock maximum dose x1 if Ventricular Fibrilation (Vfib) or Ventricular

Tachycardia (Vtach). Shock #1
Resume compressions for two (2) minutes (200 compressions)
Re-analyze rhythm. If Vfib or Vtach, deliver shock. Shock #2
Resume compressions for two (2) minutes (200 compressions)
Re-analyze rhythm. If Vfib or Vtach, deliver shock. Shock #3
Resume compressions for two (2) minutes (200 compressions) insert an advanced nonvisualized airway while doing compressions. Artificially ventilate with high concentration
of oxygen 1 second squeeze six (6) breaths/minute. If unable to insert advanced airway,
ventilate with BVM at six (6) breaths/minute.
For all of the above, if patient is in asystole continue with compressions after analyzing.
Consider calling Medical Control for cessation of resuscitation in field after 600 compressions.
For all of the above, check pulse only if signs of life and possible perfusing rhythm.
Persistent Vfib and Vtach and No Available ALS Backup:
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Continue the sequence of one shock followed by two (2) minutes compressions for as
long as a shockable rhythm persists. Consider contacting On-Line Medical Control.
EMT Intermediate Technician: Consider establishing an IV/IO during compressions.
Considerations for Patients <18 Years Old 30:2 Compressions to Ventilations
If rescuer is alone, perform CPR for two (2) minutes before applying the defibrillator.
Pediatric pads are the preferred method for children under the age of 8, but standard pads may
be used if placed anterior and posterior.
AED per manufacturer instructions for children <1 year old.
Pearls for all age consideration:

It is not necessary to stop the ambulance to analyze unless artifact is interfering with
interpretation.
If you successfully resuscitated a patient from Vfib and the patient subsequently reverts back to a
shockable rhythm, you may have to re-institute the entire protocol.
Successful resuscitation requires planning and clear role definition.
CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac
nature. It is not indicated in those situations where other etiologies are probable (OD, drowning,
hanging, electrocution, etc) in these instances CPR is indicated. Also consider placing a nonvisualized airway sooner.
DO NOT INTERRUPT CHEST COMPRESSIONS
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Treatment Protocol Cardiac Arrest due to Trauma or Hypovolemia

1. Perform scene survey. Do not approach the patient until the scene is safe.
2. Perform initial patient assessment.
3. Start and continue CPR. Stabilize spine.

4. Start IV/IO of NS using large bore catheter.
5. Titrate IV rate to patients condition to maintain BP greater than 90-100 systolic.
6. If time permitting, consider second IV. DO NOT DELAY TRANSPORT.
7. IVs should be established while en route to the designated receiving hospital.
8. Consider the designated trauma center.
CONTACT MEDICAL CONTROL. If patient is without signs of life following blunt trauma and the monitor
shows a flat line after non-visualized airway insertion and two minutes of CPR, ask Medical Control if
resuscitation efforts should be terminated at the scene.
Some patient with cardiac arrest due to penetrating torso trauma maybe salvageable with emergent
surgery, even with no signs of life, especially if the event was witnessed. If penetrating trauma is
witnessed, immediate transport is advised. If the injury event and cardiac arrest are not witnessed,
CONTACT MEDICAL CONTROL for a decision whether to stop in the field.
*Note: Rarely, an accident with trauma may be the result of unsuspected ventricular fibrillation as the
primary event, and there is a chance of reviving such a patient with defibrillation. Ventricular fibrillation
also occurs as a secondary result of exsanguinations, asphyxia, etc., from trauma. This later type of
patient will not be revived in the field with typical treatment of a medical arrest. After performing a trial of
the defibrillation protocol (with a strict limit of two shocks), transport rapidly to a prepared hospital without
delay. If fibrillation is identified while en route, stop the ambulance briefly to defibrillate.
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Treatment Protocol Indications for Withholding Resuscitation in

Traumatic and Cardiopulmonary Arrest
Under the following circumstances:
Pulseless, apneic and no other signs of life present AND

The presence of one or more of the following:\
a. Rigor Mortis
b. Decomposition of body tissues
c. Dependant Lividity
d. Injuries incompatible with life (e.g. incineration, decapitation, transected torso)
e. Evidence of significant time lapse since pulselessness.
This criteria does not apply in the following scenarios:
When the cardiac arrest is inconsistent with cardiac arrest due to trauma
Lightning or other high voltage injuries
Drowning
Suspected hypothermia
Transport has been initiated
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Treatment Protocol Cardiac Ischemia (Chest Pain)

Symptoms may include pain in the chest, arms, jaw, neck, back or shoulders.
EMT Basic
1. Perform Initial patient assessment, focused history and physical exam.
2. Position for comfort, and minimize patient exertion, initiate transporting immediately.
3. Oxygen Therapy Protocol- Administer oxygen by mask and support ventilations as needed
4. Aspirin - 4 baby size (81 mg) if deemed necessary
5. Assist patient to take Nitroglycerin. ONLY IF SYSTOLIC BP IS > 100 AND PULSE IS >60.REPEAT
VITALS BEFORE EACH DOSE. MONITOR CLOSELY! YOU MAY REPEAT NITRO IN 5 MINUTES IF
CHEST PAIN IS NOT RELIEVED TO A MAXIMUM OF 3 DOSES
6. Cardiac Monitor with initial strip, pulse oximeter (if available)
7. During transport, monitor ECG
8. Monitor vital signs every 5 minutes and record.
9. Record patient history to include:
A. type, location and any radiation of pain
B. What was patient doing when pain began; onset of pain. Rate on a scale of 0 to 10 10 being the
worst pain youve ever had.
C. Does anything relieve pain
D. Past cardiac history
Contact Medical Control for Further orders

1. Place patient on cardiac monitor
2. Oxygen therapy protocol
3. Administer (4) 81 mg aspirin
4. IV Normal Saline at TKO rate
5. Administer one dose of nitroglycerine spray, sublingually every five minutes. Up to three doses.
Systolic blood pressure should be >100 and pulse is > than 60 before giving any additional doses.
Report findings to medical control and adjust IV drip rate accordingly*.
NOTE: REMEMBER IV, OXYGEN and MONITOR ALL @ SAME TIME.
*Assess males and females for usage of Viagra, Cyalis, Levitra (or similar substance) within the past 48
hours.
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Treatment Protocol Cardiogenic Shock

Signs and Symptoms:
A hypotensive patient (BP less than approximately 90 systolic) in the setting of a cardiac event such as
Acute Myocardial Infarction or Congestive Heart Failure.
EMT Basic
1. Perform patient assessment. Monitor closely for worsening condition (i.e., dyspnea, chest pain or
heaviness, cool, clammy skin).
2. Airway Management and Oxygen Therapy Protocol
3. Elevate patients head - these patients may be allowed to sit-up if BP tolerates it during transport.
4. Follow Chest Pain Protocol as needed.
5. Monitor EKG and Pulse Oximeter.
6. Consider CPAP.

7. IV, Normal Saline TKO.
8. Consider CPAP.
9. Consider fluid challenge 250ml over 5 minutes (except with CHF).
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Treatment Protocol Chest Trauma

Open Chest Injury
Signs and symptoms include:
1. Obvious or superficial trauma to the chest
2. Defect in chest wall or impaled object
EMT Basic
1.
2.
3.
4.
5.
Immobilize as a multiple trauma patient

Stabilize penetrating objects. DO NOT REMOVE!!
Sterile occlusive dressing for sucking chest wounds (see below)

1.
2.
3.
4.
As per BASIC
IV LR or NS TKO for BP>100 systolic. If BP <100mm/HG systolic, titrate to BP effect
Place non-visualized airway if needed
Contact Medical Control For further orders
Rib Fractures
Signs and Symptoms include:
1. Localized rib cage pain
2. Pain aggravated by respirations and coughing
3. Rib deformity
4. Lacerated or contused chest
5. Crepitus
EMT Basic
1. Position for comfort, if not contraindicated by possible C-Spine injury
2. Stabilize ribs with bulky trauma dressing

1.
2.
3.
4.
As per BASIC
IV LR or NS TKO for BP>100 systolic. If BP <100 mm/HG systolic, titrate to BP effect.
Non-visualized airway if needed.
Contact Medical Control for further orders
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Flail Chest
1. Localized pain
2. Painful breathing, coughing
3. Deformity of ribs
4. Lacerated or contused chest
5. Shortness of breath
6. Paradoxical chest movement
EMT basics
1. Immobilize flail segment with your gloved hand, patients arm, pillows or trauma dressings taped over
the site.
2. Place patient in the supine position or on affected side if not contraindicated by possible C- spine
injury

1.
2.
3.
4.
As per BASIC
IV NS TKO for BP>100 systolic. If BP<100 mm/HG systolic, titrate to BP effect
Non-visualized airway if needed
Contact Medical Control for further orders
Sucking Chest Wound

1. Signs of generalized chest trauma
2. Air moving through open wound
EMT Basic
1.
2.
3.
4.
Seal wound immediately with occlusive dressing after patient exhales

Place on affected side unless contraindicated by possible C-Spine injury

1. As per BASIC
2. Proceed with shock protocol
3. Non-visualized airway placement if needed
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Tension Pneumothorax
1. May or may not be signs of chest trauma
2. May be sucking chest wound, which has been sealed, and patient worsens rapidly for no other
apparent reason
3. Severe respiratory distress
4. Tracheal deviation to the unaffected side
EMT Basic
1. If sucking chest wound, open occlusive dressing and allow air to escape
2. THIS IS A LIFE THREATENING EMERGENCY - TRANSPORT IMMEDIATELY!!
3. Non-visualized airway placement if needed

1. IV NS TKO for BP > 100 systolic. If BP< 100 mm/HG systolic, titrate to BP effect
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Treatment Protocol Child Abuse

Child abuse and neglect are social diseases that affect all socioeconomic groups. When child abuse is
suspected, it is important to protect the child from further abuse and to assist the family in seeking
treatment.
Historical Clues to Abuse
1.
2.
3.
4.
5.
The parents may describe the accident in a way that sounds fabricated or implausible
The parents may have waited an excessive length of time before calling for emergency help
The parents may show hostility, detachment or lack of cooperation.
The parents may insist that the child be hospitalized for a monitor problem
The parents may show behavior related to psychosis or drug/alcohol abuse
Exam Clues to Abuse

1. Trauma (burns, fractures, bruises or injuries of varying age, or in various stages of healing,
dislocations, head injuries, falls that may be bizarre or poorly explained)
2. Victims of child abuse are often uncomplaining of painful injuries or procedures
Assessment
Your suspicion that the child is at risk for abuse or neglect is often sufficient reason to transport the child
for hospitalization. This is especially important for children under four years of age.
Management
1. Control your negative impulses toward the parents. DO NOT interrogate, accuse, or threaten the
parents. Generally, the parents are cooperative and may have made the emergency call as a means
of asking for help.
2. Transport the child by ambulance. If possible, DO NOT give the parents the option of transporting the
child.
3. Tactfully explain to the parents why the child should be transported. Tell the parents how deeply
concerned you are that their child has an unexplained injury. Express your uneasy feelings about the
situation, which compel you to recommend further evaluation and treatment in the hospital.
4. If the parents refuse to allow transportation, do not argue; report the incident to the emergency room
physician and local police. The EMT and the physician must report their findings to the Department of
Social Services. The endangered child may be detained in temporary protective custody.
Treat all injuries appropriately. Follow appropriate protocols.
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Treatment Protocol Continuous Positive Airway Pressure

(CPAP)
Continuous Positive Airway Pressure has been show to rapidly improve vital signs, gas exchange, reduce
the work of breathing, decrease the sense of dyspnea, and decrease the need for endotracheal intubation
in patients who suffer from shortness of breath from COPD, pulmonary edema, CHF, and pneumonia. In
patients with CHF, CPAP improves hemodynamics by reducing left ventricular preload and afterload.
1. Perform initial patient assessment.
A. Assess for:
1) INDICATIONS:
a) Any patient who is in respiratory distress with signs and symptoms consistent with
COPD, pulmonary edema, CHF, or pneumonia and who is:
b) Awake and able to follow commands
c) Is over 12 years old and is able to fit the CPAP mask.
d) Has the ability to maintain an open airway.
e) AND exhibits two or more of the following:
(1) A respiratory rate greater than 25 breaths per minute.
(2) SPO2 of less than 94% at any time
(3) Use of accessory muscles during respirations.
2) CONTRAINDICATIONS:
f) Patient is in respiratory arrest/apneic.
(1) Patient is suspected of having a pneumothorax or has suffered trauma to the chest.
(2) Patient has a tracheostomy.
(3) Patient is actively vomiting or has upper GI bleeding.
2. PROCEDURE
A. EXPLAIN THE PROCEDURE TO THE PATIENT.
B. Ensure adequate oxygen supply to ventilation device.
C. Place the patient on continuous pulse oximetry.
D. Place the patient on cardiac monitor and record rhythm strips with vital signs.
E. Place the delivery device over the mouth and nose.
F. Secure the mask with provided straps or other provided devices.
G. Start at 5cm. H2O of PEEP valve.
H. Check for air leaks.
I. Monitor and document the patients respiratory response to treatment.
J. Check and document vital signs every 5 minutes.
K. Administer appropriate medication as certified (continuous nebulized Albuterol for COPD/Asthma
and repeated administration of nitroglycerin spray or tablets for CHF)
L. Continue to coach patient to keep mask in place and readjust as needed.
M. Contact Medical Control to advise them of CPAP initiation.
N. Request ALS intercept if needed.
O. If respiratory status deteriorates, remove device and consider intermittent positive pressure
ventilation via BVM and/or placement of non-visualized airway.
3. REMOVAL PROCEDURE
A. CPAP therapy needs to be continuous and should not be removed unless the patient can not
tolerate the mask or experiences respiratory arrest or begins to vomit.
B. Intermittent positive pressure ventilation with a Bag-Valve-Mask, placement of a non-visualized
airway should be considered if the patient is removed from CPAP therapy.
4. SPECIAL NOTES
A. Do not remove CPAP until hospital therapy is ready to be placed on patient.
B. Watch patient for gastric distention, which can result in vomiting.
C. Procedure may be performed on patient with Do Not Resuscitate Order.
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D. Due to changes in preload and after-load of the heart during CPAP therapy, a complete set of vital
signs must be obtained every 5 minutes.
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Treatment Protocol - Cyclic Antidepressant Overdose

Signs and Symptoms include: CNS Depression (disorientations, coma, seizures, drowsiness, confusion,
coma), Anticolinergic Toxicity (dry mucus membranes, sinus tachycardia, urinary retention, mild
hypertension), and Cardiac Conduction depression (QRS Widening, SVT, and/or PVCs), Respiratory
depression, and hypotension.
Cyclic drugs include: Amitrytyline, Amoxapine, Clomipramine, Desipramine, Doxepin, Imipramine,
Maprotiline, Notriptyline, Protriptyline, Trimipramine.
EMT BASIC
1. Maintain patent airway (see airway and ventilation protocol)
2. High Flow Oxygen
3. Transport and monitor vitals en route

4. IV NS TKO (large bore catheter)
A. If systolic pressure drops less than 90, infuse warmed NS wide open 500ml
B. Establish a second large bore catheter
5. Monitor ECG
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Treatment Protocol Diabetic Emergencies

This protocol may be used for the treatment of patients who have been previously diagnosed with
diabetes and are currently experience an altered mental status.
EMT Basic
1. Perform patient assessment. Look for medical alert tags.
2. Conduct focused history and physical exam
A. Determine last meal
B. Any related illness
3. Oxygen Therapy Protocol
4. Obtain a blood glucose level using a glucometer
A. If blood sugar is less than 60 mg/dl and if:
1) Patient is awake enough to protect own airway. Administer oral glucose by mouth.
2) Patient has an altered level of consciousness. Follow protocol for Altered Level of
Consciousness.
5. Administer Glucagon if blood sugar is less than 60 mg/dl and if patient is not able to protect own
airway.
A. Administration of IM glucagon
1) Must be reconstituted before using.
2) Add the diluent to the powdered medication
3) Gently shake to mix thoroughly
4) Draw up 1 mg. of the medication and administer intramuscularly (subcutaneous
administration will lengthen time to absorption)
6. Record actions, transport and continue to monitor
7. Perform ongoing assessment. Reassess BS using glucometer in 15-20 minutes. .

1. As per BASIC
2. IV NS in DKA or high blood sugar.
3. If blood sugar is less than 60 and patient has altered level of consciousness Start and IV of D5W and
run 200 ml or start IV of NS and give 1 amp 50% Dextrose (D50) SLOW IV push
4. Check blood glucose after Administration of D5W or D50 push
5. If no IV can be established, continue with Glucagon Protocol
A. Administration of IM Glucagon
1) Must be reconstituted before using.
2) Add the dilutent to the powdered medication
3) Gently shake to mix thoroughly
4) Draw up 1 mg. of the medication and administer intramuscularly (subcutaneous
administration will lengthen time to absorption)
6. Record actions, transport and continue to monitor
7. Perform ongoing assessment. Reassess BS using glucometer in 15-20 minutes. Glucagon may be
repeated in 20 minutes with physician authorization.
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Insulin Reaction
(Hypoglycemia - Very Low Blood Sugar)
1. Signs and symptoms: confusion, restlessness, moist skin, rapid pulse, may lose consciousness, or
have a seizure
2. Patient setting: patient on insulin or oral hypoglycemic agents who develop the above symptoms
usually after a period of more than four hours without caloric intake.
Diabetic Ketoacidosis
(Very High Blood Sugar)
1. Signs and symptoms: progressive lethargy and perhaps coma, deep respirations, skin warm and
pulse full, vomiting frequently present in earlier stage, acetone odor on breath (fruity odor)
2. Patient setting: known diabetic, usually insulin dependent, may have missed or skipped recent insulin
dose or have an acute illness
TREAT AND RELEASE PROTOCOL (MEDICAL CONTROL AUTHORIZATION ONLY)
Consider no transport with medical control authorization of patients who have received the treatment
noted above and have met ALL of the following criteria:
Blood Sugar greater than 70mg/dl

Patient is able to eat a meal
Patient is in the company of responsible adults(s) who will stay with him/her for at least 12 hours
or ensure that somebody else does.
Patient agrees to contact their primary health care provider within 24 hours.
Patient has the capability of measuring their own blood sugar and adjusting their medications (i.e.
insulin) accordingly.
There are no other acute medical issues involved (i.e. suspected stroke, MI, trauma, drugs,
alcohol, use of oral hypoglycemic medications or serious infections.)
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Treatment Protocol Eye Irrigation

1. Perform initial assessment.
2. Perform focused history and physical exam.
3. Assess the need for irrigation of one or both eyes - i.e. exposure to toxic chemicals (acid or base).
4. Tilt head forward and brush eyelid/lashes if dry chemical present.
5. Remove contact lenses if present.
6. Irrigate with sterile NS continuously during entire transport.
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Treatment Protocol - Fractures & Dislocations

EMT Basic
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.

Dress all open wounds
Expose suspected fracture sites by cutting away clothing
Straighten severe angulated fracture- then safely splint
DO NOT STRAIGHTEN FRACTURES INVOLVING JOINT. IMMOBILIZE IN THE POSITION FOUND
OR POSITION IN WHICH A PULSE HAS BEEN REGAINED (Exception is wrist; immobilize wrist with
hand in position of function)
Do not push protruding bone segments back into wound
Immobilize extremity prior to moving patient
Immobilize extremity above and below suspected fracture/dislocation site
Evaluate loss of motion, deformity, pain and skin color
ALWAYS CHECK PULSES, strength and sensation distal to the injury

1. As per BASIC
2. Shock Protocol as needed
3. IV NS TKO
Note: Splint joints before long bones unless it is a femur. Femur is immobilized first.
Revised: 03/2015
Page 65 of 83
Treatment Protocol Gas & Smoke Inhalation

Overview scene for potential hazard to EMS personnel!!!
EMT Basic
1.
2.
3.
4.
5.
6.
7.
SCENE SAFETY!! Protect yourself from becoming a patient

Remove patients clothing if contaminated
Determine nature of inhalation injury
Airway and Oxygen Therapy Protocol
Cardiac Monitor, pulse oximeter or Rad57
Obtain patient information regarding
A. Type of inhalation
B. Symptoms may include: headache, blurred vision, nausea, cough, coughing up blood
C. Wheezing, slurred speech
D. Length of exposure

1.
2.
3.
4.
5.
As per BASIC
IV NS TKO
Non-Visualized Airway placement if patient is apnic
Neublized Albuterol 2.5 mg/3ml (unit dose) if patient is wheezing
If patient is in severe respiratory distress and unable to take nebulizer treatment, consider
Epinephrine 0.3 ml of 1:1000 sub-q/IM for bronchospasm (EpiPen)
Revised: 03/2015
Page 66 of 83
Treatment Protocol Gynecological Emergencies

1. PREDELIVERY EMERGENCIES ADVISE MEDICAL CONTROL EARLY.
A. Pre-eclampsia/Eclampsia (seizures as a result of toxemia during pregnancy)
1) Ensure patent airway; administer high flow oxygen. Suction if necessary.
2) Check blood pressure (hypertension is significant).
3) Obtain brief history including sudden weight gain, swelling in extremities, decreased urine
output, severe/persistent headache, persistent vomiting, altered mental status, blurred vision
or spots before eyes.
4) Observe for seizure activity provide quiet, non-stimulating environment. Consider ALS
intercept if seizure activity continues.
5) Transport to hospital in position of comfort, left lateral recumbent if tolerated.
EMT Intermediate Technician May start IV of NS or LR. Titrate IV rate to

patients condition.
B. VAGINAL BLEEDING
1) Administer high flow oxygen.
2) Assess amount of vaginal bleeding; place sterile obstetrical pads loosely over vaginal
opening.
3) Place in supine position. Elevate legs if possible.
4) Transport immediately to hospital.
EMT Intermediate Technician May start IV of NS or LR. Titrate IV rate to

patients condition to maintain BP greater then 90-100 systolic.
Revised: 03/2015
Page 67 of 83
Treatment Protocol Heat Illnesses/Hyperthermia

(Heat Exposure)
EMT Basic
1.
2.
3.
4.
Move patient to a cool environment

Patient assessment, with temperature
Assess patient for signs/symptoms of Heat Stroke vs. Heat Exhaustion (see guidelines below)
Heat Stroke (temperature greater than 106)
A. Cool the patient rapidly by placing the patient in a cool water bath (tub, river, lake)
B. If unable to provide a cool water bath, place cold packs in groin, axillary, and over torso

1. As per BASIC
2. IV NS - First liter wide open for previously healthy adult. For Children, run at rate prescribed by
Medical Control
3. Severe Respiratory distress and no gag reflex, consider Non-Visualized Airway
Characteristics
Mental State
Temperature
Skin
Cramping
Blood Pressure
ECG
Revised: 03/2015
HEAT EXPOSURE EMERGENCIES

Heat Stroke
Heat Exhaustion
Convulsions, stupor or coma
Usually
clear;
may
be
confused
Extremely high
Normal or slightly elevated
Hot, dry, no sweating (50% of Cool, pale, moist
patients)
Not present
Occasionally present
Hypotension often present
Occasionally hypotensive
T-wave changes
Normal
Page 68 of 83
Hypothermia General Information

1. Shivering occurs between 90-98 degrees F (32-37 degrees C), but not below this.
2. Use a Hypothermia thermometer - most thermometers dont register below 96 degrees F. (35 degrees
C)
3. Hypothermia may be a sign of hypoglycemia
4. Avoid stimulating the airway unnecessarily
5. Occasional sudden deterioration occurs during re-warming due to re-warming shock - Dont rewarm
in the field
6. A PERSON IS NOT DEAD UNTIL THEY ARE WARM AND DEAD. Therefore, CPR should be
initiated and continued on all severely hypothermic patients who might appear dead. The victim must
be re-warmed and evaluated at the hospital before resuscitation is terminated. Aggressive rewarming should not be initiated in the field, as many problems can occur during the re-warming
process.
7. Thawing should be done under controlled conditions. It is extremely painful.
8. Complete re-warming requires active heating for a prolonged period
9. Partial re-warming is worse than none. Therefore, re-warming should not be done in the field
10. HANDLE PATIENT GENTLY AT ALL TIMES!!
Revised: 03/2015
Page 69 of 83
Treatment Protocol Hypothermia

(Low Body Temperature)
Regardless of etiology, hypothermic patients can be graded into three categories.
[Clinical estimates only if temperature is unable to be taken}
1. Mild/Moderate-conscious patients with some degree of depressed level of consciousness including
slowed motor responses, slurred speech and confusion. These patients have an intact shivering
mechanism. Temperature is usually at 90 degrees F. or above.
2. Severe-patients with severely depressed LOC or coma, who often display some degree of rigidity.
Temperature is usually under 90 degrees F.
3. Arrested-patients in cardio-respiratory arrest. Temperature is usually above 77 degrees F.
EMT Basic
1. Patient assessment with temperature
4. General principles
A. Prevent further heat loss
B. Remove wet, cold clothing
C. Cover with warm blankets
D. Increase patient compartment temperature
E. Gentle handling (avoid rough or jarring movements)
F. Monitor ECG during transport
5. If frostbite evident:
A. Protect injured areas from exposure, pressure trauma, friction. Do not rub, or break blisters.
B. Do not allow patient to walk on thawed limb. If patient must walk out, leave limb frozen
C. Do not allow limb to thaw if there is a chance for refreeze prior to evacuation
D. Maintain core temperature by keeping patient warm with blankets
6. Initiate passive re-warming by placing hot packs in the groin area, axillae, on chest and abdomen.
Use caution as the patients skin may be desensitized and may burn easily.
7. If patients ECG is V-Fib or pulseless V-Tach, defibrillate per protocol. If continued shocking
appropriate, should not be performed more than every 10 minutes unless medical control advises
differently

1. IV NS TKO (warmed if possible)
2. If airway is compromised, Non-Visualized Airway is indicated
3. Contact Medical Control for further orders, which may include:
A. Dextrose 50%, 50 ml pre-filled syringe and Blood Glucose check after administration.
Revised: 03/2015
Page 70 of 83
Treatment Protocol Medication/Drug Overdose/Poisioning

(Ingestion of drug or toxin)
Signs and Symptoms include: altered LOC, depressed respiratory rate, constricted pupils, cyanosis, noncardiac pulmonary edema, and respiratory arrest.
EMT Basic
1. Ensure scene safety. If HAZMAT situation suspected, notify the local fire department immediately.
2. Determine chemical agent or name of medications, if possible.
3. Move patient to safe environment. Take appropriate precautions to protect self from contamination
(dust, fumes). Use appropriate PPE.
4. Secure and protect airway. Administer high-flow oxygen as needed.
A. Observe pattern and depth of respirations
B. If decreased level of consciousness or unconscious: Consider Nasopharyngeal Airway or NonVisualized Airway
5. Consider nasal Naloxone if there is reason to suspect narcotic overdose
*Note: EMT INTERMEDIATE TECHNICIAN: DO NOT PLACE Non-Visualized

Airway PRIOR TO NARCAN ADMINISTRATION - UNLESS PATIENT IS IN FULL
RESPIRATORY ARREST, AND THEN ONLY AFTER VENTILATING WITH BVM.
6. lf HAZMAT situation, remove patients contaminated clothing, and decontaminate the patient by
brushing off or rinsing off substances with copious amounts of water PRN.
7. Obtain information about names, descriptions, and amounts of item(s) ingested. Bring bottles and
containers, etc., of ingested materials to hospital. CONTACT MEDICAL CONTROL EARLY to
advise them of situation. Consider contacting Poison Control.
8. Apply cardiac monitor and pulse oximeter and/or RAD57
1. Monitor Vital Signs, ECG, LOC
Notes: Absorption
A. Remove contaminated clothing and any solid or liquid chemical that may provide continuing
contamination
A. Copiously irrigate skin and eyes with water (for at least 15 minutes during transport)
B. Remove rings, bracelets, constricting bands
C. Wrap burned area in clean, dry cloth or sterile gauze for transport
D. Keep patient warm
Notes: Ingestion
A.
B.
C.
D.
E.
Prepare for uncooperative patient (restrain if necessary)

Transport in the recovery position if unconscious
Have suction available and ready for use
If conscious observe and transport
Collect bottles/drugs and bring to ER
Revised: 03/2015
Page 71 of 83

EMT INTERMEDIATE TECHNICIAN May start IV of NS. Titrate IV rate to patients
condition to maintain BP greater then 90-100 systolic. If patient has altered
level of consciousness, check blood glucose and take appropriate action.
2. If normal level of consciousness, ensure patient airway and administer high flow oxygen.
3. If altered level of consciousness:
A. Protect the airway. Use protected side position if spine trauma not suspected. Use airway
adjuncts and assist ventilations if needed.
B. Administer high flow oxygen.
4. Consider ALS intercept for the patient with unstable vital signs, cyclic antidepressant overdose or
organophosphate poisonings.
5. Consider nasal or IV Naloxone if there is reason to suspect narcotic overdose.
EMT INTERMEDIATE TECHNICIAN If there is reason to suspect narcotic

overdose, consider use of Naloxone.(2mg. IV /children 0.1 mg/kg, up to 2
mg) may repeat as necessary up to 10mg.
NARCAN is effective against:
Darvon and Darvocet (propoxyphene)

Talwin (pentazocine)
Demerol (Meperidine)
Codeine
Heroin
Dilaudid (hydromorphone)
Morphine
Lomotil (Diphenoxylate)
Dolophine (methadone hydrochloride)
Paregoric (tincture of opium)
Percodan and Percocet (oxycodone)
Vicodin (hydrocodone)
Revised: 03/2015
Page 72 of 83
Treatment Protocol Neonatal Emergency

1. Following delivery, suction the infants airway (mouth, oropharynx and then nostrils) before drying the
infant.
2. Dry infant by gently rubbing to provide stimulation and to prevent chilling. Keep infant warm.
3. If infant is not breathing or is breathing but has poor color or muscle tone, perform tactile stimulation
(rub back or flick the soles of the infants feet). If infant still does not have adequate respirations or a
heart rate >100, provide assisted ventilation at a rate of 40-60 breaths per minute.
4. For a heart rate <60, ventilate with 100% oxygen and begin chest compressions.
5. CONTACT MEDICAL CONTROL and report.
6. Consider ALS intercept.
7. Acquire an APGAR
Revised: 03/2015
Page 73 of 83
Treatment Protocol Obsterics/Childbirth

Childbirth is a natural event and usually is uncomplicated. If you suspect an uncomplicated delivery and
imminent birth is not present, transport the patient positioned on the left side. If birth is impending, follow
the protocol. If you suspect a complicated delivery, refer to the appropriate section and request additional
resources.
EMT Basic
1. NORMAL DELIVERY
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Patient assessment
Administer oxygen
Place patient in position of comfort. Assess frequency of contractions.
Wear eye protection. Open O.B. pack and done sterile gloves and create a sterile field around
the vaginal opening.
Determine if the infants head is crowning.
Assist with delivery of infants head by applying gentle pressure with your gloved hands to
prevent an explosive delivery. Tear the amniotic sac if it is not already ruptured.
Feel around the neck for the umbilical cord; if present, gently slip the cord around the infants
head.
Suction the infants mouth then nose with bulb syringe. (observe the color of the fluid looking for
merconium staining)
Support the infants head and assist in rotating the shoulders thru the vaginal opening. The rest of
the infants body will follow.
Hold the baby level with the mothers vagina until the umbilical cord is cut. (if possible, wait for the
pulsating in the cord to stop) Place a clamp on the cord 7 from the body and the second one at
10 from the body. Cut between the two clamps with a sterile scissors or scalpel.
Suction the baby again and dry. Inspect the cord for bleeding. Wrap the baby in a blanket and
place on its side next to the mother.
Observe for the delivery of the placenta, which usually occurs within 20 minutes. DO NOT
DELAY TRANSPORT WHILE WAITING FOR THE DELIVERY OF THE PLACENTA. Let the
placenta delivery normally. Do NOT pull on umbilical cord. Place placenta and cord into plastic
bag, tie and transport to hospital with mother and infant.
After placenta delivers, massage the top of the uterus by rubbing the mothers abdomen firmly.
BE SURE TO KEEP OTHER HAND PRESSING DOWN INTO THE LOWER ABDOMEN NEXT
TO THE PUBIC BONE WHILE MASSAGING THE UTERUS.
Place sterile sanitary napkins/sterile dressings over the vaginal opening.
Record the time of delivery of infant and placenta and transport to hospital.
Note APGAR score of infant at 1 and 5 minutes after birth.
EMT Intermediate Technician may start IV of NS. Titrate IV rate to patients

condition to maintain BP greater then 90-100 systolic.
2. VAGINAL BLEEDING (Post Delivery)
Q. Administer high-flow oxygen
R. Massage the fundus of the uterus by using a kneading or circular motion with fingertips. It should
feel like a hard grapefruit. BE SURE TO KEEP OTHER HAND PRESSING DOWN INTO THE
LOWER ABDOMEN NEXT TO THE PUBIC BONE WHILE MASSAGING THE UTERUS.
S. Allow the infant to suckle on the mothers breast.
T. Continue transporting mother and infant to hospital
U. Contact Medical Control as early as possible.
Revised: 03/2015
Page 74 of 83

3. Prolapsed Cord ADVISE MEDICAL CONTROL EARLY
V. Elevate hips by raising buttocks with pillows or position the patient with her head down in a kneechest position.
W. Administer high flow oxygen and keep patient warm. May apply cardiac monitor.
X. Keep babys head away from cord by inserting sterile, gloved hand into the vagina and gently
pushing the presenting part of the fetus back and away from the pulsating cord.
Y. Cover the umbilical cord with a sterile dressing moistened with a sterile saline solution. DO NOT
ATTEMPT TO PUSH THE CORD BACK IN.
Z. Transport the patient rapidly while maintaining pressure on the presenting part to keep pressure
off the cord; monitor pulsations in the cord. (Pulsations should be present.)

4. Breach Presentation ADVISE MEDICAL CONTROL EARLY
A.
B.
C.
D.
Allow delivery to progress spontaneously

Support infants body as it is delivered
If head delivers spontaneously, proceed as with normal delivery
If head does not deliver within 4-6 minutes, insert gloved hand into vagina, create an airway for
the baby
5. TRANSPORT IMMEDIATELY, DO NOT REMOVE HAND UNTIL RELIEVED BY HOSPITAL STAFF

1. Limb Presentation
E.
F.
G.
H.
Place mother in Trendelenburg position

Administer high flow oxygen.
Consider Med Flight or transport immediately
If transporting by ambulance CONTACT MEDICAL CONTROL EARLY
EMT INTERMEDIATE TECHNICIAN May start IV of NS. Titrate IV rate to patients

Sign
Appearance
Pulse (HR)
Grimace
APGAR
0
Whole body completely
bluish-gray or pale
No heart rate
No response to airway
being suctioned
Activity
Limp; No movement
Respirations
Not breathing
Revised: 03/2015
SCORE
1
Good color in body with
bluish hands or feet
Fewer than 100 bpm
Grimace during
suctioning
Some flexion of arms
and legs
Weak cry; may sound
like whimpering, slow or
irregular breathing
2
Good color all over
At least 100 bpm
Grimace and pull away,
cough, or sneeze during
suctioning
Active motion
Good, strong cry;
normal rate and effort of
breathing
Page 75 of 83
Treatment Protocol Pediatric Respiratory Distress

Croup/Epiglotitis in Infant/Child
An infant or child who present with acute respiratory distress accompanied by fever, drooling, hoarseness,
stridor and tripod positioning may have a partial airway obstruction. Do nothing to upset the child. Do
not attempt any procedures or maneuvers (including examination of oropharynx) which may increase the
childs anxiety and thereby cause laryngospasm, unless absolutely necessary to preserve the airway.
Consider keeping the child on providers lap.
1. Perform critical assessment only. Do no upset the infant/child. Let care provider handle child.
2. Ensure patent airway, when assessing the ABCs.
3. Administer blow-by oxygen. Can be done by care provider.
4. Have care provider place in position of comfort.
5. Do not attempt vascular access.
6. Transport immediately if suspected epiglottis or severe respiratory distress is evident. Consider no
red lights and sirens.
Revised: 03/2015
Page 76 of 83
Treatment Protocol Respiratory Arrest

1. Perform initial patient assessment. If cardiac arrest, go to Cardiac Arrest protocol.
2. Look for signs of airway obstruction including choking, absent breath sounds, cyanosis, tachypnea,
bradycardia, intercostal retractions, stridor or drooling. Remove foreign body obstruction of airway if
suspected and if patient is conscious.
3. Open airway with head tile/chin lift method if no spinal trauma is suspected, or use the modified jaw
thrust if spinal trauma is suspected if patient is unconscious. Remove obstruction if present and
attempt ventilations using a pocket mask or bag-valve-mask with supplemental oxygen. If no gag
reflex present, insert an oropharyngeal or nasalpharyngeal airway adjunct.
4. If patient is apneic (no respirations) and ventilation not effective with bag-valve mask and patient has
tolerated an oral airway, insert Non-Visualized Airway ventilate with 100% oxygen.
EMT INTERMEDIATE TECHNICIAN If narcotic overdose suspected (e.g.,

bystanders give such a history), administer 2mg of Naloxone (2cc) as
outlined in Medication-Drug Overdose/PoisioningProtocol.
5. Check blood sugar with blood glucose monitor. If blood sugar less than 60, treat hypoglycemia with
IV D5W, IM Glucagon or 50% Dextrose, as outlined in the Altered Level of Consciousness Protocol.
6. Transport to hospital immediately, monitoring patient closely. Consider ALS if needed.
Revised: 03/2015
Page 77 of 83
Treatment Protocol - Seizures

EMT Basic
1.
2.
3.
4.
5.
6.
7.

Protect Airway (do not force anything in between patients teeth)
Protect head from injury. Avoid physical restraint unless absolutely necessary to protect the patient
Protect patients dignity by removing bystanders and covering patient
Observe and record pattern and duration of seizure
A. Note body parts involved
B. Was there a loss of consciousness?
C. Was there a loss of bladder control?
8.
9.
10.
11.
12.
Monitor pulse and ECG

Check blood glucose level with glucometer, if <70 go to diabetic protocol
Single isolated seizures require no treatment other than ABCs and supportive care.
For pediatric febrile seizures, remove clothing and institute cooling procedures
Transport all:
A. First time seizures (no previous history)
B. Seizures lasting longer than 5 minutes
C. Status Epilepticus (seizure activity lasting 10 min or longer or a recurrent seizure without and
intervening period of consciousness
D. Seizures following any trauma or hypoxic event.

1. As per BASIC
2. IV NS TKO
Revised: 03/2015
Page 78 of 83
Treatment Protocol Sexual Assault

1. Use tact and sensitivity
2. Assess and care for urgent medical problems
A. Patient assessment
B. Treat any abrasions, lacerations
C. Allow patient respect and privacy
D. AS MUCH AS POSSIBLE, PRESERVE MEDICAL/LEGAL EVIDENCE
3. Do not allow patient to wash, comb hair, eat or drink, change clothing or go to the bathroom. Make
sure the patient understands the reasons. Caution patient that washing could destroy evidence.
4. Make a quick overview of the scene; be cooperative with law enforcement in collection of clothing and
history
5. Treat concurrent injuries according to appropriate treatment protocols
6. Transport
Revised: 03/2015
Page 79 of 83
Treatment Protocol Shock, Hypotension, and Hemorrhage

This protocol includes patients with non-traumatic hemorrhage and includes GI bleeding, significant
hemoptysis, major nosebleeds, etc.
EMT Basic
1.
2.
3.
4.
5.
6.
7.
Perform initial patient assessment.

Ensure patent airway. Administer 100% oxygen via NRB.
Assess LOC, peripheral pulses and capillary refill.
Apply cardiac monitor.
Control hemorrhage if able.
Monitor pulse oximeter.
Place patient in Trendelenburg position if possible.
EMT Intermediate Technician Start IV of NS using large bore needle. Titrate IV

rate to patients condition to maintain BP greater then 90-100 systolic. If
time permitting, consider second IV DO NOT DELAY TRANSPORT.
Revised: 03/2015
Page 80 of 83
Treatment Protocol Spinal/Neurological Injury

If there is any reason to suspect that the patient may have sustained a spinal injury, he/she must be
treated as though the injury has occurred.
If there is an immediate threat to safety, remove the patient from danger by dragging him/her along the
ground while keeping the entire spinal column in a longitudinal axis. Maintain moderate straight
stabilization on the head and neck during patient extrication.
If the patient is in the water without danger of hypothermia, keep the patient in the water until C-Spine
protection is in place and the patient is placed on a long board.
EMT Basic
1.
2.
3.
4.
5.
6.

Immobilize the spinal column with a backboard and KED. Apply cervical collar
Airway and Oxygen Therapy Protocol
Cardiac Monitor Protocol
Treat concurrent injuries according to appropriate protocol
Keep the patient warm, increase compartment heat above normal

1. As per BASIC
2. IV NS with large bore needle (watch for neurogenic shock); infuse to keep BP> 100 systolic
3. Non-Visualized Airway if needed
Revised: 03/2015
Page 81 of 83
Treatment Protocol Stroke/Cerebral Vascular Accident

EMT Basic
2. Ready suction equipment and suction as needed
3. If unconscious protect airway
4. If history of trauma go to Shock - Trauma Protocol
5. If C-Spine injury, immobilize
6. Assess for (PERFORM CINCINNATI STROKE SCALE):
A. unilateral weakness/paralysis
B. facial drooping
C. speech difficulty
7. Minimize on scene time
8. While en route determine onset time of symptoms.
9. Position lying on side, or semi upright position, place on cardiac monitor, pulse ox and blood glucose
check.
11. Vital signs every 15 minutes

1. As per BASIC
2. IV NS TKO
Revised: 03/2015
Page 82 of 83
Treatment Protocol Upper Airway Obstruction

Signs and symptoms: The universal choking sign (hands about the neck), expiratory stridor, cyanosis,
severe respiratory distress, unconsciousness with apnea and unable to ventilate.

1.
2.
3.
4.
If patient is conscious, instruct to cough

If patient cannot cough or speak, do Heimlich maneuver or abdominal thrusts
If patient is unconscious: Initiate CPR/CCR and be sure to visually check airway prior to ventilating.
The second EMT prepares to directly visualize the airway with a laryngoscope and manually remove
foreign body with Magill forceps or suction.
5. If after the obstruction is removed, there is no spontaneous respirations, reposition airway and
attempt to ventilate. If successful go to rescue breathing protocol. If not return,
6. to step 3.
Note: Pediatric patients obstructions can often be relieved with BVM bagging. Follow American
Heart Association guidelines for pediatric patients.
Revised: 03/2015
Page 83 of 83

2015 Laems Protocols

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2015 Laems Protocols

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Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

EMT Intermediate Technician Scope of Practice

EMT Intermediate Technician skills

Advanced procedures used by the EMT Basic

Advanced Procedures (used by both EMT Basics and EMT Intermediate

Advanced Airways (Combitube,King)

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

EMT Basic and EMT Intermediate Technician Level of Practice

EMT Intermediate Technician

Airway Nasal (Nasopharyngeal)

Airway Oral (Oropharyngeal)

Cricoid Pressure (Sellick)

Manual Airway Maneuvers

Obstruction Forceps & Laryngoscope

Oxygen Therapy Nasal Cannula

Oxygen Therapy Non-rebreather mask

Oxygen Therapy Nebilizer

Suctioning Upper Airway (soft & rigid)

Medication Administration Routes

Assisted Medications Patients Own

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Medicated Inhaler Prescribed Atrovent

Approved Medication by Protocol

Atrovent (Nebulized Unit Dose)

Aspirin (ASA) for Chest Pain

Epinephrine for Anaphylaxis (Unit Dose)

Mark I Auto-Injector (for Self and Crew)

Nitroglycerin (SL only, Service Carried)

ECG Monitor (non-interpretive)

12-Lead ECG (acquire but non-interpretive)

Hemorrhage Control Direct Pressure

Hemorrhage Control Pressure Point

Hemorrhage Control Tourniquet

Spinal Immobilization Long Board

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Splinting Pelvic Wrap

Blood Glucose Monitoring

Blood Pressure Automated

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Physician at the Scene

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

Patients Who Decline Treatment or Transport

Minor is in armed forces

Lodi Area Emergency Medical Service

EMT BASIC and EMT INTERMEDIATE TECHNICIAN PROTOCOLS

DNR and Termination of Resuscitation in the Field

Lodi Area Emergency Medical Service