National Model EMS Clinical Guidelines

National Model EMS

Clinical Guidelines

March 2022

VERSION 3.0

These guidelines will be maintained by the National Association of

State EMS Officials (NASEMSO) to facilitate the creation of state

and local EMS system clinical guidelines, protocols, or operating

procedures. System medical directors and other leaders are

invited to harvest content as will be useful. These guidelines are

either evidence-based or consensus-based and have been

formatted for use by field EMS professionals.

NASEMSO Medical Directors Council

www.nasemso.org

 
 
NASEMSO  
National Model EMS Clinical Guidelines 
 
  Rev. March 2022 
  2 
Version 3.0 
 
Contents 
INTRODUCTION ..................................................................................................................... 6 
PURPOSE AND NOTES ........................................................................................................... 7 
TARGET AUDIENCE .................................................................................................................. 8 
WHAT IS NEW IN THE 2022 EDITION ........................................................................................... 8 
ACKNOWLEDGEMENTS ............................................................................................................. 8 
UNIVERSAL CARE ................................................................................................................... 9 
UNIVERSAL CARE GUIDELINE ..................................................................................................... 9 
FUNCTIONAL NEEDS .............................................................................................................. 19 
PATIENT REFUSALS ................................................................................................................ 23 
CARDIOVASCULAR .............................................................................................................. 26 
ADULT AND PEDIATRIC SYNCOPE AND NEAR SYNCOPE .................................................................... 26 
CHEST PAIN/ACUTE CORONARY SYNDROME (ACS)/ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION (STEMI)
........................................................................................................................................ 31 
BRADYCARDIA ..................................................................................................................... 35 
IMPLANTABLE VENTRICULAR ASSIST DEVICES ............................................................................... 39 
TACHYCARDIA WITH A PULSE ................................................................................................... 42 
SUSPECTED STROKE/TRANSIENT ISCHEMIC ATTACK ........................................................................ 48 
GENERAL MEDICAL .............................................................................................................. 51 
ABDOMINAL PAIN ................................................................................................................ 51 
ABUSE AND MALTREATMENT ................................................................................................... 55 
AGITATED OR VIOLENT PATIENT/BEHAVIORAL EMERGENCY ............................................................. 59 
ANAPHYLAXIS AND ALLERGIC REACTION ..................................................................................... 66 
ALTERED MENTAL STATUS ...................................................................................................... 71 
BACK PAIN ......................................................................................................................... 75 
END-OF-LIFE CARE/HOSPICE CARE ............................................................................................ 78 
HYPERGLYCEMIA .................................................................................................................. 81 
HYPOGLYCEMIA ................................................................................................................... 84 
NAUSEA-VOMITING .............................................................................................................. 89 
PAIN MANAGEMENT ............................................................................................................. 93 
SEIZURES .......................................................................................................................... 101 
SHOCK ............................................................................................................................. 107 
SICKLE CELL PAIN CRISIS ....................................................................................................... 114 
RESUSCITATION ................................................................................................................ 117 
CARDIAC ARREST (VF/VT/ASYSTOLE/PEA).............................................................................. 117 
ADULT POST-ROSC (RETURN OF SPONTANEOUS CIRCULATION) CARE .............................................. 126 
DETERMINATION OF DEATH/WITHHOLDING RESUSCITATIVE EFFORTS ............................................... 130 
DO NOT RESUSCITATE STATUS/ADVANCE DIRECTIVES/HEALTHCARE POWER OF ATTORNEY (POA) STATUS 133 
TERMINATION OF RESUSCITATIVE EFFORTS ................................................................................ 136 

 
 
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National Model EMS Clinical Guidelines 
 
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Version 3.0 
RESUSCITATION IN TRAUMATIC CARDIAC ARREST ........................................................................ 141 
PEDIATRIC-SPECIFIC GUIDELINES ....................................................................................... 144 
BRIEF RESOLVED UNEXPLAINED EVENT (BRUE) & ACUTE EVENTS IN INFANTS .................................... 144 
PEDIATRIC RESPIRATORY DISTRESS (BRONCHIOLITIS) .................................................................... 150 
PEDIATRIC RESPIRATORY DISTRESS (CROUP) .............................................................................. 155 
NEONATAL RESUSCITATION ................................................................................................... 159 
OB/GYN ............................................................................................................................ 165 
CHILDBIRTH....................................................................................................................... 165 
ECLAMPSIA/PRE-ECLAMPSIA ................................................................................................. 171 
OBSTETRICAL AND GYNECOLOGICAL CONDITIONS ........................................................................ 175 
RESPIRATORY .................................................................................................................... 178 
AIRWAY MANAGEMENT ....................................................................................................... 178 
RESPIRATORY DISTRESS (INCLUDES BRONCHOSPASM, PULMONARY EDEMA) ...................................... 190 
MECHANICAL VENTILATION (INVASIVE) .................................................................................... 198 
TRACHEOSTOMY MANAGEMENT ............................................................................................. 203 
TRAUMA ........................................................................................................................... 208 
GENERAL TRAUMA MANAGEMENT .......................................................................................... 208 
BLAST INJURIES .................................................................................................................. 215 
BURNS ............................................................................................................................. 218 
CRUSH INJURY/CRUSH SYNDROME .......................................................................................... 222 
EXTREMITY TRAUMA/EXTERNAL HEMORRHAGE MANAGEMENT...................................................... 225 
FACIAL/DENTAL TRAUMA ..................................................................................................... 230 
HEAD INJURY..................................................................................................................... 233 
HIGH THREAT CONSIDERATIONS/ACTIVE SHOOTER SCENARIO ........................................................ 238 
SPINAL CARE ..................................................................................................................... 241 
TRAUMA MASS CASUALTY INCIDENT ....................................................................................... 249 
TOXINS AND ENVIRONMENTAL ......................................................................................... 252 
POISONING/OVERDOSE UNIVERSAL CARE ................................................................................. 252 
ACETYLCHOLINESTERASE INHIBITORS (CARBAMATES, NERVE AGENTS, ORGANOPHOSPHATES) EXPOSURE ... 260 
RADIATION EXPOSURE ......................................................................................................... 271 
TOPICAL CHEMICAL BURN ..................................................................................................... 275 
STIMULANT POISONING/OVERDOSE ........................................................................................ 279 
CYANIDE EXPOSURE ............................................................................................................ 283 
BETA BLOCKER POISONING/OVERDOSE .................................................................................... 287 
BITES AND ENVENOMATION .................................................................................................. 291 
CALCIUM CHANNEL BLOCKER POISONING/OVERDOSE .................................................................. 295 
OPIOID POISONING/OVERDOSE ............................................................................................. 303 
AIRWAY RESPIRATORY IRRITANTS ........................................................................................... 308 
RIOT CONTROL AGENTS ....................................................................................................... 317 
HYPERTHERMIA/HEAT EXPOSURE ........................................................................................... 320 
HYPOTHERMIA/COLD EXPOSURE ............................................................................................ 326 
DROWNING ...................................................................................................................... 333 

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National Model EMS Clinical Guidelines

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Version 3.0

DIVE (SCUBA) INJURY/ACCIDENTS......................................................................................... 337

ALTITUDE ILLNESS ............................................................................................................... 341

CONDUCTED ELECTRICAL WEAPON INJURY (I.E., TASER®) ............................................................ 345

ELECTRICAL INJURIES ........................................................................................................... 348

LIGHTNING/LIGHTNING STRIKE INJURY ..................................................................................... 352

APPENDICES ...................................................................................................................... 357

I. AUTHOR, REVIEWER AND STAFF INFORMATION ........................................................................ 357

II. UNIVERSAL DOCUMENTATION GUIDELINE .............................................................................. 363

III. MEDICATIONS ............................................................................................................... 377

IV. APPROVED ABBREVIATIONS .............................................................................................. 394

V. BURN AND BURN FLUID CHARTS ......................................................................................... 398

VI. NEUROLOGIC STATUS ASSESSMENT .................................................................................... 404

VII. ABNORMAL VITAL SIGNS ................................................................................................ 405

VIII. EVIDENCE-BASED GUIDELINES: GRADE METHODOLOGY ....................................................... 406

IX. 2022 NATIONAL GUIDELINE FOR THE FIELD TRIAGE OF INJURED PATIENTS .................................... 407

NASEMSO

National Model EMS Clinical Guidelines

Rev. March 2022

Version 3.0

This publication was developed with funding from the National Highway Traffic Safety Administration

(NHTSA), Office of Emergency Medical Services (Cooperative Agreement 693JJ92050001-0002) and the

Health Resources and Services Administration/Maternal and Child Health Bureau/EMS for Children

program. The opinions, findings, and conclusions expressed in this publication are those of the authors and

not necessarily those of the United States Government. The United States Government assumes no liability

for its content or use thereof. If trade or manufacturers’ names or products are mentioned, it is because

they are considered essential to the object of the publication and should not be construed as an

endorsement. The United States Government does not endorse products or manufacturers. For more

information, please visit EMS.gov and HRSA.gov.

NASEMSO

National Model EMS Clinical Guidelines

Rev. March 2022

Version 3.0

Introduction

We are honored to present the third edition of the National Association of State EMS Officials (NASEMSO)

National Model EMS Clinical Guidelines and want to thank the entire EMS community for contributing to its

evolution. The inaugural edition, released in September 2014, has been warmly welcomed by EMS

clinicians, agencies, medical directors, and healthcare organizations in our nation as well as abroad. The

creation of this document is a pinnacle event in the practice of EMS medicine as it fulfilled a

recommendation in The Future of Emergency Care: Emergency Medical Services at the Crossroads published

by the Institute of Medicine (now the National Academies of Sciences) in 2007. Specifically, this report

states “NHTSA, in partnership with professional organizations, should convene a panel of individuals with

multidisciplinary expertise to develop evidence-based model prehospital care protocols for the treatment,

triage, and transport of patients.”

The National Association of State EMS Officials (NASEMSO) recognizes the need for national EMS clinical

guidelines to help state EMS systems ensure a more standardized approach to the practice of patient care

now and, as experience dictates, the adoption of future practices. The value of EMS clinicians to the patient

has no boundaries as magnified by the historic 2019 novel coronavirus pandemic as well as other

interjurisdictional and global responses. Model EMS clinical guidelines promote uniformity in EMS medicine

which, in turn, fosters a more consistent skilled practice as EMS clinicians move across healthcare

systems. They also provide a standard to EMS medical directors upon which to base practice. Supported by

initial and subsequent grant funding from NHTSA’s Office of Emergency Medical Services (OEMS) and the

Health Resources and Services Administration (HRSA) Maternal and Child Health Bureau’s EMS for Children

program, NASEMSO continues to authorize its Medical Directors Council to partner with national

stakeholder organizations with expertise in EMS medical direction and subject matter experts to create a

unified set of patient care guidelines. For those aspects of clinical care where evidence-based guidelines

derived in accordance with the national evidence-based guideline model process were not available,

consensus-based clinical guidelines are developed utilizing current available research.

The NASEMSO Model EMS Clinical Guidelines are not mandatory, are not meant to be all-inclusive, nor are

they meant to determine local scope of practice. The focus of these guidelines is solely patient-centric. As

such, they are designed to provide a resource for EMS clinical practice, appropriate patient care, safety of

patients and clinicians, and outcomes regardless of the existing resources and capabilities within an EMS

system. This document provides a clinical standard that can be used as is or adapted for use on a state,

regional, local, or organizational level to enhance patient care and to set benchmark performance of EMS

practice. The Guidelines should be adapted to align with federal, state, regional, and jurisdictional laws and

regulations. NASEMSO’s ongoing support of this project underlines the critical evolution of the model EMS

clinical guidelines as new EMS research and evidence-based patient care measures emerge.

We are most grateful to be able to partner with a group of talented, committed individuals in this

worthwhile endeavor.

Carol Cunningham, M.D. Richard Kamin, M.D.

Co-Principal Investigator Co-Principal Investigator

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Version 3.0

Purpose and Notes

These guidelines are intended to help state EMS systems ensure a more standardized approach to the

practice of patient care, and to encompass evidence-based guidelines (EBG) as they are developed.

The long-term goal is to develop a full range of evidence-based clinical guidelines for the practice of EMS

medicine. However, until there is a sufficient body of evidence to fully support this goal, there is a need for

this interim expert, consensus-based step.

The National Model EMS Clinical Guidelines can fill a significant gap in uniform clinical guidance for EMS

patient care, while also providing input to the evidence-based guideline (EBG) development process.

These guidelines will be maintained by the Medical Directors Council of the National Association of State

EMS Officials (NASEMSO) and will be reviewed and updated periodically. As EBG material is developed, it

will be substituted for the consensus-based guidelines now comprising the majority of the content of this

document. In the interim, additional consensus-based guidelines will also be added as the need is identified.

For guidelines to be considered for inclusion, they must be presented in the format followed by all

guidelines in the document.

Universal Care and Poisoning/Overdose Universal Care guidelines are included to reduce the need for

extensive reiteration of basic assessment and other considerations in every guideline.

The appendices contain material such as neurologic status assessment and burn assessment tools to which

many guidelines refer to increase consistency in internal standardization and to reduce duplication.

While some specific guidelines have been included for pediatric patients, considerations of patient age and

size (pediatric, geriatric, and bariatric) have been interwoven in the guidelines throughout the document.

Where IV access and drug routing are specified, it is intended to include IO access and drug routing when IV

access and drug routing is not possible.

Generic medication names are utilized throughout the guidelines. A complete list of these, along with

respective brand names, may be found in Appendix III. “Medications”.

Accurate and quality data collection is crucial to the advancement of EMS and a critical element of EMS

research. The National EMS Information System (NEMSIS) has the unique ability to unify EMS data on a

national scope to fulfill this need. Each guideline, therefore, is also listed by the closest NEMSIS Version 3

Label and Code corresponding to it, listed in parentheses below the guideline name.

Quality assurance (QA) and/or continued performance improvement (CPI) programs are an indispensable

element of medical direction as they facilitate the identification of gaps and potential avenues of their

resolution within an EMS system. The National EMS Quality Alliance (NEMSQA) Performance Measures is a

resource for these programs. This edition of the NASEMSO National Model EMS Clinical Guidelines

incorporates many of the NEMSQA performance measures into the key performance measures associated

with each clinical guideline.

NASEMSO

National Model EMS Clinical Guidelines

Rev. March 2022

Version 3.0

Target Audience

While this material is intended to be integrated into an EMS system’s operational guidance materials by its

medical director and other leaders, it is written with the intention that it will be consumed by field EMS

clinicians.

To the degree possible, it has been assembled in a format useful for guidance and quick reference so that

leaders may adopt it in whole or in part, harvesting and integrating as they deem appropriate to the format

of their guideline, protocol, or procedure materials.

Any set of guidelines must determine a balance between education and patient care. This document

purposefully focuses on the patient care aspect of EMS response. This does not preclude the individual

medical director from using these guidelines and including additional education as well as incorporation of

state, local, or jurisdictional operational procedures.

What is New in the 2022 Edition

All of the 2017 guidelines have been reviewed and updated, and additional guidelines and new evidence-

based guidelines have been added to this edition. While some of the new material has been added as

guidelines in the appropriate chapter, other topics have been incorporated into a previously existing

guideline. New guidelines have been added to the 2022 edition for the following clinical conditions or

scenarios:

•

Brief Resolved Unexplained Event (BRUE) & Acute Events in Infants

•

Resuscitation in Traumatic Cardiac Arrest

•

Tracheostomy Management

•

Trauma Mass Casualty Incident

In addition, with the permission and assistance of the American College of Surgeons – Committee on

Trauma, we have included the 2022 National Guideline for the Field Triage of Injured Patients as Appendix

IX.

Acknowledgements

The authors of this document are NASEMSO Medical Director Council members partnered with

representatives of seven EMS medical director stakeholder organizations. The stakeholder organizations are

the American Academy of Emergency Medicine (AAEM), the American Academy of Pediatrics (AAP), the

American College of Emergency Physicians (ACEP), the American College of Surgeons Committee on Trauma

(ACS-COT), the Air Medical Physician Association (AMPA), and the National Association of EMS Physicians

(NAEMSP).

In honor and gratitude, the authors of the inaugural NASEMSO National Model EMS Clinical Guidelines are

also included. Their invaluable contributions and expertise to build the foundation of this evolutionary

document will always be deeply respected and appreciated.

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Universal Care

Universal Care Guideline

Aliases

Patient assessment Patient history Physical assessment

Primary survey Secondary survey

Patient Care Goals

Facilitate appropriate initial assessment and management of any EMS patient and link to appropriate

specific guidelines as dictated by the findings within the Universal Care guideline

Patient Presentation

Inclusion Criteria

All patient encounters with and care delivery by EMS personnel

Exclusion Criteria

None

Patient Management

Assessment

1. Assess scene safety

a. Evaluate for hazards to EMS personnel, patient, bystanders

b. Safely remove patient from hazards prior to beginning medical care

c. Determine number of patients

d. Determine mechanism of injury or potential source of illness

e. Request additional resources if needed and weigh the benefits of waiting for additional

resources against rapid transport to definitive care

f. Consider declaration of mass casualty incident if needed

2. Use appropriate personal protective equipment (PPE)

a. Consider suspected or confirmed hazards on scene

b. Consider suspected or confirmed highly contagious infectious disease (e.g., contact [bodily

fluids], droplet, airborne)

3. Wear high-visibility, retro-reflective apparel when deemed appropriate (e.g., operations at night

or in darkness, on or near roadways)

4. Consider cervical spine stabilization and/or spinal care if traumatic injury suspected. [See Spine

Care Guideline]

5. Primary survey

(Airway, Breathing, Circulation (ABC) is cited below; although there are specific circumstances

where Circulation, Airway, Breathing (CAB) may be indicated, such as for cardiac arrest, or

Massive hemorrhage, Airway, Respirations, Circulation, Hypothermia and head injury (MARCH)

may be indicated for trauma or major arterial bleeding)

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a. Airway (assess for patency and open the airway as indicated) – go to Airway Management

Guideline

i. Patient is unable to maintain airway patency—open airway

1. Head tilt/chin lift

2. Jaw thrust

3. Suction

4. Consider use of the appropriate airway management adjuncts and devices: oral

airway, nasal airway, supraglottic airway device or endotracheal tube

5. For patients with laryngectomies or tracheostomies, remove all objects or clothing

that may obstruct the opening of these devices, maintain the flow of prescribed

oxygen, and reposition the head and/or neck

b. Breathing

i. Evaluate rate, breath sounds, accessory muscle use, retractions, patient positioning,

oxygen saturation

ii. Provide supplemental oxygen as appropriate to achieve the target of 94–98% oxygen

saturation (SPO

) based upon clinical presentation and assessment of ventilation (e.g.,

EtCO

)

iii. Apnea (not breathing) – go to Airway Management Guideline

c. Circulation

i. Control any major external bleeding [See General Trauma Management Guideline

and/or Extremity Trauma/External Hemorrhage Management Guideline]

ii. Assess pulse

1. If none – go to Resuscitation Section

2. Assess rate and quality of carotid and radial pulses

iii. Evaluate perfusion by assessing skin color and temperature

1. Evaluate capillary refill

d. Disability

i. Evaluate patient responsiveness: AVPU (Alert, Verbal, Painful, Unresponsive)

ii. Evaluate gross motor and sensory function in all extremities

iii. Check blood glucose in patients with altered mental status (AMS) or suspected stroke. If

blood glucose is less than 60 mg/dL – go to Hypoglycemia Guideline

iv. If acute stroke suspected – go to Suspected Stroke/Transient Ischemic Attack Guideline

e. Expose patient for exam as appropriate to complaint

i. Be considerate of patient modesty

ii. Keep patient warm

6. Assess for urgency of transport

7. Secondary survey

The performance of the secondary survey should not delay transport in critical patients. See

also secondary survey specific to individual complaints in other protocols. Secondary surveys

should be tailored to patient presentation and chief complaint. The following are suggested

considerations for secondary survey assessment:

a. Head

i. Pupils

ii. Ears

iii. Naso-oropharynx

iv. Skull and scalp

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b. Neck

i. Jugular venous distension

ii. Tracheal position

iii. Spinal tenderness

c. Chest

i. Retractions

ii. Breath sounds

iii. Chest wall tenderness, deformity, crepitus, and excursion

iv. Respiratory pattern, symmetry of chest movement with respiration

d. Abdomen/Back

i. Tenderness or bruising

ii. Abdominal distension, rebound, or guarding

iii. Spinal tenderness, crepitus, or step-offs

iv. Pelvic stability or tenderness

e. Extremities

i. Pulses

ii. Edema

iii. Deformity/crepitus

f. Neurologic

i. Mental status/orientation

ii. Motor/sensory

g. Evaluate for medical equipment (e.g., pacemaker/defibrillator, left ventricular assist device

(LVAD), insulin pump, dialysis fistula)

8. Obtain baseline vital signs (an initial full set of vital signs is required: pulse, blood pressure,

respiratory rate, neurologic status assessment and obtain pulse oximetry if indicated)

a. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment] involves

establishing a baseline and then trending any change in patient neurologic status

i. Glasgow Coma Score (GCS) is frequently used, but there are often errors in applying and

calculating this score. With this in consideration, a more simple field approach may be

as valid as GCS. Either AVPU or only the motor component of the GCS may more

effectively serve in this capacity

ii. Sternal rub as a stimulus is discouraged

b. Patients with cardiac or respiratory complaints

i. Pulse oximetry

ii. 12-lead electrocardiogram (EKG) should be obtained promptly in patients with cardiac

or suspected cardiac complaints

iii. Continuous cardiac monitoring, if available

iv. Consider waveform capnography for patients with respiratory complaints (essential for

critical patients and those patients who require invasive airway management)

c. Patient with altered mental status

i. Check blood glucose. If low, go to Hypoglycemia Guideline

ii. Consider waveform capnography (essential for critical patients and those patients who

require invasive airway management) or digital capnometry

d. Stable patients should have at least two sets of pertinent vital signs. Ideally, one set should

be taken shortly before arrival at receiving facility

e. Critical patients should have pertinent vital signs frequently monitored

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9. Obtain OPQRST history:

a. Onset of symptoms

b. Provocation: location; any exacerbating or alleviating factors

c. Quality of pain

d. Radiation of pain

e. Severity of symptoms: pain scale

f. Time of onset and circumstances around onset

10. Obtain SAMPLE history:

a. Symptoms

b. Allergies: medication, environmental, and foods

c. Medications: prescription and over the counter; bring containers to ED if possible

d. Past medical history

i. Look for medical alert tags, portable medical records, advance directives

ii. Look for medical devices/implants (some common ones may be dialysis shunt, insulin

pump, pacemaker, central venous access port, gastric tubes, urinary catheter)

iii. For females of childbearing age, inquire of potential or recent pregnancy.

e. Last oral intake

f. Events leading up to the 911 call

In patients with syncope, seizure, altered mental status, or acute stroke, consider bringing

the witness to the hospital or obtain their contact phone number to provide to ED care

team

Treatment and Interventions

1. Administer oxygen as appropriate with a target of achieving 94–98% saturation and select the

appropriate method of oxygen delivery to mitigate or treat hypercarbia associated with

hypoventilation

2. Place appropriate monitoring equipment as dictated by assessment; these may include:

a. Continuous pulse oximetry

b. Cardiac rhythm monitoring

c. Waveform capnography or digital capnometry

d. Carbon monoxide assessment

3. Establish vascular access if indicated or in patients who are at risk for clinical deterioration.

a. If IO is to be used for a conscious patient, consider the use of 0.5 mg/kg of lidocaine 0.1

mg/mL with slow push through IO needle to a maximum of 40 mg to mitigate pain from IO

medication administration

4. Monitor pain scale if appropriate

5. Monitor agitation-sedation scale if appropriate

6. Reassess patient

Transfer of Care

1. The content and quality of information provided during the transfer of patient care to

another party is critical for seamless patient care and maintenance of patient safety

2. Ideally, a completed electronic or written medical record should be provided to the next

caregiver at the time of transfer of care

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3. If provision of the completed medical record is not possible at the time of transfer of care, a

verbal report and an abbreviated written run report should be provided to the next caregiver

4. The information provided during the transfer of care should include, but is not limited to,

a. Patient’s full name

b. Age

c. Chief complaint

d. History of present illness/Mechanism of injury

e. Past medical history

f. Medications

g. Allergies

h. Vital signs with documented times

i. Patient assessment and interventions along with the timing of any medication or

intervention and the patient’s response to such interventions

5. The verbal or abbreviated written run report provided at the time of transfer of care does not

take the place of or negate the requirement for the provision of a complete electronic or

written medical record of the care provided by EMS personnel

Patient Safety Considerations

1. Routine use of lights and sirens is not warranted

2. Even when lights and sirens are in use, always limit speeds to level that is safe for the

emergency vehicle being driven and road conditions on which it is being operated

3. Be aware of legal issues and patient rights as they pertain to and impact patient care (e.g.,

patients with functional needs or children with special healthcare needs)

4. Be aware of potential need to adjust management based on patient age and comorbidities,

including medication dosages

5. The maximum weight-based dose of medication administered to a pediatric patient should not

exceed the maximum adult dose except where specifically stated in a patient care guideline

6. Medical direction should be contacted when mandated or as needed

7. Consider air medical transport, if available, for patients with time-critical conditions where

ground transport time exceeds 30 minutes

Notes/Educational Pearls

Key Considerations

1. Pediatrics: use a weight-based assessment tool (length-based tape or other system) to estimate

patient weight and guide medication therapy and adjunct choice

a. Although the defined age varies by state, the pediatric population is generally defined by

those patients who weigh up to 40 kg or up to 14 years of age, whichever comes first

b. Consider using the pediatric assessment triangle (appearance, work of breathing,

circulation) when first approaching a child to help with assessment

2. Geriatrics: although the defined age varies by state, the geriatric population is generally defined

as those patients who are 65 years old or more

a. In these patients, as well as all adult patients, reduced medication dosages may apply to

patients with renal disease (i.e., on dialysis or a diagnosis of chronic renal insufficiency) or

hepatic disease (i.e., severe cirrhosis or end-stage liver disease)

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3. Co-morbidities: reduced medication dosages may apply to patients with renal disease (i.e., on

dialysis or a diagnosis of chronic renal insufficiency) or hepatic disease (i.e., severe cirrhosis or

end-stage liver disease)

4. Vital Signs:

a. Oxygen

i. Administer oxygen as appropriate with a target of achieving 94–98% saturation

ii. Supplemental oxygen administration is warranted to patients with oxygen saturations

below this level and titrated based upon clinical condition, clinical response, and

geographic location and altitude

iii. The method of oxygen delivery should minimize or treat hypercarbia associated with

hypoventilation (e.g., non-invasive positive airway pressure devices)

b. Normal vital signs (See Table 1. Normal Vital Signs)

i. Hypotension is considered a systolic blood pressure less than the lower limit on the

chart

ii. Tachycardia is considered a pulse above the upper limit on the chart

iii. Bradycardia is considered a pulse below the lower limit on the chart

iv. Tachypnea is considered a respiratory rate above the upper limit on the chart

v. Bradypnea is considered a respiratory rate below the lower limit on the chart

c. Hypertension. Although abnormal, may be an expected finding in many patients

i. Unless an intervention is specifically suggested based on the patient’s complaint or

presentation, the hypertension should be documented, but otherwise, no intervention

should be taken acutely to normalize the blood pressure

ii. The occurrence of symptoms (e.g., chest pain, dyspnea, vision change, headache, focal

weakness or change in sensation, altered mental status) in patients with hypertension

should be considered concerning, and care should be provided appropriate with the

patient’s complaint or presentation

5. Secondary Survey: if patient has critical primary survey problems, it may not be possible to

complete

6. Critical Patients: proactive patient management should occur simultaneously with assessment

a. Ideally, one clinician should be assigned to exclusively monitor and facilitate patient-

focused care

b. Other than lifesaving interventions that prevent deterioration en route, treatment and

Interventions should be initiated as soon as practical, but should not impede extrication or

delay transport to definitive care

7. Air Medical Transport: air transport of trauma patients should generally be reserved for higher

acuity trauma patients where there is a significant time saved over ground transport, where the

appropriate destination is not accessible by ground due to systemic or logistical issues, and for

patients who meet the American College of Surgeons Committee on Trauma (ACS-COT) 2022

National Guideline for the Field Triage of Injured Patients anatomic, physiologic, and situational

high-acuity triage criteria. In selected circumstances, air medical resources may be helpful for

non-trauma care (e.g., stroke, STEMI when geographically constrained)

8. Additional Protective Measures for the EMS Clinician: Due to suspected or confirmed hazards

and/or highly infectious contagious diseases, traditional patient treatment and care delivery

may be altered due to recommendations by federal, state, local or jurisdictional officials

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Pertinent Assessment Findings

Refer to individual guidelines

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914075 – General - Universal Patient Care/Initial Patient Contact

Key Documentation Elements

• At least two sets of vital signs should be documented for every patient

• All patient interventions and response to care should be documented

• All major changes in clinical status including, but not limited to, vital signs and data from

monitoring equipment, should be documented

Performance Measures

• Abnormal vital signs should be addressed and reassessed

• Response to therapy provided should be documented including pain scale or agitation-sedation

scale (e.g., Richmond Agitation-Sedation Scale (RASS)) reassessment if appropriate

• Limit scene time for patients with time-critical illness or injury unless clinically indicated

• Appropriate utilization of air medical services

• Blood glucose level obtained when indicated

• Compliance with provision of critical information during patient transfer of care

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

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Table 1. Normal Vital Signs

Age

Pulse-Awake

(beats/

minute)

Pulse-Sleeping

(beats/

minute)

Respiratory

Rate

(breaths/

minute)

Systolic

(mmHg)

Preterm less than 1 kg

120–160

30–60

39–59

Preterm 1–3 kg

120–160

30–60

60–76

Newborn

100–205

85–160

30–60

67–84

Up to 1 year

100–190

90–160

30–60

72–104

1–2 years

100–190

90–160

24–40

86–106

2–3 years

98–140

60–120

24–40

86–106

3–4 years

80–140

60–100

24–40

89–112

4–5 years

80–140

60–100

22–34

89–112

5–6 years

75–140

58–90

22–34

89–112

6–10 years

75–140

58–90

18–30

97–115

10–12 years

75–118

58–90

18–30

102–120

12–13 years

60–100

58–90

15–20

110–131

13–15 years

60–100

50–90

15–20

110–131

15 years or older

60–100

50–90

15–20

110–131

Source: Extrapolated from the 2020 American Heart Association Pediatric Advanced Life Support’s

tables from the Nursing Care of the Critically Ill Child, and from Web Box 1: Existing reference ranges

for respiratory rate and heart rate in the appendix of the article by Fleming, et al, published in Lancet

Note: While many factors affect blood pressure (e.g., pain, activity, hydration), it is imperative to

rapidly recognize hypotension, especially in children. For children of the ages 1–10, hypotension is

present if the systolic blood pressure is less than 70 mmHg + (child’s age in years x 2) mmHg.

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Table 2. Glasgow Coma Scale

ADULT GLASGOW COMA SCALE

PEDIATRIC GLASGOW COMA SCALE

Eye Opening (4)

Spontaneous

To Speech

To Pain

None

Best Motor Response (6)

Obeys Commands

Spontaneous Movement

Localizes Pain

Withdraws to Touch

Withdraws from Pain

Abnormal Flexion

Abnormal Extension

None

Verbal Response (5)

Oriented

Coos, Babbles

Confused

Irritable Cry

Inappropriate

Cries to Pain

Incomprehensible

Moans to Pain

None

Total

Source: https://www.cdc.gov/masstrauma/resources/gcs.pdf

References

1. 2020 Pediatric Advanced Life Support Provider Manual, American Heart Association, 2020

2. Bass, R. R., Lawner, B., Lee, D. and Nable, J. V. 2015 Medical oversight of EMS systems, in

Emergency Medical Services: Clinical Practice and Systems Oversight, Second Edition (eds D. C.

Cone, J. H. Brice, T. R. Delbridge and J. B. Myers), John Wiley & Sons, Ltd, Chichester, UK

3. Bledsoe BE, Porter RS, Cherry RA. Paramedic Care: Principles & Practice, Volume 3, 4

Ed. Brady,

2012

4. Duckworth, Rom, EMS Trauma Care: ABCs vs. MARCH, Rescue Digest, September 1, 2017

5. Emergency Cardiovascular Care: For Healthcare Providers. American Heart Association, 2020.

6. Fleming, S, et al, Normal ranges of heart rate and respiratory rate in children from birth to 18

years: a systematic review of observational studies, Lancet, March 19, 2011,377(9770),1011–

1018

7. Gerecht, Ryan, et al, “Understanding when to Request a Helicopter for Your Patient”, Journal of

EMS, October 3, 2014. https://www.jems.com/operations/ambulances-vehicle-

ops/understanding-when-request-helicopter-yo/. Accessed March 11, 2022

8. Gill M, Steele R, Windemuth R, Green SM. A comparison of five simplified scales to the out-of-

hospital Glasgow Coma Scale for the prediction of traumatic brain injury outcomes. Acad Emerg

Med. 2006;13(9):968–73

9. Haziinski, MF, Children are Different, Nursing Care of the Critically Ill Child, 3rd ed, Mosby,

2013,1–18

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10. Kupas, D. Lights and Siren Use by Emergency Medical Services (EMS): Above All Do No Harm.

National Highway Traffic Safety Administration Contract DTNH22-14-F-00579. Published May

2017

11. National Association of State Emergency Medical Services Officials. State model rules for the

regulation of air medical services. September 2016

12. O’Driscoll BR, Howard LS, Davison AG. BTS guideline for emergency oxygen use in adult patients.

Thorax 2008;63:vi1-vi68

13. Thomas SH, Brown KM, Oliver ZJ, Spaite DW, Sahni R, Weik TS, et al. An evidence-based

guideline for the air medical transportation of trauma patients. Prehosp Emerg Care 2014;18

Suppl 1:35–44

14. U.S. Fire Administration. Traffic incident management systems, FA-330. March 2012.

https://www.usfa.fema.gov/downloads/pdf/publications/fa_330.pdf. Accessed March 11, 2022

Revision Date

March 24, 2022

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Functional Needs

Aliases

Developmental delay Disabled Handicapped

Impaired Mental Illness Intellectual Disability

Special needs

Patient Care Goals

To meet and maintain the additional support required for patients with functional needs during the delivery

of prehospital care

Patient Presentation

Inclusion Criteria

Patients who are identified by the World Health Organization’s International Classification of

Functioning, Disability, and Health that have experienced a decrement in health resulting in some

degree of disability. According to the U.S. Department of Health and Human Services, this includes,

but is not limited to, individuals with physical, sensory, mental health, and cognitive and/or

intellectual disabilities affecting their ability to function independently without assistance

Exclusion Criteria

None noted

Patient Management

Assessment

1. Identify the functional need by means of information from the patient, the patient’s family,

bystanders, medic alert bracelets or documents, or the patient’s adjunct assistance devices

2. The physical examination should not be intentionally abbreviated, although the way the exam is

performed may need to be modified to accommodate the specific needs of the patient

Treatment and Interventions

Medical care should not intentionally be reduced or abbreviated during the triage, treatment, and

transport of patients with functional needs, although the way the care is provided may need to be

modified to accommodate the specific needs of the patient

Patient Safety Considerations

For patients with communication barriers (language or sensory), it may be desirable to obtain

secondary confirmation of pertinent data (e.g., allergies) from the patient’s family, interpreters, or

written or electronic medical records. The family members can be an excellent source of

information and the presence of a family member can have a calming influence on some of these

patients

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Notes/Educational Pearls

Key Considerations

1. Communication Barriers

a. Language Barriers:

i. Expressive and/or receptive aphasia

ii. Nonverbal

iii. Fluency in a different language than that of the EMS professional

iv. Examples of tools to overcome language barriers include:

1. Transport of an individual who is fluent in the patient’s language along with the

patient to the hospital

2. Medical translation cards

3. Telephone-accessible services with live language interpreters

4. Methods through which the patient augments his/her communication skills (e.g.,

eye blinking, nodding) should be noted, utilized as able, and communicated to the

receiving facility

5. Electronic applications for translation

b. Sensory Barriers:

i. Visual impairment

ii. Auditory impairment

iii. Examples of tools to overcome sensory barriers include:

1. Braille communication card

2. Sign language

3. Lip reading

4. Hearing aids

5. Written communication

2. Physical Barriers:

a. Ambulatory impairment (e.g., limb amputation, bariatric)

b. Neuromuscular impairment

3. Cognitive Barriers:

a. Mental illness

b. Developmental challenge or delay

Pertinent Assessment Findings

1. Assistance Adjuncts. Examples of devices that facilitate the activities of daily living for the

patient with functional needs include, but are not limited to:

a. Extremity prostheses

b. Hearing aids

c. Magnifiers

d. Tracheostomy speaking valves

e. White or sensory canes

f. Wheelchairs or motorized scooters

2. Service Animals

As defined by the American Disabilities Act, “any guide dog, signal dog, or other animal

individually trained to do work or perform tasks for the benefit of an individual with a disability,

including, but not limited to guiding individuals with impaired vision, alerting individuals with

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impaired hearing to intruders or sounds, providing minimal protection or rescue work, pulling a

wheelchair, or fetching dropped items”

a. Services animals are not classified as a pet and should, by law, always be permitted to

accompany the patient with the following exceptions:

i. A public entity may ask an individual with a disability to remove a service animal from

the premises if:

1. The animal is out of control and the animal's handler does not take effective action

to control it; or

2. The animal is not housebroken

b. Service animals are not required to wear a vest or a leash. It is illegal to make a request for

special identification or documentation from the service animal’s partner. EMS clinicians

may only ask the patient if the service animal is required because of a disability and the

form of assistance the animal has been trained to perform.

c. EMS clinicians are not responsible for the care of the service animal. If the patient is

incapacitated and cannot personally care for the service animal, a decision can be made

whether to transport the animal in this situation.

d. Animals that solely provide emotional support, comfort, or companionship do not qualify as

service animals

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914063 – General - Individualized Patient Protocol

•

9914165 – Other

Key Documentation Elements

• Document all barriers in the NEMSIS element “eHistory.01 – Barriers to Patient Care” (NEMSIS

Required National Element)

• Document specific physical barriers in the appropriate exam elements (e.g., “blind” under Eye

Assessment; or paralysis, weakness, or speech problems under Neurological Assessment)

• Document any of the following, as appropriate in the narrative:

o Language barriers:

▪ The patient’s primary language of fluency

▪ The identification of the person assisting with the communication

▪ The methods through which the patient augments his/her communication skills

o Sensory barriers:

▪ The methods through which the patient augments his/her communication skills

▪ Written communication between the patient and the EMS professional is part of the

medical record, even if it is on a scrap sheet of paper, and it should be retained with the

same collation, storage, and confidentiality policies and procedures that are applicable

to the written or electronic patient care report

o Assistance adjuncts (devices that facilitate the activities of life for the patient)

Performance Measure

• Accuracy of key data elements (chief complaint, past medical history, medication, allergies)

• Utilization of the appropriate adjuncts to overcome communication barriers

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• Documentation of the patient’s functional need and avenue exercised to support the patient

• Documentation of complete and accurate transfer of information regarding the functional need

to the receiving facility

• Barriers documented under “eHistory.01—Barriers to Patient Care”

References

International classification of functioning, disability, and health. Presented at: 54

World Health

Assembly, WHA 54.21, Agenda Item 13.9; May 21, 2001

U.S. Department of Health and Human Services, Office of the Assistant Secretary of

Preparedness and Response. FEMA’s Functional Needs Support Services Guidance. 2012.

http://www.phe.gov/Preparedness/planning/abc/Documents/fema-fnss.pdf. Accessed August

18, 2017

US Department of Labor. Americans with Disabilities Act; 28 Code of Federal Regulations Part

35. July 23, 2010

US Department of Labor. Americans with Disabilities Act; 42 U.S. Code, Chapter 126. 1990

US Department of Labor. Americans with Disabilities Act; Amendments Act; 42 U.S. Code. 2008

Revision Date

March 11, 2022

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Patient Refusals

Aliases

Against medical advice Refusal of treatment Refusal of transport

Patient Care Goals/Patient Presentation (Overview)

If an individual (or the parent or legal guardian of the individual) refuses secondary care and/or ambulance

transport to a hospital after prehospital clinicians have been called to the scene, clinicians should determine

the patient’s capacity to make decisions. Competency is generally a legal status of a person’s ability to make

decisions. However, state laws vary in the definition of competency and its impact upon authority.

Therefore, one should consult with the respective state EMS office for clarification on legal definitions and

patient rights.

Patient Management

Assessment

1. Decision-Making Capacity

a. An individual who is alert, oriented, and can understand the circumstances surrounding

his/her illness or impairment, as well as the possible risks associated with refusing

treatment and/or transport, typically is considered to have decision-making capacity

b. The individual’s judgment must also not be significantly impaired by illness, injury, or

drugs/alcohol intoxication. Individuals who have attempted suicide, verbalized suicidal

intent, or had other factors that lead EMS clinicians to suspect suicidal intent, should not be

regarded as having decision-making capacity and may not decline transport to a medical

facility

Treatment and Interventions

1. Obtain a complete set of vital signs and complete an initial assessment, paying particular

attention to the individual’s neurologic and mental status

2. Determine the individual’s capacity to make a valid judgment concerning the extent of his/her

illness or injury; if the EMS clinician has doubts about whether the individual has the mental

capacity to refuse or if the patient lacks capacity, the EMS clinician should contact medical

direction

3. If patient has capacity, clearly explain to the individual and all responsible parties the possible

risks and overall concerns with regards to refusing care and that they may reengage the EMS

system if needed

4. Perform appropriate medical care with the consent of the individual

5. Complete the patient care report clearly documenting the initial assessment findings and the

discussions with all involved individuals regarding the possible consequences of refusing

additional prehospital care and/or transportation

Notes/Educational Pearls

Key Considerations

1. An adult or emancipated minor who has demonstrated possessing sufficient mental capacity for

making decisions has the right to determine the course of his/her medical care, including the

refusal of care

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2. Individuals must be advised of the risks and consequences resulting from refusal of medical care

to enable an informed decision regarding consent or refusal of treatment

3. An individual determined to lack decision-making capacity by EMS clinicians should not be

allowed to refuse care against medical advice or to be released at the scene. Mental illness,

drugs, alcohol intoxication, or physical/mental impairment may significantly impair an

individual’s decision-making capacity. Individuals who have attempted suicide, verbalized

suicidal intent, or had other factors that lead EMS clinicians to suspect suicidal intent, should

not be regarded as having demonstrated sufficient decision-making capacity

4. The determination of decision-making capacity may be challenged by communication barriers

or cultural differences

5. EMS clinicians should not put themselves in danger by attempting to treat and/or transport an

individual who refuses care. Law enforcement personnel should be requested if needed

6. Always act in the best interest of the patient. EMS clinicians, with the support of direct medical

oversight, must strike a balance between abandoning the patient and forcing care

7. Special Considerations – Minors

It is preferable for minors to have a parent or legal guardian who can provide consent for

treatment on behalf of the child

a. All states allow healthcare clinicians to provide emergency treatment when a parent is not

available to provide consent. This is known as the emergency exception rule or the doctrine

of implied consent. For minors, this doctrine means that the EMS clinician can presume

consent and proceed with appropriate treatment and transport if the following six

conditions are met:

i. The child is suffering from an emergent condition that places their life or health in

danger

ii. The child’s legal guardian is unavailable or unable to provide consent for treatment or

transport

iii. Treatment or transport cannot be safely delayed until consent can be obtained

iv. The EMS clinician administers only treatment for emergency conditions that pose an

immediate threat to the child

v. As a rule, when the EMS clinician’s authority to act is in doubt, EMS clinicians should

always do what they believe to be in the best interest of the minor

vi. If a minor is injured or ill and no parent contact is possible, the EMS clinician may

contact medical direction for additional instructions

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914189 – General - Refusal of Care

Key Documentation Elements

• Document patient capacity with:

o All barriers to patient care in the NEMSIS element “eHistory.01—Barriers to Patient Care” (a

Required National Element of NEMSIS)

o Exam fields for “eExam.19—Mental Status” and “eExam.20—Neurological Assessment”

o Vitals for level of responsiveness and Glasgow Coma Scale

o Alcohol and drug use indicators

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o Blood glucose level (as appropriate to situation and patient history)

• Patient Age

• Minors who are not emancipated and adults with a legal guardian: guardian name, contact, and

relationship

• Any efforts made to contact guardians if contact could not be made

• What the patient’s plan is after refusal of care and/or transport

• Who will be with the patient after EMS departs

• Patient was advised that they can change their mind and EMS can be contacted again at any

time

• Patient was advised of possible risks to their health resulting from refusing care and/or

transport

• Patient voices understanding of risks. A quotation of the patient’s actual words, stating they

understand, is best

• Reason for patient refusing care. A quotation of the patient’s actual words, stating they

understand, is best

• Medical direction contact

• Any assessments and treatments performed

Performance Measures

• Patient decision-making capacity was determined and documented

• Medical direction was contacted as indicated by EMS agency protocol

• Guardians contacted or efforts to contact the guardians for minor patients who are not or

cannot be confirmed to be emancipated

References

1. Patient Autonomy and Destination Factors in Emergency Medical Services (EMS) and EMS-Affiliated

Mobile Integrated Healthcare/Community Paramedicine Programs. Acep.org.

https://www.acep.org/globalassets/new-pdfs/policy-statements/patient-autonomy-and-

destination-factors-in-ems.pdf Revised October 2015. Accessed March 11, 2022

Revision Date

March 11, 2022

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Cardiovascular

Adult and Pediatric Syncope and Near Syncope

Aliases

Loss of consciousness

Patient Care Goals

1. Stabilize and resuscitate when necessary

2. Initiate monitoring and diagnostic procedures

3. Transfer for further evaluation

Patient Presentation

1. Syncope is heralded by both the loss of consciousness and the loss of postural tone and resolves

spontaneously without medical interventions. Syncope typically is abrupt in onset and resolves

equally quickly. EMS clinicians may find the patient awake and alert on initial evaluation

2. Near syncope is defined as the prodromal symptoms of syncope. The symptoms that can

precede syncope last for seconds to minutes with signs and symptoms that may include pallor,

sweating, lightheadedness, visual changes, or weakness. It may be described by the patient as

“nearly blacking out” or “nearly fainting”.

3. Rapid first aid during the onset may improve symptoms and prevent syncope

Inclusion Criteria

1. Abrupt loss of consciousness with loss of postural tone

2. Prodromal symptoms of syncope

Exclusion Criteria

Conditions other than the above, including:

1. Patients with alternate and obvious cause of loss of consciousness (e.g., trauma – See Head

Injury Guideline)

2. Patients with ongoing mental status changes or coma should be treated per the Altered Mental

Status Guideline

3. Patients with persistent new neurologic deficit [See Suspected Stroke/Transient Ischemic Attack

Guideline]

Patient Management

Assessment

1. Pertinent History 

a. Review the patient’s past medical history including a history of:

i. Cardiovascular disease (e.g., cardiac disease/stroke, valvular disease, hypertrophic

cardiomyopathy, mitral valve prolapse)

ii. Seizure

iii. Recent trauma

iv. Active cancer diagnosis

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v. Dysrhythmias including prior electrophysiology studies/pacemaker and/or implantable

cardioverter defibrillator (ICD)

vi. History of syncope

vii. History of thrombosis or emboli

b. History of Present Illness, including:

i. Conditions leading to the event: after transition from recumbent/sitting to standing;

occurring with strenuous exercise (notably in the young and seemingly healthy)

1. Syncope that occurs during exercise often indicates an ominous cardiac cause.

Patients should be evaluated in the emergency department

ii. Patient complaints before or after the event including prodromal symptoms

iii. History of symptoms described by others on scene, including seizures or shaking,

presence of pulse/breathing (if noted), duration of the event, events that lead to the

resolution of the event

c. Review of Systems:

i. Current medications (new medications, changes in doses)

ii. Fluid losses (nausea/vomiting/diarrhea) and fluid intake

iii. Last menstrual period/pregnant

iv. Occult blood loss (gastrointestinal (GI)/genitourinary (GU))

v. Palpitations

vi. Unilateral Leg swelling, history of recent travel, prolonged immobilization, malignancy

d. Pertinent Physical Exam including:

i. Attention to vital signs and evaluation for trauma

ii. Note overall patient appearance, diaphoresis, pallor

iii. Detailed neurologic exam (including stroke screening and mental status)

iv. Heart, lung, abdominal, and extremity exam

v. Additional Evaluation: 

1. Cardiac monitoring

2. Oxygen saturation (SPO

)

3. Ongoing vital signs

4. 12-lead EKG

5. Blood glucose level (BGL)

Treatment and Interventions:

1. Should be directed at abnormalities discovered in the physical exam or on additional

examination and may include management of cardiac dysrhythmias, cardiac ischemia/infarct,

hemorrhage, shock, etc.

a. Manage airway as indicated

b. Oxygen as appropriate

c. Evaluate for hemorrhage and treat for shock if indicated

d. Establish IV access

e. Fluid bolus if appropriate

f. Cardiac monitor 

g. 12-lead EKG

h. Monitor for and treat arrhythmias (if present, refer to appropriate guideline)

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Patient Safety Considerations:

1. Patients suffering from syncope due to arrhythmia may experience recurrent arrhythmias and

should therefore be placed on a cardiac monitor

2. Geriatric patients suffering falls from standing may sustain significant injury and should be

diligently screened for trauma. [General Trauma Management Guideline]

Notes/Educational Pearls

Key Considerations

1. By being most proximate to the scene and to the patient’s presentation, EMS clinicians are

commonly in a unique position to identify the cause of syncope. Consideration of potential

causes, ongoing monitoring of vitals and cardiac rhythm and detailed exam and history are

essential pieces of information to pass on to hospital clinicians

2. For patients where a lower risk etiology is suspected, e.g., vasovagal syncope, decisions

regarding delayed or non-transport should be made in consultation with medical direction

3. High-risk causes of syncope include, but are not limited to, the following:

a. Cardiovascular

i. Myocardial infarction

ii. Aortic stenosis

iii. Hypertrophic cardiomyopathy (consider in young patient with unexplained syncope

during exertion)

iv. Pulmonary embolus 

v. Aortic dissection 

vi. Dysrhythmia 

vii. Mitral valve prolapse is associated with higher risk for sudden death

b. Neurovascular

i. Intracranial hemorrhage 

ii. Transient ischemic attack or stroke 

iii. Vertebral basilar insufficiency

c. Hemorrhagic

i. Ruptured ectopic pregnancy

ii. GI bleed

iii. Aortic rupture

4. Consider high-risk 12-lead EKG features including, but not limited to: 

a. Evidence of QT prolongation (generally over 500 msec)

b. Delta waves

c. Brugada syndrome (incomplete right bundle branch block (RBBB) pattern in V1/V2 with ST

segment elevation)

d. Hypertrophic obstructive cardiomyopathy

Pertinent Assessment Findings

1. 12-lead EKG findings

2. Evidence of alternate etiology, including seizure

3. Evidence of cardiac dysfunction (e.g., evidence of congestive heart failure (CHF), arrhythmia) 

4. Evidence of hemorrhage

5. Evidence of neurologic compromise

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6. Evidence of trauma

7. Initial and ongoing cardiac rhythm

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914149 – Medical – Syncope

Key Documentation Elements

• Presenting cardiac rhythm

• Cardiac rhythm present when patient is symptomatic

• Any cardiac rhythm changes

• Blood pressure

• Pulse 

• Blood glucose level (BGL)

• Symptoms immediately preceding event

• Patient status on EMS arrival: recovered or still symptomatic

Performance Measures

• Acquisition of 12-lead EKG 

• Application of cardiac monitor

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Stroke — 01: Suspected Stroke Receiving Prehospital Stroke Assessment

References

1. Anderson JB, Willis M, Lancaster H, Leonard K, Thomas C. The evaluation and management of

pediatric syncope. Pediatr Neurol. 2016; 55:6–13

https://doi.org/10.1016/j.pediatrneurol.2015.10.018

2. Benditt DG, Adkisson WO. Approach to the patient with syncope. Cardiol Clin. 2013;31(1):9–25

3. Dovgalyuk J, Holstege C, Mattu A, Brady WJ. The electrocardiogram in the patient with

syncope. Am J Emerg Med. 2007; 25:688–701

4. Fischer J, Choo CS. Pediatric syncope: cases from the emergency department. Emerg Med Clin

North Am. 2010;28(3):501–16

5. Herbert M, Spangler M, Swadron S, Mason J. Emergency Medicine Reviews and Perspectives

(EM:RAP). C3 Continuous Core Content Podcast. Syncope – Introduction. November 2016.

https://www.emrap.org/episode/c3syncope/syncope. Accessed March 11, 2022

6. Huff JS, Decker WW, Quinn JV, Perron AD, Napoli AM, Peeters S, et al; American College of

Emergency Physicians. Clinical policy: critical issues in the evaluation and management of adult

patients presenting to the emergency department with syncope. Ann Emerg

Med. 2007;49(4):431–44

7. Kessler C, Tristan JM, De Lorenzo R. The emergency department approach to syncope:

evidence-based guidelines and prediction rules. Emerg Med Clin North Am. 2010;28(3):248–500

8. Khoo C, Chakrabarti S, Arbour L, Krahn AD. Recognizing life-threatening causes of

syncope. Cardiol Clin. 2013;31(1):51–66

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9. Orman R, Mattu A; Emergency Medicine Reviews and Perspectives (EMRAP). Spring Forward

into PE. Cardiology Corner – Syncope. March 2016.

https://www.emrap.org/episode/springforward/cardiology. Accessed March 11, 2022

10. Ouyang H, Quinn J. Diagnosis and management of syncope in the emergency

department. Emerg Med Clin North Am. 2010;28(3):471.485

Revision Date

March 11, 2022

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Chest Pain/Acute Coronary Syndrome (ACS)/ST-segment Elevation Myocardial

Infarction (STEMI)

Aliases

Heart attack Myocardial infarction (MI)

Patient Care Goals

1. Identify ST-elevation myocardial infarction (STEMI) quickly

2. Determine the time of symptom onset

3. Activate hospital-based STEMI system of care

4. Monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibrillation if

needed

5. Administer appropriate medications

6. Transport to appropriate facility

Patient Presentation

Inclusion Criteria

1. Chest pain or discomfort in other areas of the body (e.g., arm, jaw, epigastrium) of suspected

cardiac origin, shortness of breath, associated or unexplained sweating, nausea, vomiting, or

dizziness. Atypical or unusual symptoms are more common in women, the elderly, and diabetic

patients. May also present with CHF, syncope, and/or shock

2. Chest pain associated sympathomimetic use (e.g., cocaine, methamphetamine)

3. Some patients will present with likely non-cardiac chest pain and otherwise have a low

likelihood of ACS (e.g., blunt trauma to the chest of a child). For these patients, defer the

administration of aspirin (ASA) and nitrates per the Pain Management Guideline

Exclusion Criteria

None noted

Patient Management

Assessment, Treatment, and Interventions

1. Signs and symptoms include chest pain, congestive heart failure (CHF), syncope, shock,

symptoms similar to a patient’s previous MI

2. Assess the patient’s cardiac rhythm and immediately address pulseless rhythms,

symptomatic tachycardia, or symptomatic bradycardia [See Cardiovascular

Section and Resuscitation Section]

3. If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure, EMS clinicians

should administer oxygen as appropriate with a target of achieving 94–98% saturation

[Refer to Universal Care Guideline]

4. The 12-lead EKG is the primary diagnostic tool that identifies a STEMI; it is imperative that

EMS clinicians routinely acquire a 12-lead EKG within 10 minutes for all patients exhibiting

signs and symptoms of ACS

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a. The EKG may be transmitted for remote interpretation by a physician or screened for

STEMI by properly trained EMS clinicians or other healthcare providers with or without

the assistance of computer-interpretation

b. Advance notification should be provided to the receiving hospital for patients identified as

having a STEMI

c. Performance of serial EKGs is encouraged for symptomatic patients with EKGs initially non-

diagnostic for STEMI 

d. All EKGs should be made available to treating personnel at the receiving hospital, whether

hand delivered as hard copy or transmitted from the field

5. Administer aspirin; chewable, non-enteric-coated aspirin preferred (162–325 mg)

6. Establish IV access

7. Nitroglycerin 0.4 mg sublingual (SL), can repeat q (quaque, every) 3–5 minutes if SBP greater

than 100 mmHg

a. The use of nitrates should be avoided in any patient who has used a phosphodiesterase

inhibitor within the past 48 hours

b. Examples include sildenafil (Viagra®, Revatio®), vardenafil (Levitra®, Staxyn®), tadalafil

(Cialis®, Adcirca®) which are used for erectile dysfunction and pulmonary hypertension.

Also avoid use in patients receiving intravenous epoprostenol (Flolan®)

or treporstenil (Remodulin®) which is used for pulmonary hypertension

c. Care should always be taken when giving nitroglycerin when the patient’s blood pressure

is marginal.  If used in this setting, the clinician should weigh the risk and benefit of nitrate

administration over the administration of an opiate analgesic and be ready to respond to

hypotension with fluid bolus or pressor

8. The location of the infarct does not preclude the use of nitrates. Right-sided leads are of no

additional value if an inferior STEMI has been diagnosed and such findings (presumed RV

infarct) do not preclude the use of nitroglycerin: however, continually monitor the patient’s

hemodynamic status and be prepared to resuscitate if hypotension occurs

9. If the pain is unresponsive to nitrates, opiates are an acceptable alternative. Morphine should

be used with caution in unstable angina (UA)/non-STEMI due to an association with increased

mortality

10. Transport and destination decisions should be based on local resources and system of care

11. Early notification to receiving facility of any changes in patient condition or serial EKGs

Patient Safety Considerations

1. Observe for signs of clinical deterioration: dysrhythmias, chest pain, shortness of breath,

decreased level of consciousness/syncope, or other signs of shock/hypotension

2. Perform serial 12-lead EKGs (especially if clinical changes are noted)

3. Consider placing defibrillator pads on high-risk patients 

4. Consider configuring monitor/defibrillator to allow automatic VT/VF alert

5. Consider configuring monitor/defibrillator to allow ST-segment trending if available

Notes/Educational Pearls

Key Considerations

Acute coronary syndrome may present with atypical pain, vague or only generalized complaints.

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Ischemic burden time is a risk for morbidity and mortality, EMS can help decrease first medical

contact to intervention time/reflow by efficient scripting/training of safely minimizing scene time

Pertinent Assessment Findings

A complete medication list should be obtained from each patient. It is especially important for the

treating physician and healthcare providers to be informed if the patient is taking beta-blockers,

calcium channel blockers, clonidine, digoxin, blood thinners (anticoagulants), and medications for

the treatment of erectile dysfunction or pulmonary hypertension

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914117 – Medical - Cardiac Chest Pain

• 9914143 – Medical - ST-Elevation Myocardial Infarction (STEMI)

Key Documentation Elements

• The time of symptom onset

• The time of patient contact by EMS to the time of 12-lead EKG acquisition

• The time aspirin (ASA) administered, or reason why not given

• The time of STEMI notification

Performance Measures

• The time of patient contact by the first medical contact to the time of 12-lead EKG acquisition

within 10 minutes

• The time from first diagnostic 12-lead EKG to STEMI notification

• Confirmation patient received ASA (taken prior to EMS arrival, advised by dispatch, given by

EMS, or substantiated by other pertinent negatives)

• The time of a STEMI patient’s ultimate arrival to a receiving hospital

*The time of EMS notification to the time of activation of a cardiac catheterization laboratory

*The time of arrival at the percutaneous coronary intervention (PCI) center to the time of cardiac

catheterization (door-to-balloon time) or if patient not transported directly to PCI center, the time

of arrival at receiving hospital to thrombolytics

*The time of prehospital 12-lead EKG acquisition to the time of device deployment (formerly EKG-

to-balloon time)

*NOTE: These measures can only be evaluated if EMS documentation can be combined with

information provided by the receiving hospital

References

1. Bosson KN, Kaji AH, Niemann JT, et al The utility of prehospital EKG transmission in a large EMS

system. Prehosp Emerg Care. 2015;19(4):496–503

2. De Champlain F, Boothroyd LJ, Vadeboncoeur A, et al. Computerized interpretation of the

prehospital electrocardiogram: predictive value for ST-segment elevation myocardial infarction

and impact on on-scene time. CJEM. 2014;16(2):94–105

3. Meine TJ, Roe MT, Chen AY, et al. Association of intravenous morphine use and outcomes in

acute coronary syndromes: results from the CRUSADE quality improvement initiative. Am Heart

J. 2005;149(6):1043–9

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4. Mission: Lifeline EMS Recognition. American Heart Association. Heart.org.

https://www.heart.org/en/professional/quality-improvement/mission-lifeline/mission-lifeline-

ems-recognition. Accessed March 11, 2022

5. Nam J, Caners K, Bowen JM, O’Reilly D. Systematic review and meta-analysis of the benefits of

out-of-hospital 12-lead EKG and advance notification in ST-segment elevation myocardial

infarction patients. Ann Emerg Med. 2014;64(2):176–86

6. O’Connor RE, Abudulaziz AAS, Brady WJ, et al. Part 9: acute coronary syndromes. Circulation.

2015;132(18 Suppl 2):S483–500

7. Robichaud L, Ross D, Proulx M-H, et al. Prehospital Nitroglycerin Safety in Inferior ST Elevation

Myocardial Infarction. Prehospital Emergency Care. 2016;20(1):76–

81. doi:10.3109/10903127.2015.1037480

8. Squire BT, Tamaryo-Sarver JH, Rashi P, Koenig W, Niemann JT. Effect of prehospital cardiac

catheterization lab activation on door-to-balloon time, mortality, and false-positive

activation. Prehosp Emerg Care. 2014;18(1):1–8

9. Verbeek PR, Ryan D, Turner L, Craig AM. Serial prehospital 12-lead electrocardiograms increase

identification of ST-segment elevation myocardial infarction. Prehosp Emerg

Care. 2012;16(1):109–14

Revision Date

March 11, 2022

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Bradycardia

Aliases

Heart block Junctional rhythm

Patient Care Goals

1. Maintain adequate perfusion 

2. Treat underlying cause: 

a. Hypoxia

b. Shock

c. Second- or third-degree atrioventricular (AV) block

d. Toxin exposure (beta-blocker, calcium channel blocker, organophosphates, digoxin)

e. Electrolyte disorder

f. Hypoglycemia

g. Increased intracranial pressure (ICP)

h. Other

Patient Presentation

Inclusion Criteria

1. Heart rate less than 60 beats per minute (BPM) with either symptoms (altered mental status

(AMS), chest pain (CP), congestive heart failure (CHF), seizure, syncope, shock, pallor,

diaphoresis) or evidence of hemodynamic instability

2. The major EKG rhythms classified as bradycardia include:

a. Sinus bradycardia

b. Second-degree AV block

i. Type I-Wenckebach/Mobitz I

ii. Type II-Mobitz II

c. Third-degree AV block, complete heart block

d. Ventricular escape rhythms

3. See additional inclusion criteria for pediatric patients

Exclusion Criteria

None noted

Patient Management

Assessment, Treatment, and Interventions

1. Adult Management

a. Manage airway as necessary

b. Administer oxygen as appropriate with a target of achieving 94–98% saturation

c. Initiate monitoring and perform 12-lead EKG

d. Establish IV access

e. Check blood glucose and treat hypoglycemia per the Hypoglycemia

Guideline and Hyperglycemia Guideline

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f. Consider the following additional therapies if bradycardia and symptoms or hemodynamic

instability continue:

Atropine 1 mg IV q 3–5 minutes (maximum total dose of 3 mg) 

ii.

Vasopressor medications (in order of preference)

1. Epinephrine IV drip 0.02–0.2 mcg/kg/min titrated to a MAP greater than 65 mmHg

2. Epinephrine by push dose (dilute boluses): for example, prepare 10 mcg/mL by

adding 1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline, then administer

10–20 mcg boluses (1–2 mL) q 2 minutes titrated MAP greater than 65 mmHg 

3. Norepinephrine 0.02–0.4 mcg/kg/minute IV titrated to a MAP greater than 65

mmHg 

iii.

Transcutaneous Pacing – If pacing is performed, consider sedation or pain control

2. Pediatric Management

Treatment is only indicated for patients who are symptomatic (pale/cyanotic, diaphoretic,

altered mental status, hypoxic)

a. For infants and newborns, initiate chest compressions for heart rate less than 60 BPM and

signs of poor perfusion (altered mental status, hypoxia, hypotension, weak pulse, delayed

capillary refill, cyanosis)

b. Manage airway and assist ventilations as necessary with minimally interrupted chest

compressions using a compression-to-ventilation ratio 15:2 (30:2 if single clinician is

present)

c. Administer oxygen as appropriate with a target of achieving 94–98% saturation

d. Initiate monitoring and perform 12-lead EKG

e. Establish IV access

f. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline

g. Consider the following additional therapies if bradycardia and symptoms or hemodynamic

instability continue:

i. Epinephrine by push dose (dilute boluses). For example, prepare 10 mcg/mL by adding

1 mL of 0.1 mg/mL epinephrine to 9 mL of normal saline, then administer 0.01 mg/kg

(0.1 mL/kg) maximum single dose 10 mcg (1 mL) q 3–5 minutes titrated to MAP greater

than 65 mmHg

ii. Also consider atropine 0.01–0.02 mg/kg IV with minimum dose of 0.1 mg if increased

vagal tone or cholinergic drug toxicity to maximum initial dose of 0.5 mg (maximum

total dose of 3 mg)

iii. Transcutaneous pacing: If pacing is performed, consider sedation or pain control

iv. Epinephrine may be used for bradycardia and poor perfusion unresponsive to

ventilation and oxygenation

1. It is reasonable to administer atropine for bradycardia caused by increased vagal

tone or cholinergic drug toxicity

Patient Safety Considerations

If pacing is performed, consider sedation or pain control

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Bradycardia 37

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Notes/Educational Pearls

Key Considerations

1. Observe for signs of decreased end-organ perfusion: chest pain (CP), shortness of breath (SOB),

decreased level of consciousness, syncope, or other signs of shock/hypotension 

2. Patients who have undergone cardiac transplant will not respond to atropine 

3. Consider potential culprit medications including beta-blockers, calcium channel blockers,

sodium channel blockers/anti-depressants, digoxin, and clonidine

a. If medication overdose is considered, refer to appropriate guideline in the Toxins and

Environmental Section

4. The differential diagnosis includes the following: myocardial infarction (MI), hypoxia, pacemaker

failure, hypothermia, sinus bradycardia, athletes, head injury with increased intracranial

pressure (ICP), stroke, spinal cord lesion, sick sinus syndrome, AV blocks, overdose, cholinergic

nerve agents

5. Consider hyperkalemia in the patient with wide complex bradycardia

6. Bradycardia should be managed via the least invasive manner possible, escalating care as

needed

a. Third-degree heart block or the denervated heart (as in cardiac transplant) may not respond

to atropine and in these cases, proceed quickly to chronotropic agents (such as epinephrine

or dopamine) or transcutaneous pacing

b. Dopamine is not indicated for pediatric patients

c. In cases of impending hemodynamic collapse, proceed directly to transcutaneous pacing

d. For shock that is suspected to be from sepsis, norepinephrine is preferred over dopamine

due to its reduced risk of arrhythmias and its lower mortality rate

7. Be aware of acute coronary syndrome as a cause of bradycardia in adult patients

8. When dosing medications for pediatric patients, dose should be weight-based for non-obese

patients and based on ideal body weight for obese patients

9. Although dopamine is often recommended for the treatment of symptomatic bradycardia,

recent research suggests that patients in cardiogenic or septic shock treated with

norepinephrine have a lower mortality rate compared to those treated with dopamine

10. Caution: Norepinephrine can theoretically cause reflex bradycardia

Pertinent Assessment Findings

None noted

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914115 – Medical - Bradycardia

Key Documentation Elements

• Cardiac rhythm/rate

• Time, dose, and response of medications given

• Pacing: Time started or stopped, rate, joules, capture, and response rate

• Patient weight 

• Pediatric length-based tape color (for pediatrics who fit on tape)

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• History of event supporting treatment of underlying causes

Performance Measures

• Blood sugar obtained

• Correct medication(s) and dose given for patient condition, age, and weight

• Correct application and use of cardiac pacing

• Use of sedation or pain management with cardiac pacing

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Hypoglycemia—01: Treatment Administered for Hypoglycemia

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. Berg KM, Soar J, Andersen LW, et al. Adult Advanced Life Support: 2020 International Consensus

on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment

Recommendations. Circulation. 2020;142(16_suppl_1): S92-S139.

doi:10.1161/CIR.0000000000000893

2. Brady W, Swart G, Mao R, Aufderheide TP. The efficacy of atropine in the treatment of

hemodynamically unstable bradycardia and atrioventricular block: prehospital and emergency

department considerations. Resuscitation. 1999;41(1):47–55

3. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the

treatment of shock. N Engl J Med. 2010; 362:779–89

4. De Backer, Daniel et al. “Dopamine versus norepinephrine in the treatment of septic shock: a

meta-analysis*.” Critical care medicine vol. 40,3 (2012): 725-30.

doi:10.1097/CCM.0b013e31823778ee

5. Gottlieb M. Bolus dose of epinephrine for refractory post-arrest hypotension. CJEM. 2017;

10:1–5

6. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life

support. Circulation. 2010;122(18 Suppl.3): S876-S908

7. Link MS, Berkow PJ, Kudenchuk HR, et. al. Part 7: adult advanced cardiovascular life

support. Circulation. 2015;132(18 Suppl 2): S444–64

8. Marik, Paul E., Dopamine increases mortality in pediatric septic shock. Current Best Evidence.

January 01, 2016; 168:253-256 doi.org/10.1016/j.jpeds.2015.10.073

9. Sherbino J, Verbeek PR, MacDonald RD, Sawadsky BV, McDonald AC, Morrison LJ. Prehospital

transcutaneous cardiac pacing for symptomatic bradycardia or bradyasystolic cardiac arrest: a

systematic review. Resuscitation. 2006;70(2):193–200

10. Weingart S. Push-dose pressors for immediate blood pressure control. Clin Exp Emerg Med.

2015;2(2):131–132

11. Xu, Xudong, Xu, Xianghua and Wu, Yueying. "Norepinephrine was superior in death risk

reducing and hemodynamics compared to dopamine in treatment of patients with septic shock"

Pteridines, 2021;32(1):5-10.

Revision Date

March 11, 2022

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Implantable Ventricular Assist Devices 39

Version 3.0

Implantable Ventricular Assist Devices

Aliases

Biventricular assist device (BiVAD) Left ventricular assist device (LVAD)

Right ventricular assist device (RVAD) Ventricular assist device (VAD)

Patient Care Goals

1. Rapid identification of, and interventions for, cardiovascular compromise in patients with VADs

2. Rapid identification of, and interventions for, VAD-related malfunctions or complications

Patient Presentation

Inclusion Criteria

1. Adult patients that have had an implantable ventricular assist device (VAD), including a left

ventricular assist device (LVAD), right ventricular assist device (RVAD), or biventricular-assist

device (BiVAD) and have symptoms of cardiovascular compromise

2. Patients with VADs that are in cardiac arrest

3. Patients with VADs that are experiencing a medical or injury-related event not involving the

cardiovascular system or VAD malfunction

Exclusion Criteria

Adult patients who do not have a VAD in place

Patient Management

Assessment

1. Assess for possible pump malfunction

a. Assess for alarms

b. Auscultate for pump sound “hum”

c. Signs of hypoperfusion including pallor, diaphoresis, altered mental status

2. If the VAD pump has malfunctioned:

a. Utilize available resources to troubleshoot potential VAD malfunctions and to determine

appropriate corrective actions to restore normal VAD function:

i. Contact the patient’s VAD-trained companion, if available

ii. Contact the patient’s VAD coordinator, using the phone number on the device

iii. Check all the connections to system controller

iv. Change VAD batteries, and/or change system controller if indicated

v. Have patient stop all activity and assess for patient tolerance

vi. Follow appropriate cardiovascular condition-specific protocol(s) as indicated

Treatment and Interventions

1. Manage airway as indicated

2. Cardiac monitoring

3. IV access

4. Acquire 12-lead EKG

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5. If patient is experiencing VAD-related complications or cardiovascular problems, expedite

transport to the medical facility where VAD was placed if patient’s clinical condition and time

allows

6. If patient has a functioning VAD and is experiencing a non-cardiovascular-related problem,

transport to a facility that is appropriate for the patient’s main presenting problem without

manipulating the device

7. If patient has a functioning VAD and is hypoperfused:

a. Administer IV fluids (30 mL/kg isotonic fluid; maximum of 1 liter) over less than 15 minutes,

using a push-pull method of drawing up the fluid in a syringe and pushing it through the IV

b. May repeat up to 3 times based on patient’s condition and clinical impression for a total

cumulative dose not to exceed 3 L

8. If patient is in full cardiac arrest:

a. CPR should not be performed if there is any evidence the pump is still functioning. The

decision whether to perform CPR should be made based upon best clinical judgment in

consultation with the patient’s VAD-trained companion and the VAD coordinator (or direct

medical oversight if VAD coordinator unavailable)

b. CPR may be initiated only where:

i. You have confirmed the pump has stopped and troubleshooting efforts to restart it

have failed, and

ii. The patient is unresponsive and has no detectable signs of life

Notes/Educational Pearls

1. You do not need to disconnect the controller or batteries to:

a. Defibrillate or cardiovert

b. Acquire a 12-lead EKG

2. Automatic non-invasive cuff blood pressures may be difficult to obtain due to the narrow pulse

pressure created by the continuous flow pump

3. Flow though many VAD devices is not pulsatile, and patients may not have a palpable pulse or

accurate pulse oximetry

4. The blood pressure, if measurable, may not be an accurate measure of perfusion

5. Ventricular fibrillation, ventricular tachycardia, or asystole/PEA may be the patient’s “normal”

underlying rhythm. Evaluate clinical condition and provide care in consultation with VAD

coordinator

6. The patient’s travel bag should always accompany them with back-up controller and spare

batteries

7. If feasible, bring the patient’s power module, cable, and display module to the hospital

8. All patients should carry a spare pump controller with them

9. The most common cause for VAD alarms is low batteries or battery failures

10. Although automatic non-invasive blood pressure cuffs are often ineffective in measuring

systolic and diastolic pressure, if they do obtain a measurement, the MAP is usually accurate

11. Other VAD complications:

a. Infection

b. Stroke/Transient ischemic attack (TIA)

c. Bleeding

d. Arrhythmias

e. Cardiac tamponade

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f. Congestive heart failure (CHF)

g. Aortic insufficiency

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914065 – General - Indwelling Medical Devices/Equipment

• 9914069 – General - Medical Device Malfunction

Key Documentation Elements

• Information gained from the VAD control box indicating any specific device malfunctions

• Interventions performed to restore a malfunctioning VAD to normal function

• Time of notification to and instructions from VAD-trained companion and/or VAD coordinator

Performance Measures

• Identify and mitigate any correctable VAD malfunctions

• Perform CPR for patients in cardiac arrest when indicated

References

1. Garg S, Ayers CR, Fitzsimmons C, et al. In-hospital cardiopulmonary arrests in patients with left

ventricular assist devices. J Card Fail. 2014;20(12):899–904

2. Mabvuure NT, Rodrigues JN. External cardiac compression during cardiopulmonary

resuscitation with left ventricular assist devices. Interact Cardiovasc Thorac Surg.

2014;19(2):286–9

3. Mechem M. Prehospital assessment and management of patients with ventricular-assist

devices. Prehosp Emerg Care. 2013;17(2):223–9

4. Shinar Z, Bellezzo J, Stahovich M, Cheskes S, Chillcott S, Dembitsky W. Chest compressions may

be safe in arresting patients with left ventricular assist devices (LVADs). Resuscitation.

2014;85(5):702–4

5. Sepsis: SIRS 4 Criteria, Severe Sepsis Criteria and Treatment Nursing Jobs Exam The Beginner's

Guide to Intensive Care: A Handbook for Junior Doctors and Allied Professionals. Nurses Notes.

2021. https://nursingjobsexam.com/sepsis-sirs-criteria-severe-sepsis-criteria/. Accessed March

11, 2022

Revision Date

March 11, 2022

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Tachycardia with a Pulse 42

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Tachycardia with a Pulse

Aliases

Atrial fibrillation (A-FIB) Atrial flutter

Supraventricular tachycardia (SVT) Multifocal atrial tachycardia (MAT)

Torsades Ventricular tachycardia (VT)

Patient Care Goals

1. Maintain adequate oxygenation, ventilation, and perfusion

2. Control ventricular rate

3. Restore regular sinus rhythm in unstable patient

4. Search for underlying cause:

a. Medications (caffeine, diet pills, thyroid, decongestants)

b. Drugs (cocaine, amphetamines)

c. History of dysrhythmia

d. congestive heart failure (CHF)

Patient Presentation

Patients will manifest elevated heart rate for age and may or may not also present with associated signs or

symptoms such as palpitations, dyspnea, chest pain, syncope/near-syncope, hemodynamic compromise,

altered mental status, or other signs of end organ malperfusion

Inclusion Criteria

Heart rate greater than 100 BPM in adults or relative tachycardia in pediatric patients

Exclusion Criteria

Sinus tachycardia

Patient Management

Assessment, Treatments, and Interventions

1. Adult Management

a. Manage airway as necessary

b. Administer oxygen as appropriate with a target of achieving 94–98% saturation

c. Initiate monitoring and perform 12-lead EKG

d. Establish IV access

e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline

f. Consider the following additional therapies if tachycardia with signs and symptoms or

hemodynamic instability continues:

i. Regular Narrow Complex Tachycardia – Stable (SVT)

1. Perform vagal maneuvers

2. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus

a. If tachycardia continues, give adenosine 12 mg IV

b. A third dose of adenosine, 12 mg IV, can be given

3. Diltiazem 0.25 mg/kg slowly IV over 2 minutes

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a. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be given if

needed

b. For patients older than 65 years old, recommend maximum initial dose of

diltiazem 10 mg IV and a maximum second dose of 20 mg

4. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5 minutes for

a total of 3 doses

5. Verapamil 2.5–5 mg IV given over 2 minutes. May repeat with verapamil 5–10 mg

after 15–30 minutes.

ii. Regular Narrow Complex Tachycardia – Unstable

1. Deliver a synchronized shock based on manufacturer’s recommendations

2. For responsive patients, consider sedation and analgesia

iii. Irregular Narrow Complex Tachycardia – Stable (atrial fibrillation (A-FIB), atrial flutter,

multifocal atrial tachycardia)

1. Diltiazem 0.25 mg/kg slowly IV over 2 minutes

a. After 15 minutes, a second dose of diltiazem 0.35 mg/kg IV may be given if

needed

b. For patients older than 65 years old, recommend maximum initial dose of

diltiazem 10 mg IV and a maximum second dose of 20 mg

2. Metoprolol 5 mg IV given over 1–2 minutes. May repeat as needed q 5 minutes for

a total of 3 doses

iv. Irregular Narrow Complex Tachycardia – Unstable

1. Deliver a synchronized shock based on manufacturer’s recommendation

2. For responsive patients, consider sedation

v. Regular Wide Complex Tachycardia – Stable (ventricular tachycardia, supraventricular

tachycardia, atrial fibrillation/flutter with aberrancy, accelerated idioventricular

rhythms, pre-excited tachycardias with accessory pathways)

1. Amiodarone 150 mg IV over 10 minutes

a. May repeat once as needed

2. Procainamide 20–50 mg/min until arrhythmia suppressed, hypotension ensues, QRS

duration increases greater than 50%, or maximum dose 17 mg/kg given

a. Maintenance infusion: 1–4 mg/min

b. Avoid if prolonged QT or CHF

3. Lidocaine 1–1.5 mg/kg IV

a. May be repeated at 5-minute intervals for a maximum dose of 3 mg/kg IV

4. Adenosine 6 mg IV (proximal site) followed by 10 mL fluid bolus

a. If monomorphic tachycardia continues, give adenosine 12 mg IV

vi. Regular Wide Complex Tachycardia – Unstable

1. Deliver a synchronized shock based on manufacturer’s recommendation

2. For responsive patients, consider sedation

vii. Irregular Wide Complex Tachycardia – Stable (A-FIB with aberrancy, pre-excited A-FIB

(i.e., A-FIB using an accessory pathway), multifocal atrial tachycardia (MAT) or

polymorphic VT/torsades de pointes

1. Procainamide 20–50 mg/min until arrhythmia suppressed, hypotension ensues, QRS

duration increases greater than 50%, or maximum dose 17 mg/kg given

a. Maintenance infusion: 1–4 mg/min

b. Avoid if prolonged QT or CHF

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2. If torsades, give magnesium 1–2 g IV over 10 minutes

3. Amiodarone 150 mg IV over 10 minutes

a. May repeat once as needed

b. Administration of amiodarone, if needed, should follow procainamide in patients

with Wolff–Parkinson–White syndrome

viii. Irregular Wide Complex Tachycardia – Unstable

1. Deliver a synchronized shock based on manufacturer’s recommendation

2. For responsive patients, consider sedation

2. Pediatric Management

a. Manage airway as necessary

b. Administer oxygen as appropriate with a target of achieving 94–98% saturation

c. Initiate monitoring and perform 12-lead EKG

d. Establish IV access

e. Check blood glucose and treat hypoglycemia per the Hypoglycemia Guideline

f. Consider the following additional therapies if tachycardia and symptoms or hemodynamic

instability continue:

i. Regular Narrow Complex Tachycardia – Stable (SVT)

1. Perform vagal maneuvers

2. Adenosine 0.1 mg/kg (maximum of 6 mg)

a. If unsuccessful, may repeat with 0.2 mg/kg (maximum of 12 mg)

ii. Regular Narrow Complex Tachycardia – Unstable

1. Deliver a synchronized shock: 0.5–1 J/kg for the first dose

2. Repeat doses should be 2 J/kg

iii. Regular, Wide Complex Tachycardia — Stable

1. Consider adenosine 0.1 mg/kg (maximum of 6 mg) for SVT with aberrancy

2. Otherwise give amiodarone 5 mg/kg IV (maximum of 150 mg) over 10 minutes

iv. Regular, Wide Complex Tachycardia – Unstable

1. Synchronized cardioversion 0.5–1.0 J/kg

Notes/Educational Pearls

Key Considerations

1. Causes:

a. Hypovolemia

b. Hypoxia

c. Hydrogen (acidosis)

d. Myocardial infarction

e. Hypokalemia/Hyperkalemia

f. Hypoglycemia

g. Hypothermia

h. Toxins/Overdose

i. Tamponade

j. Tension pneumothorax

k. Thrombus – central or peripheral

l. Trauma

m. Hyperthyroidism

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2. A-FIB rarely requires cardioversion in the field. As it is difficult to ascertain the onset of this

rhythm, the risk of stroke needs to be considered prior to cardioversion

3. A wide-complex irregular rhythm should be considered pre-excited A-FIB; extreme care must be

taken in these patients

a. Characteristic EKG findings include a short PR interval and, in some cases, a delta wave

b. Avoid AV nodal blocking agents such as adenosine, calcium channel blockers, digoxin, and

possibly beta-blockers in patients with pre-excitation A-FIB (e.g., Wolff-Parkinson-White

Syndrome, Lown-Ganong-Levine Syndrome) because these drugs may cause a paradoxical

increase in the ventricular response

c. Blocking the AV node in some of these patients may lead to impulses that are transmitted

exclusively down the accessory pathway, which can result in ventricular fibrillation

d. Amiodarone or procainamide may be used as an alternative

4. Amiodarone or procainamide can be used as a rate-controlling agent for patients who are

intolerant of or unresponsive to other agents, such as patients with CHF who may not otherwise

tolerate diltiazem or metoprolol

a. Caution should be exercised in those who are not receiving anticoagulation, as amiodarone

can promote cardioversion

5. Administer metoprolol to patients with SBP greater than 120 mmHg

a. Worsening CHF, chronic obstructive pulmonary disease (COPD), asthma, as well as

hypotension and bradycardia can occur with use of metoprolol

6. Biphasic waveforms have been proven to convert A-FIB at lower energies and higher rates of

success than monophasic waveforms

a. Strategies include dose escalation (70, 120, 150, 170 joules (J) for biphasic or 100, 200, 300,

360 J for monophasic) versus beginning with single high energy/highest success rate for

single shock delivered

7. Studies in infants and children have demonstrated the effectiveness of adenosine for the

treatment of hemodynamically stable or unstable SVT

8. Adenosine should be considered the preferred medication for stable SVT

a. Verapamil may be considered as alternative therapy in older children but should not be

routinely used in infants

b. Procainamide or amiodarone given by a slow IV infusion with careful hemodynamic

monitoring may be considered for refractory SVT

Pertinent Assessment Findings

None noted

Patient Safety Considerations

1. Only use one antidysrhythmic at a time

2. Patients who receive beta-blockers (e.g., metoprolol) with calcium channel blockers (e.g.,

diltiazem) are at increased risk for hypotension and bradycardia

3. If using cardioversion, consider sedation and pain control

4. With irregular wide complex tachycardia (A-FIB with aberrancy such as Wolff-Parkinson-White

and Lown-Ganong Levine), avoid use of AV nodal blocking agents (e.g., adenosine, calcium

channel blockers, beta-blockers)

5. Patients with Wolff–Parkinson–White should be given procainamide prior to amiodarone

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914147 – Medical - Supraventricular Tachycardia (including A-FIB)

• 9914151 – Medical - Ventricular Tachycardia (with pulse)

• 9914199 – Medical-Tachycardia

Key Documentation Elements

• Initial rhythm and all rhythm changes

• Time, dose, and response to medications given

• Cardioversion times, synchronization, attempts, joules, and response

• Obtain monitor strips after each intervention

• Patient weight

• Pediatric length-based tape color (for pediatrics who fit on tape)

• History of event supporting treatment of underlying causes

Performance Measures

• Time to clinical improvement from patient contact

• Blood sugar obtained

• Correct medication(s) and dose given for patient condition, age, and weight

• Correct cardioversion joules delivered given patient weight and/or condition

• Use of sedation for responsive patient

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Hypoglycemia—01: Treatment Administered for Hypoglycemia

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. DeSouza IS, Martindale JL, Sinert R. Antidysrhythmic drug therapy for the termination of stable,

monomorphic ventricular tachycardia: a systematic review. Emerg Med J. 2015;32(2):161–7

2. Fengler BT, Brady WJ, Plautz CU. Atrial fibrillation in the Wolff-Parkinson-White Syndrome: EKG

recognition and treatment in the ED. Am J Emerg Med. 2007;25(5):576–83

3. Fuster V, Rydén LE, Cannom DS, et al. ACC/AHA/ESC 2006 guidelines for the management of

patients with atrial fibrillation – executive summary. Rev Port Cardiol. Apr;26(4):383–446

4. Link MS, Berkow LC, Kudenchuk HR, et al. Part 7: adult advanced cardiovascular life support.

Circulation. 2015;132(18 Suppl 2):S444–64

5. Long B, Koyfman A. Best clinical practice: emergency medicine management of stable

monomorphic ventricular tachycardia. J Emerg Med. Epub 2016 Oct 15. 2017;4(15):484–492.

doi:10.1016/j.jemermed.2016.09.010.

6. McNamara RL, Tamariz LJ, Segal JB, Bass EB. Management of atrial fibrillation: review of the

evidence for the role of pharmacologic therapy, electrical cardioversion, and echocardiography.

Ann Intern Med. 2003;139(12):1018–33

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7. Ortiz M, Martin A, Arribas F, et al. Randomized comparison of intravenous procainamide vs.

intravenous amiodarone for the acute treatment of tolerated wide QRS tachycardia: the

PROCAMIO study. Eur Hear J. 2017;38(17):1329–35

8. Somberg JC, Bailin SJ, Haffajee CI, et al. Intravenous lidocaine versus intravenous amiodarone

(in a new aqueous formulation) for incessant ventricular tachycardia. Am J Cardiol.

2002;90(8):853–9

9. Wann LS, Curtis AB, January CT, et al. 2011 ACCF/AHA/HRS focused update on the management

of patients with atrial fibrillation (updating the 2006 guideline): a report of the American

College of Cardiology Foundation/American Heart Association task force on practice guidelines.

Circulation. 2011; 123:104–23

10. Zimetbaum P, Reynolds MR, Ho KK, et al. Impact of a practice guideline for patients with atrial

fibrillation on medical resource utilization and costs. Am J Cardiol, 2003;92(6):677–81

Revision Date

March 11, 2022

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Suspected Stroke/Transient Ischemic Attack

Aliases

Cerebrovascular accident (CVA) Transient ischemic attack (TIA)

Patient Care Goals

1. Detect neurological deficits

2. Determine eligibility for transport to a stroke center

3. Identify patients who have potentially sustained a stroke involving a large vessel occlusion (LVO)

Patient Presentation

1. Neurologic deficit such as facial droop, localized weakness, gait disturbance, slurred speech,

altered mentation, sudden onset of dizziness/vertigo

2. Hemiparesis or hemiplegia

3. Dysconjugate gaze, forced or crossed gaze (if patient is unable to voluntarily respond to exam,

makes no discernible effort to respond, or is unresponsive)

4. Severe headache, neck pain/stiffness, difficulty seeing

Inclusion Criteria

Patient has signs and symptoms consistent with stroke or transient ischemic attack (TIA)

Exclusion Criteria

1. If glucose less than 60 mg/dL (deciliter), treat per the Hypoglycemia Guideline

2. If trauma and Glasgow Coma Score (GCS) less than or equal to 13, treat per the Head Injury

Guideline and General Trauma Management Guideline

Patient Management

Assessment

1. Use a validated prehospital stroke scale that may include, but is not limited to:

a. Facial smile/grimace – ask patient to smile

b. Arm drift – close eyes and hold out arms for count of 10 seconds

c. Speech – ask patient to say “You can’t teach an old dog new tricks”

2. Use a validated prehospital stroke severity scale that may include, but is not limited to:

a. Vision changes

b. Sensory neglect

c. Aphasia

3. Pertinent historical data includes:

a. History – “last known well” and source of that information

b. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment]

c. Patient is taking warfarin or any anticoagulant medication

d. History of recent trauma

e. History of recent seizure

f. History of recent surgery

g. History of recent hemorrhage (e.g., GI bleed)

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4. Evaluate for the presence of stroke mimics including:

a. Hypoglycemia

b. Seizure

c. Sepsis

d. Migraine

e. Intoxication

Treatment and Interventions

1. Determine “last known well” time

2. Administer oxygen as appropriate with a target of achieving 94–98% saturation

3. If seizure activity present, treat per Seizures Guideline

4. Check blood glucose level (BGL)

a. Treat only if glucose less than 60 mg/dL

5. Acquire 12-lead EKG, if possible

6. Early hospital notification per local stroke plan that should include any suspected large vessel

occlusion (LVO) stroke

Patient Safety Considerations

1. Prevent aspiration – elevate head of stretcher 15–30 degrees if systolic BP greater than 100

mmHg

a. Maintain head and neck in neutral alignment, without flexing the neck

2. Protect paralyzed limbs from injury

3. Avoid multiple IV attempts

Notes/Educational Pearls

Key Considerations

1. Transport and destination decisions should be based on local resources and stroke system of

care

a. Destination hospitals may include:

i. Stroke Ready

ii. Primary Stroke Center

iii. Thrombectomy-capable Stroke Center

iv. Comprehensive Stroke Center

2. Time of onset of stroke or last known well is critical data for patient treatment

a. Positive stroke scale with time of onset or last known well less than 4½ hours may be

eligible for thrombolytic agents

b. Positive stroke severity scale with time of onset or last known well less than 24 hours may

be eligible for mechanical thrombectomy

i. Consider transport to hospital capable of mechanical thrombectomy per local stroke

plan

3. Do not treat hypertension

4. Place on cardiac monitor

5. Pediatrics:

a. Treatment principles remain the same

b. Although rare, pediatric patients can have strokes

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c. Stroke scales are not validated for pediatric patients

d. The EMS crew should call ahead to make sure that the hospital can manage the patient

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

● 9914145 – Medical - Stroke/TIA

Key Documentation Elements

● “Last known well” must be specific

o If the patient was last known well prior to bedtime the night before, this is the time to be

documented (not time the patient woke up with symptoms present)

● Blood glucose results

● Specific validated stroke scale used and findings

● Time of notification to receiving hospital

Performance Measures

● Documentation of time “last known well”

● Use of validated stroke scale

● Blood glucose level obtained

● Minimize EMS scene time

● Hospital stroke team pre-arrival alert or activation occurred as early as possible after positive

stroke assessment finding

● National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Stroke—01: Suspected Stroke Receiving Prehospital Stroke Assessment

NOTE: This measure can only be evaluated if EMS documentation can be combined with

information provided by the receiving hospital

References

1. Kleindorfer, D, Towfighi, A, et al. 2021 Guideline for the Prevention of Stroke in Patients With

Stroke and Transient Ischemic Attack: A Guideline From the American Heart

Association/American Stroke Association, Stroke 2021;52:e364–e467.

Revision Date

March 11, 2022

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General Medical

Abdominal Pain

Aliases

None noted

Patient Care Goals

1. Improve patient comfort

2. Identify life-threatening causes of abdominal pain

Patient Presentation

Inclusion Criteria

Abdominal pain or discomfort related to a non-traumatic cause

Exclusion Criteria

1. Abdominal pain due to trauma [See General Trauma Management Guideline]

2. Abdominal pain due to or related to pregnancy [See OB/GYN Section]

Patient Management

Assessment

1. Perform airway assessment and management per the Airway Management Guideline

2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status assessment

3. Obtain blood glucose if hyperglycemia is suspected per Hyperglycemia Guideline

4. Provide evaluation and management of pain per the Pain Management Guideline

5. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation

6. Assess for life-threatening causes of abdominal pain, which may include:

a. Signs and symptoms of ischemic, necrotic, or perforated bowel

i. Severe tenderness

ii. Abdominal pain with motion or palpation of the abdomen

iii. Fever

iv. Bloody stool

v. Nausea and vomiting

vi. Absence of passage of stool or gas

vii. Abdominal distention, with tympany to percussion

b. Signs and symptoms of dissecting or ruptured abdominal aortic aneurysm (AAA)

i. Unequal femoral or distal lower extremity pulses

ii. “Pulsatile” abdominal mass

iii. Associated back pain and/or chest pain

iv. Known history of abdominal aortic aneurysm

c. Signs and symptoms of ruptured ectopic pregnancy

i. Vaginal bleeding

ii. Recently diagnosed pregnancy

iii. Recent missed period/menstrual cycle in women of childbearing age

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d. Signs and symptoms of appendicitis

i. Focal right lower quadrant tenderness, possibly with rebound and guarding

ii. Right lower quadrant tenderness noted during palpation of the left lower

quadrant (positive Rovsing’s sign)

iii. Peri-umbilical or diffuse abdominal tenderness with palpation of the

abdomen/pelvis

iv. Fever

v. Nausea, vomiting

vi. Lack of appetite

e. Signs and symptoms of acute cholecystitis

i. Right upper quadrant or epigastric tenderness

ii. Fever

iii. Nausea and vomiting

iv. History of gallstones

f. Signs and symptoms of pyelonephritis

i. Fever

ii. Nausea, vomiting

iii. Urinary frequency/urgency

iv. Dysuria

v. Hematuria

vi. Back/flank pain

vii. Costovertebral angle tenderness to percussion

7. Assess for signs of shock

a. If shock is present, provide treatment per appropriate Shock Guideline

8. Assess for other non-life-threatening causes of abdominal pain

a. Signs and symptoms of kidney stone

i. Unilateral flank pain

ii. Nausea, vomiting

iii. Hematuria

Treatment and Interventions

1. Medication Administration:

a. Provide analgesia per the Pain Management Guideline

b. Administer antiemetics per the Nausea-Vomiting Guideline

c. Provide transport to an appropriate receiving facility. Consider specialty destination

centers for conditions such as suspected abdominal aortic aneurysm and aortic

dissection

d. Reassess vital signs and response to therapeutic interventions throughout transport

Patient Safety Considerations

Abdominal pain in older adults, patients with bleeding disorders, patients on anticoagulation

medications, children less than 2 years old and patients that are immunocompromised may be a

harbinger for severe illness.

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Notes/Educational Pearls

Key Considerations

1. Assess for life-threatening causes of abdominal pain

2. Provide appropriate treatment for pain, vomiting, and shock

3. Consider transport to a specialty surgical center if aortic aneurysm or aortic dissection is

suspected

Pertinent Assessment Findings

1. Rebound tenderness

2. Guarding

3. Abdominal distension

4. Abdominal tympany to percussion

5. Tenderness focal to a specific abdominal quadrant

6. Presence of “pulsatile” abdominal mass

7. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities

8. Hyper or hypothermia

9. Rectal bleeding, hematemesis, vaginal bleeding

10. Jaundice

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914109 – Medical - Abdominal Pain

Key Documentation Elements

• Assessment of abdomen to include findings on palpation/percussion including presence or

absence of masses and presence and nature of tenderness/pain

• Treatment and response to treatment

Performance Measures

• Assessment for life-threatening etiology

• Mitigation of pain per the Pain Management Guideline

References

1. Attard AR, Corlett MJ, Kidner NJ, Leslie AP, Fraser IA. Safety of early pain relief for acute

abdominal pain. BMJ. 1992;305(6853):554–6

2. Brewster GS, Herbert ME, Hoffman JR. Medical myth: analgesia should not be given to

patients with acute abdominal pain because it obscures the diagnosis. West J Med.

2000;172(3):209–10

3. LoVecchio F, Oster N, Sturmann K, Nelson LS, Flashner S, Finger R. The use of analgesics in

patients with acute abdominal pain. J Emerg Med 1997; 15:775–9

4. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with

acute abdominal pain. Cochrane Database of Syst Rev. 2011;1:CD005660

5. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute

abdominal pain. Acad Emerg Med. 1996; 3:1086–92

6. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of

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patients with acute abdominal pain? JAMA. 2006;296(14):1764–74

7. Vermuelen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on

the accuracy of clinical and US findings in the decision to operate – a randomized trial.

Radiology. 1999; 210:639–43

Revision Date

March 11, 2022

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Abuse and Maltreatment

Aliases

Maltreatment of vulnerable populations Non-accidental trauma

Definitions

1. Abuse/Maltreatment: Any act or series of acts of commission or omission by a caregiver or

person in a position of power over the patient that results in harm, potential for harm, or

threat of harm to a patient of any age group. EMS clinicians should have a heightened

awareness for vulnerable populations which include, but is not limited to, children, elderly,

and adults with mental or physical disabilities

2. Child Abuse/Maltreatment: Child maltreatment includes any act or series of acts of

commission or omission by a parent or other caregiver that results in harm, potential for

harm, or threat of harm to a child. An act of commission (child abuse) is the physical, sexual,

or emotional maltreatment or neglect of a child or children. An act of omission (child neglect)

includes, but is not limited to, failure to provide for the child’s needs (e.g., physical, emotional,

medical/dental, and educational neglect) and failure to supervise (e.g., inadequate supervision

or safety precautions, lack of appropriate car seat use, and exposure to violent or dangerous

environments)

3. Human Trafficking: when people are abducted or coerced into service (e.g., being forced into

servitude without compensation and/or prostitution). Signs may include, but are not limited

to, patient with branding/tattoos and environmental clues such as padlocks and/or doorknobs

removed on interior doors and intact windows that are boarded up

Patient Care Goals

1. Recognize any act or series of acts of commission or omission by a caregiver or person in a

position of power over the patient that results in harm, potential for harm, or threat of harm to

a patient

2. Take appropriate steps to protect the safety of the responders as well as bystanders

3. Remove the patient from immediate danger

4. Assess any patient injuries that may be the result of acute or chronic events

5. Attempt to preserve evidence whenever possible; however, the overriding concern should be

providing appropriate emergency care to the patient

6. Complete all mandatory reporting requirements per state guidelines

Patient Presentation

1. Clues to abuse or maltreatment can vary with age group of the patient and type of abuse

2. Not all abuse or maltreatment is physical

3. EMS role is to:

a. Document concerns

b. Assess potentially serious injuries

c. Disclose concerns to appropriate authorities

d. Initiate help to get the patient and any other vulnerable individuals at the scene into a safe

situation

e. Not to investigate or intervene beyond the steps above

f. Leave further intervention to law enforcement personnel

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Inclusion/Exclusion Criteria

Absolute inclusion/exclusion criteria are not possible in this area. Rather, clues consistent with

different types of abuse/maltreatment should be sought:

1. Potential clues to abuse/maltreatment from caregivers or general environment:

a. Caregiver apathy about patient’s current situation

b. Caregiver overreaction to questions about situation

c. Inconsistent histories from caregivers or bystanders regarding what happened

d. Information provided by caregivers or patient that is not consistent with injury patterns

e. Injuries not appropriate for patient’s age or physical abilities (e.g., infants with injuries

usually associated with ambulatory children, elders who have limited mobility with

injury mechanisms inconsistent with their capabilities)

f. Caregiver not allowing adult patient to speak for themself, or who appears controlling –

pay special attention to patients who cannot communicate due to young age or language

and/or cultural barriers

g. Inadequate safety precautions or facilities where the patient lives and/or evidence of

security measures that appear to confine the patient inappropriately

2. Potential clues to abuse or maltreatment that can be obtained from the patient:

a. Multiple bruises in various stages of healing

b. Age-inappropriate behavior (e.g., adults who are submissive or fearful, children who act

in a sexually inappropriate way)

c. Pattern burns, bruises, or scars suggestive of specific weaponry used

d. Evidence of medical neglect for injuries or infections

e. Unexplained trauma to genitourinary systems or frequent infections to this system

f. Evidence of malnourishment and/or serious dental problems

3. Have a high index of suspicion for abuse in children presenting with a Brief Resolved

Unexplained Event (BRUE) [See Brief Resolved Unexplained Event (BRUE) & Acute

Events in Infants Guideline]

Patient Management

Assessment

1. Primary survey and identify any potentially life-threatening issues

2. Document thorough secondary survey to identify clues of for potential abuse/maltreatment:

a. Multiple bruises in various stages of healing. A complete skin exam can help identify

suggestive findings that would otherwise be missed

b. Age-inappropriate behavior (e.g., adults who are submissive or fearful, children who act

in a sexually inappropriate way)

c. Pattern burns, bruises, or scars suggestive of specific weaponry used

d. Evidence of medical neglect for injuries or infections

e. Unexplained trauma to genitourinary systems or frequent infections to this system

f. Evidence of malnourishment and/or serious dental problems

3. Assess physical issues and avoid extensive investigation of the specifics of abuse or

maltreatment, but document any statements made spontaneously by patient

a. Avoid asking directed questions of a child

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Treatment and Interventions

1. Address life-threatening issues

2. Remove the patient to a safe place even if no medical indication for transport

3. Report concerns about potential abuse/maltreatment to law enforcement immediately, in

accordance with state law, including:

a. Caregivers impeding your ability to assess/transport patient

b. Caregivers refusing care for the patient

4. For patients transported, report concerns to hospital and/or law enforcement personnel

(including Child Protective Services agencies where appropriate) per mandatory reporting laws

Patient Safety Considerations

1. If no medical emergency exists, the next priority is safe patient disposition/removal from the

potentially abusive situation

2. Do not confront suspected perpetrators of abuse/maltreatment. This can create an unsafe

situation for EMS and for the patient

3. In situations of parental or religious objections to life-saving medical care when EMS

suspects abuse, law enforcement should be notified for assistance

Notes/Educational Pearls

Key Considerations

1. All states have specific mandatory reporting laws that dictate which specific crimes such as

suspected abuse or maltreatment must be reported and to whom they must be reported. It is

important to be familiar with the specific laws in your state including specifically who must

make disclosures, what the thresholds are for disclosures, and to whom the disclosures must

be made

2. Clues to abuse or maltreatment can vary depending on the age group of the patient and on

the nature of the abuse. Remember that not all abuse or maltreatment involves physical

harm. EMS clinicians are often unique in being the only members of the medical team to

observe the home environment or injury scene. It is important to realize that the job of EMS is

to document their concerns, assess the patient for potentially serious injuries, make sure that

their concerns are disclosed to the appropriate legal authorities, and work towards getting the

patient into a safe situation. EMS personnel should not take it upon themselves to investigate,

interview, or intervene above and beyond those concepts and should leave further

intervention to the appropriate law enforcement personnel

3. Abuse and maltreatment can happen to patients of all ages

4. Patients may be unwilling or unable to disclose abuse or maltreatment, so the responsibility

falls on EMS personnel to assess the situation, document appropriately, and take appropriate

action to secure a safe place for the patient

5. Document findings by describing what you see and not ascribing possible causes (e.g., “0.5-

inch round burn to back” as opposed to “burn consistent with cigarette burn”)

Pertinent Assessment Findings

As noted above

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914187 – General - Neglect or Abuse Suspected

Key Documentation Elements

Meticulous documentation of any statements by the patient and any physical findings on the

patient or the surroundings are critical in abuse or maltreatment cases

Performance Measures

None noted

References

1. Blue Campaign. DHS.gov. https://www.dhs.gov/blue-campaign. Accessed March 11,

2022

2. Child Abuse and Neglect Prevention. CDC.gov.

https://www.cdc.gov/violenceprevention/childabuseandneglect/index.html. Accessed

March 11, 2022

3. Christian, Committee on Child Abuse and Neglect. The Evaluation of Suspected Child Physical

Abuse. Pediatrics. 2015;135(5): e1337-e1354

4. COMMITTEE ON BIOETHICS. Conflicts between religious or spiritual beliefs and pediatric

care: informed refusal, exemptions, and public funding. Pediatrics 2013; 132:962.

5. Elder Abuse. CDC.gov. https://www.cdc.gov/violenceprevention/elderabuse/index.html.

Accessed March 11, 2022

Revision Date

March 11, 2022

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Agitated or Violent Patient/Behavioral Emergency

Aliases

Acute psychosis Patient restraint

Patient Care Goals

1. Provision of emergency medical care to the agitated, violent, or uncooperative patient

2. Maximizing and maintaining safety for the patient, EMS personnel, and others

Patient Presentation

Inclusion Criteria

Patients of all ages who are exhibiting agitated or violent behavior, are a danger to self or others

and in the sole assessment of the EMS clinician require physical and/or pharmacologic restraint to

mitigate injury to self or others

Exclusion Criteria

1. Patients exhibiting agitated or violent behavior due to medical conditions including, but not

limited to:

a. Head injury

b. Metabolic disorders (e.g., hypoglycemia, hypoxia)

Patient Management

Assessment

1. Note medications/substances on scene that may contribute to the agitation, or may be relevant

to the treatment of a contributing medical condition

2. Maintain and support airway

3. Note respiratory rate and effort – If possible, monitor pulse oximetry and/or capnography

4. Assess circulatory status:

a. Blood pressure (if possible)

b. Pulse rate

c. Capillary refill

5. Assess mental status

a. Check blood glucose (if possible)

6. Obtain temperature (if possible)

7. Assess for evidence of traumatic injuries

8. Use a validated risk assessment tool such as RASS (Richmond Agitation Sedation Score), AMSS

(Altered Mental Status Score), or BARS (Behavioral Activity Rating Scale) to risk stratify violent

patients to help guide interventions

Treatment and Interventions

1. Establish patient rapport

a. Attempt verbal reassurance and calm patient prior to use of pharmacologic and/or physical

management devices

b. Engage family members/loved ones to encourage patient cooperation if their presence

does not exacerbate the patient’s agitation

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c. Continued verbal reassurance and calming of patient following use of chemical/physical

management devices

2. Pharmacologic management

a. Notes:

i. Selection of medications for pharmacologic management should be based upon the

patient’s clinical condition, current medications, and allergies in addition to EMS

resources and medical direction

ii. The medications are annotated to indicate when they are preferred for patients that

are particularly high-risk for violence as assessed by a validated scale – note that the

dosing can be adjusted to achieve different levels of sedation

iii. The numbering of medications below is not intended to indicate a hierarchy/preference

of administration

b. Benzodiazepines

i. Diazepam

1. Adults:

a. 5 mg IV; 2–5 minute onset of action

b. 10 mg IM; 15–30 minute onset of action

2. Pediatrics:

a. 0.05–0.1 mg/kg IV (maximum dose is 5 mg)

b. 0.1–0.2 mg/kg IM (maximum dose is 10 mg)

ii. Lorazepam

1. Adults:

a. 2 mg IV; 2–5 minute onset of action

b. 4 mg IM; 15–30 minute onset of action

2. Pediatrics:

a. 0.05 mg/kg IV (maximum dose is 2 mg)

b. 0.05 mg/kg IM (maximum dose is 2 mg)

iii. Midazolam

1. Adults:

a. 5 mg IV; 3–5 minute onset of action

b. 5 mg IM; 10–15 minute onset of action

c. 5 mg IN; 3–5 minute onset of action

2. Pediatrics:

a. 0.05–0.1 mg/kg IV (maximum dose 5 mg)

b. 0.1–0.15 mg/kg IM (maximum dose is 5 mg)

c. 0.3 mg/kg IN (maximum dose is 5 mg)

c. Antipsychotics

i. Droperidol (option for high violence risk)

1. Adults:

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a. 2.5 mg IV; 10-minute onset of action

b. 5–10 mg IM; 20-minute onset of action

2. Pediatrics: Not routinely recommended

ii. Haloperidol (Limited data available, optimal dose not established)

1. Adults:

a. 5 mg IV; 5–10 minute onset of action

b. 5–10 mg IM; 10–20 minute onset of action

2. Pediatrics: Age 6–12 years old: 1–3 mg IM (maximum dose 0.15 mg/kg)

iii. Olanzapine

(Note: Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended

as fatalities have been reported)

1. Adults:

a. 10 mg IM; 15–30 minute onset of action

b. 10 mg ODT PO or SL

2. Pediatrics:

a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use)

b. Age 12–18 years old: 10 mg IM

c. Age 6–18 years old: 5 mg ODT PO or SL

iv. Ziprasidone

1. Adults: 10 mg IM; 10-minute onset of action

2. Pediatrics:

a. Age 6–11 years old: 5 mg IM (limited data available for pediatric use)

b. Age 12–18 years old: 10 mg IM

d. Dissociative Agents (provide sedation and anesthesia)

i. Ketamine (option for high violence risk)

1. Adults:

a. 2 mg/kg IV; 1 minute onset of action

b. 4 mg/kg IM; 3–5 minute onset of action

2. Pediatrics:

a. 1 mg/kg IV

b. 3 mg/kg IM

e. Antihistamines

i. Diphenhydramine

1. Adults: 25–50 mg IM/IV/PO

2. Pediatrics: 1 mg/kg IM/IV/PO (maximum dose of 25 mg)

2. Physical Management Devices

a. Body

i. Stretcher straps should be applied as the standard procedure for all patients during

transport

ii. Physical management devices, including stretcher straps, should never restrict the

patient’s chest wall motion

iii. If necessary, sheets may be used as improvised supplemental stretcher straps. Other

forms of improvised physical management devices should be discouraged

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iv. Supplemental straps or sheets may be necessary to prevent flexion/extension of torso,

hips, legs by being placed around the lower lumbar region, below the buttocks, and

over the thighs, knees, and legs

b. Extremities

i. Soft or leather devices should not require a key to release them

ii. Secure all four extremities to maximize safety for patient, staff, and others

iii. Secure all extremities to the stationary frame of the stretcher

iv. Multiple knots should not be used to secure a device

Patient Safety Considerations

The management of violent patients requires a constant reevaluation of the risk/benefit balance for

the patient and bystanders to provide the safest care for all involved. These are complex and high-

risk encounters. There is no “one size fits all” solution for addressing these patients

1. Don PPE

2. Do not attempt to enter or control a scene where physical violence or weapons are present

3. Dispatch law enforcement immediately to secure and maintain scene safety

4. Urgent de-escalation of patient agitation is imperative in the interest of patient safety as well as

for EMS personnel and others on scene

5. Uncontrolled or poorly controlled patient agitation and physical violence can place the patient

at risk for sudden cardiopulmonary arrest due to the following etiologies:

a. Delirium with agitated behavior: A postmortem diagnosis of exclusion for sudden death

thought to result from metabolic acidosis (most likely from lactate) stemming from physical

agitation or physical control measures and potentially exacerbated by stimulant drugs (e.g.,

cocaine) or alcohol withdrawal

b. Positional asphyxia: Sudden death from restriction of chest wall movement and/or

obstruction of the airway secondary to restricted head or neck positioning resulting in

hypercarbia and/or hypoxia

6. Apply a cardiac monitor as soon as possible, particularly when pharmacologic management

medications have been administered

7. All patients who have received pharmacologic management medications must be monitored

closely for the development of hypoventilation and oversedation

a. Utilize capnography if available

8. Patients who have received antipsychotic medication for pharmacologic management must be

monitored closely for the potential development of:

a. Dystonic reactions (this can easily be treated with diphenhydramine/benzodiazepines)

b. Mydriasis (dilated pupils)

c. Ataxia

d. Cessation of perspiration

e. Dry mucous membranes

f. Cardiac arrhythmias (particularly QT prolongation)

9. Patients who require physical management should also receive pharmacological treatment for

agitation to prevent consequences of delirium with agitated behavior

10. Placement of stretcher in sitting position prevents aspiration and reduces the patient’s physical

strength by placing the abdominal muscles in the flexed position

11. Patients who are more physically uncooperative should be physically secured with one arm

above the head and the other arm below the waist, and both lower extremities individually

secured

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12. The following techniques should be expressly prohibited for use by EMS clinicians:

a. Secure or transport in a prone position with or without hands and feet behind the back

(hobbling or “hog-tying”)

b. "Sandwiching” patients between backboards

c. Techniques that constrict the neck or compromise the airway

13. Concurrent use of IM/IV benzodiazepines and olanzapine IM is not recommended as fatalities

have been reported

Notes/Educational Pearls

Key considerations

1. Direct medical direction should be contacted at any time for advice, especially when patient’s

level of agitation is such that transport may place all parties at risk

2. Transport by air is not advised

3. Stretchers with adequate foam padding, particularly around the head, facilitates patient’s

ability to self-position the head and neck to maintain airway patency

4. For patients with key-locking devices, applied by another agency, consider the following

options:

a. Remove device and replace it with a device that does not require a key

b. Administer pharmacologic management medication then remove and replace device with

another non-key-locking device after patient has become more cooperative

c. Transport patient accompanied in patient compartment by person who has device key

d. Transport patient in the vehicle of person who has the device key if medical condition of

patient is deemed stable, direct medical direction so authorizes, and law allows

Pertinent Assessment Findings

1. Continuous monitoring of:

a. Airway patency

b. Respiratory status with pulse oximetry and/or capnography

c. Circulatory status with frequent blood pressure measurements

d. Mental status and trends in level of patient cooperation

e. Cardiac status, especially if the patient has received pharmacologic management

medication

f. Extremity perfusion with capillary refill in patients in physical management device

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914053 – General - Behavioral/Patient Restraint

Key Documentation Elements

• Etiology of agitated or violent behavior if known

• Patient’s medications, other medications or substances found on scene

• Patient’s medical history or other historic factors reported by patient, family, or bystanders

• Physical evidence or history of trauma

• Adequate oxygenation by pulse oximetry

• Blood glucose measurement

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• Measures taken to establish patient rapport

• Dose, route, and number of doses of pharmacologic management medications administered

• Clinical response to pharmacologic management medications

• Number and physical sites of placement of physical management devices

• Duration of placement of physical management devices

• Repeated assessment of airway patency

• Repeated assessment of respiratory rate, effort, pulse oximetry/capnography

• Repeated assessment of circulatory status with blood pressure, capillary refill, cardiac

monitoring

• Repeated assessment of mental status and trends in the level of patient cooperation

• Repeated assessment of capillary refill in patient with extremity securing devices

• Communications with EMS medical direction

• Initiation and duration of engagement with law enforcement

Performance Measures

• Incidence of injuries to patient, EMS personnel, or others on scene

• Incidence of injuries to patient, EMS personnel, or others during transport

• Medical or physical complications (including sudden death) in patients

• Advance informational communication of EMS protocols for the management of agitated and

violent patients to others within the emergency care system and law enforcement

• Initiation and engagement with EMS medical direction

• Initiation and duration of engagement with law enforcement

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. Adimando AJ, Poncin YB, Baum CR. Pharmacological management of the agitated pediatric

patient. Pediatr Emerg Care. 2010;26(11):856–60

2. Calver L, Drinkwater V, Gupta R, Page CB, Isbister GK. Droperidol v. haloperidol for sedation of

aggressive behaviour in acute mental health: randomized controlled trial. Br J Psychiatry.

2015;206(3):223-228.

3. Calver L, Page CB, Downes MA, et al. The Safety and Effectiveness of Droperidol for Sedation of

Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med. 2015;66(3):230-

238.e1.

4. Calver L, Isbister GK. High dose droperidol and QT prolongation: analysis of continuous 12‐lead

recordings. British Journal of Clinical Pharmacology. 2014;77(5):880-886

5. Drayna PC, Estrada C, Wang W, Saville BR, Arnold DH. Ketamine sedation is not associated with

clinically meaningful elevation of intraocular pressure. Am J Emerg Med. 2012;30(7):1215–8.

6. Ely EW, Truman B, Shintani A, et al. Monitoring sedation status over time in ICU patients:

reliability and validity of the Richmond Agitation-Sedation Scale (RASS). JAMA.

2003;289(22):2983–91.

7. Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best Practices for Evaluation

and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department:

Consensus Statement of the American Association for Emergency Psychiatry [published

correction appears in West J Emerg Med. 2019 May;20(3):537] [published correction appears in

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West J Emerg Med. 2019 Jul;20(4):688-689]. West J Emerg Med. 2019;20(2):409-418.

doi:10.5811/westjem.2019.1.41344

8. Halstead SM, Deakyne SJ, Bajaj L, Enzenauer R, Roosevelt GE. The effect of ketamine on

intraocular pressure in pediatric patients during procedural sedation. Acad Emerg Med.

2012;19(10):1145–50.

9. Ho JD, Smith SW, Nystrom PC, et al. Successful management of excited delirium syndrome with

prehospital ketamine: two case examples. Prehosp Emerg Care, 2013;17(2): 274–9.

10. Isbister GK, Calver LA, Page CB, Stokes B, Bryant JL, Downes MA. Randomized controlled trial of

intramuscular droperidol versus midazolam for violence and acute behavioral disturbance: the

DORM study. Ann Emerg Med. 2010;56(4):392-401 e1.

11. Kupas DF, Wydro GC. Patient restraint in emergency medical services systems. Prehosp Emerg

Care. 2002;6(3):340–5.

12. Sonnier L, Barzman D. Pharmacologic management of acutely agitated pediatric patients.

Paediatr Drugs. 2011 1;13(1):1–10.

13. Swift RH, Harrigan EP, Cappelleri JC, Kramer D, Chandler LP. Validation of the behavioural

activity rating scale (BARS): a novel measure of activity in agitated patients. J Psychiatr Res.

2002;36(2):87–95.

14. Tsze DS, Steele DW, Machan JT, Akhlaghi F, Linakis JG. Intranasal ketamine for procedural

sedation in pediatric laceration repair: a preliminary report. Pediatr Emerg Care.

2012;28(8):767–70

15. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task Force, American

College of Emergency Physicians; September 10, 2009.

Revision Date

March 11, 2022

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Anaphylaxis and Allergic Reaction

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based

Prehospital Guideline Model Process)

Aliases

Anaphylactic Shock

Patient Care Goals

1. Provide timely therapy for potentially life-threatening reactions to known or suspected

allergens to prevent cardiorespiratory collapse and shock

2. Provide symptomatic relief for symptoms due to known or suspected allergens

Patient Presentation

Inclusion Criteria

Patients of all ages with suspected allergic reaction and/or anaphylaxis

Exclusion Criteria

None noted

Patient Management

Assessment

1. Evaluate for patent airway and presence of oropharyngeal edema

2. Auscultate for wheezing and assess level of respiratory effort

3. Assess for adequacy of perfusion

4. Assess for presence of signs and symptoms of anaphylaxis

a. Anaphylaxis – More severe and is characterized by an acute onset involving:

i. The skin (urticaria) and/or mucosa with either respiratory compromise or decreased BP

or signs of end-organ dysfunction

ii. Hypotension for that patient after exposure to a known allergen

1. Adults: Systolic BP less than 90

2. Pediatrics: See Appendix VIII. Abnormal Vital Signs

iii. Two or more of the following occurring rapidly after exposure to a likely allergen:

1. Skin and/or mucosal involvement (urticaria, itchy, swollen tongue/lips)

a. Skin involvement may be ABSENT in up to 40% of cases of anaphylaxis

2. Respiratory compromise (dyspnea, wheezing, stridor, hypoxemia)

3. Persistent gastrointestinal symptoms (vomiting, abdominal pain, diarrhea)

4. Hypotension or associated symptoms (syncope, hypotonia, chest tightness,

incontinence)

b. Non-anaphylactic Allergic Reaction

i. Signs involving only one organ system (e.g., localized angioedema that does not

compromise the airway, or not associated with vomiting; hives alone)

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Treatment and Interventions

1. If signs of allergic reaction without signs of anaphylaxis, go to Step 8

2. Epinephrine administration is the primary treatment for anaphylaxis. If signs of anaphylaxis,

administer epinephrine 1 mg/mL at the following dose and route:

a. Adult (25 kg or more) 0.3 mg IM in the anterolateral thigh

b. Pediatric (less than 25 kg) 0.15 mg in the anterolateral thigh

c. Epinephrine 1 mg/mL may be administered from a vial or via auto-injector, if available

3. If respiratory distress with wheezing is present, consider administering

a. Albuterol 2.5–5 mg nebulized

AND/OR

b. Epinephrine 1 mg/mL, 5 mL nebulized

4. If stridor is present, consider administering epinephrine 1 mg/mL, 5 mL nebulized

5. If signs of anaphylaxis and hypoperfusion persist following the first dose of epinephrine,

additional IM epinephrine can be repeated q5–15 minutes at above noted doses

6. For signs of hypoperfusion, also administer 20 mL/kg isotonic fluid (normal saline or lactated

Ringer’s) rapidly (over 15 minutes) via IV or IO, and repeat as needed for ongoing

hypoperfusion

7. Consider an epinephrine IV drip (0.5 mcg/kg/minute) when cardiovascular collapse

(hypotension with altered mental status, pallor, diaphoresis and/or delayed capillary refill) is

present despite repeated IM doses of epinephrine in conjunction with at least 60 mL/kg isotonic

fluid boluses

8. For urticaria or pruritus, administer a diphenhydramine 1 mg/kg, up to maximum dose of 50

mg IM, IV, or PO)

a. The IV route is preferred for the patient in severe symptoms

b. As a supplement to diphenhydramine given for urticaria, any H2-blocking antihistamine

(e.g., famotidine, cimetidine) can be given IV or PO in conjunction with diphenhydramine

9. Transport as soon as possible, and perform ongoing assessment as indicated. Cardiac monitoring

is not required, but should be considered for those with known heart problems or who received

multiple doses of epinephrine

Patient Safety Considerations

1. Time to epinephrine delivery

2. Concentration of epinephrine in relation to route

3. Weight-based dosing of medications

Notes/Educational Pearls

Key Considerations

1. When anaphylaxis is suspected, EMS personnel should always consider epinephrine as first-

line treatment

2. Allergic reactions and anaphylaxis are serious and potentially life-threatening medical

emergencies. It is the body’s adverse reaction to a foreign protein (e.g., food, medicine, pollen,

insect sting or any ingested, inhaled, or injected substance). A localized allergic reaction (e.g.,

urticaria or angioedema that does not compromise the airway) may be treated with

antihistamine therapy. Cardiovascular collapse may occur abruptly, without the prior

development of skin or respiratory symptoms. Constant monitoring of the patient’s airway and

breathing is essential

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3. Contrary to common belief that all cases of anaphylaxis present with cutaneous manifestations,

such as urticaria or mucocutaneous swelling, a significant portion of anaphylactic episodes may

not involve these signs and symptoms on initial presentation. Moreover, most fatal reactions to

food-induced anaphylaxis in children were not associated with cutaneous manifestations

4. A thorough assessment and a high index of suspicion are required for all potential allergic

reaction patients – consider:

a. History of Present Illness

i. Onset and location

ii. Insect sting or bite

iii. Food allergy/exposure

iv. New clothing, soap, detergent

v. Past history of reactions

vi. Medication history

b. Signs and Symptoms

i. Itching or urticaria

ii. Coughing, wheezing, or respiratory distress

iii. Chest tightness or throat constriction

iv. Hypotension or shock

v. Persistent gastrointestinal symptoms (nausea, vomiting, and diarrhea)

vi. Altered mental status (AMS)

c. Other Considerations

i. Angioedema (drug-induced)

ii. Aspiration/airway obstruction

iii. Vasovagal event

iv. Asthma or chronic obstructive pulmonary disease (COPD)

v. Heart failure

5. Gastrointestinal symptoms occur most commonly in food-induced anaphylaxis, but can occur

with other causes

a. Oral pruritus is often the first symptom observed in patients experiencing food-induced

anaphylaxis

b. Abdominal cramping is also common, but nausea, vomiting, and diarrhea are frequently

observed as well

6. Patients with asthma are at high-risk for a severe allergic reaction

7. There is no proven benefit to using steroids in the management of allergic reactions and/or

anaphylaxis

8. There is controversy among experts with very low-quality evidence to guide management for

the use of empiric IM epinephrine after exposure to a known allergen in asymptomatic patients

with a history of prior anaphylaxis

Pertinent Assessment Findings

1. Presence or absence of angioedema

2. Presence or absence of respiratory compromise

3. Presence or absence of circulatory compromise

4. Localized or generalized urticaria

5. Response to therapy

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914111 – Medical - Allergic Reaction/Anaphylaxis

Key Documentation Elements

• Medications given

• Dose and concentration of epinephrine given

• Route of epinephrine administration

• Time of epinephrine administration

• Signs and symptoms of the patient

Performance Measures

• Percentage of patients with anaphylaxis that receive epinephrine for anaphylaxis:

o Via the IM route (vs. other routes)

o Via the IM route in the anterolateral thigh (vs. other locations)

• Percentage of patients with anaphylaxis who receive:

o Epinephrine within 10 minutes of arrival

o The appropriate weight-based dose of epinephrine

• Percentage of patients that require airway management in the prehospital setting (and/or the

emergency department)

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. Banerji, A, Rudders SA, Corel B, Garth AP, Clark S, Camargo, CA Jr. Predictors of hospital

admission for food-related allergic reactions that present to the emergency department. Ann

Allergy Asthma Immunol. 2011;106(1):42–8

2. Breuer C, Wachall B, Gerbeth K, Abdel-Tawab M, Fuhr U. Pharmacokinetics, and

pharmacodynamics of moist inhalation epinephrine using a mobile inhaler. Eur J Clin Pharmacol.

2013;69(6):303–10

3. Capps JA, Sharma V, Arkwright, PD. Prevalence, outcome, and pre–hospital management of

anaphylaxis by first aiders and paramedical ambulance staff in Manchester, UK. Resuscitation.

2010;81(6):653–7

4. Dahlof C, Mellstrand T, Svedmyr N. Systemic absorption of adrenaline after aerosol, eye–drop

and subcutaneous administration to healthy volunteers. Allergy. 1987;42(3):215–21

5. Hauswald M. Can paramedics safely decide which patients do not need ambulance transport or

emergency department care? Prehosp Emerg Care. 2002;6(4):383–6

6. Heilborn H, Hjemdahl P, Daleskog M, Adamsson U. Comparison of subcutaneous injection and

high-dose inhalation of epinephrine – implications for self-treatment to prevent anaphylaxis. J

Allergy Clin Immunol. 1986;78(6):1174–9

7. Hompes S, Köhli A, Nemat K, et al. Provoking allergens and treatment of anaphylaxis in children

and adolescents – data from the anaphylaxis registry of German-speaking countries. Pediatr

Allergy Immunol, 2011;22(6):568–74

8. Huang F, Chawla K, Jarvinen KM, Nowak-Wegrzyn A. Anaphylaxis in a New York City pediatric

emergency department: Triggers, treatments, and outcomes. J Allergy Clin Immunol.

2012;129(1):162–168.e1–3

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9. Iribarren C, Tolstykh IV, Miller MK, Eisner, MD. Asthma and the prospective risk of anaphylactic

shock and other allergy diagnoses in a large integrated health care delivery system. Ann Allergy

Asthma Immunol. 2010;104(5):371–7

10. Kanwar M, Irvin CB, Frank JJ, Weber K, Rosman H. Confusion about epinephrine dosing leading

to iatrogenic overdose: a life-threatening problem with a potential solution. Ann Emerg Med.

2010;55(4):341–4

11. Lieberman P, Nicklas RA, Randolph C, et al. Anaphylaxis-a practice parameter update 2015. Ann

Allergy Asthma Immunol. 2015;115(5):341–84

12. Pointer JE, Levitt MA, Young JC, Promes SB, Messana BJ, Ader ME. Can paramedics using

guidelines accurately triage patients? Ann Emerg Med. 2011;38(3):268–77

13. Rea TD, Edwards C, Murray JA, Cloyd DJ, Eisenberg, MS. Epinephrine use by emergency medical

technicians for presumed anaphylaxis. Prehosp Emerg Care. 2004;8(4):405–10

14. Runge JW, Martinez JC, Caravati EM, Williamson SG, Hartsell, SC. Histamine antagonists in the

treatment of acute allergic reactions. Ann Emerg Med. 1992;21(3):237–42

15. Sampson HA. Anaphylaxis and emergency treatment. Pediatrics. 2003;111(6 Pt 3):1601–8

16. Sampson HA, Munoz–Furlong A, Campbell RL, et al. Second symposium on the definition and

management of anaphylaxis: summary report – Second National Institute of Allergy and

Infectious Disease/Food Allergy and Anaphylaxis Network Symposium. J Allergy Clin Immunol.

2004;117(2):391–7

17. Sheikh A, Shehata YA, Brown SG, Simons FE. Adrenaline (epinephrine) for the treatment of

anaphylaxis with and without shock. Cochrane Database Syst Rev. (4) 2008 CD006312

18. Sheikh A, Simons FE, Barbour V, Worth A. Adrenaline auto-injectors for the treatment of

anaphylaxis with and without cardiovascular collapse in the community. Cochrane Database

Syst Rev. 2012 Aug 15;(8):CD008935

19. Sheikh A, ten Broek V, Brown SG, Simons FE. H1-antihistamines for the treatment of anaphylaxis

with and without shock. Cochrane Database Syst Rev. 2007 Jan 24;(1):CD006160

20. Silvestri S, Rothrock SG, Kennedy D, Ladde J, Bryant M, Pagane J. Can paramedics accurately

identify patients who do not require emergency department care? Prehosp Emerg Care.

2002;6(4):387–90

21. Simons FE, Chan ES, Gu X, Simons KJ. Epinephrine for the out-of-hospital (first aid) treatment of

anaphylaxis in infants: is the ampule/syringe/needle method practical? J Allergy Clin Immunol.

2001;108(6):1040–4

22. Simons FE, Gu X, Johnston, LM, Simons KJ. Can epinephrine inhalations be substituted for

epinephrine injection in children at risk for systemic anaphylaxis? Pediatrics. 2000;106(5):1040–

23. Simons FE, Roberts JR, Gu X, Simons KJ. Epinephrine absorption in children with a history of

anaphylaxis. J Allergy Clin Immunol. 1998;101(1 Pt 1):33–7

24. Taillac PP, Brown L, Lubogo N, Nichols J, Shah MI. An evidence-based guideline for pediatric

prehospital allergic reaction management using GRADE methodology. Manuscript in

preparation

25. Watson NT, Weiss EL, Harter PM. Famotidine in the treatment of acute urticaria. Clin Exp

Dermatol. 2000;25(3):186–9

26. Yavuz ST, Sahiner UM, Buyuktiryaki B, et al. Clinical features of children with venom allergy and

risk factors for severe systemic reactions. Int Arch Allergy Immunol. 2013;160(3):313–21

Revision Date

March 11, 2022

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Altered Mental Status

Aliases

Altered level of consciousness Confusion

Patient Care Goals

1. Identify treatable causes

2. Perform appropriate assessment and diagnostics (e.g., oxygen saturation, glucose check,

monitor)

3. Protect patient from complications of altered mental status (e.g., respiratory failure, shock,

cardiopulmonary arrest)

Patient Presentation

Inclusion Criteria

Impaired decision-making capacity

Exclusion Criteria

Traumatic brain injury

Patient Management

Assessment

Look for treatable causes of altered mental status (AMS):

1. Airway: Make sure airway remains patent; reposition patient as needed

2. Breathing: Look for respiratory depression; check SPO

, EtCO

, and CO detector readings

3. Circulation: Look for signs of poor perfusion

4. Glasgow Coma Score and/or AVPU

5. Pupils

6. Head and neck: Evaluate for signs of trauma

7. Neck: Rigidity or pain with range of motion

8. Stroke assessment tool including focal neurologic findings

9. Blood glucose level

10. EKG or cardiac monitor: arrhythmia limiting perfusion

11. Breath odor: Possible unusual odors include alcohol, acidosis, ammonia

12. Chest/Abdominal: Intra-thoracic hardware, assist devices, abdominal pain or distention, signs of

trauma

13. Extremities/skin: Track marks, hydration, edema, dialysis shunt, temperature to touch (or if

able, use a thermometer), signs of trauma

14. Signs of infection: Fever, cough, skin changes, dysuria

15. Environment: Survey for pills, paraphernalia, substance use, medication patches, medical

devices, ambient temperature, social indicators of neglect, carbon monoxide exposures,

multiple casualties with same complaint

Treatment and Interventions

1. Oxygen [Refer to Universal Care Guideline]

2. Glucose [Refer to Hypoglycemia Guideline or Hyperglycemia Guideline]

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3. Naloxone [Refer to Opioid Poisoning/Overdose Guideline]

4. Restraint: physical and chemical [See Agitated or Violent Patient/Behavioral Emergency

Guideline]

5. Anti-dysrhythmic medication [See Cardiovascular Section for specific dysrhythmia guidelines]

6. Active cooling or warming [See Hypothermia/Cold Exposure Guideline or Hyperthermia/Heat

Exposure Guideline]

7. IV fluids [See fluid administration doses in Shock Guideline and Hypoglycemia Guideline or

Hyperglycemia Guideline]

8. Vasopressors [See Shock Guideline]

Patient Safety Considerations

1. With depressed mental status, initial focus is on airway protection, oxygenation, ventilation,

and perfusion

2. The violent patient may need pharmacologic and/or physical management to insure proper

assessment and treatment

3. Hypoglycemic and hypoxic patients can be irritable and violent [See Agitated or Violent

Patient/Behavioral Emergency Guideline]

Notes/Educational Pearls

Key Considerations

1. History from bystanders and caregivers

2. Age of the patient

3. Development age and baseline functional status

4. Consider the following differential using the mnemonic AEIOU-TIPS:

A – Alcohol, Abuse, Atypical migraine

E – Epilepsy, Electrolytes

I – Insulin (hypoglycemia)

O – Oxygen, Overdose

U – Uremia (kidney failure)

T – Trauma, Tumor

I – Infection

P – Psych, Poisoning

S – Seizure, Subarachnoid hemorrhage, Sepsis

5. Environment where patient found

6. Recent complaints (e.g., headache, chest pain, difficulty breathing, vomiting, fever)

7. Medical alert tags and accessory medical devices

8. Evaluate for reduced PO intake and/or vomiting and/or diarrhea or dehydration as a cause of

AMS in the pediatric and geriatric populations

9. Evidence of ingestion or topical placement (e.g., pill bottles/medications, patches, detergent

pods)

10. Medications a child may have access to including but not limited to (includes patches, drops,

pills, injectables):

a. Analgesics

b. Antidepressants

c. Antihypertensives/Cardiac medications

d. Oral hypoglycemic

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e. Opioids

f. Benzodiazepines

g. Antiepileptics

h. Prenatal vitamins

11. Substance use in the home (e.g., tobacco, marijuana, cocaine, amphetamines, PCP, alcohol)

12. Use of herbal or holistic medications

Pertinent Assessment Findings

1. Track marks

2. Breath odor

3. Skin temperature

4. Rash and/or petechiae

5. Evidence of trauma

6. Focal neurologic changes

7. Location

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914113 – Medical - Altered Mental Status

Key Documentation Elements

• Glasgow Coma Score (GCS) or AVPU description

• Baseline developmental status and change from baseline

• Temperature was taken when able

• Patient and medic safety were considered

• Pupil and neck exam were done

• Evaluation of perfusion and skin exam were performed

• IV fluids given for poor perfusion

Performance Measure

• Hypoglycemia considered and treated appropriately

o Blood glucose level obtained

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Hypoglycemia—01: Treatment Administered for Hypoglycemia

• Sepsis considered as a possible cause of hypotension

• Hypotension appropriately treated

• Naloxone is used as therapeutic intervention, not a diagnostic tool

• CO detector is used when available

References

1. Frisch A, Miller T, Haag A, Martin-Gill C, Guyette FX, Suffoletto BP. Diagnostic accuracy of a rapid

checklist to identify delirium in older patients transported by EMS. Prehosp Emerg Care, 2013

Apr-Jun; 17(2): 230–4

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2. Kumar A, Roberts D et al. Duration of hypotension before initiation of effective antimicrobial

therapy is the critical determinant of survival in human septic shock. Crit Care Med, 2006 Jun;

34(6): 1,589–96

3. Leong LB, Jian KH, Vasu A, Seow E. Prospective study of patients with altered mental status:

clinical features and outcome. Int J Emerg Med, 2008 Sep; 1(3): 179–82

4. Sanello A, Gausche-Hill M, Mulkerin W, Sporer KA, Brown JF, Koenig KL, Rudnick EM, Salvucci

AA, Gilbert GH. Altered mental status: Current evidenced-based guidelines for prehospital care.

West J Emerg Med 2018;19(3):527–541

5. Thomas AA, Mazor S. Unintentional marijuana exposure presenting as altered mental status in

the pediatric emergency department: A case series. J Emerg Med. 2017 Dec;53(6): e119–e123.

Pediatric Education for Prehospital Professionals, Fourth Edition; https://www.peppsite.com.

Accessed March 11, 2022

Revision Date

March 11, 2022

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Back Pain

Aliases

None noted

Patient Care Goals

1. Improve patient discomfort

2. Identify life-threatening causes of back pain

Patient Presentation

Inclusion Criteria

Back pain or discomfort related to a non-traumatic cause

Exclusion Criteria

1. Back pain from spinal trauma [See Trauma Section]

2. Back pain due to sickle cell pain crisis [See Sickle Cell Pain Crisis Guideline]

3. Back pain from suspected labor [See OB/GYN Section]

Patient Management

Assessment

1. Perform airway assessment and management, per the Airway Management Guideline

2. Obtain vital signs including pulse, blood pressure, respiratory rate, neurologic status

assessment, pulse oximetry, temperature

3. Provide evaluation and management of pain, per the Pain Management Guideline

4. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation

5. Assess for life-threatening causes of back pain, which may include:

a. Spinal cord compression (e.g., from spinal epidural abscess, malignancy, spinal epidural

hematoma for patients on anticoagulants)

i. Urinary and/or bowel incontinence

ii. Inability to walk due to weakness

iii. New neurologic deficits in extremities

iv. Loss of sensation in saddle distribution

b. Aortic dissection or ruptured abdominal aortic aneurysm

i. Unequal femoral or distal lower extremity pulses

ii. “Pulsatile” abdominal mass

iii. Associated abdominal pain and/or chest pain

iv. Known history of abdominal aortic aneurysm or dissection

c. Pyelonephritis

i. Fever

ii. Nausea, vomiting

iii. Urinary frequency/urgency

iv. Dysuria

v. Hematuria

vi. Abdominal pain

vii. Costovertebral angle tenderness to percussion

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6. Assess for signs of shock. If shock is present, provide treatment per appropriate Shock

Guideline

7. Assess for other non-life-threatening causes of back pain

a. Kidney stone

i. Unilateral flank pain

ii. Nausea, vomiting

iii. Possible hematuria

iv. History of kidney stones

Treatment and Interventions

1. Medication Administration

a. Provide analgesia, per Pain Management Guideline

b. Administer antiemetics, per Nausea-Vomiting Guideline

c. Provide transport to an appropriate receiving facility. Consider specialty destination

centers for conditions such as suspected aortic emergency

d. Reassess vital signs and response to therapeutic interventions throughout transport

Patient Safety Considerations

None noted

Notes/Educational Pearls

Key Considerations

1. Assess for life-threatening causes of back pain

2. Provide appropriate treatment for pain, vomiting, and shock

3. Consider transport to appropriate specialty center if aortic emergency suspected

4. Back and abdominal pain can often coexist with similar disease processes

5. Identify patients on anticoagulants since they are higher risk for spinal epidural hematoma or

retroperitoneal hemorrhage which can present as back pain

6. Identify patients with intravenous drug abuse (IVDA) history and/or impaired immune system

since they are higher risk for spinal epidural abscess

7. Identify patients with a history of cancer or with one suspicious for cancer – spinal

metastases can cause spinal cord compression

8. Identify older adults or patients with prolonged use of corticosteroids at risk for

vertebral body compression fracture

Pertinent Assessment Findings

1. Midline back tenderness

2. Back erythema or swelling

3. Motor and/or sensory loss in arms or legs

4. Loss of perianal sensation

5. Absence of or significant inequality of femoral or distal arterial pulses in lower extremities

6. Hyper or hypothermia

7. Rectal bleeding or hematemesis

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914051 – General - Back Pain

Key Documentation Elements

• Assessment of back and abdomen to include findings on palpation/percussion including

presence or absence of masses and presence and nature of tenderness/pain

• Assesses initial and changes in neurologic status

• Assesses initial and changes in perfusion/pulses

Performance Measures

• Assessment for life-threatening etiology

• Mitigation of pain, per the Pain Management Guideline

References

None note

Revision Date

March 11, 2022

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End-of-Life Care/Hospice Care

Aliases

None noted

Patient Care Goals

1. When providing care for a patient near end-of-life:

a. Provide relief from pain and other distressing symptoms

b. Affirm dying as a normal process

c. Integrate psychological and spiritual aspects of patient care

d. Offer a support system to help the family cope during the patient’s illness and in their

own bereavement

Patient Presentation

Inclusion Criteria

Patients enrolled in hospice or end-of-life care, or who have advance care directives, experiencing

complaints related to the illness for which the patient is receiving those services

Exclusion Criteria

Complaints unrelated to the illness for which the patient is receiving those services

Patient Management

Assessment, Treatment, and Interventions

1. Perform general patient management

2. Engage with the patient’s hospice or end-of-life care team or their primary care

physician if possible. If not a viable option, contact medical direction

3. If the patient can communicate and has the capacity to make decisions regarding

treatment and transport, consult directly with the patient before treatment and/or

transport

4. If the patient lacks the capacity to make decisions regarding treatment and/or transport,

identify any advanced care planning in place for information relating to advanced care

planning and consent for treatment

a. Advance directives

b. Medical/Physician Order for Life-Sustaining Treatment (MOLST/POLST) or similar directing

forms

c. Guardian, power of attorney, or other accepted healthcare proxy

5. If the patient requires pain relief [See Pain Management Guideline]

a. Opioid medications are frequently the most appropriate choices for pain management

b. Multimodal analgesia may be required for pain relief

c. Do not withhold opioids for fear of respiratory depression as patient comfort is the primary

goal for hospice and end-of-life care

6. If the patient is experiencing severe respiratory distress, consider:

a. Oxygen and bedside/handheld fan

b. Noninvasive ventilation (BiPAP/CPAP) if aligned with patient care goals

c. Opioids are the drug of choice for dyspnea for hospice and end-of-life care. Morphine 1–5

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mg IV, IM or SQ initially and repeat as needed. If symptoms are unrelieved, follow written

hospice orders or contact medical direction for additional doses to administer

d. Anxiolytic if needed for anxiety, lorazepam 1 mg SL (pediatric 0.1 mg/kg) If not avail,

consider the administration of diazepam or midazolam.

7. If the patient has nausea [See Nausea-Vomiting Guideline]

8. If the patient has excessive secretions or aspiration, provide suctioning

9. If the patient is anxious or has delirium, in addition to nonpharmacologic interventions such as

creating a quiet environment, frequent reassurance, touch and verbal orientation, consider:

a. Benzodiazepines (diazepam, lorazepam, midazolam)

b. Haloperidol 5 mg PO/IM/IV (pediatric: 0.5-1 mg)

c. Ziprasidone 20 mg IM (pediatric 5 years old or older 0.2 mg/kg IM

10. If the patient appears dehydrated

a. Encourage PO fluid intake if patient can swallow

b. If available, offer ice chips and swabs soaked in ice water

c. Consider administration of normal saline at 10–20 mL/kg IV

11. In collaboration with hospice or end-of-life care clinician, coordinate with guardian, power of

attorney, or other accepted healthcare proxy if non-transport is considered

Patient Safety Considerations

1. Careful and thorough assessments should be performed to identify complaints not related

to the illness for which the patient is receiving hospice or end-of-life care

2. Care should be delivered with the utmost patience and compassion

Notes/Educational Pearls

Key Considerations

1. Social interactions with family may affect end-of-life care

2. Scene safety should be considered when deciding on management

Pertinent Assessment Findings

1. Vital signs

2. Pain score

3. Neurologic exam

4. Lung sounds

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914169 – Cardiac Arrest - Do Not Resuscitate

• 9914171 – Cardiac Arrest - Special Resuscitation Orders

• 9914177 – General - Exception Protocol

Key Documentation Elements

• Interaction with hospice or end-of-life care clinician

• Confirmation of advanced directive or other advanced care documentation

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• Pain score if applicable

Performance Measures

• If patient in pain, pain score change

• If patient is nauseated, symptom relief

• If patient is dehydrated, symptom relief or vital sign change

References

1. Coyne PJ, Viswanathan R, Smith TJ. Nebulized fentanyl citrate improves patients' perception of

breathing, respiratory rate, and oxygen saturation in dyspnea. J Pain Symptom Manage.

2002;23(2):157–60

2. Farahmand S, Shiralizadeh S, Talebian MT, et al. Nebulized fentanyl vs intravenous morphine for

ED patients with acute limb pain: a randomized clinical trial. Am J Emerg Med. 2014;32(9):1011–

3. Portenoy RK, Mehta Z, Ahmed E. Cancer pain management with opioids: Optimizing analgesia.

Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc. https://www.uptodate.com/contents/

cancer-pain-management-with-opioids-optimizing-analgesia.. Accessed March 11, 2022

4. Prehospital Evidence Based Practice Program (PEP) [Internet]. Halifax, Nova Scotia: Dalhousie

University - Division of Emergency Medical Services https://emspep.cdha.nshealth.ca.Accessed

March 11, 2022

5. Shirk MB, Donahue KR, Shirvai J. Unlabeled uses of nebulized medications. Am J Health Syst

Pharm. 2006;63(18):1704–16

Revision Date

March 11, 2022

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Hyperglycemia

Aliases

Diabetes Diabetic ketoacidosis (DKA)

Hyperosmolar hyperglycemic state (HHS)

Patient Care Goals

1. Limit morbidity from hyperglycemia by:

a. Appropriate use of glucose monitoring

b. Appropriate hydration for hyperglycemia

Patient Presentation

Inclusion Criteria

1. Adult or pediatric patient with altered level of consciousness [See Altered Mental Status

Guideline]

2. Adult or pediatric patient with stroke symptoms (e.g., hemiparesis, dysarthria) [See

Suspected Stroke/Transient Ischemic Attack Guideline]

3. Adult or pediatric patient with seizure [See Seizures Guideline]

4. Adult or pediatric patient with symptoms of hyperglycemia (e.g., polyuria, polydipsia,

weakness, dizziness, abdominal pain, tachypnea)

5. Adult or pediatric patient with history of diabetes and other medical symptoms

Exclusion Criteria

Patient in cardiac arrest

Patient Management

Assessment

1. Monitoring:

a. Check blood glucose level

2. Secondary survey pertinent to altered blood glucose level:

a. Constitutional: assess for tachycardia, hypotension, and tachypnea

b. Eyes: assess for sunken eyes from dehydration

c. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure

d. Abdominal pain including nausea and vomiting especially in children

e. Neurologic:

i. Assess Glasgow Coma Score (GCS) and mental status

ii. Assess for focal neurologic deficit: motor and sensory

3. Evaluate for possible concomitant sepsis and septic shock [See Shock Guideline]

4. Obtain 12-lead EKG to assess for findings consistent with hyperkalemia or acute

coronary syndrome

Treatment and Interventions

1. If altered level of consciousness, stroke, or sepsis/septic shock, treat per Altered Mental

Status Guideline, Suspected Stroke/Transient Ischemic Attack Guideline, or Shock

Guideline accordingly

2. If glucose greater than 250 mg/dL with symptoms of dehydration, vomiting, abdominal pain,

or altered level of consciousness:

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a. Provide volume expansion with normal saline bolus

i. Adult: Normal saline 20 mL/kg at rate of 1000 mL/hr; if symptoms of hypovolemic

shock, follow Shock Guideline.

ii. Pediatric: Normal saline 10 mL/kg bolus IV, reassess, and repeat up to 40 mL/kg

total; if symptoms of hypovolemic shock, follow Shock Guideline.

3. If findings of hyperkalemia are present, administer IV fluids and consider administration of:

a. Calcium chloride: 1 gm IV/IO over 5 minutes, ensure IV patency and do not exceed 1

mL per minute

b. Calcium gluconate: 2 gm IV/IO over 5 minutes, with constant cardiac monitoring

4. If findings of hyperkalemia, consider administration of sodium bicarbonate 1 mEq/kg (max

dose of 50 mEq) IV bolus over 5 minutes and consider albuterol 5 mg via nebulizer (can be

repeated if no response is seen) to the two places in the document where the administration

of albuterol is suggested for the treatment of hyperkalemia

5. Reassess patient

a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment),

mental status, and signs of dehydration

b. If mental status changes, reassess blood glucose level and provide appropriate

treatment if hypoglycemia has developed

6. Disposition

a. Transport to closest appropriate receiving facility

Patient Safety Considerations

1. Overly aggressive administration of fluid in hyperglycemic patients may cause cerebral

edema or dangerous hyponatremia. Cerebral edema is a leading cause of death in

children with DKA but is very rare in adults

a. Closely monitor for signs of altered mental status, increased intracranial pressure, and

immediately discontinue IV fluids and elevate head of bed if signs of increased ICP

develop

b. Reassess and manage airway as needed

2. Asymptomatic hyperglycemia poses no risk to the patient while inappropriately aggressive

interventions to manage blood sugar may harm patients

Notes/Educational Pearls

Key Considerations

1. New onset DKA in pediatric patients commonly presents with nausea, vomiting,

abdominal pain, and/or urinary frequency

2. Consider causes for hyperglycemia by thinking about the 3 I’s:

a. Insulin: This refers to any medication changes for insulin or oral medications including

poor compliance or malfunctioning insulin pump

b. Ischemia: This refers to hyperglycemia sometimes being an indication of physiologic

stress in a patient and can be a clue to myocardial ischemia in particular

c. Infection: Underlying infection can cause derangements in glucose control

Pertinent Assessment Findings

1. Concomitant trauma

2. Abdominal pain, “fruity breath,” and rapid-deep respirations (Kussmaul respirations) may

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be associated with DKA

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914121 – Medical - Hyperglycemia

Key Documentation Elements

• Document reassessment of vital signs and mental status after administration of IV fluids

• Document glucose level (if in scope of practice) when indicated

Performance Measures

• When in scope of practice, point of care blood glucose checked for all patients with

symptoms of altered level of consciousness, seizure, stroke, or hyperglycemia

• When hyperglycemia documented, appropriate volume replacement given while avoiding

overzealous repletion before insulin therapy at receiving center

• 12-lead EKG obtained

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org )

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. Corwell B, Knight B, Olivieri L, Willis GC. Current diagnosis and treatment of hyperglycemic

emergencies. Emerg Med Clin North Am. 2014;32(2):437–52

2. Desachy A, Vuagnat AC, Ghazali AD, et al. Accuracy of bedside glucometry in critically ill

patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc.

2008;83(4):400–5

3. Funk DL, Chan L, Lutz N, Verdile VP. Comparison of capillary and venous glucose

measurements in healthy volunteers. Prehosp Emerg Care. 2001;5(3):275–7

4. Holstein A, Kuhne D, Elsing HG, et al. Practicality and accuracy of prehospital rapid venous

blood glucose determination. Am J Emerg Med. 2000;18(6):690–4

5. Holstein A, Plaschke A, Vogel MY, Egberts EH. Prehospital management of diabetic

emergencies – a population–based intervention study. Acta Anaesthesiol Scand.

2003;47(5):610–5

6. Jones JL, Ray VG, Gough JE, Garrison HG, Whitley TW. Determination of prehospital blood

glucose: a prospective, controlled study. J Emerg Med. 1992;10(6):679–82

7. Kitabchi AE, Umpierrez GE, Miles JM, et al. Hyperglycemic crises in adult patients with

diabetes. Diabetes Care. 2009;32(7):1335–43

8. Kulkarni A, Saxena M, Price G., et al. Analysis of blood glucose measurements using capillary

and arterial blood samples in intensive care patients. Intensive Care Med. 2005; 31:142

9. Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with laboratory

determination. Prehosp Emerg Care. 2004;8(4):378–83

10. Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a

hypoglycemic episode, and an exploration of treat and release protocols: a review of the

literature. Emerg J Med. 2003;20(3):274–6

Revision Date

March 11, 2022

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Hypoglycemia

Aliases

None noted

Patient Care Goals

1. Limit morbidity from hypoglycemia by:

a. Describing appropriate use of glucose monitoring

b. Treating symptomatic hypoglycemia

Patient Presentation

Inclusion Criteria

1. Patients with blood glucose less than 60 mg/dL with symptoms of hypoglycemia

2. Patients with altered level of consciousness [See Altered Mental Status Guideline]

3. Patients with stroke symptoms (e.g., hemiparesis, dysarthria) [See Suspected

Stroke/Transient Ischemic Attack Guideline]

4. Patients with seizure [See Seizures Guideline]

5. Patients with history of diabetes and other medical symptoms

6. Patients with suspected alcohol ingestion

7. Patients with metabolic disorders (glycogen storage disease, fatty oxidation or organic acid

disorders, maple syrup urine disease)

8. Patients who appear to be intoxicated

Exclusion Criteria

Patient in cardiac arrest

Patient with normal mental status in absence of inclusion criteria listed above

Patient Management

Assessment

1. Monitoring:

a. Check blood glucose level

2. Secondary survey pertinent to altered blood glucose level:

a. Evaluate for presence of an automated external insulin delivery device (insulin pump)

b. Constitutional: assess for tachycardia and hypotension

c. Eyes: assess for sunken eyes from dehydration

d. Nose/mouth/ears: assess for dry mucous membranes or tongue bite from seizure

e. Neurologic:

i. Assess GCS and mental status

ii. Assess for focal neurologic deficit: motor and sensory

Treatment and Interventions

1. If altered level of consciousness or stroke, treat per Altered Mental Status Guideline or

Suspected Stroke/Transient Ischemic Attack Guideline accordingly

2. If blood glucose is 60 mg/dL or less administer one of the following:

a. Conscious patient with a patent airway:

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i. Glucose, oral (in form of glucose tablets, glucose gel, tube of cake icing, etc.)

1. Adult Dosing: 25 g

2. Pediatric Dosing: 0.5–1 g/kg

b. Unconscious patient, or patients who are unable to protect their own airway:

i. Dextrose IV – administer in incremental doses until mental status improves or

maximum field dosing is reached (if available, D10% is preferred)

1. Maximum field adult dosing: 25 g of 10–50% dextrose IV

a. 50 mL of 50% dextrose

b. 100 mL of 25% dextrose

c. 250 mL of 10% dextrose

2. Maximum field pediatric dosing: 0.5–1 g/kg of 10–25% dextrose IV

a. 2–4 mL/kg of 25% dextrose for those greater than 8 years old

b. 5–10 mL/kg of 10% dextrose (newborns 2 mL/kg)

ii. Glucagon IM/IN – an option for patients for whom IV access cannot be established

1. Adult dosing: 1 mg IM/IN (or prefilled 3 mg dry powder IN or prefilled IM

autoinjector)

2. Pediatric dosing:

a. 1 mg IM/IN if ≥ 20 kg (or ≥ 5 years old (or prefilled 4 mg dry powder IN for

patients greater than 4 years old or prefilled IM autoinjector)

b. 0.5 mg IM/IN if less than 20 kg (or less than 5 years old)

iii. Remove or disable insulin pump if above treatments cannot be completed

a. For patients with an insulin pump who are hypoglycemic with associated altered mental

status (GCS less than 15):

i. Stop the pump, disconnect, or remove at insertion site if patient cannot ingest oral

glucose or ALS is not available

ii. Leave the pump connected and running if able to ingest oral glucose or receive ALS

interventions

2. Reassess patient

a. Reassess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

and mental status

b. Repeat check of blood glucose level if previous hypoglycemia and mental status has not

returned to normal

i. It is not necessary to repeat check of blood glucose level blood sugar if mental status

has returned to normal

c. If maximal field dosage of dextrose solution does not achieve euglycemia and

normalization of mental status:

i. Initiate transport to closest appropriate receiving facility for further treatment of

refractory hypoglycemia

ii. Evaluate for alternative causes of altered mental status

iii. Continue treatment of hypoglycemia using dextrose solutions as noted above

3. Disposition

a. If hypoglycemia with continued symptoms, transport to closest appropriate receiving

facility

b. Hypoglycemic patients who have had a seizure should be transported to the hospital

regardless of their mental status and response to therapy

c. If symptoms of hypoglycemia resolve after treatment, release without transport should

only be considered if all the following are true:

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i. Repeat glucose is greater than 80 mg/dL

ii. Patient takes insulin or metformin to control diabetes and does not take long-acting

oral sulphunylurea agents (e.g., glipizide, glyburide, or others)

iii. Patient returns to normal mental status, with no focal neurologic

signs/symptoms after receiving glucose/dextrose

iv. Patient can promptly obtain and will eat a carbohydrate meal

v. Patient or legal guardian refuses transport and EMS clinicians agree transport not

indicated

vi. A reliable adult will be staying with patient

vii. No major co-morbid symptoms exist, like chest pain, shortness of breath,

seizures, intoxication

viii. A clear cause of the hypoglycemia is identified (e.g., missed meal)

Patient Safety Considerations

1. Dextrose 10% can be safely used in all ages of patient. Dextrose 10% works as effectively and

quickly as other concentrations

2. Dextrose 50% can cause local tissue damage if it extravasates from vein and may cause

hyperglycemia. Dextrose 50% carries risk for little clinical gain. EMS systems may consider

carrying no more than 25% concentration of dextrose for treating hypoglycemia in adults

3. For children less than 8 years old, dextrose concentration of no more than 25% should be used

4. For neonates and infants less than 1 month of age, dextrose concentration of no more than 10–

12.5% should be used

5. Sulfonylureas (e.g., glyburide, glipizide) have long half-lives ranging from 12–60 hrs. Patients

with corrected hypoglycemia who are taking these agents are at particular risk for recurrent

symptoms and frequently require hospital admission

Notes/Educational Pearls

A formula for calculating a 0.5 g/kg dose of IV dextrose:

(____% concentration of glucose) x (_____mL/kg) = 50

For example:

Desired

Fluid type

mL of fluid Dose

0.5 g/kg

25% dextrose

2mL/kg

10% dextrose

5mL/kg

1 g/kg

25% dextrose

4mL/kg

10% dextrose

10mL/kg

Key Considerations

1. Using 10% dextrose is as effective and safer than other stronger concentrations

2. Consider contribution of oral diabetic medications to hypoglycemia

3. If possible, have family/patient turn off insulin pump

4. Consider potential for intentional overdose of hypoglycemic agents

5. Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer dextrose-

containing IV fluids in small doses until either mental status improves or a maximum field

dose is achieved

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Pertinent Assessment Findings

1. Concomitant trauma

2. Diaphoresis or hypothermia may be associated with hypoglycemia

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914125 – Medical - Hypoglycemia/Diabetic Emergency

Key Documentation Elements

• Document reassessment of vital signs and mental status after administration of

glucose/dextrose/glucagon

• Document point of care glucose level (if in scope of practice) when indicated

Performance Measures

• When in scope of practice, blood glucose is checked for all patients with symptoms of

altered level of consciousness, seizure, stroke, or hypoglycemia

• If patient released at scene, criteria documented for safe release

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Hypoglycemia—01: Treatment Administered for Hypoglycemia

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. A review of the efficiency of 10% dextrose as an alternative to high concentration glucose in

the treatment of out-of-hospital hypoglycemia. J Emerg Prim Health Care. 2009;7(3):990341

2. Desachy A, Vuagnat AC, Ghazali AD, et al. Accuracy of bedside glucometry in critically ill

patients: influence of clinical characteristics and perfusion index. Mayo Clin Proc.

2008;83(4):400–5

3. Funk DL, Chan L, Lutz N, Verdile VP. Comparison of capillary and venous glucose

measurements in healthy volunteers. Prehosp Emerg Care. 2001;5(3):275–7

4. Hern HG, Kiefer M, Louie D, Barger J, Alter HJ. D10 in the treatment of prehospital

hypoglycemia: a 24-month observational cohort study. Prehosp Emerg Care. 2017;21(1):63–7

5. Holstein A, Kuhne D, Elsing HG, et al. Practicality and accuracy of prehospital rapid venous

blood glucose determination. Am J Emerg Med. 2000;18(6):690–4

6. Holstein A, Plaschke A, Vogel MY, Egberts EH. Prehospital management of diabetic

emergencies – a population-based intervention study. Acta Anaesthesiol Scand.

2003;47(5):610–5

7. Jones JL, Ray VG, Gough JE, Garrison HG, Whitley TW. Determination of prehospital blood

glucose: a prospective, controlled study. J Emerg Med. 1992;10(6):679–82

8. Kulkarni A, Saxena M, Price G, O'Leary MJ, Jacques T, Myburgh JA. Analysis of blood glucose

measurements using capillary and arterial blood samples in intensive care patients. Intensive

Care Med. 2005;31(1):142–5

9. Kumar G, Sng BL, Kumar S. Correlation of capillary and venous glucometry with laboratory

determination. Prehosp Emerg Care. 2004;8(4):378–83

10. Moore C, Woollard M. Dextrose 10% or 50% in the treatment of hypoglycaemia out of

hospital? a randomized controlled trial. Emerg Med J. 2005; 22:512–5

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11. Roberts K, Smith A. Outcome of diabetic patients treated in the prehospital arena after a

hypoglycemic episode, and an exploration of treat and release protocols: a review of the

literature. Emerg J Med. 2003;20(3):274–6

12. Vilke GM, Castillo EM, Ray LU, Murrin PA, Chan TC. Evaluation of pediatric glucose

monitoring and hypoglycemic therapy in the field. Pediatr Emerg Care. 2005;21(1):1–5

Revision Date

March 11, 2022

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Nausea-Vomiting

Aliases

Emesis Gastroenteritis

Patient Care Goals

Identify hypoglycemia or hyperglycemia

Prevent dehydration

Patient Presentation

Inclusion Criteria

Currently nauseated and/or vomiting

Exclusion Criteria

None noted

Patient Management

Assessment

1. Routine patient care (e.g., vital signs)

2. History and physical examination focused on potential causes of nausea and vomiting (e.g.,

gastrointestinal, cardiovascular, obstetric, gynecologic, hypoglycemia, hyperglycemia,

neurologic, oncologic, psychogenic, or toxidrome) as well as medications that may prolong

the QT interval

3. Obtain glucose level

Treatment and Interventions

1. Antiemetic medication administration

a. Isopropyl alcohol: Allow patient to inhale vapor from isopropyl alcohol wipe 3 times q

(quaque, every) 15 minutes as tolerated

b. Ondansetron (contraindicated for suspected or known diagnosis of prolonged QT

syndrome)

i. Adult:

1. 4 mg IV/PO/SL

2. 4 or 8 mg SL of the ODT formulation

ii. Pediatric (6 months – 14 years old):

1. 0.15 mg/kg IV/PO (maximum dose of 4 mg)

2. 2 mg SL for ages 1–5 years old; age 6 and older use 4 mg of the ODT formulation

c. Metoclopramide

i. Adult: 10 mg IV/IM

ii. Pediatric (greater than 2 years old only and greater than 12 kg):

1. 0.1 mg/kg IM

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2. 0.1 mg/kg IV (maximum 10 mg)

a. May repeat x 1 in 20–30 minutes if no relief

d. Prochlorperazine

i. Adult: 5 mg IV/IM

ii. Pediatric (over 2 years old only and greater than 12 kg):

1. 0.1 mg/kg slow IV

2. 0.1 mg/kg deep IM (maximum 10 mg)

e. Droperidol

i. Adult: 1.25 mg IV/IM (contraindicated for suspected or known diagnosis of prolonged

QT syndrome)

f. Diphenhydramine

i. Adult: 12.5–25 mg IV/IM/PO

ii. Pediatric (over 2 years old only and greater than 12 kg): 0.1 mg/kg IV (maximum 25 mg)

Patient Safety Considerations

1. Ondansetron should not be administered to patients who have a prolonged QT interval as it can

cause torsades.

2. For very young pediatric patients, ondansetron can be sedating

3. Dystonic and extrapyramidal symptoms are possible side effects of antiemetics – If

encountered, consider diphenhydramine:

a. Adult: 25–50 mg IV/IM/PO

b. Pediatric: 1 mg/kg IV/IM/PO (maximum dose 50 mg)

4. Medications that prolong the QT interval may alter treatment options.

Notes/Educational Pearls

Key Considerations

1. Ondansetron is preferred in children for the treatment of nausea and vomiting

2. Metoclopramide has fewer adverse effects than prochlorperazine in children

3. Prochlorperazine and metoclopramide (phenothiazines) have an increased risk of dystonic

reactions

a. Some phenothiazines also have an increased risk of respiratory depression when used

with other medications that cause respiratory depression, and some phenothiazines can

cause neuroleptic malignant syndrome

b. Prochlorperazine carries a black box warning for use in elderly patients with dementia-

related psychosis.

4. IV form of ondansetron may be given PO in same dose

5. Nausea and vomiting are symptoms of illness – in addition to treating the patient’s nausea and

vomiting a thorough history and physical are key to identifying what may be a disease in need

of emergent treatment (e.g., bowel obstruction, myocardial infarction, pregnancy)

6. While ondansetron has not been adequately studied in pregnancy to determine safety,

women should be counseled regarding the available data. In the first trimester of

pregnancy, the administration of metoclopramide 5–10 mg IV with diphenhydramine 25

mg IV is recommended over the administration of ondansetron

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Pertinent Assessment Findings

1. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

2. Risk factors for heart disease/EKG if applicable

3. Pregnancy status

4. Abdominal exam

5. Blood glucose levels

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914131 – Medical - Nausea/Vomiting

Key Documentation Elements

• Patient age

• Patient weight and/or length-based weight measure for pediatric patients

• Medications given, including time, clinician level, dose, dose units, route, response, and

complications

• Vital signs before and after medication administration

• History and physical regarding etiology of nausea/vomiting

• EKG performed and interpretation documented if cardiac risk factors are present

Performance Measures

• In patients with nausea and vomiting, appropriate medication(s) was/were administered

(including proper dosage) and the patient's response to treatment is documented

• Any event where complications occurred, such as a dystonic reaction, should have event

and appropriate responsive interventions performed and documented

• EMS® NEMSQA Measure (for additional information, see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

1. ACOG Practice Bulletin No. 189: Nausea and Vomiting of Pregnancy. Committee on Practice

Bulletins-Obstetrics. Obstet Gynecol. 2018;131(1): e15

2. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl alcohol nasal inhalation for

nausea in the emergency department: a randomized controlled trial. Ann Emerg Med.

2016;68(1):1–9

3. Colletti J. Brown KM, Sharieff GQ, Barata IA, Ishimine P; ACEP Pediatric Emergency Medicine

Committee. The management of children with gastroenteritis and dehydration in the

emergency department. J Emerg Med. 2010;38(5):686–98

4. Kenneday D. Ondansetron and pregnancy: understanding the data. Obstet Med.

2016;9(1):28–33

5. Nausea and Vomiting of Pregnancy. The American College of Obstetricians and

Gynecologists; September 2015. Practice Bulletin Number 153

6. Niño-Serna LF, Acosta-Reyes J, Veroniki A, et al. Antiemetics in Children with Acute

Gastroenteritis: A Meta-analysis. Pediatrics. 2020;145(4): e20193260

7. Patanwala A, Amini R, Hays DP, Rosen P. Antiemetic therapy for nausea and vomiting in the

emergency department. J Emerg Med. 2010;39(3):330–6

8. Salvucci AA, Squire B, Burdick M, Luoto M, Brazzel D, Vaezazizi R. Ondansetron is safe and

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effective for prehospital treatment of nausea and vomiting by paramedics. Prehosp Emerg

Care. 2011;15(1):34–8

9. Warden CR, Moreno R, Daya M. Prospective evaluation of ondansetron for undifferentiated

nausea and vomiting in the prehospital setting. Prehosp Emerg Care. 2008;12(1):87–91

Revision Date

March 11, 2022

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Pain Management

Aliases

Analgesia Pain control

Patient Care Goals

1. Compassionately manage all patients with pain

2. Minimize adverse events in the treatment of pain

Patient Presentation

Inclusion Criteria

Patients who are experiencing pain regardless of transport interval

Exclusion Criteria

Pregnancy with active labor

Patient Management

Assessment, Treatment, and Interventions

1. Choice of medication class, route of administration, dosing and frequency are based on pain

severity and the need for escalation from oral to parenteral routes

2. The dosing guidelines apply to patients of all ages except where noted

3. Determine patient’s pain score assessment using standard pain scale

a. Less than 4 years old or those with cognitive impairment unable to self-report:

i. Observational Scales

1. Faces, Legs, Arms, Cry, Consolability (FLACC)

2. Children’s Hospital of Eastern Ontario Pain Scale (CHEOPS)

b. 4–12 years old:

i. Self-report scale

1. Wong Baker Faces

2. Faces Pain Scale (FPS)

3. Faces Pain Scale Revised (FPS-R)

c. Greater than 12 years old:

i. Self-report scale

1. Numeric Rating Scale (NRS)

4. Non-pharmacologic pain management options include

a. Placement of the patient in a position of comfort

b. Application of ice packs and/or splints for pain secondary to trauma

c. Verbal reassurance to control anxiety

5. Minor pain or as an adjunct for moderate/severe pain consider the following non-opioid

analgesic options:

a. Acetaminophen 15 mg/kg PO or IV (maximum dose 1 g)

b. Nonsteroidal anti-inflammatories

i. Ibuprofen 10 mg/kg PO for patients greater than 6 months of age (maximum dose

800 mg) OR

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ii. Ketorolac

1. Adult: 30 mg IM or 15 mg IV

2. Pediatric age 2–16 years old: 0.5 mg/kg (maximum dose of 30 mg IM or 15 mg IV)

c. Nitrous Oxide

6. For Moderate to Severe pain, analgesics include:

a. Morphine sulfate:

i. 0.1 mg/kg IM, IV or IO (maximum initial dose is 10 mg)

b. Fentanyl:

i. 1 mcg/kg IN, IM, IV or IO (maximum initial dose of 100 mcg)

c. Hydromorphone:

i. 0.015 mg/kg IM, IV, or IO (maximum initial dose 2 mg; maximum cumulative

dose of 4 mg)

d. Ketamine:

i. 0.25 mg/kg IM, IV or IO (maximum initial dose 25 mg; maximum cumulative dose 100

mg)

7. Use of non-invasive capnography is an earlier predictor of hypoventilation than pulse

oximetry if opioid medications are administered

8. Consider administration of oral, sublingual, or IV antiemetics to prevent nausea [See

Nausea/Vomiting Guideline]

9. If indicated based on pain assessment, and vital signs allow, repeat pain medication

administration (excluding acetaminophen and nonsteroidal anti-inflammatory

medicines) after 5 minutes of the previous dose

10. Transport in position of comfort and reassess as indicated

Patient Safety Considerations

1. All patients should have drug allergies identified prior to administration of pain medication

2. Administer opioids with caution to patients with Glasgow Coma Score (GCS) less than 15,

hypotension, identified medication allergy, hypoxia (SPO

less than 90%) after maximal

supplemental oxygen therapy, or signs of hypoventilation

3. Opioids are contraindicated for patients who have taken monoamine oxidase inhibitors

(MAOI) during the previous 14 days

4. Avoid non-steroidal anti-inflammatory medications such as ibuprofen and ketorolac in patients

with NSAID allergy, aspirin-sensitive asthma, renal insufficiency, pregnancy, or known peptic

ulcer disease

5. Ketorolac should not be used in patients with hypotension (due to renal toxicity)

6. Use of splinting techniques and application of ice should be done to reduce the total

amount of medication used to keep the patient comfortable

Notes/Educational Pearls

Key Considerations

1. Intranasal routes of opioid analgesia are preferred as the initial dosing route in

pediatrics where IV access may be problematic; consider in other patient

populations when an IV in not otherwise indicated

2. Onset of action is dependent on the pharmacokinetics of the drug class as well

as route of administration; oral analgesics are effective for pain control but

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have a slower onset of action so plan accordingly

3. Pain severity scores should be recorded before and after analgesic medication

administration and upon arrival at destination

4. Patients with acute abdominal pain should receive analgesic interventions – Use of

analgesics for acute abdominal pain does not mask clinical findings or delay diagnosis

5. Opiates may cause a rise in intracranial pressure

Pertinent Assessment Findings

1. Mental status (Glasgow Coma Score (GCS) and pain level)

2. Respiratory system (tidal volume, chest rigidity)

3. Gastrointestinal (assess for tenderness, rebound, guarding, and nausea)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914071 – General - Pain Control

Key Documentation Elements

• Documentation of patient vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment) with pulse oximetry

• Acquisition of patient’s allergies prior to administration of medication

• Documentation of initial patient pain scale assessment

• Documentation of medication administration with correct dose

• Documentation of patient reassessment with repeat vital signs and patient pain scale

assessment

Performance Measures

• The clinical efficacy of prehospital analgesia in terms of adequacy of dosing parameters

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

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Table 1. Adult Nonverbal Pain Scale University of Rochester Medical Center

Source: Odhner M, Wegman D, Freeland N, Ingersoll G. Evaluation of a newly developed

non-verbal pain scale (NVPS) for assessment of pain in sedated critically ill patients.

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Table 2. Universal Pain Assessment Tool

Verbal

Descriptor

Scale

No Pain

Mild

Pain

Moderate

Pain

Severe Pain

Very

Severe Pain

Excruciating

Pain

Descriptive

Scale

Alert

Smiling

Humor

Serious,

Flat

Furrowed

Brow

Pursed Lips

Breath

Holding

Wrinkled Nose

Raised Upper

Lip

Rapid

Breathing

Slow Blink

Open Mouth

Eyes Closed

Moaning

Crying

Activity

Tolerance

Scale

No Pain

Can be

Ignored

Interferes

with Tasks

Interferes with

Concentration

Interferes with

Basic Needs

Bed Rest

Required

Spanish

Nada de

Dolor

Poquito

de Dolor

Un Dolor Leve

Dolor Fuerte

Dolor

Desmasiado

Fuerte

Un Dolor

Insoportable

Source: Hybrid of scales by authors. Wong-Baker FACES® Pain Scale Rating license grants this use.

Reproduction of the Wong-Baker FACES® material requires licensing at www.wongbakerfaces.org.

Wong- Baker

FACES®

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Pediatric-Appropriate Pain Assessment Tools

Table 3. Faces, Legs, Activity, Cry, Consolability (FLACC) Behavioral Scale

Categories

Appropriate age for use (per guideline): less than 4 years

Scoring

Face

No particular

expression or smile

Occasional grimace or

frown, withdrawn,

disinterested

Frequent to constant

frown, clenched jaw,

quivering chin

Legs

Normal position or

relaxed

Uneasy, restless, tense

Kicking,

or legs drawn up

Activity

Lying quietly, normal

position, moves easily

Squirming, shifting

back and forth, tense

Arched, rigid, or jerking

Cry

No cry (awake or

asleep)

Moans or whimpers,

occasional complaint

Crying steadily, screams

or sobs, frequent

complaints

Consolability

Content, relaxed

Reassured by

occasional touching,

hugging,

or being talked to,

distractible

Difficult to console or

comfort

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0–2, which

results in a total score between zero and ten.

Instructions:

• Patients who are awake: Observe for at least 1–2 minutes. Observe legs and body uncovered.

Reposition patient or observe activity, assess body for tenseness and tone. Initiate consoling

interventions if needed

• Patients who are asleep: Observe for at least 2 minutes or longer. Observe body and legs uncovered. If

possible, reposition the patient. Touch the body and assess for tenseness and tone.

Face

• Score 0 point if patient has a relaxed face, eye contact and interest in surroundings

• Score 1 point if patient has a worried look to face, with eyebrows lowered, eyes partially closed, cheeks

raised, mouth pursed

• Score 2 points if patient has deep furrows in the forehead, with closed eyes, open mouth and deep

lines around nose/lips

Legs

• Score 0 points if patient has usual tone and motion to limbs (legs and arms)

• Score 1 point if patient has increase tone, rigidity, tense, intermittent flexion/extension of limbs

• Score 2 points if patient has hyper tonicity, legs pulled tight, exaggerated flexion/extension of limbs,

tremors

Activity

• Score 0 points if patient moves easily and freely, normal activity/restrictions

• Score 1 point if patient shifts positions, hesitant to move, guarding, tense torso, pressure on body part

• Score 2 points if patient is in fixed position, rocking, side-to-side head movement, rubbing body part

Cry

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• Score 0 points if patient has no cry/moan awake or asleep

• Score 1 point if patient has occasional moans, cries, whimpers, sighs

• Score 2 points if patient has frequent/continuous moans, cries, grunts

Consolability

• Score 0 points if patient is calm and does not require consoling

• Score 1 point if patient responds to comfort by touch or talk in ½ – 1 minute

• Score 2 points if patient require constant consoling or is unconsoled after an extended time

Whenever feasible, behavioral measurement of pain should be used in conjunction with self-report. When self-

report is not possible, interpretation of pain behaviors and decision-making regarding treatment of pain

requires careful consideration of the context in which the pain behaviors were observed.

Each category is scored on a 0–2 scale, which results in a total score of 0–10

Assessment of Behavioral Score:

0 = Relaxed and comfortable

1–3 = Mild discomfort

4–6 = Moderate pain

7–10 = Severe discomfort/pain

Source: The FLACC: A behavioral scale for scoring postoperative pain in young children, by S Merkel and others,

1997, Pediatr Nurse 23(3), p. 293–297.

Graphic 1. Faces Pain Scale – Revised (FPS-R)

In the following instructions, say "hurt" or "pain", whichever seems right for a particular child. "These faces show

how much something can hurt. This face [point to face on far left] shows no pain. The faces show more and more

pain [point to each from left to right] up to this one [point to face on far right] — it shows very much pain. Point to

the face that shows how much you hurt [right now]."

Score the chosen face 0, 2, 4, 6, 8, or 10, counting left to right, so “0” = “no pain” and “10” = “very much pain”. Do not

use words like “happy” or “sad.” This scale is intended to measure how children feel inside, not how their face looks.

Source: Permission for Use. Copyright of the FPS-R is held by the International Association for

research use. For reproduction of the FPS-R in a journal, book or web page, or for any commercial use of the scale,

request permission from IASP online at https://www.iasp-pain.org/publications/copyright-permissions/.

References

1. Attard AR, Corlett MJ, Kidner NJ, Leslie AP, Fraser IA. Safety of early pain relief for acute

abdominal pain. BMJ. 1992;305(6853):554–6

2. Bieri D, Reeve R, Champion GD, Addico at L, Ziegler J. The Faces Pain Scale for the self-

assessment of the severity of pain experienced by children: Development, initial validation

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and preliminary investigation for ratio scale properties. Pain 1990;41:139–150

3. Brewster GS, Herbert ME. Hoffman JR. Medical myth: analgesia should not be given to

patients with acute abdominal pain because it obscures the diagnosis. West J Med.

2000;172(3):209–10

4. De Nadal M, Munar F, Poca MA, Sahuquillo J, Garnacho A, Rosselló J. Cerebral hemodynamic

effects of morphine and fentanyl in patients with severe head injury: absence of correlation to

cerebral autoregulation. Anesthesia. 2000; 92:1–11

5. Hicks CL, von Baeyer CL, Spafford P, van Korlaar I, Goodenough B. The Faces Pain Scale –

Revised: Toward a common metric in pediatric pain measurement. Pain. 2001; 93:173–83

6. Jennings PA, Cameron P, Bernard S. Ketamine as an analgesic in the pre-hospital setting: a

systematic review. Acta Anaesthsiol Scand. 2011;55(6):638–43

7. Lindbeck, George et al. (Evidence-Based Guidelines for Prehospital Pain Management:

Literature and Methods (nasemso.org). Accessed March 11, 2022

8. LoVecchio F, Oster N, Sturmann K, Nelson LS, Flashner S, Finger R. The use of analgesics in

patients with acute abdominal pain. J Emerg Med. 1997;15(6):775–9

9. Manterola C, Astudillo P, Losada H, Pineda V, Sanhueza A, Vial M. Analgesia in patients with

acute abdominal pain. Cochrane Database Syst Rev. 2007 Jul 18;(3) CD005660

10. Merkel S, e al. The FLACC: A behavioral scale for scoring postoperative pain in young

children., Pediatr Nurse. 1997;23(3):293–7

11. Pace S, Burke TF. Intravenous morphine for early pain relief in patients with acute

abdominal pain. Acad Emerg Med. 1996;3(12):1086–92

12. Prehospital use of Ketamine in Battlefield Analgesia 2012–13. Falls Church, VA: Defense

Health Agency; March 8, 2012. Correspondence to Assistant Secretary of Defense (Health

Affairs)

13. Porter K. Ketamine in prehospital care. Emerg Med J 2004; 21:351–4

14. Powell, Jonathan R., et al. Evidence-Based Guidelines for Prehospital Pain Management:

Literature and Methods. Prehospital Emergency Care.

15. Ranji SR, Goldman LE, Simel DL, Shojania KG. Do opiates affect the clinical evaluation of

patients with acute abdominal pain? JAMA. 2006;296(14):1764–74

16. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J

Emerg Med. 2007; 25:977–80

17. Vermuelen B, Morabia A, Unger PF, et al. Acute appendicitis: influence of early pain relief on

the accuracy of clinical and US findings in the decision to operate – a randomized trial.

Radiology. 1999;210(3):639–43

18. Wiel E, Zitouni D, Assez N, et al. Continuous infusion of ketamine for out-of-hospital isolated

orthopedic injuries secondary to trauma: a randomized controlled trial. Prehosp Emerg Care.

2015;19(1);10–16

19. Wood PR. Ketamine: prehospital and in-hospital use. Trauma. 2003;5(2):137–40

Revision Date

March 11, 2022

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Seizures

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline

Model Process)

Aliases

Convulsions Eclampsia Febrile seizure

Status epilepticus

Patient Care Goals

1. Prompt cessation of seizures in the prehospital setting

2. Minimizing adverse events in the treatment of seizures in the prehospital setting

3. Minimizing seizure recurrence during transport

Patient Presentation

Seizures due to trauma, pregnancy, hyperthermia, or toxic exposure should be managed according to those

condition-specific guidelines

Inclusion Criteria

Seizure activity upon arrival of prehospital personnel or new/recurrent seizure activity lasting

greater than 5 minutes

Exclusion Criteria

None noted

Patient Management

Assessment

1. History

a. Duration of current seizure

b. Prior history of seizures, diabetes, or hypoglycemia

c. Typical appearance of seizures

d. Baseline seizure frequency and duration

e. Focality of onset, direction of eye deviation

f. Concurrent symptoms of apnea, cyanosis, vomiting, bowel/bladder incontinence, or fever

g. Bystander administration of medications to stop the seizure

h. Current medications, including anticonvulsants

i. Recent dose changes or non-compliance with anticonvulsants

j. History of trauma, pregnancy, heat exposure, or toxin exposure

2. Exam

a. Airway patency

b. Breath sounds, respiratory rate, and effectiveness of ventilation

c. Signs of perfusion (pulses, capillary refill, color)

d. Neurologic status (GCS, nystagmus, pupil size, focal neurologic deficit, or signs of stroke)

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Treatment and Interventions

1. If signs of airway obstruction are present and a chin-lift, jaw thrust, positioning, and/or

suctioning does not alleviate it, place oropharyngeal airway (if gag reflex is absent) or

nasopharyngeal airway

2. Place pulse oximeter and/or waveform capnography to monitor oxygenation/ventilation

3. Administer oxygen as appropriate with a target of achieving 94–98% saturation. Use bag-

valve-mask (BVM) ventilation if oxygenation/ventilation are compromised

Assess perfusion

5. Assess neurologic status

6. Routes for treatment

a. IN/IM routes are preferred over IV or IO routes (if not already established) and rectal

(PR) route as an alternative

i. If no other route of delivery (IM/IV/IO/IN), diazepam 0.2 mg/kg PR (maximum dose

20 mg)

b. IV placement is not necessary for treatment of seizures, but could be obtained if needed

for other reasons

Anticonvulsant Treatment

a. If vascular access is absent

i. Midazolam 0.2 mg/kg (maximum dose 10 mg), IM preferred, or IN

b. If vascular access (IV or IO) is present:

i. Diazepam 0.2 mg/kg IV or IO, maximum 10 mg

ii. Lorazepam 0.1 mg/kg IV or IO, maximum 4 mg

iii. Midazolam 0.1 mg/kg IV or IO, maximum 4 mg

Glucometry

a. If still actively seizing, check blood glucose level

b. If less than 60 mg/dL, treat per the Hypoglycemia Guideline

9. Administer magnesium sulfate in the presence of seizure in the third trimester of pregnancy or

postpartum [See Eclampsia/Pre-eclampsia Guideline]

10. For febrile seizures, consider the following interventions after stopping the seizure. Please note

that the administration of nonsteroidal anti-inflammatory medications is contraindicated in

infants less than 6 months of age. The following interventions provide symptomatic relief for

fevers, but do not stop the seizure:

b. Acetaminophen 15 mg/kg, maximum dose 650 mg, PR/IV/IO (if unable to swallow) or PO

(if able to swallow)

AND/OR

c. Ketorolac 1 mg/kg, maximum dose 15 mg, IV (if unable to swallow) OR Ibuprofen 10

mg/kg, maximum dose 600 mg, PO (if able to swallow)

AND/OR

d. Removing excessive layers of clothing

AND/OR

e. Applying cool compresses to the body

11. Consider acquiring a 12-lead EKG following cessation of seizure in patients without a history of

seizure to determine possible cardiac cause

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Patient Safety Considerations

1. Trained personnel should be able to give medication without contacting medical direction,

however, more than two doses of benzodiazepines are associated with high-risk of airway

compromise

a. Use caution, weigh risks/benefits of deferring treatment until hospital, and/or consider

consultation with medical direction if patient has received two doses of benzodiazepines by

bystanders and/or prehospital clinicians

2. Hypoglycemic patients who are treated in the field for seizure should be transported to hospital,

regardless of whether they return to baseline mental status after treatment

Notes/Educational Pearls

Key Considerations

1. Many airway/breathing issues in seizing patients can be managed without intubation or

placement of an advanced airway. Reserve these measures for patients that fail less invasive

maneuvers as noted above

2. For children with convulsive status epilepticus requiring medication management in the

prehospital setting, trained EMS personnel should be allowed to administer medication without

medical direction

3. For new onset seizures or seizures that are refractory to treatment, consider other potential

causes including, but not limited to, trauma, stroke, electrolyte abnormality, toxic ingestion,

pregnancy with eclampsia, hyperthermia

4. A variety of safe and efficacious doses for benzodiazepines have been noted in the literature for

seizures

a. The doses for anticonvulsant treatment noted above are those that are common to the forms

and routes of benzodiazepines noted in this guideline

b. One dose, rather than a range, has been suggested to standardize a common dose in

situations when an EMS agency may need to switch from one type of benzodiazepine to

another due to cost or resource limitations

5. Recent evidence supports the use of midazolam IM as an intervention that is at least as safe and

effective as intravenous lorazepam for prehospital seizure cessation

Pertinent Assessment Findings

The presence of fever with seizure in children less than 6 months old and greater than 6 years

old is not consistent with a simple febrile seizure, and should prompt evaluation for meningitis,

encephalitis, or other cause

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914141 – Medical - Seizure

Key Documentation Elements

• Actively seizing during transport and time of seizure onset/cessation

• Onset, focality, direction of eye deviation

• Concurrent symptoms of apnea, cyanosis, vomiting, bowel/bladder incontinence, or fever

• Medication amounts/routes given by bystanders or prehospital clinicians

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• Neurologic status (GCS, nystagmus, pupil size, focal neurologic deficit, or signs of stroke)

• Blood glucose level

Performance Measures

•

Frequency of performing glucometry

•

Time to administration of anticonvulsant medication

•

Rate of respiratory failure

•

Rate of seizure recurrence

References

1. Alldredge BK, Gelb AM, Isaacs SM, et al. A comparison of lorazepam, diazepam, and placebo for

the treatment of out-of-hospital status epilepticus. N Engl J Med. 2001;345(9):631–7

2. Alldredge BK, Wall DB, Ferriero DM. Effect of prehospital treatment on the outcome of status

epilepticus in children. Pediatr Neurol. 1995;12(3):213–6

3. Appleton R, Sweeney A, Choonara I, Robson J, Molyneux E. Lorazepam versus diazepam in the

acute treatment of epileptic seizures and status epilepticus. Dev Med Child Neurol.

1995;37(8):682–8

4. Arya R, Gulati S, Kabra M, Sahu JK, Kalra V. Intranasal versus intravenous lorazepam for control of

acute seizures in children: a randomized open-label study. Epilepsia. 2011;52(4):788–93

5. Bhattacharyya M, Kalra V, Gulati S. Intranasal midazolam vs rectal diazepam in acute childhood

seizures. Pediatr Neurol. 2006;34(5):355–9

6. Cain E, Ackroyd-Stolarz S, Alexiadis P, Murray D. Prehospital hypoglycemia: the safety of not

transporting treated patients. Prehosp Emerg Care. 2003;7(4):458–65

7. Chamberlain JM, Altieri MA, Futterman C, Young GM, Ochsenschlager DW, Waisman Y. A

prospective, randomized study comparing intramuscular midazolam with intravenous diazepam

for the treatment of seizures in children. Pediatr Emerg Care. 1997;13(2):92–4

8. Chin RF, Neville BG, Peckham C, Wade A, Bedford H, Scott RC. Treatment of community-onset,

childhood convulsive status epilepticus: a prospective, population-based study. Lancet Neurol.

2008;7(8):696–703

9. Fisgin T, Gurer Y, Tezic T, et al. Effects of intranasal midazolam and rectal diazepam on acute

convulsions in children: prospective randomized study. J Child Neurol. 2002;17(2):123–6

10. Frascone RJ, Jensen J, Wewerka SS, Salzman JG. Use of the pediatric EZ-IO needle by emergency

medical services providers. Pediatr Emerg Care. 2009;25(5):329–32

11. Galustyan SG, Walsh-Kelly CM, Szewczuga D, Bergholte J, Hennes H. The short-term outcome of

seizure management by prehospital personnel: a comparison of two protocols. Pediatr Emerg

Care. 2003;19(4);221–5

12. Holliman CJ, Wuerz RC, Vazquez-de Miguel G, Meador SA. Comparison of interventions in

prehospital care by standing orders versus interventions ordered by direct (online) medical

command. Prehosp Disaster Med. 1994;9(4):202–9

13. Holsti M, Dudley N, Schunk J, et al. Intranasal midazolam vs rectal diazepam for the home

treatment of acute seizures in pediatric patients with epilepsy. Arch Pediatr Adolesc Med.

2010;164(8):747–53

14. Lahat E, Goldman M, Barr J, Bistritzer T, Berkovitch M. Comparison of intranasal midazolam with

intravenous diazepam for treating febrile seizures in children: prospective randomized study. Br

Med J. 2000;321(7253):83–6

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15. Lamhaut L, Dagron C. Comparison of intravenous and intraosseous access by pre-hospital medical

emergency personnel with and without CBRN protective equipment. Resuscitation.

2010;81(1):65–8

16. Mahmoudian T, Zadeh MM. Comparison of intranasal midazolam with intravenous diazepam for

treating acute seizures in children. Epilepsy Behav. 2004;5(2):253–5

17. McIntyre J, Robertson S, Norris E, et al. Safety and efficacy of buccal midazolam versus rectal

diazepam for emergency treatment of seizures in children: a randomized controlled trial. Lancet.

2005;366(9481):205–10

18. McMullan J, Sasson C, Pancioli A, Silbergleit R. Midazolam versus diazepam for the treatment of

status epilepticus in children and young adults: a meta-analysis. Acad Emerg Med.

2010;17(6):575–82

19. Mittal P, Manohar R, Rawat AK. Comparative study of intranasal midazolam and intravenous

diazepam sedation for procedures and seizures. Indian J Pediatr. 2006;73(11):975–8

20. Mpimbaza A, Ndeezi G, Staedke S, Rosenthal PJ, Byarugaba J. Comparison of buccal midazolam

with rectal diazepam in the treatment of prolonged seizures in Ugandan children: a randomized

clinical trial. Pediatrics. 2008;121(1):58–64

21. Muchohi SN, Kokwaro GO, Ogutu BR, et al. Pharmacokinetics and clinical efficacy of midazolam in

children with severe malaria and convulsions. Br J Clin Pharmacol. 2008;66(4):529–38

22. Muchohi SN, Obiero K, Newton CR, et al. Pharmacokinetics and clinical efficacy of lorazepam in

children with severe malaria and convulsions. Br J Clin Pharmacol. 2008;65(1):12–21

23. Rainbow J, Browne GJ, Lam LT. Controlling seizures in the prehospital setting: diazepam or

midazolam? J Paediatr Child Health. 2002;38(6):582–6

24. Schwartz D, Amir L, Dichter R, et al. The use of a powered device for intraosseous drug and fluid

administration in a national EMS: a 4-year experience. J Trauma. 2008;64(3):650–5

25. Shah I, Deshmukh CT. Intramuscular midazolam vs. intravenous diazepam for acute seizures.

Indian J Pediatr. 2005;72(8):667–70

26. Shah MI, Macias CG, Dayan PS, et al. An evidence-based guideline for pediatric prehospital

seizure management using GRADE methodology. Prehosp Emerg Care. 2014;18 Suppl 1:15–24

27. Silbergleit R, Durkalski V, Lowenstein D, et al. Intramuscular versus intravenous therapy for

prehospital status epilepticus. N Engl J Med. 2012;366(7):591–600

28. Silbergleit R, Durkalski V, Lowenstein D, et al; NETT Investigators. Intramuscular versus

intravenous therapy for prehospital status epilepticus. N Engl J Med. 2012;366(7):591–600

29. Silbergleit R et al. RAMPART (rapid anticonvulsant medication prior to arrival trial): a double-blind

randomized clinical trial of the efficacy of IM midazolam versus IV lorazepam in the pre-hospital

treatment of status epilepticus by paramedics. Epilepsia. 2011;52 Suppl 8:45–7

30. Sporer KA, Johnson NJ. Detailed analysis of prehospital interventions in medical priority dispatch

system determinants. West J Emerg Med. 2011;12(1):19–29

31. Sreenath TG, Gupta P, Sharma KK, Krishnamurthy S. Lorazepam versus diazepam-phenytoin

combination in the treatment of convulsive status epilepticus in children: a randomized

controlled trial. Eur J Paediatr Neurol. 2010;14(2):162–8

32. Talukdar B, Chakrabarty B. Efficacy of buccal midazolam compared to intravenous diazepam in

controlling convulsions in children: a randomized control trial. Brain Dev. 2009;31(10):744–9

33. Vilke GM, Sharieff GQ, Marino A, Gerhart AE, Chan TC. Midazolam for the treatment of out-of-

hospital pediatric seizures. Prehosp Emerg Care. 2002;6(2):215–7

34. Wuerz RC, Swope GW, Holliman J, Vazquez-de Miguel G. Online medical direction: a prospective

study. Prehosp Disaster Med. 1995;10(3):51–4

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35. Zarate L, Mandleco B, Wilshaw R, Ravert P. Peripheral intravenous catheters started in

prehospital and emergency department settings. J Trauma Nurs. 2008;15(2):47–52

Revision Date

March 11, 2022

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Shock

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based Guideline

Model Process)

Aliases

None noted

Patient Care Goals

1. Initiate early fluid resuscitation and vasopressors to maintain/restore adequate perfusion to

vital organs

2. Differentiate between possible underlying causes of shock to promptly initiate additional

therapy

Patient Presentation

Inclusion Criteria

1. Signs of poor perfusion (due to a medical cause) such as one or more of the following:

a. Altered mental status

b. Delayed capillary refill (> 3 seconds)

c. Flash capillary refill (> 1 second) seen in early septic shock

d. Decreased urine output

e. Respiratory rate greater than 20 breaths per minute in adults or elevated in children (See

normal vital signs table)

f. Hypotension for age (lowest acceptable systolic blood pressure in mmHg):

i. Less than 1 years of age: 60

ii. 1–10 years old: (age in years) (2) + 70

iii. Greater than 10 years old: 90

g. Tachycardia or bradycardia for age, out of proportion to temperature [See Appendix

VIII. Abnormal Vital Signs]

h. Weak, decreased or bounding pulses

i. Cool/mottled or flushed/ruddy skin

2. Potential etiologies of shock:

a. Hypovolemic (hemorrhagic or non-hemorrhagic)

b. Distributive (sepsis, anaphylaxis, neurogenic, overdose, endocrine)

c. Cardiogenic (cardiomyopathy, dysrhythmia, valve disorder)

d. Obstructive (pulmonary embolism (PE), tension pneumothorax, cardiac tamponade)

e. Combined (one form causing another)

Exclusion Criteria

Shock due to suspected trauma [See Trauma Section]

Patient Management

Assessment

1. History

a. History of GI bleeding

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b. Cardiac problems

c. Stroke

d. Fever

e. Nausea/vomiting, diarrhea

f. Frequent or no urination

g. Syncopal episode

h. Allergic reaction

i. Immunocompromise (malignancy, transplant, asplenia)

j. Adrenal insufficiency

k. Presence of a central line or port

l. Other risk of infection (spina bifida or other genitourinary anatomic abnormality)

m. Overdose

2. Exam

a. Airway/breathing (airway edema, rales, wheezing, pulse oximetry, respiratory rate)

b. Circulation (heart rate, blood pressure, capillary refill)

c. Abdomen (hepatomegaly)

d. Mucous membrane hydration

e. Skin (turgor, rash)

f. Neurologic (GCS, sensorimotor deficits)

3. Determination of type of shock

a. Cardiogenic

b. Distributive (neurogenic, septic, anaphylactic)

c. Hypovolemic

d. Obstructive (e.g., pulmonary embolism, cardiac tamponade, tension pneumothorax)

Treatment and Interventions

1. Check vital signs

2. Administer oxygen as appropriate with a target of achieving 94–98% saturation

3. Cardiac monitor

Pulse oximetry and

EtCO

(reading of less than 25 mmHg may be sign of poor perfusion)

5. Check blood sugar, and correct if less than 60 mg/dL

6. EKG

7. Check lactate, if available (greater than 2 mmol/L is abnormal)

8. Establish IV access. If unable to obtain within two attempts or less than 90 seconds, place an

IO needle

9. IV fluid volume goal attained by giving boluses that are pressure infused over less than 15

minutes each based on patient’s condition and clinical impression. Fluid volume goal to

achieve a mean arterial pressure (adults) or other targets (pediatrics). Mean Arterial

Pressure is calculated: (MAP = [(2X diastolic) + (systolic]/3)

a. Adult

i. Physiologic target: MAP goal 65 mmHg

ii. Fluid goal of up to 30 mL/kg of isotonic fluid by administering rapid, predetermined

boluses (e.g., 500 mL) unless the MAP goal is achieved, or pulmonary edema

develops.

iii. If available, the administration of packed red blood cells or whole blood may be

indicated for hemorrhagic shock

b. Pediatric

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i. Physiologic targets: Systolic blood pressure at least fifth percentile for age, strong

distal pulses, warm skin perfusion, capillary refill less than 2 seconds and improving

mental status.

ii. Fluid goal of up to a total of 60 mL/kg or 1 liter of isotonic fluid by giving 20 mL/kg

of isotonic fluid by administering rapid boluses (for cardiogenic shock give 10

mL/kg boluses)

iii. If available, the administration of packed red blood cells or whole blood may be

indicated for hemorrhagic shock

10. If there is a history of adrenal insufficiency, long-term steroid dependence, or fluid-refractory

shock requiring vasopressors give:

a. Hydrocortisone succinate, 2 mg/kg (maximum 100 mg) IV/IM (preferred)

b. Methylprednisolone 2 mg/kg IV (maximum 125 mg)

c. Dexamethasone 0.6 mg/kg IV/IM (maximum dose of 16 mg)

11. Vasopressors (shock unresponsive to IV fluids) titrated to physiologic targets

a. Cardiogenic, hypovolemic, obstructive shock and distributive shock:

i. Norepinephrine 0.05–0.5 mcg/kg/minute

1. Preference in both neurogenic and infectious (sepsis) causes of distributive

shock

ii. Epinephrine, 0.05–0.3 mcg/kg/minute

1. Alternative to a drip, push dose epinephrine may be administered:

a. Prepare 10 mcg/mL by diluting 1 mL of epinephrine 0.1 mg/mL (1:10,000) in 9 mL

of normal saline

b. Administer 0.01 mg/kg (0.1 mL/kg) up to a maximum single dose of 10 mcg (1

mL) q 3–5 minutes titrated to maintain goal MAP. An example is shown below:

• 10 kg child receives 1 mL of the diluted epinephrine

• 20 kg child receives 2 mL of the diluted epinephrine

• 30 kg child receives 3 mL of the diluted epinephrine

iii. Dopamine, 2–20 mcg/kg/minute if norepinephrine or epinephrine is not available or for

other specific causes of shock.

12. For anaphylactic shock, treat per the Anaphylaxis and Allergic Reaction Guideline

13. Provide advanced notification to the hospital

14. Consider empiric antibiotics for suspected septic shock if transport time is anticipated to be

prolonged, if blood cultures can be obtained in advance, and/or EMS has coordinated with

regional receiving hospitals about choice of antibiotic therapy

15. Antipyretics for fever – nonsteroidal anti-inflammatory agents are contraindicated in infants less

than 6 months of age

a. Acetaminophen (15 mg/kg; maximum dose of 1000 mg)

b. Ibuprofen (10 mg/kg; maximum dose of 800 mg)

Patient Safety Considerations

Recognition of cardiogenic shock - If the patient condition deteriorates after fluid administration,

rales or hepatomegaly develop, then consider cardiogenic shock and withholding further fluid

administration

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Notes/Educational Pearls

Key Considerations

1. Early, aggressive IV fluid administration is essential in the treatment of suspected septic shock

2. Patients predisposed to shock:

a. Immunocompromised (patients undergoing chemotherapy or with a primary or

acquired immunodeficiency)

b. Adrenal insufficiency (Addison's disease, congenital adrenal hyperplasia, chronic or

recent steroid use)

c. History of a solid organ or bone marrow transplant

d. Infants

e. Elderly

3. In most adults, tachycardia is the first sign of compensated shock, and may persist for hours.

Tachycardia can be a late sign of shock in children and a tachycardic child may be close to

cardiovascular collapse

4. Hypotension indicates uncompensated shock, which may progress to cardiopulmonary

failure within minutes. Hypotension is a late and ominous sign in pediatric

uncompensated shock

5. Hydrocortisone succinate, if available, is preferred over methylprednisolone and

dexamethasone for the patient with adrenal insufficiency because of its dual glucocorticoid

and mineralocorticoid effects

a. Patients with no reported history of adrenal axis dysfunction may have adrenal

suppression due to their acute illness, and hydrocortisone should be considered for any

patient showing signs of treatment-resistant shock

b. Patients with adrenal insufficiency may have an emergency dose of hydrocortisone

available that can be administered IV or IM

Pertinent Assessment Findings

1. Decreased perfusion manifested by altered mental status, or abnormalities in capillary refill or

pulses, decreased urine output (1 mL/kg/hr):

a. Cardiogenic, hypovolemic, obstructive shock: capillary refill greater than 2 seconds,

diminished peripheral pulses, mottled cool extremities

b. Distributive shock: flash capillary refill, bounding peripheral pulses

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914127 – Medical - Hypotension/Shock (Non-Trauma)

Key Documentation Elements

• Medications administered

• Full vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) with

reassessment q 15 minutes or more frequently as appropriate

• Lactate level (if available)

• Neurologic status assessment [See Appendix VII. Neurologic Status Assessment]

• Amount of fluids given

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Performance Measures

•

Percentage of patients who have full vital signs (pulse, blood pressure, respiratory rate,

neurologic status assessment), temperature and O

saturation) documented

•

Presence of a decision support tool (laminated card, a protocol, or electronic alert) to identify

patients in shock

•

Percentage of patients with suspected shock for whom advanced notification to the hospital was

provided

•

Mean time from abnormal vitals to initiation of a fluid bolus

•

Percentage of patients who receive pressors for ongoing hypotension after receiving 30 mL/kg

isotonic fluid in the setting of shock

References

1. Annane D, Bellissant E, Bollaert P, Briegel J, Keh, D, Kupfer Y. Corticosteroids for treating

severe sepsis and septic shock. 2004. Cochrane Database Syst Rev. 2004;(1):CD002243

2. Band, RA, Gaieski DF, Hylton JH, Shofer FS, Goyal M, Meisel ZF. Arriving by emergency

medical services improves time to treatment endpoints for patients with severe sepsis or

septic shock. Acad Emerg Med. 2011;18(9):934–40

3. Bernardin G, Pradier C, Tiger F, Deloffre P, Mattei M. Blood pressure and arterial lactate level

are early indicators of short-term survival in human septic shock. Intensive Care Med.

1996;22(1):17–25

4. Boluyt N, Bollen C, Bos A, Kok J, Offringa M. Fluid resuscitation in neonatal and pediatric

hypovolemic shock: A Dutch Pediatric Society evidence-based clinical practice guideline.

Intensive Care Med. 2006;32(7):995–1003

5. Brierley J, Carcillo JA, Choong K, et al. Clinical practice parameters for hemodynamic support of

pediatric and neonatal patients in septic shock. Crit Care Med. 2009;37(2):666–8

6. Carcillo JA, Davis AL, Zaritsky A. Role of early fluid resuscitation in pediatric septic shock. JAMA.

1991;266(9):1242–5

7. Choong K, Bohn D, Fraser DD, et al. Vasopressin in pediatric vasodilatory shock: a

multicenter randomized controlled trial. Am J Respir Crit Care Med. 2009;180(7):632–9

8. Chopra A, Kumar V, Dutta A. Hypertonic versus normal saline as initial fluid bolus in pediatric

septic shock. Indian J Pediatr. 2011;78(7):833–7

9. Cronin L, Cook DJ, Carlet J, et al. Corticosteroid treatment for sepsis: a critical appraisal and

meta-analysis of the literature. Crit Care Med. 1995;23(8):1430–9

10. Cruz AT, Perry AM, Williams EA, Graf JM, Wuestner ER, Patel B. Implementation of goal-

directed therapy for children with suspected sepsis in the emergency department. Pediatrics.

2011;127(3): e758–66

11. De Backer D, Aldecoa C, Njimi H, Vincent J. Dopamine versus norepinephrine in the treatment of

septic shock: a meta-analysis. Crit Care Med. 2011;13(6):1–6

12. De Backer D, Biston P, Devriendt J, et al. Comparison of dopamine and norepinephrine in the

treatment of shock. N Engl J Med. 2010;362(9):779–89

13. Guyette F, Suffoletto B, Castillo JL, Quintero J, Callaway C, Puyana, JC. Prehospital serum

lactate as a predictor of outcomes in trauma patients: a retrospective observational study. J

Trauma. 2011;70(4):782–6

14. Guyette FX, Gomez H, Suffoletto B, et al. Prehospital dynamic tissue oxygen saturation response

predicts in-hospital lifesaving interventions in trauma patients. J Trauma Acute Care Surg.

2012;72(4):930–5

15. Han YY, Carcillo JA, Dragotta MA, et al. Early reversal of pediatric-neonatal septic shock by

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community physicians is associated with improved outcome. Pediatrics. 2013;112(4):793–9

16. Hartholt KA, van Lieshout EM, Thies WC, Patka P, Schipper IB. Intraosseous devices: a

randomized controlled trial comparing three intraosseous devices. Prehosp Emerg Care.

2010;14(1):6–13

17. Howell MD, David AM. Management of sepsis and septic shock. JAMA. 2017;317(8):847–8

18. Hunter CL, Silvestri S, Dean M, Falk JL, Papa L. End-tidal carbon dioxide is associated with

mortality and lactate in patients with suspected sepsis. Am J Emerg Med (2013) 31, 64–71

19. Jansen TC, van Bommel J, Mulder PG, Rommes JH, Schieveld SJ, Bakker, J. The prognostic

value of blood lactate levels relative to that of vital signs in the pre-hospital setting: a pilot

study. Crit Care. 2008;12(6): R160

20. Kumar A, Roberts D, Wood KE, et al. Duration of hypotension before initiation of effective

antimicrobial therapy is the critical determinant of survival in human septic shock. Crit Care

Med. 2006;34(6):1589–96

21. Lampard JG, Lang E. Vasopressors for hypotensive shock. Ann Emerg Med. 2013;31(3):351–2

22. Larsen GY, Mecham N, Greenberg R. An emergency department septic shock protocol and

care guideline for children initiated at triage. Pediatrics. 2011;127(6): e1585–92

23. Levy B, Bastien O, Karim B, et al. Experts’ recommendations for the management of adult

patients with cardiogenic shock. Ann Intensive Care. 2015;5(1):17

24. Lillis KA, Jaffe DM. Prehospital intravenous access in children. Ann Emerg Med.

1992;21(12):1430–4

25. Martin C, Papazian L, Perrin G, Saux P, Gouin F. Norepinephrine or dopamine for the

treatment of hyperdynamic septic shock? Chest. 1993;103(6):1826–31

26. Martin C, Viviand X, Leone M, Thirion X. Effect of norepinephrine on the outcome of septic

shock. Crit Care Med. 2000;28(8):2758–65

27. Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in

severe sepsis independent of organ failure and shock. Crit Care Med. 2009;37(5):1670–7

28. Morimatsu H, Singh K, Uchino S, Bellomo R, Hart G. Early and exclusive use of norepinephrine in

septic shock. Resuscitation. 2004;62(2):249–54

29. Nawrocki PS, Poremba M, Lawner BJ. Push dose epinephrine use in the management of

hypotension during critical care transport. Prehosp Emerg Care. 2020;24(2):188–95.

//doi.org/10.1080/10903127.2019.1588443.

30. Oliveira CF, Nogueira de Sá FR, Oliveira DS, et al. Time- and fluid-sensitive resuscitation for

hemodynamic support of children in septic shock: barriers to the implementation of the

American College of Critical Care Medicine/Pediatric Advanced Life Support Guidelines in a

pediatric intensive care unit in a developing world. Pediatr Emerg Care. 2008;24(12):810–5

31. Patel GP, Grahe JS, Sperry M, et al. Efficacy and safety of dopamine versus norepinephrine in

the management of septic shock. Shock. 2010;33(4):375–80

32. Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines

for management of sepsis and septic shock: 2016. Intensive Care Med. Epub 2017 Jan 18

33. Santhanam I, Sangareddi S, Venkataraman S, Kissoon N, Thiruvengadamudayan V, Kasthuri

RK. A prospective randomized controlled study of two fluid regimens in the initial

management of septic shock in the emergency department. Pediatr Emerg Care.

2008;24(10):647–55

34. Sebat F, Johnson D, Musthafa AA, et al. A multidisciplinary community hospital program for

early and rapid resuscitation of shock in nontrauma patients. Chest. 2005;127(5):1729–43

35. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients

with severe sepsis: a cohort study. J Crit Care. 2010;25(4):553–62

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36. Shapiro NI, Howell MD, Talmor D, et al. Implementation and outcomes of the multiple urgent

sepsis therapies (MUST) protocol. Crit Care Med. 2006;34(4):1025–32

37. Sholl JM, Chung S, Prentiss S, Smith JM, Shah MI. An evidence-based guideline for pediatric

prehospital shock management using GRADE methodology. Manuscript in preparation

38. Studnek JR, Artho MR, Garner CL Jr., Jones AE. The impact of emergency medical services on

the ED care of severe sepsis. Am J Emerg Med. 2012;30(1):51–6

39. Trzeciak S, Dellinger RP, Chansky ME, et al. Serum lactate as a predictor of mortality in

patients with infection. Intensive Care Med. 2007;33(6):970–7

40. Up To Date. Evaluation of and Initial approach to the adult patient with undifferentiated

hypotension and shock. Accessed May 27, 2021

41. Up To Date. Initial management of shock in children. Accessed May 27, 2021

42. Van Beest PA, Mulder PJ, Oetomo SB, van den Broek B, Kuiper MA, Spronk PE. Measurement of

lactate in a prehospital setting is related to outcome. Eur J Emerg Med. 2009;16(6):318–22

Revision Date

March 11, 2022

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Sickle Cell Pain Crisis

Aliases

None noted

Patient Care Goals

1. Identify potentially life-threatening complications of a sickle cell disease

2. Improve patient comfort

Patient Presentation

Inclusion Criteria

Patient with known sickle cell disease experiencing a pain crisis

Exclusion Criteria

1. Pain due to acute traumatic injury [See Trauma Section]

2. Abdominal pain due to or related to pregnancy [See OB/GYN Section]

3. Patients with sickle cell trait

Patient Management

Assessment

1. Perform airway assessment and management per the Airway Management Guideline

2. Obtain vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) and

pulse oximetry

3. Provide evaluation and management of altered mental status per the Altered Mental Status

Guideline

4. Provide evaluation and management of pain per the Pain Management Guideline

5. Obtain vascular access as necessary to provide analgesia and/or fluid resuscitation

6. Assess for potentially serious complications other than pain crisis which may include:

a. Acute chest syndrome

i. Hypoxia

ii. Chest pain

iii. Fever

b. Stroke [See Suspected Stroke/Transient Ischemic Attack Guideline]

i. Focal neurologic deficits

c. Meningitis

i. Headache

ii. Altered mental status

iii. Fever

d. Septic arthritis

i. Severe pain in a single joint

ii. Fever

e. Splenic sequestration crisis (usually young pediatric patients)

i. Abdominal pain, LUQ

ii. Splenic enlargement (examine with care)

iii. Hypotension, tachycardia

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f. Severe anemia

i. Pallor

ii. Fatigue

iii. Dyspnea or dyspnea on exertion

iv. Shock

g. Infections

i. Pneumonia (cough, fever, sputum shortness of breath)

h. Priapism

i. Painful, prolonged erection in the absence of sexual activity

i. Venous thromboembolism

i. Calf pain, tenderness, swelling, chest/back pain especially with inspiration, shortness of

breath

7. Assess for signs of shock – If shock is present, treat per Shock Guideline

Treatment and Interventions

1. Medication Administration:

a. Provide analgesia per the Pain Management Guideline

b. Start oxygen by nasal cannula if hypoxic

c. Start an IV and provide saline 10 mL/kg normal saline bolus (up to 1 L)

d. Provide transport to an appropriate receiving facility.

e. Reassess vital signs and response to therapeutic interventions throughout transport

2. Comfort measures:

a. Keep patient warm and dry

b. Transport in a position of comfort unless clinical condition requires otherwise

Patient Safety Considerations

None noted

Notes/Educational Pearls

Key Considerations

1. Assess for life-threatening complications of sickle cell disease – these patients have significantly

higher risk of numerous complications in addition to pain crises

2. Provide appropriate treatment for pain, respiratory distress, and shock

3. These patients may have a higher tolerance to narcotic pain medications if they are taking them

on a regular basis

4. These patients will tolerate acute blood loss poorly due to baseline anemia

5. Patients with sickle cell trait can have acute pain crises in extreme conditions (e.g., heat

exhaustion, dehydration) and several college athlete deaths have been linked to sickle cell trait

Pertinent Assessment Findings

1. Lung exam and assessment of respiratory distress

2. Altered mental status

3. Focal neurologic deficits

4. Inability to move a joint

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914165 – Other

Key Documentation Elements

• Documentation of normal respiratory and neuro status

• Documentation of how this pain crisis compares with others in terms of location, severity, and

triggers

• Documentation of home pain medications used

Performance Measures

• Assessment for life-threatening etiology

• Mitigation of pain per the Pain Management Guideline

Reference

1. Cintho Ozahata M, Page GP, Guo Y, et al. Clinical and Genetic Predictors of Priapism in Sickle Cell

Disease: Results from the Recipient Epidemiology and Donor Evaluation Study III Brazil Cohort

Study. J Sex Med 2019; 16:1988

2. Mitchell BL. Sickle cell trait and sudden death – bringing it home. J Natl Med Assoc.

2007;99(3):300–5

Revision Date

March 11, 2022

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Resuscitation

Cardiac Arrest (VF/VT/Asystole/PEA)

Aliases

Arrest Full arrest Heart attack

Patient Care Goals

1. Return of spontaneous circulation (ROSC)

2. Preservation of neurologic function

3. High-quality chest compressions/CPR with minimal interruption from recognition of cardiac

arrest until confirmation of ROSC or field termination of care

Patient Presentation

Inclusion Criteria

Patients with cardiac arrest

Exclusion Criteria

1. Patients suffering cardiac arrest due to severe hypothermia [See Hypothermia/Cold Exposure

Guideline]

2. Patients with identifiable Do Not Resuscitate (or equivalent such as POLST) order [See Do Not

Resuscitate Status/Advance Directive/Healthcare Power of Attorney (POA) Status Guideline]

3. Patients in arrest due to traumatic etiology [See General Trauma Management Guideline]

Patient Management

Assessment

1. The patient in cardiac arrest requires a prompt balance of treatment and assessment

2. In cases of cardiac arrest, assessments should be focused and limited to obtaining enough

information to reveal the patient is pulseless

3. Once pulselessness is discovered, treatment should be initiated immediately, and any further

history must be obtained by bystanders while treatment is ongoing

Treatment and Interventions

The most important therapies for patients suffering from cardiac arrest are prompt cardiac

defibrillation for shockable rhythms and minimally interrupted effective chest compressions

1. Initiate chest compressions in cases with no bystander chest compressions or take over

compressions from bystanders while a second rescuer is setting up the AED or defibrillator

a. If adequate, uninterrupted bystander CPR has been performed or if the patient arrests in

front of the EMS clinicians, immediately proceed with rhythm analysis and defibrillation, if

appropriate

b. It is realistic for EMS clinicians to tailor the sequence of rescue actions to coincide the

most likely cause of arrest

c. There is insufficient evidence to recommend for or against delaying defibrillation to

provide a period of CPR for patients in VF/pulseless VT out-of-hospital cardiac arrest

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d. For adults and children with unwitnessed cardiac arrest or for whom an AED is not

immediately available, it is reasonable that CPR be initiated while the defibrillator

equipment is being retrieved and applied and that defibrillation, if indicated, be

attempted as soon as the device is ready for use

2. The maximum setting on the defibrillator should be used for initial and subsequent

defibrillation attempts. Defibrillation dosing should follow manufacturer’s recommendation in

the case of biphasic defibrillators. If the manufacturer’s recommendation is unknown, use

highest setting possible. In the case of monophasic devices, the setting should be 360J (joule)

(or 4 J/kg for children)

3. Chest compressions should resume immediately after defibrillation attempts with no pauses

for pulse checks for 2 minutes regardless of the rhythm displayed on the cardiac monitor

4. All attempts should be made to prevent avoidable interruptions in chest compressions, such

as pre-charging the defibrillator and hovering over the chest, rather than stepping away

during defibrillations

5. If feasible, IV or IO access should be obtained. Administer epinephrine during the first or

second round of compressions. Prioritize early administration of epinephrine for non-

shockable rhythms

6. Continue the cycle of chest compressions for 2 minutes, followed by rhythm analysis and

defibrillation of shockable rhythms; during this period, the proper strategy of airway

management is currently not defined and many options for airway management exist.

Regardless of the airway management and ventilation strategy, consider the following

principles:

a. The airway management strategy should not interrupt compressions

b. Successful resuscitation from cardiac arrest depends primarily on effective, minimally

interrupted chest compressions and prompt defibrillation if the patient is in pulseless

VT/VF. As opposed to children, an adult’s airway management is of secondary importance

and should not interfere with compressions and defibrillation. Options for airway

management include:

i. Passive ventilation:

1. High flow oxygen is applied via a non-rebreather mask with an oropharyngeal

airway

2. Some oxygen will be entrained with each decompression of the chest

3. This may be applied for the first 3–4 compression cycles (6–8 minutes), after

which one may consider BVM ventilation or placement of an advanced airway

ii. BVM ventilation at 10 breaths per minute (1 breath every 10 compressions), applied

during the upstroke between compressions, without interrupting the compressions

iii. BVM ventilation with 30:2 ventilation to compression ratio: Each 30 compressions, the

compressions are paused briefly to allow 2 BVM ventilations, then compressions

immediately resumed

1. Pediatric Consideration: For multiple rescuer CPR in children, 15:2 is the

recommended compression-to-ventilation ratio (30:2 for single rescuer)

2. Pediatric Consideration: For neonates, 3:1 is the recommended compression-to-

ventilation ratio

iv. Advanced airway placement:

1. Either a supraglottic airway or an endotracheal tube may be placed without

interruption of compressions

2. Ventilations are provided at 10 breaths/minute for adults

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3. Pediatric Consideration: for children, 1 breath every 3–5 seconds is

recommended (12–20 breaths/minute)

4. Pediatric Consideration: deliver volume needed to achieve chest rise

7. Consider use of antiarrhythmic for recurrent VF/Pulseless VT

a. The principal objective of antiarrhythmic drug therapy in shock-refractory VF and

pulseless VT is to facilitate the restoration and maintenance of a spontaneous perfusing

rhythm in concert with the shock termination of VF/VT; some antiarrhythmic drugs have

been associated with increased rates of ROSC and hospital admission, but none have yet

been proven to increase long-term survival or survival with good neurologic outcome

i. Amiodarone (5 mg/kg IV, max of 300 mg) may be considered for VF/pulseless VT that

is unresponsive to CPR, defibrillation, and a vasopressor therapy

ii. Lidocaine (1 mg/kg IV) may be considered as an alternative to amiodarone for

VF/pulseless VT that is unresponsive to CPR, defibrillation, and vasopressor therapy

iii. The routine use of magnesium for VF/pulseless VT is not recommended in adult

patients unless it is refractory, polymorphic VT, or Torsades de pointes.

b. There is inadequate evidence to support the routine use of lidocaine and beta-blockers

after cardiac arrest by EMS. There is insufficient evidence to recommend for or against the

routine initiation or continuation of other antiarrhythmic medications after ROSC from

cardiac arrest

c. For torsades de pointes, give magnesium sulfate 2 g IV administered over 1–2 minutes (or

25–50 mg/kg for pediatrics). There is insufficient evidence to recommend for or against

the routine administration during cardiac arrest

8. Consider reversible causes of cardiac arrest which include the following:

a. Hypothermia – additions to care include attempts at active rewarming [See

Hypothermia/Cold Exposure Guideline]

b. The dialysis patient/known hyperkalemic patient – Additions to care include the following:

i. Calcium gluconate 10% 1 g IV bolus over 2 minutes (for pediatrics, the dose is 100

mg/kg which is 1 mL/kg), can repeat the dose if no response

ii. Calcium chloride 10% 1 g IV bolus over 2 minutes (for pediatrics, the dose is 20 mg/kg

which is 0.2 mL/kg)

iii. Sodium bicarbonate 1 mEq/kg IV

c. Tricyclic antidepressant overdose. Additions to care include sodium bicarbonate 1 mEq/kg

d. Hypovolemia. Additions to care include normal saline 2 L IV (or 20 mL/kg, repeated up to

3 times for pediatrics)

e. If the patient is intubated at the time of arrest, assess for tension pneumothorax and

misplaced ETT

f. If tension pneumothorax suspected, perform needle decompression. Assess ETT, if

misplaced, replace ETT

9. If at any time during this period of resuscitation the patient regains return of spontaneous

circulation, treat per Adult Post-ROSC (Return of Spontaneous Circulation) Care Guideline

10. If resuscitation remains ineffective, consider termination of resuscitation [See Termination of

Resuscitative Efforts Guideline]

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Patient Safety Considerations

1. Performing manual chest compressions in a moving vehicle may pose a clinician safety

concern

2. In addition, manual chest compressions during patient movement are less effective in regard

to hands on time, depth, recoil and rate

3. Ideally, patients should be resuscitated as close to the scene as operationally possible

4. Risks and benefits should be considered before patient movement in cardiac arrest situations

Notes/Educational Pearls

Key Considerations

1. Effective chest compressions and defibrillation are the most important therapies to the

patient in cardiac arrest. Effective chest compressions are defined as:

a. A rate of greater than 100 and less than 120 compressions/minute

b. Depth of at least 2 inches (5 cm) and less than 2.4 inches (6 cm) for adults and children or

1.5 inches (4 cm) for infants; adolescents who have entered puberty should receive the

same depth of chest compressions as an adult

c. Allow for complete chest recoil (avoid leaning)

d. Minimize interruptions in compressions

e. Avoid rescuer fatigue by rotating rescuers at least every 2 minutes. Some EMS pit crew

approaches use a clinician on either side of the chest, alternating compressions every

minute or every 100 compressions to avoid fatigue

2. Avoid excessive ventilation and consider delayed airway management – If no advanced

airway, consider:

a. Passive ventilation using an NRB with 3–4 cycles of uninterrupted chest compressions (for

arrests of suspected cardiac etiology). Consider BVM ventilation or advanced airway after

3–4 cycles

b. BVM ventilation every 10–15 compressions with cycles of uninterrupted chest

compressions. Upstroke ventilation between compressions.30:2 ventilation to

compression ratio for adults, and 15:2 for children when 2 rescuers are present

c. If an advanced airway is placed, ventilations should not exceed 10 breaths/minute (1

breath every 6 seconds or 1 breath every 10 compressions) in adults. Pediatric

Consideration: For children with an advanced airway, 1 breath every 3–5 seconds is

recommended (equivalent to 12–20 breaths/minute)

3. Quantitative end-tidal capnography (EtCO

) should be used to monitor effectiveness of chest

compressions

a. If EtCO

less than 10 mmHg during the initial phases of resuscitation, attempt to improve

chest compression quality

b. Consider additional monitoring with biometric feedback which may improve compliance

with suggested Resuscitation Section

4. Chest compressions are usually the most rapidly applied therapy for the patient in cardiac

arrest and should be initiated as soon as the patient is noted to be pulseless. If the patient is

being monitored with pads in place at the time of arrest, immediate defibrillation should take

precedence over all other therapies. However, if there is any delay in defibrillation (e.g., in

order to place pads), chest compressions should be initiated while the defibrillator is being

applied. There is no guidance on how long these initial compressions should be applied;

however, it is reasonable to either complete between 30 seconds and 2 minutes of chest

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compressions in cases of no bystander chest compressions or to perform defibrillation as soon

as possible after chest compressions initiated in cases of witnessed arrest

5. There is insufficient evidence to recommend the routine use of extracorporeal CPR (ECPR) for

patients with cardiac arrest. In settings where it can be rapidly implemented, ECPR may be

considered for select cardiac arrest patients for whom the suspected etiology of the cardiac

arrest is potentially reversible during a limited period of mechanical cardiorespiratory support

6. Chest compressions should be reinitiated immediately after defibrillation as pulses, if present,

are often difficult to detect and rhythm and pulse checks interrupt compressions

7. Continue chest compressions between completion of AED analysis and AED charging

8. The effectiveness of chest compressions decreases when moving patients

a. Patients should therefore be resuscitated as close to the point at which they are first

encountered and should only be moved if the conditions on scene are unsafe or do not

operationally allow for resuscitation

b. Chest compressions are also less effective in a moving vehicle

c. It is also dangerous to EMS clinicians, patients, pedestrians, and other motorists to

perform chest compressions in a moving ambulance

d. For these reasons and because in most cases the care provided by EMS clinicians is

equivalent to that provided in emergency departments, resuscitation should occur on

scene

9. The maximum setting on the defibrillator should be used for initial and subsequent

defibrillation attempts. Defibrillation dosing should follow manufacturer’s recommendation in

the case of biphasic defibrillators. If the manufacturer’s recommendation is unknown, use

highest setting possible. In the case of monophasic devices, the setting should be 360 J (joule)

(or 4 J/kg for children)

10. IV or IO access without interrupting chest compressions

11. Administer epinephrine (0.1 mg/kg, maximum dose 1 mg) IV/IO during the first or second

round of compressions

12. At present, the most effective mechanism of airway management is uncertain due to some

systems managing the airway aggressively and others managing the airway with basic

measures and both types of systems finding excellent outcomes. Regardless of the airway

management style, consider the following principles:

a. Airway management should not interrupt chest compressions

b. Carefully follow ventilation rate and prevent hyperventilation

c. Consider limited tidal volumes

d. There is uncertainty regarding the proper goals for oxygenation during resuscitation

i. Current recommendations suggest using the highest flow rate possible through NRB

or BVM

ii. This should not be continued into the post-resuscitation phase in which the goal

should be an oxygen saturation (SpO

) of 94–98%

e. Pediatric Considerations: Special attention should be applied to the pediatric population

and airway management/respiratory support. Given that the most likely cause of cardiac

arrest is respiratory, airway management may be considered early in the patient’s care

i. However, the order of Circulation-Airway-Breathing is still recommended as the order

of priority by the American Heart Association for pediatric resuscitation to ensure

timely initiation of chest compressions to maintain perfusion, regardless of the

underlying cause of the arrest

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ii. In addition, conventional CPR is preferred in children, since it is associated with better

outcomes when compared to compression-only CPR

13. Special Circumstances in Cardiac Arrest

a. Trauma, treat per the General Trauma Management Guideline

b. Pregnancy

i. The best hope for fetal survival is maternal survival

ii. Position the patient in the supine position with a second rescuer performing manual

uterine displacement to the left to displace the gravid uterus and increase venous

return by avoiding aorto-caval compression

iii. If manual displacement is unsuccessful, the patient may be placed in the left lateral tilt

position at 30°. This position is less desirable than the manual uterine displacement as

chest compressions are more difficult to perform in this position

iv. Chest compressions should be performed slightly higher on the sternum than in the

non-pregnant patient to account for elevation of the diaphragm and abdominal

contents in the obviously gravid patient

v. Defibrillation should be performed as in non-pregnant patients

c. Arrests of respiratory etiology (including drowning). In addition to the above, consider

early management of the patient’s airway. Passive ventilation with a NRB is not indicated

for these patients

14. Application of the “pit crew” model of resuscitation

a. Ideally, clinicians in each EMS agency will use a “pit crew” approach when using this

protocol to ensure the most effective and efficient cardiac arrest care. Training should

include teamwork simulations integrating first responders, BLS, and ALS crewmembers

who regularly work together. High-performance systems should practice teamwork using

“pit crew” techniques with predefined roles and crew resource management principles.

For example (the Pennsylvania State EMS Model for Pit Crew):

i. Rescuer 1 and 2 set up on opposite sides of patient’s chest and perform continuous

chest compressions, alternating after every 100 compressions to avoid fatigue

ii. Use a metronome or CPR feedback device to ensure that compression rate is 100–

120/minute

iii. Chest compressions are only interrupted during rhythm check (AED analysis or

manual) and defibrillation shocks – Continue compressions when AED/defibrillator is

charging

iv. Additional rescuer obtains IO (or IV) access and gives epinephrine. For IO access:

1. The proximal humerus is the preferred site for adults

2. The tibial site is preferred for infants and children

v. During the first four cycles of compressions/defibrillation (approximately 10 minutes)

avoid advanced airway placement

vi. One responding clinician assumes code leader position overseeing the entire response

vii. Use a CPR checklist to ensure that all best practices are followed during CPR

b. For efficient “pit crew” style care, the EMS agency medical director should establish the

options that will be used by clinicians functioning within the EMS agency. Options include

establishing:

i. The airway/ventilation management, if any, that will be used

ii. The initial route of vascular access

15. The EMS agency must perform a Quality Improvement (QI) review of care and outcome,

overseen by the agency medical director, for every patient that receives CPR

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a. The QI should be coordinated with local receiving hospitals to include hospital admission,

discharge, and condition information. This EMS agency QI can be accomplished by

participation an organized cardiac arrest registry

b. The QI should be coordinated with local PSAP/dispatch centers to review opportunities to

assure optimal recognition of possible cardiac arrest cases and provision of dispatch-

assisted CPR (including hands-only CPR when appropriate)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914011 – Cardiac Arrest - Asystole

•

9914013 – Cardiac Arrest - Hypothermia-Therapeutic

•

9914015 – Cardiac Arrest - Pulseless Electrical Activity

•

9914017 – Cardiac Arrest - Ventricular Fibrillation/Pulseless Ventricular Tachycardia)

•

9914055 – General - Cardiac Arrest

•

9914087 – Injury - Cardiac Arrest

Key Documentation Elements

• Should be tailored to any locally utilized data registry but may include as a minimum the

following elements:

o Resuscitation attempted and all interventions performed

o Arrest witnessed

o Location of arrest

o First monitored rhythm

o CPR before EMS arrival

o Outcome

o Any ROSC

o Presumed etiology

▪ Presumed cardiac

▪ Trauma

▪ Submersion

▪ Respiratory

▪ Other non-cardiac

▪ Unknown

Performance Measures

• Time to scene

• Time to patient

• Time to first CPR

• Time to first shock

• Time of ROSC

• Review of CPR quality

o Compression fraction

o Average and longest peri-shock pause

o Rate and depth of compressions

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References

1. Atkins DL, Berger S, Duff JP, et al. Part 11: Pediatric Basic Life Support: 2015 American Heart

Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care.

Circulation. 2015;132(18 Suppl 2): S519–25

2. Bobrow BJ, Clark LL, Ewy GA, et al. Minimally interrupted cardiac resuscitation by emergency

medical services for out-of-hospital cardiac arrest. JAMA. 2008;299(10):1158–65

3. Brooks, Anderdon ML, Bruder E, et al. Part 6: alternative techniques and ancillary devices for

cardiopulmonary resuscitation: 2015 American Heart Association guidelines for

cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015;132(18

Suppl 2): S436–43

4. De Caen R, Berg MD, Chameides L, et al. Part 12: Pediatric Advanced Life Support: 2015

American Heart Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;132(18 Suppl 2) S526–42

5. Dorian P, Cass D, Schwartz B, Cooper R, Gelaznikas R, Barr A. Amiodarone as compared with

lidocaine for shock-resistant ventricular fibrillation. N Engl J Med. 2002;346(12):884–90

6. Ewy GA. The cardiocerebral resuscitation protocol for treatment of out-of-hospital primary

cardiac arrest. Scand J Trauma Resusc Emerg Med. 2012; 20:65

7. Garza AG, Gratton MC, Salomone JA, Lindholm D, McElroy J, Archer R. Improved patient

survival using a modified resuscitation protocol for out-of-hospital cardiac arrest. Circulation.

2009;119(19):2597–605

8. Grunau B, Kime N, Leroux B, et al. Association of Intra-arrest Transport vs Continued On-Scene

Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital

Cardiac Arrest. JAMA. 2020;324(11):1058-1067

9. Grunau B, Kawano T, Rea TD, et al. Emergency medical services employing intra-arrest

transport less frequently for out-of-hospital cardiac arrest have higher survival and favorable

neurological outcomes. Resuscitation. Sep 9, 2021

10. Hinchey PR, Myers JB, Lewis R, et al. Improved out-of-hospital cardiac arrest survival after the

sequential implementation of 2005 AHA guidelines for compressions, ventilations, and

induced hypothermia: the Wake County experience. Ann Emerg Med. 2010;56(4):348–357

11. Hopkins CL, Burk C, Moser S, Meersman J, Baldwin C, Youngquist ST. Implementation of pit

crew approach and cardiopulmonary resuscitation metrics for out-of-hospital cardiac arrest

improves patient survival and neurological outcome. J Am Hear Assoc. 2016,5

12. Hostler D, Everson-Stewart S, Rea TD, et al. Effect of real-time feedback during CPR. BMJ.

2011;342: d512

13. Huang CH, Yu PH, Tsai MS, et al. Acute hospital administration of amiodarone and/or lidocaine

in shockable patients presenting with out-of-hospital cardiac arrest: a nationwide cohort

study. Int J Cardiol. 2017; 227:292–8

14. Jacobs I, Hadkarni V, Bahr J, et al. Cardiac arrest and cardiopulmonary resuscitation outcome

reports: update and simplification of the Utstein templates for resuscitation registries.

Circulation. 2004;110(21):3385–97

15. Kleinman ME, Brennan EE, Goldberger ZD, et al. Part 5: Adult Basic Life Support: 2015

American Heart Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;312(18 Suppl 2): S414–35

16. Kronick SL, Kurz MC, Lin S, et al. Part 4: systems of care and continuous quality improvement:

2015 American Heart Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;132(18 Suppl 2): S397–413

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17. Kudenchuk PJ, Brown SP, Daya M, et al. Amiodarone, lidocaine, or placebo in out-of-hospital

cardiac arrest. N Engl J Med. 2016;374(18):1711–1722

18. Kudenchuk PJ, Cobb LA, Copass MK, et al. Amiodarone for resuscitation after out-of-hospital

cardiac arrest due to ventricular fibrillation. N Engl J Med. 1999;341(12):871–878

19. Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: cardiac arrest in special situations: 2015

American Heart Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;132(18 Suppl 2): S501–18

20. Link MS, Berkow LC, Kudenchuk PJ, et al. Part 7: adult advanced cardiovascular life support:

2015 American Heart Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;132(18 Suppl 2): S444–64

21. Neumar RW, Shuster M, Callaway CW, et al. Part 1: executive summary: 2015 American Heart

Association guidelines update for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2015;132(18 Suppl 2) S315–67

22. Nichol G, Leroux B, Wang H, et al. Trial of continuous or interrupted chest compressions

during CPR. N Engl J Med. 2015;373(23):2203–14

23. Sporer K, Jacobs M, Derevin L, Duval S, Pointer J. Continuous quality improvement efforts

increase survival with favorable neurologic outcome after out-of-hospital cardiac arrest.

Prehospital Emerg Care. 2017;21(1):1–6

Revision Date

March 11, 2022

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Adult Post-ROSC (Return of Spontaneous Circulation) Care

Aliases

None noted

Patient Care Goals

The immediate ROSC period is critical in stabilizing patients and preparing for transport. The goal is

therefore to maximize survival and optimize neurologic and cardiovascular function following a return of

spontaneous circulation by the following steps:

Secure airway

Obtain vascular access

Maximize blood pressure

Identify ST-elevation myocardial infarction (STEMI) or reversible causes of arrest

Recognize pending re-arrest

Consider appropriate destination choice

Patient Presentation

Inclusion Criteria

Patient returned to spontaneous circulation following cardiac arrest resuscitation

Exclusion Criteria

None noted

Patient Management

Assessment, Treatment, and Interventions

1. Perform general patient assessment attempting to identify cause of cardiac arrest.

2. Support life-threatening problems associated with airway, breathing, and circulation.

a. For example, most of the pediatric cardiac arrest occurs due to non-cardiac causes such as

respiratory failure (hypoxemia) or shock (hypovolemia).

3. Monitor closely for recurrence of cardiac arrest using clinical and adjunctive criteria such as

cardiac monitoring, EtCO

monitoring, and physical signs of perfusion

4. Administer oxygen as appropriate with a target of achieving 94–98% saturation.

Do not hyperoxygenate.

5. Do not hyperventilate. Maintain a ventilation rate of 8–10 breaths per minute, targeting an

EtCO

of 35–45 mmHg.

6. For hypotension (SBP less than 90 mmHg or MAP less than 65 in adults) see Shock Guideline

7. Perform serial 12-lead EKGs to assess for evidence of reversible cause of arrest such as STEMI

or electrolyte derangement (e.g., hyperkalemia)

8. Post-cardiac arrest patients with evidence or interpretation consistent with ST elevation

myocardial infarction (STEMI/acute MI) should be transported preferably to a facility capable

of emergent cardiac catheterization or, as a secondary option, to a STEMI receiving facility

based upon local resources and system of care

9. Check blood glucose

a. If hypoglycemic, treat per Hypoglycemia Guideline

b. If hyperglycemic, notify hospital on arrival

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10. If patient seizes, treat per Seizures Guideline

11. Consider transporting patients to an age-appropriate facility which offers specialized adult or

pediatric post-resuscitation care

Patient Safety Considerations

1. Avoid hyperthermia (temperature greater than 37.5° C or 99.5° F) by avoiding excessive

environmental heat exposure, warm blankets, etc.

a. Beyond interventions to prevent hyperthermia or fever, prehospital initiation of

therapeutic hypothermia (targeted temperature management) is not routinely

recommended

Notes/Educational Pearls

Key Considerations

1. Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the

post resuscitation phase and must be avoided. Similarly, hypoventilation (suggested by an

EtCO

greater than 40–45) contributes to worsening acidosis and may precipitate re-arrest

2. Most patients are comatose immediately after resuscitation and will require airway

management and ventilatory assistance

3. Many patients experience “stunning” of the cardiac muscle after ROSC. Hypotension is

common, and volume resuscitation or vasopressor support is often required. Refer to the

[Shock Guideline] for further recommendations

4. Common non-cardiac causes of post-resuscitation hypotension include hyperventilation,

hypovolemia, and traumatic pneumothorax from chest compressions

5. The condition of post-resuscitation patients fluctuates rapidly and continuously requiring close

monitoring. A significant percentage of post-ROSC patients will re-arrest

6. Current research has demonstrated that care of patients with ROSC at specialized centers is

associated with both decreased mortality and improved neurologic outcomes

7. Maintain mechanical CPR device in place in preparation for re-arrest

8. A moderate number of adult post-ROSC patients may have transient ST-elevation on EKG

Consider performing serial EKGs. Post-ROSC patients should preferentially be transported to

centers capable of managing STEMI, whenever possible

Pertinent Assessment Findings

Assess post-ROSC rhythm, lung sounds, and for signs of hypoperfusion

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914019 – Cardiac Arrest - Post Resuscitation Care

Key Documentation Elements

• Immediate post-arrest rhythms, vital signs (pulse, blood pressure, respiratory rate, neurologic

status assessment) and oxygen saturation

• Post-ROSC 12-lead EKG

Performance Measures

• Percent of ROSC patients transported to appropriate facility as defined by the EMS system

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References

1. Aufderheide TP, Lurie KG. Death by hyperventilation: a common and life-threatening problem

during cardiopulmonary resuscitation. Crit Care Med. 2004;32(suppl): S345–51

2. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose survivors of out-of-hospital

cardiac arrest with induced hypothermia. N Engl J Med. 2002; 346:557–63

3. Callaway CW, Donnino MW, Fink EL, et al. Part 8: Post cardiac arrest care: 2015 American

Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular

care. Circulation. 2015;132(18 Suppl 2): S465–82

4. De Backer D et al. Comparison of dopamine and norepinephrine in the treatment of shock. N

Engl J Med. 2010; 362:779–89

5. Garot P, Lefevre T, Eltchaninoff H, et al. Six-month outcome of emergency percutaneous

coronary intervention in resuscitated patients after cardiac arrest complicating ST-elevation

myocardial infarction. Circulation. 2007;115(11):1354–62

6. Highlights of the 2020 American Heart Association's ... https://cpr.heart.org/-/media/cpr-

files/cpr-guidelines-files/highlights/hghlghts_2020_ecc_guidelines_english.pdf. Accessed

March 11, 2022

7. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on

survival and neurological status among adults with cardiac arrest. JAMA. 2014;311(1):45–52

8. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on

survival and neurological status among adults with cardiac arrest: a randomized clinical

trial. JAMA. 2014;311(1):45–52

9. Kim F, Olsufka M, Longstreth WT Jr., et al. Pilot randomized clinical trial of prehospital

induction of mild hypothermia in out-of-hospital cardiac arrest patients with a rapid infusion

of 4°C normal saline. Circulation. 2007;115(24):3064–70

10. Kliegel A, Janata A, Wandaller C, et al. Cold infusions alone are effective for induction of

therapeutic hypothermia but do not keep patients cool after cardiac

arrest. Resuscitation. 2007;73(1):46–53

11. Nielsen N, Wetterslev J, Cronberg T, et al. Targeted temperature management at 33 degrees C

versus 36 degrees C after cardiac arrest. N Engl J Med. 2013;369(23):2197–206

12. Nolan JP, Neumar RW, Adrie C, et al. Post-cardiac arrest syndrome: epidemiology,

pathophysiology, treatment, and prognostication. A scientific statement from the

International Liaison Committee on Resuscitation; the American Heart Association Emergency

Cardiovascular Care Committee; the Council on Cardiovascular Surgery and Anesthesia; the

Council on Cardiopulmonary, Perioperative, and Critical Care; the Council on Clinical

Cardiology; the Council on Stroke. Circulation. 2008;79(3):350–79

13. Oddo M, Schaller MD, Feihl F, Ribordy V, Liaudet L. From evidence to clinical practice: effective

implementation of therapeutic hypothermia to improve patient outcome after cardiac

arrest. Crit Care Med. 2006;34(7):1865–73

14. Quintero-Moran B, Moreno R, Villarreal S, et al. Percutaneous coronary intervention for

cardiac arrest secondary to ST-elevation acute myocardial infarction: influence of immediate

paramedical/medical assistance on clinical outcome. J Invasive Cardiol. 2006;18(6):269–72

15. Vega RM, Kaur H, Edemekong PF. Cardiopulmonary Arrest in Children. [Updated 2020 Jul 17].

In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan

16. Vereczki V, Martin E, Rosenthal RE, Hof PR, Hoffman GE, Fiskum G. Normoxic resuscitation

after cardiac arrest protects against hippocampal oxidative stress, metabolic dysfunction, and

neuronal death. J Cereb Blood Flow Metab. 206;26(6):821–35

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17. Virkkunen I, Yli-Hankala A, Silfvast T. Induction of therapeutic hypothermia after cardiac arrest

in prehospital patients using ice-cold Ringer’s solution: a pilot

study. Resuscitation. 2004;62(3):299–302

Revision Date

March 11, 2022

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Determination of Death/Withholding Resuscitative Efforts

Aliases

None noted

Patient Care Goals

All clinically dead patients will receive all available resuscitative efforts including cardiopulmonary

resuscitation (CPR) unless contraindicated by one of the exceptions defined below

Patient Presentation

A clinically dead patient is defined as any unresponsive patient found without respirations and without a

palpable carotid pulse

Inclusion/Exclusion Criteria:

1. Resuscitation should be started on all patients who are found apneic and pulseless unless the

following conditions exist (does not apply to victims of lightning strikes, drowning, or

hypothermia):

a. Medical cause or traumatic injury or body condition clearly indicating biological death

(irreversible brain death), limited to:

i. Decapitation: the complete severing of the head from the remainder of the patient’s

body

ii. Decomposition or putrefaction: the skin is bloated or ruptured, with or without soft

tissue sloughed off. The presence of at least one of these signs indicated death

occurred at least 24 hours previously

iii. Transection of the torso: the body is completely cut across below the shoulders and

above the hips through all major organs and vessels. The spinal column may or may

not be severed

iv. Incineration: 90% of body surface area with full thickness burns as exhibited by ash

rather than clothing and complete absence of body hair with charred skin

v. Injuries incompatible with life (such as massive crush injury, complete exsanguination,

severe displacement of brain matter)

vi. Futile and inhumane attempts as determined by agency policy/protocol related to

“compelling reasons” for withholding resuscitation

vii. In blunt and penetrating trauma, if the patient is apneic, pulseless, and without other

signs of life upon EMS arrival including, but not limited to spontaneous movement,

EKG activity, or pupillary response

viii. Nontraumatic arrest with obvious signs of death including dependent lividity or rigor

mortis

b. A valid DNR order (form, card, bracelet) or other actionable medical order (e.g., Physician

Orders for Life-Sustaining Treatment (POLST)/Medical Orders for Life-Sustaining

Treatment (MOLST) form) is present, and it:

i. Conforms to the state specifications for color and construction

ii. Is intact: it has not been cut, broken, or shows signs of being repaired

iii. Displays the patient’s name and, if required by state law or regulation, the physician’s

name

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Patient Management

Assessment

Assess for dependent lividity with rigor mortis and/or other inclusion criteria

Treatment and Interventions

1. If all the components above are confirmed, no CPR is required

2. If CPR has been initiated but all the components above have been subsequently confirmed,

CPR should be discontinued, and medical direction contacted as needed

3. If any of the findings are different than those described above, clinical death is not confirmed,

and resuscitative measures should be immediately initiated or continued. The Termination of

Resuscitative Efforts Guideline should then be implemented

4. Do Not Resuscitate (DNR) order (DNR/MOLST/POLST) with signs of life:

a. If there is a DNR bracelet or DNR transfer form and there are signs of life (pulse and

respirations), provide standard appropriate treatment under existing protocols matching

the patient’s condition

b. To request permission to withhold treatment under these conditions for any reason

contact medical direction

c. If there is documentation of a Do Not Intubate (DNI/MOLST/POLST) advanced directive,

the patient should receive full treatment per protocols except for any intervention

specifically prohibited in the patient’s advanced directive

d. If for any reason an intervention that is prohibited by an advanced directive is being

considered, contact medical direction

Patient Safety Considerations

In cases where the patient's status is unclear and the appropriateness of withholding resuscitation

efforts is questioned, EMS personnel should initiate CPR immediately and then contact medical

direction

Notes/Educational Pearls

Key Considerations

1. For scene safety and/or family wishes, clinician may decide to implement CPR even if all the

criteria for death are met

2. At a likely crime scene, disturb as little potential evidence as possible

Pertinent Assessment Findings

None noted

Quality improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

● 9914169 – Cardiac Arrest - Do Not Resuscitate

● 9914201 – Cardiac Arrest - Determination of Death/Withholding Resuscitative Efforts

Key Documentation Elements

• Clinical/situational details that may be available from bystanders/caregivers

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• Documentation of details surrounding decision to determine death

o Time of contact with medical direction

o Time of death determination

• Names/contact information for significant bystanders

Performance Measures

None noted

References

1. 'Do Not Attempt Resuscitation' in the Out-of-Hospital Setting. American College of Emergency

Physicians; October 2003. ACEP Policy Statement

2. Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM. Withholding and termination of

resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the

joint NAEMSP-ACSCOT position statements. J Trauma Acute Care Surg. 2013;75(3):459–67

3. National Guidelines for Statewide Implementation of EMS "Do Not Resuscitate" (DNR)

Programs National Association of Emergency Medical Services Directors and the National

Association of Emergency Medical Services Physicians. Prehosp Disaster Med. 1994;9(2):197–9

4. National Association of EMS Physicians, American College of Surgeons Committee on Trauma.

Termination of resuscitation for adult traumatic cardiopulmonary arrest. Prehosp Emerg Care.

2012;16(4):571

5. National Association of EMS Physicians, et al. Withholding of resuscitation for adult traumatic

cardiopulmonary arrest. Prehosp Emerg Care. 2013;17(2):291

Revision Date

March 11, 2022

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Do Not Resuscitate Status/Advance Directives/Healthcare Power of Attorney

(POA) Status

Aliases

Comfort care Do Not Resuscitate (DNR)

Patient Care Goals

To acknowledge and maintain the variety of ways that patients can express their wishes about

cardiopulmonary resuscitation or end-of-life decision making

Patient Presentation

Inclusion/Exclusion Criteria

1. Patients must have one of the following documents or a valid alternative (such as

identification bracelet indicating wishes) immediately available. Note that some specifics can

vary widely from state to state:

a. Physician Orders for Life Sustaining Treatment (POLST) or Medical Orders for Life

Sustaining Treatment (MOLST) – explicitly describes acceptable interventions for the

patient in the form of medical orders, must be signed by a physician or other empowered

medical clinician to be valid

b. Do Not Resuscitate (DNR) order – identifies that CPR and intubation are not to be initiated

if the patient is in arrest or peri-arrest. The interventions covered by this order and the

details around when to implement them can vary widely

c. Advance directives – document that describes acceptable treatments under a variable

number of clinical situations including some or all the following: what to do for cardiac

arrest, whether artificial nutrition is acceptable, organ donation wishes, dialysis, and other

parameters. The directives frequently do not apply to emergent or potentially transient

medical conditions

d. As specified from state to state, in the absence of formal written directions (MOLST,

POLST, DNR, advanced directives), and in the presence of a person with power of attorney

for healthcare or healthcare proxy, that person may prescribe limits of treatment

2. One of the documents above is valid when it meets all the following criteria:

a. Conforms to the state specifications for color and construction

b. Is intact: it has not been cut, broken or shows signs of being repaired

c. Displays the patient’s name and, if required by state law or regulation, the physician’s

name

3. If there is question about the validity of the form/instrument, the best course of action is to

proceed with the resuscitation until additional information can be obtained to clarify the best

course of action

4. If a patient has a valid version of one of the above documents, it will be referred to as a “valid

exclusion to resuscitation” for the purposes of this protocol

Patient Management

Assessment

1. If the patient has a valid exclusion to resuscitation, then no CPR or airway management should

be attempted, however this does not exclude comfort measures including medications for

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pain as appropriate

2. If CPR has been initiated and a valid exclusion to resuscitation has been subsequently verified,

CPR may be discontinued, and medical direction contacted as needed

Treatment and Interventions

1. If there is a valid exclusion to resuscitation and there are signs of life (pulse and

respirations), EMS clinicians should provide standard appropriate treatment under existing

protocols according to the patient’s condition

a. If the patient has a MOLST or POLST, it may provide specific guidance on how to proceed

in this situation

b. Directives should be followed as closely as possible and medical direction contacted as

needed

2. The patient should receive full treatment per protocols with the exception of any intervention

specifically prohibited in the patient’s valid exclusion to resuscitation

3. If for any reason an intervention that is prohibited by an advanced directive is being

considered, medical direction should be contacted

Patient Safety Considerations

In cases where the patient's status is unclear and the appropriateness of withholding resuscitation

efforts is questioned, EMS personnel should initiate CPR immediately and contact medical

direction

Notes/Educational Pearls

Key Considerations

1. If there is a personal physician present at the scene who has an ongoing relationship with the

patient, that physician may decide if resuscitation is to be initiated

2. If there is a registered nurse from a home healthcare or hospice agency present at the scene

who has an ongoing relationship with the patient and who is operating under orders from the

patient’s private physician, that nurse (authorized nurse) may decide if resuscitation is to be

initiated

3. If the physician or nurse decides resuscitation is to be initiated, usual medical direction

procedures will be followed

4. Special Consideration: For scene safety and/or family wishes, the EMS clinician may decide to

implement CPR even if all the criteria for death are met

Pertinent Assessment Findings

None noted

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914201 – Cardiac Arrest - Determination of Death/Withholding Resuscitative Efforts

•

9914169 – Cardiac Arrest - Do Not Resuscitate

•

9914171 – Cardiac Arrest - Special Resuscitation Orders

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Key Documentation Elements

• Detailed description of the valid exclusion to resuscitation documentation used to guide

resuscitation including a copy of the document if possible

• Names/contact information for significant bystanders

Performance Measures

None noted

References

1. 'Do Not Attempt Resuscitation' in the Out-of-Hospital Setting. American College of Emergency

Physicians; October 2003. ACEP Policy Statement

2. National Guidelines for Statewide Implementation of EMS "Do Not Resuscitate" (DNR)

Programs National Association of Emergency Medical Services Directors and the National

Association of Emergency Medical Services Physicians. Prehos Disaster Med. 1994;9(2):197–9

Revision Date

March 11, 2022

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Termination of Resuscitative Efforts

Aliases

Call the code

Patient Care Goals

1. When there is no response to prehospital cardiac arrest treatment, it is acceptable and often

preferable to cease futile resuscitation efforts in the field

2. In patients with cardiac arrest, prehospital resuscitation is initiated with the goal of returning

spontaneous circulation before permanent neurologic damage occurs. In most situations, ALS

clinicians are capable of performing an initial resuscitation that is equivalent to an in-hospital

resuscitation attempt, and there is usually no additional benefit to emergency department

resuscitation in most cases

3. CPR that is performed during patient packaging and transport is much less effective than CPR

done at the scene. Additionally, EMS clinicians risk physical injury while attempting to perform

CPR in a moving ambulance while unrestrained. In addition, continuing resuscitation in futile

cases places other motorists and pedestrians at risk, increases the time that EMS crews are

not available for another call, impedes emergency department care of other patients, and

incurs unnecessary hospital charges. Lastly, return of spontaneous circulation is dependent on

a focused, timely resuscitation. The patient in arrest should be treated as expeditiously as

possible, including quality, uninterrupted CPR and timely defibrillation as indicated

4. When cardiac arrest resuscitation becomes futile, the patient’s family should become the

focus of the EMS clinicians. Families need to be informed of what is being done and that

transporting all cardiac arrest patients to the hospital is not supported by evidence. This

practice also inconveniences the family by requiring a trip to the hospital where they must

begin grieving in an unfamiliar setting. Most families understand the futility of the situation

and are accepting of ceasing resuscitation efforts in the field

5. Consider potential for organ donation if feasible.

Patient Presentation

Patient in cardiac arrest

Inclusion Criteria

1. Any cardiac arrest patient that has received resuscitation in the field but has not responded to

treatment

2. When resuscitation has begun and it is found that the patient has a DNR order or other

actionable medical order (e.g., POLST/MOLST form)

Exclusion Criteria

Consider continuing resuscitation for patients in cardiac arrest associated with medical conditions

that may have a better outcome despite prolonged resuscitation, including hypothermia (although

under certain circumstances, medical direction may order termination of resuscitation in these

conditions)

Patient Management

Resuscitation may be terminated under the following circumstances:

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1. Non-traumatic arrest

a. Patient is at least 18 years of age

b. Patient is in cardiac arrest at the time of arrival of advanced life support (ALS)

i. No pulse

ii. No respirations

iii. No evidence of meaningful cardiac activity (e.g., asystole or wide complex PEA less

than 60 BPM, no heart sounds)

c. ALS resuscitation is administered appropriate to the presenting and persistent cardiac

rhythm.

i. Resuscitation may be terminated in asystole and slow wide complex PEA if there is

1. No return of spontaneous circulation after 20 minutes in the absence of

hypothermia

AND

2. The EtCO

is less than 20 mmHg

ii. Narrow complex PEA with a rate above 40 or refractory and recurrent ventricular

fibrillation/ventricular tachycardia:

1. Consider resuscitation for up to 60 minutes from the time of dispatch.

2. Termination efforts may be ceased before 60 minutes based on factors including,

but not limited to, EtCO

less than 20 mmHg, age, co-morbidities, distance from,

and resources available at the closest hospital. Termination before this timeframe

should be done in consultation with online medical direction

d. There is no return of spontaneous pulse and no evidence of neurological function (non-

reactive pupils, no response to pain, no spontaneous movement)

e. No evidence or suspicion of hypothermia

f. All EMS clinicians involved in the patient’s care agree that discontinuation of the

resuscitation is appropriate

g. Consider contacting medical direction before termination of resuscitative efforts

2. Traumatic arrest

a. Patient is at least 18 years of age

b. Resuscitation efforts may be terminated in any blunt trauma patient who, based on

thorough primary assessment, is found apneic, pulseless, and asystolic on an EKG or

cardiac monitor upon arrival of emergency medical services at the scene

c. Victims of penetrating trauma found apneic and pulseless by EMS should be rapidly

assessed for the presence of other signs of life, such as pupillary reflexes, spontaneous

movement, response to pain, and electrical activity on EKG

i. Resuscitation may be terminated by contacting medical direction oversight if these

signs of life are absent

ii. If resuscitation is not terminated, transport is indicated

d. Cardiopulmonary arrest patients in whom mechanism of injury does not correlate with

clinical condition, suggesting a non-traumatic cause of arrest, should have standard ALS

resuscitation initiated

e. All EMS personnel involved in the patient’s care agree that discontinuation of the

resuscitation is appropriate

f. Consider contacting medical direction before termination of resuscitative efforts

Assessment

1. Pulse

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2. Respirations

3. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment; purposeful

movement, pupillary response]

4. Cardiac activity (cardiac auscultation, cardiac monitoring, and/or, if available,

ultrasonography)

5. Quantitative capnography

Treatment and Interventions

1. Focus on continuous, quality CPR that is initiated as soon as possible

2. Focus attention on the family and/or bystanders. Explain the rationale for termination

3. Consider support for family members such as other family, friends, clergy, faith leaders, or

chaplains

4. For patients that are less than 18 years of age, consultation with medical direction is

recommended

Patient Safety Considerations

All patients who are found in ventricular fibrillation or whose rhythm changes to ventricular

fibrillation should in general have full resuscitation continued on scene

Notes/Educational Pearls

Key Considerations and Pertinent Assessment Findings

1. Recent evidence has shown that, to capture over 99% of potential survivors from medical

cardiac arrest (especially VF and pulseless VT arrests), resuscitation should be continued for

approximately 40 minutes. This does not imply, however, that all resuscitations should

continue this long (e.g., asystolic rhythms)

2. In remote or wilderness situations, EMS clinicians should make every effort to contact medical

direction, but resuscitation may be terminated in the field without contacting medical

direction when the following have occurred:

a. There has been no return of pulse despite greater than 30 minutes of CPR (this does not

apply in the case of hypothermia)

b. Transport to an emergency department will take greater than 30 minutes (this does not

apply in the case of hypothermia)

c. EMS clinicians are exhausted, and it is physically impossible to continue the resuscitation

3. Logistical factors should be considered, such as collapse in a public place, family wishes, and

safety of the crew and public

4. Survival and functional neurologic outcomes are unlikely if ROSC is not obtained by EMS. It is

dangerous to crew, pedestrians, and other motorists to attempt to resuscitate a patient

during ambulance transport

5. Quantitative EtCO

measurements of less than 10 mmHg or falling greater than 25% despite

resuscitation indicates a poor prognosis and provide additional support for termination

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914055 – General - Cardiac Arrest

•

9914087 – Injury - Cardiac Arrest

•

9914169 – Cardiac Arrest - Do Not Resuscitate

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•

9914171 – Cardiac Arrest - Special Resuscitation Orders

•

9914201 – Cardiac Arrest - Determination of Death/Withholding Resuscitative Efforts

Key Documentation Elements

• All items (a–f in Non-traumatic or Traumatic arrest) listed under patient management must be

clearly documented in the EMS patient care report in addition to the assessment findings

supporting this medical decision making

• If resuscitation is continued for special circumstance or despite satisfying the criteria in this

guideline, the rationale for such decision making must be documented

Performance Measures

• Time to CPR

• Time to AED application if applicable

• Review of CPR quality

• Duration of resuscitative efforts

• Review of biometric data/CPR quality if available

• Appropriateness of termination

• Review of every patient transport from scene with patient in arrest

References

1. American College of Emergency Physicians. Discontinuing resuscitation in the out-of-hospital

setting. Ann Emerg Med. 2008;52(5):592

2. Cha WC, Lee EJ, Hwang SS. The duration of cardiopulmonary resuscitation in emergency

departments after out-of-hospital cardiac arrest is associated with the outcome: A nationwide

observational study. Resuscitation. 2015; 96:323–7

3. Eckstein M, Hatch L, Malleck J, McClung C, Henderson SO. End-tidal CO

as a predictor of

survival in out-of-hospital cardiac arrest. Prehosp Disaster Med. 2011;26(3):148–50

4. Fallat ME, American College of Surgeons Committee on Trauma, American College of

Emergency Physicians, National Association of EMS Physicians, American Academy of

Pediatrics. Withholding or termination of resuscitation in pediatric out-of-hospital traumatic

cardiopulmonary arrest. Pediatrics, 2014 Apr; 133(4): e1104–16

5. Goldberger ZD, Chan PS, Berg RA, et al. Duration of resuscitation efforts and survival after in-

hospital cardiac arrest: an observational study. Lancet. 2012;380(9852):1473–81

6. Goto Y, Funada A, Goto Y. Duration of prehospital cardiopulmonary resuscitation and

favorable neurological outcomes for pediatric out-of-hospital cardiac arrests: a nationwide,

population-based cohort study. Circulation. 2016;(1):1–10

7. Hung SC, Mou CY, Hung HC, Lin IH, Lai SW, Huang JY. Chest compression fraction in ambulance

while transporting patients with out-of-hospital cardiac arrest to the hospital in rural Taiwan.

Emerg Med J. 2016; 0:1–4

8. Kim F, Nichol G, Maynard C, et al. Effect of prehospital induction of mild hypothermia on

survival and neurological status among adults with cardiac arrest. JAMA. 2014;311(1):45–52

9. Matsuyama T, Kitamura T, Kiyohara K, et al. Impact of cardiopulmonary resuscitation duration

on neurologically favourable outcome after out-of-hospital cardiac arrest: a population-based

study in japan. Resuscitation. 2017; 113:1–7

10. Millin MG, Khandker SR, Malki A. Termination of resuscitation of nontraumatic

cardiopulmonary arrest: resource document for the National Association of EMS Physicians

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position statement. Prehosp Emerg Care. 2011;15(4):547–54

11. Morrison LJ, Verbeek PR, Zhan C, Kiss A, Allan KS. Validation of a universal prehospital

termination of resuscitation clinical prediction rule for advanced and basic life support

providers. Resuscitation. 2009;80(3):324–8

12. Ponce A, Swor R, Quest TE, Macy M, Meurer W, Sasson C. Death notification training for

prehospital providers: a pilot study. Prehosp Emerg Care. 2010;14(4):537–42

13. Reynolds JC, Grunau BE, Rittenberger JC, Sawyer KN, Kurz MC, Callaway CW. The association

between duration of resuscitation and favorable outcome after out-of-hospital cardiac arrest:

implications for prolonging or terminating resuscitation. Circulation. 2016;134(25):2084–94

Revision Date

March 11, 2022

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Resuscitation in Traumatic Cardiac Arrest

Aliases

Traumatic Cardiac Arrest (TCA)

Patient Care Goals

1. Return of spontaneous circulation

2. Treatment and resolution of the underlying pathophysiology leading to the traumatic cardiac

arrest

3. When appropriate, transport to the closest and most capable hospital within the defined

trauma system

Patient Presentation

Inclusion Criteria

Patients suffering blunt or penetrating trauma with cardiac arrest after arrival of EMS clinicians or

while under the care of EMS clinicians (witnessed arrest or recent arrest with continued signs of

life)

Exclusion Criteria

1. When the mechanism of injury does not correlate with the clinical condition, suggesting a

nontraumatic cause of cardiac arrest, standard resuscitative measures should be followed. In

such cases, refer to the Resuscitation Section

2. In victims of blunt or penetrating trauma with pulses or other signs of life on EMS clinician

assessment refer to the General Trauma Management Guideline

3. In victims of blunt or penetrating trauma with rigor mortis, lividity, or evidence of injuries

incompatible with life (including decapitation, hemicorporectomy). In such cases, refer to

Determination of Death/Withholding Resuscitative Efforts Guideline

4. Resuscitation efforts may be withheld in any blunt trauma patient who, based on thorough

primary assessment, is found apneic, pulseless, and asystolic on an EKG or cardiac monitor

upon arrival of emergency medical services at the scene. In such cases, refer to the

Determination of Death/Withholding Resuscitative Efforts Guideline

5. Resuscitation efforts may be withheld in victims of penetrating trauma found apneic,

pulseless, and without other signs of life including pupillary reflexes, respiratory effort,

spontaneous movement, response to pain, and electrical activity on EKG. In such cases, refer

to the Determination of Death/Withholding Resuscitative Efforts Guideline

Patient Management

Assessment

1. Management of traumatic cardiac arrest requires a balance of rapid, focused evaluation

followed by prompt treatment of reversible life threats, including management of massive

hemorrhage, airway management, decompression of tension pneumothorax, and

resuscitation

2. Assess for signs of life, including pulses, respiratory effort, and evaluation of other signs of life

3. Assess for evidence of massive hemorrhage

a. Including evidence of massive external hemorrhage

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b. Evidence of pelvic injury (such as instability)

4. Assess the patient’s airway

5. Assess the patient’s respiratory effort, if present, or for evidence of tension pneumothorax

6. Assess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

Treatment and Interventions

1. Manage massive hemorrhage. Refer to General Trauma Management Guideline for complete

list of therapies for the treatment of massive hemorrhage, including the following:

a. Place tourniquets for wounds amenable to tourniquet placement

b. Use a combination of wound packing and direct pressure for junctional wounds or

junctional tourniquets if available

c. Place a pelvic binder on all patients with blunt or blast trauma suffering traumatic arrest

2. Manage the patient’s airway. Refer to the Airway Management Guideline

3. Perform bilateral, rapid chest decompression

4. Establish intravenous access

5. Initiate volume resuscitation and adjunctive hemorrhage control measures (such as

tranexamic acid (TXA)) en route to the hospital

Patient Safety Considerations

None noted

Notes/Educational Pearls

Key Considerations

1. Survival from traumatic cardiac arrest requires careful coordination between rapid prehospital

assessment, EMS clinician treatment of reversible causes of traumatic cardiac arrest and

transport that is rapid, but also allows maintenance of necessary therapies in a manner that is

effective for patients as well as safe for EMS clinicians

2. Evidence for the benefit of CPR in traumatic cardiac arrest is limited. Treatment priorities

should initially focus on control of massive hemorrhage (including management of pelvis

fractures), airway management, and consideration of bilateral needle thoracostomy. If CPR is

performed at all, it should be performed en route to the hospital but only if it can be

performed in a safe and effective manner by EMS clinicians

3. Unless there is an immediate and correctable cause, patients suffering traumatic cardiac

arrest have the best chance for survival when arrival time to a hospital is within minutes

4. If transport is initiated, consider the ACS-COT’s Once the above treatments and interventions

have been performed, patients should be transported to the closest appropriate hospital

within the defined trauma system

5. In an effort to reduce on-scene time, consider IV/IO access and initiation of resuscitation

during transport

6. Optimal choices for resuscitation are (in descending order as available) as follows: whole

blood, balanced blood products (red blood cells (RBC), plasma), packed red blood cells alone,

liquid, or freeze-dried plasma alone, no fluid resuscitation. Excessive crystalloid and colloid

have little to no value and may in fact be harmful in hemorrhagic shock

7. Consider the duration of resuscitation and transport, contact online medical direction if

available to discuss. If termination of resuscitation is advised, refer to the Termination of

Resuscitation Efforts Guideline

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Pertinent Assessment Findings

1. Evidence of injuries incompatible with life

2. Evidence of signs of life

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

None noted

Key Documentation Elements

● Mechanism of injury

● Primary survey findings

● Secondary survey findings

● Scene time

● Procedures performed and patient response

Performance Measures

● Scene time

● Appropriateness of procedures, including airway management, hemorrhage control, needle

thoracostomy, intravenous access and resuscitation

● National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

▪ Weight value in kilograms or length-based weight entered for patients less than 15

years old when Type of Service Requested = 2205001—911 Response (Scene)

References

1. Evans C, Quinlan D, Engels P, Sherbino J. Reanimating patients after traumatic cardiac arrest: a

practical approach informed by best evidence. Emerg Med Clin N Am. 36 (2018) 19–40

2. Millin MG, Galvagno SM, Khandker SR, Malki A, Bulger EM. Withholding and termination of

resuscitation of adult cardiopulmonary arrest secondary to trauma: resource document to the

joint NAEMSP-ACSCOT position statements. J Trauma Acute Care Surg. 2013;75(3):459–467.

doi: 10.1097/TA.0b013e31829cfaea

3. The Royal College of Emergency Medicine. Traumatic cardiac arrest in adults best practice

guideline. Sept 2019. From the website: https://rcem.ac.uk/wp-

content/uploads/2021/10/RCEM_Traumatic_Cardiac_Arrest_Sept2019_FINAL.pdf.

Accessed March 11, 2022

Revision Date

March 11, 2022

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Pediatric-Specific Guidelines

Brief Resolved Unexplained Event (BRUE) & Acute Events in Infants

Aliases

Apparent Life-Threatening Event (ALTE)

Patient Care Goals

1. Recognize patient characteristics and symptoms consistent with a BRUE

2. Promptly identify and intervene for patients who require escalation of care

3. Choose proper destination for patient transport

Patient Presentation

Inclusion Criteria

1. Suspected BRUE: An event in an infant less than 1 year old reported by a bystander as sudden,

brief (less than 1 minute), unexplained, and completely resolved upon EMS arrival that

includes one or more of the following:

a. Breathing change (absent, decreased, or irregular)

b. Color change (central cyanosis or pallor)

c. Marked change in muscle tone (hyper- or hypotonia)

d. Altered level of responsiveness (increased, irritability, or decreased)

Exclusion Criteria

1. Any signs or symptoms suggestive of underlying or acute illness or injury present upon EMS

evaluation, such as:

a. Abnormal vital signs for age (including fever)

b. Vomiting

c. Signs of trauma

d. Noisy or labored breathing

2. Identifiable cause for the event, such as:

a. Gastric reflux (spitting up)

b. Swallowing dysfunction

c. Nasal congestion or excessive secretions from the nose and/or mouth

d. Periodic breathing of the newborn

e. Breath-holding spell

f. Change in tone associated with choking, gagging, crying, feeding

g. Seizure (e.g., eye deviation, nystagmus, tonic-clonic activity)

h. Hypoglycemia

i. Significant past medical history (e.g., congenital heart disease, pulmonary disease, VP

shunt, or seizure disorder)

j. Need for IV medication administration

3. History or exam concerning for child abuse or neglect

4. Color change that involved only redness (e.g., in the face) or isolated hands/feet cyanosis

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Patient Management

Assessment

1. History

a. History of circumstances and symptoms before, during, and after the event, including

duration, interventions done, as well as patient color, tone, breathing, feeding, position,

location, activity, and level of consciousness

b. Other concurrent symptoms (e.g., fever, congestion, cough, rhinorrhea, vomiting,

diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding)

c. Prior history of BRUE (ever, including past 24 hours)

d. Past medical history (e.g., prematurity, prenatal/birth complications, gastric reflux,

congenital heart disease, developmental delay, airway abnormalities, breathing problems,

prior hospitalizations, surgeries, or injuries)

e. Family history of sudden unexplained death or cardiac arrhythmia in other children or

young adults

f. Social history: those living at home, recent household stressors, exposures to

toxins/drugs, sick contacts

g. Considerations for possible child abuse (i.e., multiple/changing versions of the story or

reported mechanism of injury does not seem plausible, especially for child’s

developmental stage) [See Abuse and Maltreatment Guideline]

2. Exam

a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment)

b. General assessment:

i. Signs of respiratory distress or increased work of breathing (e.g., tachypnea, grunting

or other abnormal breath sounds, nasal flaring, retracting, or head bobbing)

ii. Color, both central and peripheral (pallor, cyanosis, redness, or normal), capillary refill

iii. Mental status (alert, tired, lethargic, unresponsive, or irritable)

c. Head to toe exam, including:

i. Physical exam for signs of trauma or neglect

ii. Pupillary response and anterior fontanelle

Treatment and Interventions

1. Monitoring (all patients with possible BRUE)

a. Continuous cardiac monitor

b. Continuous pulse oximetry

c. Serial observations during transport for change in condition

d. Check point-of-care (POC) blood glucose and treat symptomatic hypoglycemia [See

Hypoglycemia Guideline]

2. Airway

a. Give supplemental oxygen for signs of respiratory distress or hypoxemia — escalate from

a nasal cannula to a simple face mask to a non-rebreather mask as needed [See Airway

Management Guideline]

b. Suction excessive secretions from the nose and/or mouth (using bulb syringe or suction

catheter) [See Pediatric Respiratory Distress (Bronchiolitis) Guideline]

3. Utility of IV placement and fluids

a. Routine IVs should not be placed on all suspected BRUE patients

b. IVs should be placed only for clinical concerns of shock or to administer IV medications

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4. Transport the patient to the appropriate facility even if they appear well or have returned to

their baseline

Patient Safety Considerations

1. Regardless of the patient’s well appearance, all infants with a history of signs or symptoms

suggestive of BRUE should be transported for further evaluation

a. By definition, infants who are not completely well-appearing at EMS evaluation do not

meet the definition of possible BRUE and should be treated and transported according to

local guidelines

2. Destination considerations

a. All patients should be transported to facilities with at least baseline pediatric readiness,

i.e., appropriate equipment, resources, and trained staff capable of providing initial

emergency care and stabilization to pediatric patients prior to hospital admission or

interfacility transfer, if feasible

b. Consider transport to a facility with pediatric critical care capability for patients with any

high-risk criteria:

Notes/Educational Pearls

Key Considerations

1. BRUE is a group of symptoms, not a disease process

2. If the infant is not completely well upon EMS arrival, this excludes possible BRUE event:

a. Treat and transport according to local guidelines

3. Avoid using “BRUE”, “ALTE”, “SIDS” (sudden infant death syndrome), or “near-miss SIDS”

terminology with parent/guardian

4. EMS clinicians play a unique and important role in obtaining an accurate history soon after the

event and in observing, documenting, and reporting environmental, scene and social

indicators that may point to an alternate diagnosis

5. High-risk patients with a possible BRUE have worse outcomes and may require emergency

department (ED) or inpatient testing, intervention, and/or follow-up

6. The determination of a BRUE is made only after hospital evaluation, not in the field:

a. A few of these infants will die even after hospital evaluation and treatment

7. All patients should be transported to an ED

8. Contact medical direction if parent/guardian is refusing medical care and/or transport,

especially if any high-risk criteria are present

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914197 – Medical - Apparent Life-Threatening Event (ALTE)

i. Less than 2 months of age

ii. History of prematurity (less than or equal to 32 weeks gestation)

iii. More than one BRUE, now or in the past

iv. Event duration greater than 1 minute

v. CPR or resuscitation by caregivers or trained rescuers

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Key Documentation Elements

• Document key aspect of history

o The event:

▪ Breathing (apnea or respiratory distress)

▪ Color change (central and/or peripheral)

▪ Change in muscle tone

▪ Level of responsiveness

▪ Event duration

▪ Witnessed?

o Pre-event circumstances and history

▪ Event associated with feeding or other activity

▪ History of prematurity

▪ Prior BRUE events (ever or in past 24 hours)

▪ Past medical history, especially cardiac, respiratory, gastrointestinal, neurologic

o Caregiver resuscitation efforts

o Post-event symptoms and circumstances

• Document key aspects of the exam and assess for changes after each intervention:

o Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment), temperature, and O

saturation

o Respiratory effort

o Mental status including pupillary reaction and pediatric Glasgow Coma Score (GCS) or

AVPU

o Color (central and peripheral) and capillary refill

o Presence of signs of abuse, trauma, or neglect

• Document environmental and scene/social clues, especially those suggesting abuse, neglect,

non-accidental trauma, or unsafe sleeping practices

Performance Measures

• Complete set of vital signs recorded

• Appropriate transport destination relative to risk criteria

References

Key Reference

1. Tieder JS, Bonkowsky JL, Etzel RA, et al. Brief resolved unexplained events (formerly apparent

life-threatening events) and evaluation of lower-risk infants: a systematic review. Pediatrics.

2016;137(5): e20165090

Supplemental References

1. Alhaboob AA. Clinical Characteristics and Outcomes of Patients Admitted with Brief Resolved

Unexplained Events to a Tertiary Care Pediatric Intensive Care Unit. Cureus. 2020;12(6): e8664

2. Al-Kindy H, Gelinas J, Hatzakis G, Cote A. Risk factors for extreme events in infant hospitalized

for apparent life-threatening events. J Pediatr. 2009;154(3):332–7

3. Arane K, Claudius I, Goldman RD. Brief resolved unexplained event: new diagnosis in infants.

Can Fam Phys. Jan 2017; 63:39–41

4. Bastin JP. Brief Resolved Unexplained Events in Infants. JAAPA. 2019;32(7):38–40

5. Benham-Terneus M, Clemente M. SIDS, BRUE, and Safe Sleep Guidelines. Pediatr in Rev.

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2019;40(9):443–455

6. Brand DA, Fazzari MJ. Risk of Death in Infants Who Have Experienced a Brief Resolved

Unexplained Event: A Meta-Analysis. J Pediatr. 2018; 197:63–67

7. Bonkowsky J. Guenther E, Filloux F, Srivastatva R. Death, child abuse, and adverse neurologic

outcome of infants after an apparent life-threatening event. Pediatrics. 2008;122(1):125–31

8. Colombo M, Katz ES, Bosco A, Melzi mL, Nosetti L. Brief resolved unexplained events:

Retrospective validation of diagnostic criteria and risk stratification. Pediatric Pulmonology.

2019; 54:61–65

9. Delaroche AM, Mittal MK. But What Was “It”? Talking to Parents About BRUE. Hosp Pediatr.

July 2019;9(7):566–568

10. Delaroche AM, Haddad R, Farooqi A, Sapién RE, Tieder JS. Outcome Prediction of Higher-Risk

Brief Resolved Unexplained Events. Hosp Pediatr. April 2020;10(4):303–310

11. Gausche-Hill M, Eckstein M, Horeczko T, McGrath N, Kurobe A, et al. Paramedics Accurately

Apply the Pediatric Assessment Triangle to Drive Management. Prehosp Emerg Care.

2014;18(4):52–530.

12. Gausche-Hill M, Schmitz C, Lewis RL. Pediatric Preparedness of US Emergency Departments: A

2003 Survey. Pediatrics. Dec 2007;120(6):1229–37

13. Gerber NL, Fawcett KJ, Weber EG, Patel R, Glick AF et al. Brief Resolved Unexplained Event:

Not Just a New Name for Apparent Life-Threatening Event. Pediatr Emerg Care. 2020; May 28.

doi: 10.1097/PEC.0000000000002069. Epub ahead of print. PMID: 32472924

14. Guenther E, Powers A, Srivastava R, Bonkowsky JL. Abusive head trauma in children

presenting with an apparent life-threatening event. J Pediatr. 2010;157(5):821–5

15. Haddad R, Parker S, Farooqi A, Delaroche AM. Diagnostic Evaluation Low Yield for Patients

with a Lower-Risk Brief Resolved Unexplained Event. Global Pediatr Health. February 2021;

8:1–7

16. Kaji A, Claudius I, Santillanes G, et al. Apparent life-threatening event: multicenter prospective

cohort study to develop a clinical decision rule for admission to the hospital. Ann Emerg Med.

2013;61(4):379–87

17. Kaji A, Claudius I, Santillanes G, et al. Do infants less than 12 months of age with an apparent

life-threatening event need transport to a pediatric critical care center? Prehosp Emerg Care.

2013; Vol 17(3):304–11

18. Meyer JS, Stensland EG, Murzycki J, Gulen CR, Evindar A, Cardoso MZ. Retrospective

Application of BRUE Criteria to Patients Presenting with ALTE. Hosp Pediatr. 2018;8(12):740–

745

19. Middleton KR, Burt CW. Availability of pediatric services and equipment in emergency

departments: United States, 2002–03. Adv Data. 2006; 367:1–16

20. Mittal M, Sun G, Baren JM. A clinical decision rule to identify infants with apparent life-

threatening event who can be discharged from the emergency department. Pediatric Emerg

Care. 2012; 28:599–605

21. Oglesbee SJ, Roberts MH, Sapién RE. Implementing lower-risk brief resolved unexplained

events guidelines reduces admissions in a modelled population. J Eval Clin Pract. 2020;

26:343–356

22. Parker K, Pitetti R. Mortality and child abuse in children presenting with apparent life-

threatening events. Ped Emerg Care. 2011;27(7):591–5

23. Prezioso G, Perrone S, Biasucci G, Pisi G, Fainardi V, et al. Management of Infants with Brief

Resolved Unexplained Events (BRUE) and Apparent Life-Threatening Events (ALTE): A

RAND/UCLA Appropriateness Approach. MDPI Life. 2021;11(171):

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https://doi.org/10.3390/life11020171

24. Ramgopal S, Noorbakhsh KA, Callaway CW, Wilson PM, Pitetti RD. Changes in the

Management of Children with Brief Resolved Unexplained Events (BRUEs). Pediatr. October

2019;144(4): e20190375

25. Ramgopal S, Soung J, Pitetti RD. Brief Resolved Unexplained Events: An Analysis of an

Apparent Life Threatening Event Database. Acad Pediatr. November-December

2019;19(8):963–968

26. Remick K, Gausche-Hill M, Joseph MM, Brown K, Snow SK et al. Pediatric Readiness in the

Emergency Department. Pediatrics. November 2018;142(5): e20182459.

27. Stiell IG, Spaite DW, Field B, Nesbitt LP, Munkley D, Maloney J, et al. Advanced life support for

out-of-hospital respiratory distress. N Engl J Med. 2007;356(21):2156–64

28. Stratton S, Taves A, Lewis R, Clements H, Henderson D, McCollough M. Apparent life-

threatening events in infants: high-risk in the out-of-hospital environment. Ann Emerg Med.

2004; 43:711–7

29. Tieder JS, Altman RL, Bonkowsky JL, et al. Management of apparent life–threatening events in

infants: a systematic review. J Pediatr. 2013; 163:94–9

30. Tieder JS. Weird Baby Things or Brief Resolved Unexplained Events? Hosp Pediatr.

2018;8(12):799–800

Revision Date

March 11, 2022

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Pediatric Respiratory Distress (Bronchiolitis)

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based

Guideline Model Process)

Aliases

None noted

Patient Care Goals

1. Alleviate respiratory distress

2. Promptly identify respiratory distress, failure, and/or arrest, and intervene for patients who

require escalation of therapy

3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress

Patient Presentation

Inclusion Criteria

Child less than 2 years of age typically with diffuse rhonchi and/or wheezing with a viral or other

undifferentiated illness characterized by rhinorrhea, cough, fever, tachypnea, and/or respiratory

distress

Exclusion Criteria

1. Anaphylaxis

2. Croup

3. Epiglottitis

4. Foreign body aspiration

5. Submersion/drowning

6. Asthma

Patient Management

Assessment

1. History

a. Onset of symptoms

b. Concurrent symptoms (e.g., fever, cough, rhinorrhea, tongue/lip swelling, rash, labored

breathing, foreign body aspiration)

c. Sick contacts

d. History of wheezing

e. Respiratory and other treatments given

f. Number of emergency department visits in the past year

g. Number of admissions in the past year

h. Number of intensive care unit (ICU) admissions ever (including pediatric ICU (PICU) and

neonatal ICU (NICU))

i. History of prematurity

j. Family history of asthma, eczema, or allergies

k. Change in feeding patterns and/or number of wet diapers

2. Exam

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a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment) temperature, and O

saturation

b. Air entry (normal vs. diminished)

c. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)

d. Signs of distress (grunting, nasal flaring, retracting, accessory muscle use)

e. Weak cry or inability to speak full sentences (sign of shortness of breath)

f. Color (pallor, cyanosis, normal)

g. Mental status (alert, tired, lethargic, unresponsive)

h. Hydration status (+/- sunken eyes, delayed capillary refill, mucous membranes (moist vs.

tacky), fontanel (flat vs. sunken))

Treatment and Interventions

1. Pulse oximetry and end-tidal capnography (EtCO

) should be routinely used as an adjunct to

other forms of respiratory monitoring

2. Perform EKG only if there are no signs of clinical improvement after treating respiratory

distress

3. Airway

a. Give supplemental oxygen – escalate from a nasal cannula to a simple face mask to a non-

breather mask as needed, to maintain normal oxygenation (goal SpO

94–98%)

b. Suction the nose and/or mouth (via bulb or suction catheter) particularly if excessive

secretions are present

4. Inhaled medications – nebulized epinephrine 5 mg (5 mL of 1 mg/mL solution) should be

administered to children in severe respiratory distress with bronchiolitis in the prehospital

setting if other treatments (e.g., suctioning, oxygen) fail to result in clinical improvement; if

immediate reassessment after treatment does not demonstrate clinical improvement, airway

management should be escalated as necessary (see below and refer to Airway Management

Guideline)

5. Utility of IV placement and fluids. IVs should only be placed in children with respiratory

distress for clinical concerns of dehydration, or when administering IV medications.

Otherwise, IV access is not routinely needed in bronchiolitis.

6. Steroids are not efficacious and should not be given

7. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts

8. Supraglottic devices and intubation

a. Supraglottic devices and intubation should be utilized only if bag-valve-mask (BVM)

ventilation fails

b. The airway should be managed in the least invasive way possible

Patient Safety Considerations

Routine use of lights and sirens is not recommended during transport

High flow nasal cannula (HFNC) or continuous positive airway pressure (CPAP) can be

administered, when available, for severe respiratory distress

Bag-valve-mask ventilation should be utilized in children with respiratory failure or

impending respiratory failure

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Notes/Educational Pearls

Key Considerations

1. Suctioning can be a very effective intervention to alleviate distress since infants are obligate

nose breathers

2. Heliox should not be routinely administered to children with respiratory distress

3. Insufficient data exist to recommend the use of inhaled steam or nebulized saline

4. Although albuterol and steroids have previously been a consideration, the most recent

evidence does not demonstrate a benefit in routine use of albuterol or steroids for

bronchiolitis

Ipratropium and other anticholinergic agents should not be given to children with

bronchiolitis

in the prehospital setting

6. Although nebulized hypertonic saline has been shown to decrease hospital length of stay

when used for bronchiolitis, it does not provide immediate relief of distress and should not

be administered to children in respiratory distress in the prehospital setting

Pertinent Assessment Findings

Frequent reassessment is necessary to determine if interventions have alleviated signs of

respiratory distress.

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914221 – Medical - Respiratory Distress-Bronchiolitis

o Protocol Age Category: 3602005 - Pediatric Only

Key Documentation Elements

Document key aspects of the exam to assess for a change after each intervention:

•

Respiratory rate

•

Oxygen saturation

•

Use of accessory muscles

•

Breath sounds

•

Air entry

•

Mental status

•

Color

Performance Measures

• Supplemental oxygen, high flow oxygen by nasal cannula (HFNC), time to administration of

specified interventions in the protocol

• Rate of administration of accepted therapy (whether certain medications/interventions were

given)

• Change in vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment) temperature, O

saturation and capnography values)

• Time to administration of specified interventions in the protocol

• Number of advanced airway attempts

• Mortality

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Version 3.0

References

1. Abramo TJ, Wiebe RA, Scott SM, Primm PA, McIntyre D, Mydlyer T. Noninvasive capnometry in

a pediatric population with respiratory emergencies. Pediatr Emerg Care. 1996;12(4):252–4

2. Al-Ansari K, Sakran M, Davidson BL, El Sayyed R, Mahjoub H, Ibrahim K. Nebulized 5% or 3%

hypertonic or 0.9% saline for treating acute bronchiolitis in infants. J Pediatr. 2010;157(4):

630–4

3. Cambonie G, Milési C, Jaber S, et al. Nasal continuous positive airway pressure decreases

respiratory muscles overload in young infants with severe acute viral bronchiolitis. Intensive

Care Med. 2008;34(10):1865–72

4. Chavasse R, Seddon P, Bara A, McKean M. Short acting beta2-agonists for recurrent wheeze in

children under two years old. Cochrane Database Syst Rev. 2002;(3):CD002873

5. Chowdhury MM, McKenzie SA, Pearson CC, et al. Heliox therapy in bronchiolitis: phase III

multicenter double-blind randomized controlled trial. Pediatrics. 2013;131(4):661–9

6. Corneli HM, Zorc JJ, Mahajan P, et al. A multicenter, randomized, controlled trial of

dexamethasone for bronchiolitis. N Engl J Med. 2007;357(4):331–9

7. Denver Metro Airway Study Group. A prospective multicenter evaluation of prehospital airway

management performance in a large metropolitan region. Prehosp Emerg Care.

2009;13(3):304–10

8. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural

pediatric trauma patients. J Pediatr Surg. 2004;39(9):1376–80

9. Everard ML, Bara A, Kurian M, Elliot TM, Ducharme F. Anticholinergic drugs for wheeze in

children under the age of two years. Cochrane Database Syst Rev. 2002;(1):CD001279

10. Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis:

emergency department clinical findings and diagnostic evaluation. Pediatrics. 2007;120(6):

1278–85

11. Gausche-Hill M, Lewis RJ, Stratton SJ, Haynes BE, Gunter CS, Goodrich SM, et al. Effect of out-

of-hospital pediatric endotracheal intubation on survival and neurological outcome. JAMA.

2000;283(6):783–90

12. Grewal S, Ali S, McConnell DW, Vandermeer B, Klassen TP. A randomized trial of nebulized 3%

hypertonic saline with epinephrine in the treatment of acute bronchiolitis in the emergency

department. Arch Pediatr Adolesc Med. 2009;163(11):1007–12

13. Hartling L, Russell KF, Patel H, Klassen TP, Liang Y. Epinephrine for bronchiolitis. Cochrane

Database Syst Rev. 2004;(1):CD003123

14. Ho J, Casey B. Time saved with use of emergency warning lights and sirens during response to

requests for emergency medical aid in an urban environment. Ann Emerg Med.

1998;32(5):585–8

15. Ho J, Lindquist M. Time saved with the use of emergency warning lights and siren while

responding to requests for emergency medical aid in a rural environment. Prehosp Emerg

Care. 2001;5(2):159–62

16. Hunt RC, Brown LH, Cabinum ES, Whitley TW, Prasad NH, Owens JCF, et al. Is ambulance

transport time with lights and siren faster than that without? Ann Emerg Med. 1995;25(4):

507–11

17. Javouhey E, Barats A, Richard N, Stamm D, Floret D. Non-invasive ventilation as primary

ventilatory support for infants with severe bronchiolitis. Intensive Care Med. 2008;34(9):1608–

18. Kuzma K, Sporer KA, Michael GE, Youngblood GM. When are prehospital intravenous

catheters used for treatment? J Emerg Med. 2009;36(4):357–62

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Pediatric Respiratory Distress (Bronchiolitis) 154

Version 3.0

19. Lacher ME, Bausher JC. Lights and siren in pediatric 911 ambulance transports: are they being

misused? Ann Emerg Med. 1997;29(2):223–7

20. Lashkeri T, Howell JM, Place R. Capnometry as a predictor of admission in bronchiolitis.

Pediatr Emerg Care. 2012;28(9):895–7

21. Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox. Inhalation therapy for bronchiolitis in

infants. Cochrane Database Syst Rev. 2010;(4):CD006915

22. Martinon-Torres F, Rodriguez-Nunez A, Martinon-Sanchez JM. Heliox therapy in infants with

acute bronchiolitis. Pediatrics. 2002;109(1):68–73

23. Moses JM, Alexander JL, Agus MS. The correlation and level of agreement between end-tidal

and blood gas PCO

in children with respiratory distress: a retrospective analysis. BMC Pediatr.

2009; 9:20

24. Mussman GM, Parker MW, Statile A, Sucharew H, Brady PW. Suctioning and length of stay in

infants hospitalized with bronchiolitis. JAMA Pediatr. 2013;167(5):414–21

25. Ralston RL, Lieberthal H, Meissner HC, et al. Clinical practice guideline: the diagnosis,

management, and prevention of bronchiolitis. Pediatrics. 2014;134: e1474–502

26. Skjerven HO, Hunderi JO, Brügmann-Pieper SK, et al. Racemic adrenaline and inhalation

strategies in acute bronchiolitis. N Engl J Med. 2013;368(24):2286–93

27. Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg P. A prospective in-field comparison

of intravenous line placement by urban and nonurban emergency medical services personnel.

Ann Emerg Med. 1994;24(2):209–14

28. Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory

distress. N Engl J Med. 2007;356(21):2156–64

29. Thia LP, McKenzie SA, Blyth TP, Minasian CC, Kozlowska WJ, Carr SB. Randomized controlled

trial of nasal continuous positive airways pressure (CPAP) in bronchiolitis. Arch Dis Child.

2008;93(1):45–7

30. Umoren R, Odey F, Meremikwu MM. Steam inhalation or humidified oxygen for acute

bronchiolitis in children up to three years old. Cochrane Database Syst Rev.

2011;(1):CD006435

31. Wang HE, Mann NC, Mears G, Jacobson K, Yealy DM. Out-of-hospital airway management in

the United States. Resuscitation. 2011;82(4):378–85

32. Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulized hypertonic saline solution for

acute bronchiolitis in infants. Cochrane Database Syst Rev. 2008 Oct 8;(4):CD006458

Revision Date

March 11, 2022

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Pediatric Respiratory Distress (Croup) 155

Version 3.0

Pediatric Respiratory Distress (Croup)

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based

Guideline Model Process)

Aliases

None noted

Patient Care Goals

1. Alleviate respiratory distress

2. Promptly identify respiratory distress, respiratory failure, respiratory arrest, and intervene for

patients who require escalation of therapy

3. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress

Patient Presentation

Inclusion Criteria

Suspected croup (history of stridor or history of barky cough)

Exclusion Criteria

1. Presumed underlying cause that includes one of the following:

a. Anaphylaxis

b. Asthma

c. Bronchiolitis (wheezing in a patient less than 2 years of age)

d. Foreign body aspiration

e. Submersion/drowning

f. Epiglottitis

Patient Management

Assessment

1. History

a. Onset of symptoms (history of choking)

b. Concurrent symptoms (fever, cough, rhinorrhea, tongue/lip swelling, rash, labored

breathing, foreign body aspiration)

c. Sick contacts

d. Treatments given

e. Personal history of asthma, wheezing, or croup in past

2. Exam

a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment) temperature, and O

saturation

b. Presence of stridor at rest or when agitated

c. Description of cough

d. Other signs of distress (grunting, nasal flaring, retracting, use of accessory muscles)

e. Color (pallor, cyanosis, normal)

f. Mental status (alert, tired, lethargic, unresponsive)

Treatment and Interventions

1. Monitoring

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Pediatric Respiratory Distress (Croup) 156

Version 3.0

a. Pulse oximetry and EtCO

should be routinely used as an adjunct to other forms of

respiratory monitoring

2. Airway

a. Give supplemental oxygen. Escalate from a nasal cannula to a simple face mask to a non-

breather mask to SPO

94-98%

b. Suction the nose and/or mouth (via bulb or suction catheter) if excessive secretions are

present

3. Inhaled medications should be administered to all children with croup in respiratory distress

with signs of stridor at rest—these medications should be repeated at this dose with unlimited

frequency for ongoing respiratory distress

a. Epinephrine 5 mg (5 mL of 1 mg/mL solution) nebulized (may repeat in 20 minutes as

needed), or

b. Racemic epinephrine 0.5 mL of 2.25% solution mixed in 2.5 mL NS (may repeat in 20

minutes as needed)

c. Humidified oxygen or mist therapy is not indicated

4. Dexamethasone 0.6 mg/kg oral, IV, or IM to maximum dose of 16 mg should be administered

to patients with suspected croup

5. Utility of IV placement and fluids. IVs should only be placed in children with respiratory

distress for clinical concerns of dehydration or when administering IV medications

6. Improvement of oxygenation and/or respiratory distress with non-invasive airway adjuncts

a. Heliox for the treatment of croup can be considered for severe distress not responsive to

more than 2 doses of epinephrine

b. Continuous positive airway pressure (CPAP) should be administered for severe respiratory

distress

c. BVM ventilation should be utilized in children with respiratory failure

7. Supraglottic devices and intubation — should be utilized only if BVM ventilation fails. The

airway should be managed in the least invasive way possible

Patient Safety Considerations

1. Routine use of lights and sirens is not recommended during transport

2. Patients who receive inhaled epinephrine should be transported to definitive care

Notes/Educational Pearls

Key Considerations

1. Upper airway obstruction can have inspiratory, expiratory, or biphasic stridor

2. Foreign bodies can mimic croup, it is important to ask about a possible choking event

3. Impending respiratory failure is indicated by:

a. Change in mental status such as fatigue and listlessness

b. Pallor

c. Dusky appearance

d. Decreased retractions

e. Decreased breath sounds with decreasing stridor

4. Without stridor at rest or other evidence of respiratory distress, inhaled medications may not

be necessary

Pertinent Assessment Findings

1. Respiratory distress (retractions, wheezing, stridor, accessory muscle use)

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Pediatric Respiratory Distress (Croup) 157

Version 3.0

2. Decreased oxygen saturation

3. Skin color

4. Neurologic status assessment

5. Reduction in work of breathing after treatment

6. Improved oxygenation after breathing

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914223 – Medical - Respiratory Distress-Croup

o Protocol Age Category: 3602005 - Pediatric Only

Key Documentation Elements

• Document key aspects of the exam to assess for a change after each intervention:

o Respiratory rate

o Oxygen saturation

o Use of accessory muscles or tracheal tugging

o Breath sounds

o Air entry

o Mental status

o Color

Performance Measures

• Time to administration of specified interventions in the protocol

• Frequency of administration of specified interventions in the protocol

References

1. Abramo TJ, Wiebe RA, Scott SM, Primm PA, McIntyre D, Mydlyer T. Noninvasive capnometry in a

pediatric population with respiratory emergencies. Pediatr Emerg Care. 1996;12(4):252–4

2. Ausejo M, Saenz A, Pham B, et al. The effectiveness of glucocorticoids in treating croup: meta-

analysis. West J Med. 1999;171(4):227–32

3. Bjornson CL, Klassen TP, Williamson J, et al. A randomized trial of a single dose of oral

dexamethasone for mild croup. Pediatric Emergency Research Canada Network. N Engl J Med.

2004;351(13):1306–13

4. Bjornson C, Russell KF, Vandermeer B, Durec T, Klassen TP, Johnson DW. Nebulized

epinephrine for croup in children. Cochrane Database Syst Rev. 2011;(2):CD006619

5. Denver Metro Airway Study Group. A prospective multicenter evaluation of prehospital airway

management performance in a large metropolitan region. Prehosp Emerg Care.

2009;13(3):304–10

6. Ehrlich PF, Seidman PS, Atallah O, Haque A, Helmkamp J. Endotracheal intubations in rural

pediatric trauma patients. J Pediatr Surg. 2004;39(9):1376–80

7. Freedman SB, Haladyn JK, Floh A, Kirsh JA, Taylor G, Thull-Freedman J. Pediatric myocarditis:

Emergency department clinical findings and diagnostic evaluation. Pediatrics.

2007;120(6):1278–85

8. Gausche M, Lewis RJ, Stratton SJ, et al. Effect of out-of-hospital pediatric endotracheal

intubation on survival and neurological outcome. JAMA. 2000;283(6):783–90

9. Grosz AH, Jacobs IN, Cho C, Schears GJ. Use of helium-oxygen mixture to relieve upper airway

obstruction in a pediatric population. Laryngoscope. 2001;111(9):1512–4

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10. Guideline for the Diagnosis and Management of Croup. Alberta, ON, Canada: Alberta Medical

Association; 2015. https://actt.albertadoctors.org/CPGs/Lists/CPGDocumentList/croup-

guideline.pdf Accessed March 11, 2022

11. Ho J, Casey B. Time saved with use of emergency warning lights and sirens during response to

requests for emergency medical aid in an urban environment. Ann Emerg Med.

1998;32(5):585–8

12. Hunt RC, Brown LH, Cabinum ES, et al. Is ambulance transport time with lights and siren faster

than that without? Ann Emerg Med. 1995;25(4):507–11

13. Keahey L, Bulloch B, Becker AB, Pollack CV, Clark S, Camargo CA. Initial oxygen saturation as a

predictor of admission in children presenting to the emergency department with acute

asthma. Ann Emerg Med. 2002;40(3):300–7

14. Kline-Krammes S, Reed C, Giuliano JS Jr., et al. Heliox in children with croup: a strategy to

hasten improvement. Air Med J. 2012;31(3):131–7

15. Kunkel NC, Baker MD. Use of racemic epinephrine, dexamethasone, and mist in the outpatient

management of croup. Pediatr Emerg Care. 1996;12(3):156–9

16. Kuzma K, Sporer KA, Michael GE, Youngblood GM. When are prehospital intravenous

catheters used for treatment? J Emerg Med. 2009;36(4):357–62

17. Lacher ME, Bausher JC. Lights and siren in pediatric 911 ambulance transports: are they being

misused? Ann Emerg Med. 1997;29(2):223–7

18. Moses JM, Alexander JL, Agus MSD. The correlation and level of agreement between end-tidal

and blood gas pCO

in children with respiratory distress: A retrospective analysis. BMC Pediatr.

2009; 9:20

19. Neto GM, Kentab O, Klassen TP, Osmond MH. A randomized controlled trial of mist in the

acute treatment of moderate croup. Acad Emerg Med. 2002;9(9):873–9

20. Russell KF, Liang Y, O'Gorman K, Johnson DW, Klassen TP. Glucocorticoids for croup.

Cochrane Database Syst Rev., 2011 Jan 19;(1):CD001955.

21. Scolnik D, Coates AL, Stephens D, Da Silva Z, Lavine E, Schuh S. Controlled delivery of high vs low

humidity vs mist therapy for croup in emergency departments: a randomized controlled trial.

JAMA. 2006;295(11):1274–80

22. Spaite DW, Valenzuela TD, Criss EA, Meislin HW, Hinsberg PA. prospective in-field comparison

of intravenous line placement by urban and nonurban emergency medical services personnel.

Ann Emerg Med. 1994;24(2):209–14

23. Stiell IG, Spaite DW, Field B, et al. Advanced life support for out-of-hospital respiratory

distress. N Engl J Med. 2007;356(21):2156–64

24. Stoney PJ, Chakrabarti MK. Experience of pulse oximetry in children with croup. J Laryngol

Otol. 1991;105(4):295–8

25. Vorwerk C, Coats T. Heliox for croup in children. Cochrane Database Syst Rev.

2012;(10):CD006822

26. Warner GS. Evaluation of the effect of prehospital application of continuous positive airway

pressure therapy in acute respiratory distress. Prehosp Disast Med. 2010;25(1):87–91

27. Westley CR, Cotton EK, Brooks JG. Nebulized racemic epinephrine by IPPB for the treatment of

croup: a double-blind study. Am J Dis Child. 1978;132(5):484–7

Revision Date

March 11, 2022

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Neonatal Resuscitation

Aliases

None noted

Patient Care Goals

1. Plan for resources based on number of anticipated patients (e.g., mother and newborn or

multiple births)

2. Provide routine care to the newly born infant

3. Perform a neonatal assessment

4. Rapidly identify newly born infants requiring resuscitative efforts

5. Provide appropriate interventions to minimize distress in the newly born infant

6. Recognize the need for additional resources based on patient condition and/or environmental

factors

Patient Presentation

Inclusion Criteria

Newly born infants

Exclusion Criteria

Documented gestational age less than 20 weeks (usually calculated by date of last menstrual

period). If any doubt about accuracy of gestational age, initiate resuscitation

Patient Management

Assessment

1. History

a. Date and time of birth

b. Onset of symptoms

c. Prenatal history (prenatal care, substance abuse, multiple gestation, maternal illness)

d. Birth history (maternal fever, presence of meconium, maternal bleeding, difficult delivery

(e.g., shoulder dystocia, prolapsed or nuchal cord, breech))

e. Estimated gestational age (may be based on last menstrual period)

2. Exam

a. Respiratory rate and effort (strong, weak, or absent; regular or irregular)

b. Signs of respiratory distress (grunting, nasal flaring, retractions, gasping, apnea)

c. Heart rate (fast, slow, or absent)

i. Precordium, umbilical stump, or brachial pulse may be used

(auscultation of chest is preferred since palpation of umbilical stump is less accurate)

d. Muscle tone (poor or strong)

e. Color/Appearance (central cyanosis, acrocyanosis, pallor, normal)

f. APGAR score (Appearance, Pulse, Grimace, Activity, Respiratory effort) — may be

calculated for documentation, but not necessary to guide resuscitative efforts

g. Estimated gestational age (term, late preterm, premature)

h. Pulse oximetry should be considered if resuscitative efforts are initiated or if supplemental

oxygen is administered

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Treatment and Interventions

1. If immediate resuscitation is required and the newborn is still attached to the mother, clamp

the cord in two places and cut between the clamps. If no resuscitation is required,

warm/dry/stimulate the newborn, and then cut/clamp the cord after 60 seconds or the cord

stops pulsating

2. Dry, warm, and stimulate

a. Wrap infant in dry towel or thermal blanket to keep infant as warm as possible during

resuscitation; keep head covered if possible

b. If strong cry, regular respiratory effort, good tone, and term gestation, infant should be

placed skin-to-skin with mother and covered with dry linen

3. If weak cry, signs of respiratory distress, poor tone, or preterm gestation then position airway

(sniffing position) and clear airway as needed. If signs of respiratory distress with airway

obstruction, suction mouth then nose; routine suctioning is not recommended

4. Apply cardiac monitor, if available

5. If heart rate greater than 100 BPM

a. Monitor for central cyanosis — provide blow-by oxygen as needed

b. Monitor for signs of respiratory distress. If apneic or in significant respiratory distress:

i. Ventilate: BVM ventilation with room air at 40–60 breaths per minute

1. Positive pressure ventilation (PPV) with bag-mask device may be initiated with

room air (21% oxygen) in term and late preterm babies; otherwise use 100%

oxygen

2. Goal: SPO

at 10 minutes is 85–95%

ii. Consider endotracheal intubation per local guidelines

6. Evaluate: If heart rate less than 100 BPM

a. Initiate BVM ventilation with room air at 40–60 breaths per minute for 90 seconds with

room air

i. Primary indicator of effective ventilation is improvement in heart rate

ii. Evaluate heart rate every 30 seconds

iii. Rates and volumes of ventilation required can be variable, only use the minimum

necessary rate and volume to achieve chest rise and a change in heart rate; can control

rate and volume by saying “squeeze, release” – squeeze the bag just until chest rise is

indicated then release to allow for exhalation

b. If no improvement after 90 seconds, change oxygen delivery to 30% FiO

(fraction of

inspired oxygen) if blender available, otherwise 100% FiO

until heart rate normalizes

c. Consider endotracheal intubation or supraglottic airway per local guidelines if BVM

ventilation is ineffective

7. Resuscitate: If heart rate less than 60 BPM:

a. Ensure effective ventilations with supplementary oxygen and adequate chest rise

b. If no improvement after 30 seconds, initiate chest compressions — two-thumb-encircling-

hands technique is preferred

c. Coordinate chest compressions with positive pressure ventilation (3:1 ratio, 90

compressions and 30 breaths per minute)

d. Consider endotracheal intubation or supraglottic airway per local guidelines

e. Administer epinephrine (0.1 mg/mL) 0.01 mg/kg IV/IO (preferable if access obtained) or

0.1 mg/kg via the ETT (if unable to obtain access) q 3–5 min if heart rate remains less than

60 BPM

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8. Consider checking a blood glucose for ongoing resuscitation, maternal history of diabetes, ill

appearing or unable to feed

9. Administer 20 mL/kg normal saline IV/IO for signs of shock or post-resuscitative care

Patient Safety Considerations

1. Hypothermia is common in newborns and worsens outcomes of nearly all post-natal

complications

a. Ensure heat retention by drying the infant thoroughly, covering the head, and wrapping

the baby in dry cloth

b. When it does not encumber necessary assessment or required interventions, “kangaroo

care” (i.e., placing the infant skin-to-skin directly against mother’s chest and wrapping

them together) is an effective warming technique

c. Newborn infants are prone to hypothermia which may lead to hypoglycemia, hypoxia, and

lethargy. Aggressive warming techniques should be initiated including drying, swaddling,

and warm blankets covering body and head. When available, radiant warmers or other

warming adjuncts are suggested for babies who require resuscitation, especially for

preterm babies. Check blood glucose and follow Hypoglycemia Guideline as appropriate

2. During transport, neonate should be appropriately secured (e.g., secured to mother with

approved neonatal restraint system, car seat or isolette) and mother should be appropriately

secured

Notes/Educational Pearls

Key Considerations

1. Approximately 10% of newly born infants require some assistance to begin breathing at birth

and 1% require resuscitation to support perfusion

2. Most newborns require only drying, warming, and stimulating to help them transition from

fetal respiration to newborn respiration. The resuscitation sequence can be remembered as

Dry, Warm, and Stimulate – Ventilate – Evaluate – and Resuscitate

Table 1. Assessments that are used to initiate BMV and chest compressions

INTERVENTION INDICATED

Blow-by Oxygen

Bag-Mask-Ventilation

(BVM)

BVM and Chest

compressions

ASSESSMENT

Heart Rate (BPM)

> 100

60–100

< 60

Respiratory

Distress/Apnea

Yes

Central Cyanosis

Present

Yes

Yes/No

3. Deliveries complicated by maternal bleeding (placenta previa, vas previa, or placental

abruption) place the infant at risk for hypovolemia secondary to blood loss

4. Low birth weight infants are at high-risk for hypothermia due to heat loss

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5. Measuring the pulse oximetry on the right hand provides the most accurate oxygen saturation

(SpO

) in infants that are transitioning from fetal to normal circulation. At 60 seconds, 60% is

the target with an increase of 5% every minute until 5 minutes of life when pulse oximetry is

80–85%

Table 2. Projected Pulse Oximetry in Infants Over Time

Time Since Birth

Projected Increase in Pulse Oximeter

Over Time

1 minute

60–65%

2 minutes

65–70%

3 minutes

70–75%

4 minutes

75–80%

5 minutes

80–85%

10 minutes

85–90%

6. Both hypoxia and excess oxygen administration can result in harm to the infant. If prolonged

oxygen use is required, titrate to maintain an SPO

of 85–95%

7. While not ideal, a larger facemask than indicated for patient size may be used to provide BVM

ventilation if an appropriately sized mask is not available. Avoid pressure over the eyes as this

may result in bradycardia

8. Increase in heart rate is the most reliable indicator of effective resuscitative efforts

9. A multiple gestation delivery may require additional resources and/or clinicians

10. There is no evidence to support the routine practice of administering sodium bicarbonate for

the resuscitation of newborns

11. APGAR scoring is not critical during the resuscitation, although it may be prognostic after 20

minutes if the APGAR Score remains “0” despite resuscitation

Table 3. APGAR Score

Sign

Appearance:

Blue,

Pale

Body pink,

Extremities blue

Completely pink

Pulse:

Absent

Slow

(less than l00)

≥ 100

Grimace:

response

Grimace

Cough or

Sneeze

Activity:

Limp

Some flexion

Active motion of

extremities

Respirations:

Absent

Slow,

Irregular

Good,

Crying

Source: The Apgar Score. www.acog.org

Pertinent Assessment Findings

1. It is difficult to determine gestational age in the field – if there is any doubt as to viability,

resuscitation efforts should be initiated

2. Acrocyanosis, a blue discoloration of the distal extremities, is a common finding in the newly

born infant transitioning to extrauterine life – this must be differentiated from central

cyanosis

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914133 – Medical - Newborn/Neonatal Resuscitation

Key Documentation Elements

• Historical elements

o Prenatal complications

o Delivery complications

o Date and time of birth

o Estimated gestational age

• Physical exam findings

o Heart rate

o Respiratory rate

o Respiratory effort

o Appearance

o APGAR score at 1 minute and 5 minutes

Performance Measures

• Prehospital on-scene time

• Call time for additional resources

• Arrival time of additional unit

• Time to initiation of interventions

• Use of oxygen during resuscitation

• Presence of advanced life support (ALS) versus basic life support (BLS) clinicians

• Hypothermia on arrival in the emergency department

• Hypoglycemia evaluated and treated

• ROSC (return of spontaneous circulation) and/or normalization of heart rate

• Length of stay in neonatal intensive care unit

• Length of stay in newborn nursery

• Length of stay in hospital

• Knowledge retention of prehospital clinicians

• Number of advanced airway attempts

• Mortality

References

1. AGOG Recommends Delayed Umbilical Cord Clamping for All Healthy Infants. Agog.org.

https://www.acog.org/About-ACOG/News-Room/News-Releases/2016/Delayed-Umbilical-

Cord-Clamping-for-All-Healthy-Infants. Published December 21, 2006. Accessed August 27,

2017

2. Aziz K, Lee HC, Escobedo, MB et al. Part 5: Neonatal Resuscitation: 2020 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular

Care. Circulation 2020; 142; S524–S550

3. Vali P, Chandrasekharian P, Rawat M, et al. Evaluation of timing and route of epinephrine

administration in a neonatal model of asphyxia arrest. J Am Heart Assoc 2017;6: e004402

4. Weiner GM, Zaichkin J. Textbook of neonatal resuscitation (NRP), 7

Ed. Elk Grove Village, IL:

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American Academy of Pediatrics; 2016

5. Welsford M, Nichiyama C, Shortt C, et al. Room air for initiating term newborn resuscitation: A

systematic review and meta-analysis. Pediatrics 2019; 143

Revision Date

March 11, 2022

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OB/GYN

Childbirth

Aliases

Birth Delivery Labor

Patient Care Goals

1. Obtain necessary history to plan for birth and resuscitation of the newborn

2. Recognize imminent birth

3. Plan for resources based on number of anticipated patients (e.g., mother and child or multiple

births)

4. Assist with uncomplicated delivery of term newborn

5. Recognize complicated delivery situations (e.g., nuchal or prolapsed umbilical cord, breech

delivery, shoulder dystocia) and plan for management and appropriate transport destination

6. Apply appropriate techniques when an obstetric complication exists

Patient Presentation

Inclusion Criteria

Imminent delivery with crowning

Exclusion Criteria

1. Vaginal bleeding in any stage of pregnancy [See Obstetrical/Gynecological Conditions

Guideline]

2. Emergencies in first or second trimester of pregnancy [See Obstetrical/Gynecological

Conditions Guideline]

3. Seizure from eclampsia [See Obstetrical/Gynecological Conditions Guideline and

Eclampsia/Pre-Eclampsia Guideline]

Patient Management

Assessment:

1. Signs of imminent delivery:

a. Crowning or other presentation in vaginal opening

b. Urge to push

c. Urge to move bowels

d. Mother’s sense of imminent delivery

2. Signs of active labor

a. Contractions

b. Membrane rupture

c. Bloody show

Treatment and Interventions

1. If patient in labor but no signs of imminent delivery, transport to appropriate receiving facility

2. Delivery should be controlled to allow a slow controlled delivery of infant – This will prevent

injury to mother

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a. Support the infant’s head as needed and apply gentle counterpressure to help prevent the

head from suddenly popping out

3. Check for nuchal cord (i.e., around the baby’s neck)

a. If present, slip it over the head

b. If unable to free the cord from the neck, double clamp the cord and cut between the

clamps

4. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery

5. Grasping the head with hand over the ears, gently guide head down to allow delivery of the

anterior shoulder

6. Gently guide the head up to allow delivery of the posterior shoulder

7. Slowly deliver the remainder of the infant

8. After 1 minute, clamp cord about 5–6 inches from the abdomen with two clamps; cut the cord

between the clamps

a. If resuscitation is needed, the baby can still benefit from a 1-minute delay in cord

clamping. Start resuscitation immediately after birth and then clamp and cut the cord at 1

minute

b. While cord is attached, take care to ensure the baby is not significantly higher positioned

than the mother to prevent blood from flowing backwards from baby to placenta

9. Dry, warm, and stimulate infant, wrap in towel and place on maternal chest unless

resuscitation needed

10. Resuscitation takes priority over recording APGAR scores. Record APGAR scores at 1 and 5

minutes once neonate is stabilized

11. After delivery of infant, suctioning (including suctioning with a bulb syringe) should be

reserved for infants who have obvious obstruction to the airway or require positive pressure

ventilation (follow Neonatal Resuscitation Guideline for further care of the infant) The

placenta will deliver spontaneously, often within 5–15 minutes after the infant is delivered

a. Do not force the placenta to deliver; do not pull on the umbilical cord

b. Contain all tissue in plastic bag and transport

12. After delivery, massaging the uterus (should be located at about the umbilicus) and allowing

the infant to nurse will promote uterine contraction and help control bleeding

a. Estimate maternal blood loss

b. Treat mother for hypovolemia as needed

13. Transport infant secured to mother with approved neonatal restraint system, in car seat or

isolette unless resuscitation is needed

14. Keep infant warm during transport

15. Most deliveries proceed without complications – If complications of delivery occur, apply high

flow oxygen to mother and expedite transport to the appropriate receiving facility. Maternal

resuscitation is critical for best fetal outcome. Contact medical direction and/or closest

appropriate receiving facility for direct medical oversight and to prepare the receiving team.

The following are recommendations for specific complications:

a. Shoulder dystocia – if delivery fails to progress after head delivers, quickly attempt the

following

i. Hyperflex mother’s hips to severe supine knee-chest position (i.e., McRoberts’

maneuver)

ii. Apply firm suprapubic pressure to attempt to dislodge shoulder. This often requires

two EMS clinicians to perform and allows for delivery in up to 75% of cases

iii. Attempt to angle baby’s head as posteriorly as possible but NEVER pull

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iv. Continue with delivery as normal once the anterior shoulder is delivered

b. Prolapsed umbilical cord

i. Placed gloved hand into vagina and gently lift head/body off the cord

1. Assess for pulsations in cord, if no pulses are felt, lift the presenting part off the

cord

2. Wrap the prolapsed cord in moist sterile gauze

3. Maintain until relieved by hospital staff

ii. If previous techniques are not successful, mother should be placed in prone knee-

chest position or extreme Trendelenburg with hips elevated

c. Breech birth

i. Place mother supine, allow the buttocks, feet, and trunk to deliver spontaneously,

then support the body while the head is delivered

ii. If needed, put the mother in a kneeling position which may assist in the delivery of the

newborn

iii. Assess for presence of prolapsed cord and treat as above

iv. If head fails to deliver, place gloved hand into vagina with fingers between infant’s

face and uterine wall to create an open airway. Place your index and ring fingers on

the baby’s cheeks forming a “V” taking care not to block the mouth and allowing the

chin to be tilted toward the chest flexing the neck

v. When delivering breech, you may need to rotate the baby’s trunk clockwise; or sweep

the legs from the vagina

vi. Once the legs are delivered support the body to avoid hyperextension of the head;

keep the fetus elevated off the umbilical cord

vii. NEVER pull on the body, especially a preterm or previable baby – just support the

baby’s body while mother pushes when she feels the urge to

d. The presentation of an arm or leg through the vagina is an indication for immediate

transport to hospital

e. Nuchal cord

i. After the head has been delivered, palpate the neck for a nuchal cord, if present, slip

over the head

ii. If the loop is too tight to slip over the head, attempt to slip the cord over the

shoulders and deliver the body through the loop

iii. The cord can be doubly clamped and cut between the clamps; the newborn should be

delivered promptly

f. Excessive bleeding during active labor may occur with placenta previa or placental

abruption

i. Obtain history from patient – known previa, recent pre-eclampsia symptoms,

hypertension history, recent trauma, drug use especially cocaine

ii. Placenta previa most likely will prevent delivery of infant vaginally

iii. Place large bore IV and administer IV fluids as indicated

iv. If available, transfusion or the administration of whole blood as indicated

v. C-Section most likely needed – transport emergently

g. Postpartum hemorrhage

i. Obtain history from patient – history of prenatal or delivery complications, recent

trauma, prescription anticoagulants, drug use especially cocaine

ii. Perform fundal massage

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iii. Initiate IV fluid resuscitation and, if approved by medical direction, transfuse blood

products

iv. Consider administration of tranexamic acid (TXA)

v. Although recommended following all deliveries, if postpartum hemorrhage occurs

following delivery, consider administration of oxytocin

h. Maternal cardiac arrest

i. Apply manual pressure to displace uterus from midline

ii. Treat per the Cardiac Arrest Guideline (VF/VT/Asystole/PEA) for resuscitation care

(defibrillation and medications should be given for same indications and doses as if

non-pregnant patient)

iii. Transport as soon as possible if infant is estimated to be over 24 weeks gestation

(perimortem Cesarean section (also known as resuscitative hysterotomy) at receiving

facility is most successful if started within 5 minutes of maternal cardiac arrest)

Patient Safety Considerations

1. Supine Hypotension Syndrome:

a. If mother has hypotension before delivery, place patient in left lateral recumbent position

or manually displace gravid uterus to the left in supine position

b. Knee-chest position may create safety issues during rapid ambulance transport

2. Do not routinely suction the infant’s airway (even with a bulb syringe) during delivery

3. Newborns are very slippery, take care not to drop the infant

4. Dry, warm and stimulate all newborns to facilitate respirations and prevent hypothermia

5. Do not pull on the umbilical cord while the placenta is delivering

6. If possible, transport between deliveries if mother is expecting twins

Notes/Educational Pearls

1. OB assessment:

a. Length of pregnancy

b. Number of pregnancies

c. Number of viable births

d. Number of non-viable births

e. Due date (calculate gestational age in weeks)

i. If unknown gestational age, rough estimated gestational age with palpation of the

uterine fundus at the umbilicus is 20 weeks

f. Last menstrual period

i. Only ask for estimated last menstrual period (first day of last period) if patient has

not had prenatal care/ultrasound and does not know their due date.

g. Prenatal care

h. Number of expected babies (multiple gestations)

i. Drug use and maternal medication use

j. Any known pregnancy complications – hypertension, gestational diabetes, placenta

previa, premature labor, history of fetal demise, fetal anomalies/birth defects, etc.

k. Signs of imminent delivery (e.g., crowning, urge to push, urge to move bowels, mother

feels delivery is imminent)

l. Location where patient receives care (considered a preferred destination if time delay is

not an issue and based on local protocols)

2. Notify medical direction/receiving facility if:

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a. Antepartum hemorrhage

b. Postpartum hemorrhage

c. Breech presentation

d. Limb presentation

e. Complicated nuchal cord (around neck) – unable/difficult to reduce

f. Prolapsed umbilical cord

g. Shoulder dystocia

h. Maternal cardiac arrest

i. If anticipated transport time is greater than 30 minutes

3. Some light bleeding/bloody show (blood-tinged mucus/fluid) is normal with any childbirth

a. Large quantities of blood/clots or profuse bleeding are abnormal

Table 1. APGAR Score

Sign

Appearance:

Blue,

Pale

Body pink,

Extremities blue

Completely pink

Pulse:

Absent

Slow

(less than l00)

≥ 100

Grimace:

response

Grimace

Cough or

Sneeze

Activity:

Limp

Some flexion

Active motion of

extremities

Respirations:

Absent

Slow,

Irregular

Good,

Crying

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914133 – Medical - Neonatal/Newborn Resuscitation

•

9914155 – OB/GYN - Childbirth/Labor/Delivery

•

9914161 – OB/GYN - Pregnancy Related Disorders

•

9914163 – OB/GYN - Postpartum Hemorrhage

Key Documentation Elements

• Document all times (delivery, contraction frequency and length)

Performance Measures

• Recognition of complications

• Documentation of APGAR scores

• Maternal reassessment

References

1. Beaird DT, Ladd M, Kahwaii CI. EMS Prehospital Deliveries. Stat Pearls. 12-27-2020

2. Flanagan B, Lord B, Barnes M. Is unplanned out-of-hospital birth managed by paramedics

'infrequent', 'normal' and 'uncomplicated'? BMC Pregnancy Childbirth. 2017 Dec 22;17(1):436

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3. Piaggio G, Carvalho JF, Althabe F. Prevention of postpartum haemorrhage: a distributional

approach for analysis. Reprod Health. 2018 Jun 22;15(Suppl 1):97

4. Sheldon WR, Blum J, Vogel JP, Souza JP, Gülmezoglu AM, Winikoff B., WHO Multicountry

Survey on Maternal and Newborn Health Research Network. Postpartum haemorrhage

management, risks, and maternal outcomes: findings from the World Health Organization

Multicountry Survey on Maternal and Newborn Health. BJOG. 2014 Mar;121 Suppl 1:5–13

5. Stallard T, Burns B. Emergency delivery and perimortem C-section. Emerg Med Clin N Am.

2003; 21:679–93

6. WHO, United Nations Population Fund, UNICEF. Pregnancy, Childbirth, Postpartum and

Newborn Care: A guide for essential practice (3

edition). Geneva, Switzerland: WHO Press;

2015

Revision Date

March 11, 2022

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Eclampsia/Pre-Eclampsia

Aliases

Pregnancy induced hypertension Pregnant seizures

Toxemia of pregnancy

Patient Care Goals

1. Recognize serious conditions associated with pregnancy and hypertension

2. Prevention of eclampsia-related seizures

3. Provide adequate treatment for eclampsia-related seizures

Patient Presentation

Inclusion Criteria

1. Female patient, more than 20-weeks’ gestation, presenting with hypertension and evidence of

end organ dysfunction including renal insufficiency, liver involvement, neurological, or

hematological involvement

2. May occur up to 6 weeks postpartum but is rare after 48 hours post-delivery

a. Often the presenting symptom of postpartum pre-eclampsia is headache or SOB

3. Severe features of pre-eclampsia include:

a. Severe hypertension (SBP greater than 160, DBP greater than 110)

b. Headache

c. Confusion/altered mental status

d. Vision changes including blurred vision, spots/floaters, loss of vision (these symptoms are

often a precursor to seizure)

e. Right upper quadrant or epigastric pain

f. Shortness of breath/Pulmonary edema

g. Ecchymosis suggestive of low platelets (bruising, petechiae)

h. Vaginal bleeding suggestive of placental abruption

i. Focal neurologic deficits suggesting hemorrhagic or thromboembolic stroke

4. Eclampsia

a. Any pregnant patient who is seizing should be assumed to have eclampsia and treated as

such until arrival at the hospital

b. Seizure in any late term pregnancy or postpartum patient

5. Eclampsia/pre-eclampsia can be associated with abruptio placenta and fetal loss

Exclusion Criteria

None noted

Patient Management

Assessment

1. Obtain history

a. Gestational age in weeks or recent post-partum

b. Symptoms suggestive of end organ involvement such as headache, confusion, visual

disturbances, seizure, epigastric pain, right upper quadrant pain, nausea/vomiting, stroke

symptoms, shortness of breath

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c. Previous history of hypertension or known pre-eclampsia

2. Monitoring

a. Vital signs including repeat blood pressures every 10 min

3. Secondary survey pertinent to obstetric issues:

a. Constitutional: vital signs, skin color

b. Abdomen: distension, tenderness, uterine rigidity

c. Genitourinary: visible bleeding

d. Neurologic: mental status, focal deficits

Treatment and Interventions

1. Severe hypertension (SBP greater than 160 or DBP greater than 110) lasting more than 15 min

with associated preeclampsia symptoms

a. Severely elevated blood pressures must be treated to reduce the risk of maternal stroke

b. However, goal blood pressure should be roughly 140/90 to maintain uterine perfusion and

to keep fetus well-oxygenated

c. Goal BP is approximately 140/90 to reduce stroke risk but maintain uterine perfusion

i. Labetalol 20 mg IV over 2 minutes

1. May repeat every 10 minutes X 2 doses for persistent severe hypertension with

preeclampsia symptoms

2. Goal is to reduce MAP by 20–25% initially

3. Ensure that HR is greater than 60 BPM prior to administration

ii. Hydralazine 5 mg IV

1. May repeat 10 mg after 20 minutes for persistent severe hypertension with

preeclampsia symptoms

2. Goal is to reduce MAP by 20–25% initially

iii. Nifedipine 10 mg immediate release PO

1. May repeat 10–20 mg by mouth every 20 minutes X 2 doses for persistent severe

hypertension with pre-eclampsia symptoms

2. Goal is to reduce MAP by 20–25% initially

d. Magnesium sulfate: 4 g IV over 5–10 min, followed by 2 g/hr

e. Reassess vital signs every 10 minutes during transport

2. Seizure prophylaxis and seizure management, associated with pregnancy greater than 20-

weeks gestation

a. Magnesium sulfate

i. Seizure prophylaxis: 4 g IV over 20–30 minutes, followed by 2 g/hr IV if available

ii. Seizure Management: 6 g IV over 5–10 minutes or 8 g IM (4 grams in each buttock) to

prevent seizure

b. Benzodiazepine, per Seizures Guideline, for active seizure not responding to magnesium.

Caution: respiratory depression

3. IV fluids:

a. NS or LR – keep continuous infusion with maximum rate of fluids to 80 mL/hr

4. Administer high flow oxygen as indicated

5. Disposition

a. Transport emergently to closest appropriate receiving facility – notify en route if possible

so the receiving team can prepare

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b. Patients in second or third trimester of pregnancy should be transported on left side or

with uterus manually displaced to left to ensure adequate uterine perfusion

Patient Safety Considerations

1. Magnesium toxicity (progression)

a. Hypotension followed by

b. Loss of deep tendon reflexes followed by

c. Somnolence, slurred speech followed by

d. Respiratory paralysis followed by

e. Cardiac arrest

2. Treatment of magnesium toxicity

a. Stop magnesium drip

b. Give calcium gluconate 3 g IV or calcium chloride 1 g IV in cases of pending respiratory

arrest

c. Support respiratory effort

Notes/Educational Pearls

Key Considerations

1. Delivery of the placenta is the only definitive management for pre-eclampsia and eclampsia

2. Early treatment of severe pre-eclampsia with magnesium for seizure prophylaxis and anti-

hypertensive significantly reduces the rate of eclampsia. Use of magnesium encouraged if

signs of severe pre-eclampsia present to prevent seizure

3. Patients with a history of chronic hypertension may have superimposed pre-eclampsia

4. Although less frequent, eclampsia, including eclampsia-related seizures, can occur in

postpartum patients

Pertinent Assessment Findings

1. Vital signs assessment with repeat blood pressure monitoring before and after treatment

2. Assessment of deep tendon reflexes after magnesium therapy

3. Examination for end organ involvement

4. Evaluate fundal height

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914157 – OB/GYN - Eclampsia

•

9914159 – OB/GYN - Gynecological Emergencies

•

9914161 – OB/GYN - Pregnancy Related Disorders

Key Documentation Elements

Document full vital signs and physical exam findings

Performance Measures

• Patients with signs of hypertension and greater than 20-week gestation or recent postpartum

should be assessed for signs of pre-eclampsia

• Recognition and appropriate treatment of eclampsia

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References

1. American College of Obstetricians and Gynecologists Committee on Obstetric Practice

Emergent Therapy for Acute-onset, Severe Hypertension During Pregnancy and the

Postpartum Period. Committee opinion no 767: Obstet Gynecol. 2019;133(2): 174–180

2. American College of Obstetricians and Gynecologists Committee on Obstetric Practice

Magnesium sulfate use in obstetrics. Committee opinion no 652: Obstet Gynecol. 2016;127(1):

e52–3

3. American College of Obstetrics and Gynecologists Task Force on Hypertension in Pregnancy.

Report of the American College of Obstetricians and Gynecologists’ task force on hypertension

in pregnancy. Obstet Gynecol. 2013;122(5):1122–31

4. Cuero M, Varelas P. Neurologic complications in pregnancy. Crit Care Clin. 2016;32(1):43–59

5. Emergent therapy for acute-onset, severe hypertension during pregnancy and the postpartum

period. ACOG Committee Opinion No. 767. American College of Obstetricians and

Gynecologists. Obstet Gynecol 2019;133: e174–80

6. Gestational Hypertension and Preeclampsia. ACOG Committee Opinion No. 222. American

College of Obstetricians and Gynecologists. Obstet Gynecol 2020; 135: e237–60

7. Mol BW, Roberts CT, Thangaratinam S, Magee LA, de Groot CJ, Hofmeyr GJ. Pre-eclampsia.

Lancet. 2016;387(10022):999–1011

8. Olson-Chen C, Seligman N. Hypertensive Emergencies in Pregnancy. Crit Care Clin.

2016;32(1):29–41

Revision Date

March 11, 2022

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Obstetrical and Gynecological Conditions

Aliases

None noted

Patient Care Goals

1. Recognize serious conditions associated with hemorrhage during pregnancy even when

hemorrhage or pregnancy is not apparent (e.g., ectopic pregnancy, abruptio placenta,

placenta previa)

2. Provide adequate resuscitation for hypovolemia

Patient Presentation

Inclusion Criteria

1. Female patient with vaginal bleeding in any trimester

2. Female patient with pelvic pain or possible ectopic pregnancy

3. Consider pregnancy in any female between the ages of 10–60 years of age

Exclusion Criteria

1. Childbirth and active labor [See Childbirth Guideline]

2. Postpartum hemorrhage [See Childbirth Guideline]

Differential Diagnosis

1. Abruptio placenta: Most frequently occurs in third trimester of pregnancy; placenta

prematurely separates from the uterus causing intrauterine bleeding

a. Lower abdominal pain, uterine rigidity (often not present until abruption is advanced)

b. Vaginal bleeding – this symptom may not occur in cases of concealed abruption

c. Clinical index of suspicion for abruption (history of trauma, maternal hypertension,

maternal drug use especially cocaine)

d. Shock, with minimal or no vaginal bleeding

2. Placenta previa: placenta covers part or all of the cervical opening

a. Generally, late second or third trimester

b. Painless vaginal bleeding, unless in active labor

c. For management during active labor [See Childbirth Guideline]

3. Ectopic pregnancy

a. First trimester

b. Abdominal/pelvic pain with or without minimal bleeding

c. Shock is possible even with minimal or no vaginal bleeding

4. Spontaneous abortion (miscarriage)

a. Generally, first trimester

b. Intermittent pelvic pain (uterine contractions) with vaginal bleeding/passage of clots or

tissue

Patient Management

Assessment

1. Obtain history

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a. Obstetrical history [See Childbirth Guideline]

b. Abdominal pain – onset, duration, quality, radiation, provoking or relieving factors

c. Vaginal bleeding – onset, duration, quantity (pads saturated)

d. Syncope/lightheadedness

e. Nausea/vomiting

f. Fever or history of recent fever

2. Monitoring

a. Monitor EKG if history of syncope or lightheadedness

b. Monitor pulse oximetry if signs of hypotension or respiratory symptoms

3. Secondary survey pertinent to obstetric issues

a. Constitutional: vital signs, skin color

b. Abdomen: distension, tenderness, peritoneal signs

c. Genitourinary: visible vaginal bleeding

d. Neurologic: mental status

Treatment and Interventions

1. If signs of shock or orthostasis:

a. Position patient supine or in the left lateral recumbent position if third trimester and keep

patient warm

b. Place large bore IV

c. Volume resuscitation: crystalloid 1–2 liters IV wide open

d. Reassess vital signs and response to fluid resuscitation

e. Save all possible tissue so that the receiving team can assess

2. Disposition – transport emergently to closest appropriate receiving facility – notify en route if

possible so the receiving team may prepare

Patient Safety Considerations

1. Patients in third trimester of pregnancy should be transported on left side or with uterus

manually displaced to left if hypotensive

2. Do not place hand/fingers into vagina of bleeding patient except in cases of prolapsed cord or

breech birth that is not progressing

Notes/Educational Pearls

Key Considerations

Syncope can be a presenting symptom of intraabdominal hemorrhage from ectopic pregnancy or

antepartum hemorrhage from spontaneous abortion, placental abruption, or placenta previa

Pertinent Assessment Findings

1. Vital signs to assess for signs of shock (e.g., tachycardia, hypotension)

2. Abdominal exam (e.g., distension, rigidity, guarding)

3. If pregnant, evaluate fundal height

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914159 – OB/GYN - Gynecological Emergencies

•

9914161 – OB/GYN - Pregnancy Related Disorders

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Key Documentation Elements

Document full vital signs and physical exam findings

Performance Measures

• Patients with signs of hypoperfusion or shock should not be ambulated to stretcher

• If available, IV should be initiated on patients with signs of hypoperfusion or shock

• Recognition and appropriate treatment of shock

References

1. Coppola PT, Coppola M. Vaginal bleeding in the first 20 weeks of pregnancy. Emerg Med Clin N

Am. 2003;21(3):667–77

2. Della-Giustina D, Denny M. Ectopic Pregnancy. Emerg Med Clin N Am. 2003;21(3):565–84

3. WHO, United Nations Population Fund, UNICEF. Pregnancy, Childbirth, Postpartum and

Newborn Care: A guide for essential practice (3

edition). Geneva, Switzerland: WHO Press;

2015

Revision Date

March 11, 2022

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Respiratory

Airway Management

Patient Care Goals

1. Maintain a patent airway

2. Provide effective oxygenation and adequate ventilation using the least invasive possible

method to achieve those goals paired with pulse oximetry and end-tidal capnography (EtCO

)

data

3. Anticipate, recognize, and alleviate respiratory distress

4. Provide necessary interventions quickly and safely to patients with the need for respiratory

support

5. Anticipate, identify, and plan for a potentially difficult airway

6. Optimize the patient for any advanced airway attempts

Patient Presentation

Inclusion Criteria

1. Patients with signs of severe respiratory distress/respiratory failure

2. Patients with evidence of hypoxemia or hypoventilation with medical or traumatic etiology

3. Patients with tracheostomies (See Tracheostomy Management Guideline)

4. Patients with acute foreign body airway obstruction

Exclusion Criteria

1. Chronically ventilated patients

2. Newborn patients

Patient Management

Implement emergent interventions and monitoring [Refer to Universal Care Guideline]

Assessment

1. History – Assess for:

a. Time of onset of symptoms

b. Associated symptoms and triggers for dyspnea (e.g., exertion, exercise, lying flat)

c. History of asthma or other breathing disorders

d. Choking or other evidence of upper airway obstruction

e. History of trauma

f. Prior similar episodes (e.g., prior intubation, prior ICU stay, prior airway surgery including

tracheostomy, anaphylaxis, angioedema). If prior episodes, what has helped in the past

(meds, interventions) Home interventions for symptoms (e.g., increased home oxygen,

nebulizer)

g. Severity of shortness of breath, sensation of dyspnea

2. Physical Examination – Assess for:

a. Abnormal respiratory pattern, rate and/or effort

b. Use of accessory muscles

c. Ability to speak words/sentences

d. Quality of air exchange, including depth of respiration and equality of breath sounds

e. Abnormal breath sounds (e.g., wheezing, rhonchi, rales, or stridor)

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f. Cough

g. Skin color (cyanosis or pallor), presence of diaphoresis

h. Mental status, including anxiety

i. Airway obstruction with foreign body or swelling (e.g., angioedema, posterior pharyngeal

and laryngeal infections)

j. Signs of a difficult airway (short jaw or limited jaw thrust or mobility, small thyromental

space, upper airway obstruction, large tongue, obesity, large tonsils, large neck,

craniofacial abnormalities, excessive facial hair, tracheostomyscar or evidence of other

neck/facial surgery, trismus)

k. Signs of fluid overload (e.g., ascites, peripheral edema)

l. Traumatic injuries impairing upper and lower airway anatomy and physiology:

Facial injuries

ii.

High spine injury (affecting phrenic nerve/intercostals)

iii.

Neck injury (expanding hematoma, tracheal injury)

iv.

Chest wall injury (bruising), including rib and sternal fracture, paradoxical chest

motion, subcutaneous air, sucking chest wound

Monitoring

1. Patients with significant respiratory distress should have continuous pulse oximetry and

waveform capnography monitoring for both assessment and for guiding therapy

2. Pulse oximetry is indicated to assess oxygenation

3. Quantitative waveform capnography:

a. Is indicated:

For assessment and monitoring of ventilatory status in patients with significant

respiratory distress, with or without airway adjuncts

ii.

To assist in decision-making for patients with respiratory difficulty of unclear cause

(e.g., bronchospasm vs. pulmonary edema) and to help direct therapy

iii.

To evaluate acid-base status in critically ill patients

b. Is not indicated for every patient with shortness of breath. Rather, it is a monitoring and

decision-making tool for patients with significant respiratory distress where interpretation

of the capnography waveform and EtCO

values assist in determining the appropriate

course of treatment for the patient as well as the patient’s response

Treatment and Interventions

1. Generally, the approach is to implement the interventions below in an escalating fashion to

meet the patient care goals above

2. Administer oxygen if needed for air hunger or respiratory distress and titrate to a target SPO

of 94–98%. Depending on patient presentation, this may be accomplished with nasal cannula,

nonrebreather, BVM, NIV

a. Even in apneic patients, starting passive oxygenation while escalating interventions are

implemented may be useful

b. During CPR, maximal oxygen supplementation should be provided

c. Consider humidified oxygen for patients with tracheostomy (See Tracheostomy

Management Guideline)

3. Open and maintain patent airway. If needed,

a. Provide head tilt/chin lift, or jaw thrust if concern for potential spinal injury

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b. Suction airway: for significantly contaminated airways, consider utilizing a suction assisted

laryngeal airway decontamination (SALAD) technique

c. Oropharyngeal airways (OPA) or nasopharyngeal airways (NPA) can be placed if needed to

maintain a patent airway and make BVM ventilation more effective

i. OPA are used for patients without gag reflex

ii. NPA are used for patients with gag reflex

d. Patient positioning can significantly impact respiratory mechanics. Patients with severe

bronchospasm should be left in the position of comfort (perhaps tripod) whenever

possible. Elevating the head or padding (shoulders, occiput) can assist with opening airway

and respiratory mechanics. This can both improve the ability to ventilate and limit

aspiration

e. For patients with tracheostomy in respiratory distress, see Tracheostomy Management

Guideline

4. Use bag-valve-mask (BVM) ventilation in the setting of respiratory failure or arrest.

Whenever possible, the patient’s head should be elevated up to 30 degrees

a. Two-person, two-thumbs-up BVM ventilation is preferred

b. PEEP should be used with BVM

i. 5 cmH

0 is generally an appropriate initial PEEP setting

ii. Increase PEEP in stepwise fashion (2–3 cmH

0 at a time) as necessary, allowing

time for the patient to equilibrate with each change before further adjustments

are made. The goal is to reach the lowest PEEP needed to adequately ventilate

the patient. Higher PEEP results in greater negative hemodynamic impact.

Generally, physician consultation should be considered for higher PEEP levels

(greater than 10–15 cmH

c. Continuous wave-form capnography monitoring should be placed in line

i. In patients without primary pulmonary pathology (i.e., acute respiratory distress

syndrome (ARDS), COPD), maintain EtCO

of no less than 35 and up to 40

mmHg. Patients with specific disease processes such as acute acid-base

disorders (i.e., DKA, lactic acidosis due to severe sepsis or trauma), acute

respiratory failure due to primary pulmonary pathology, or post-cardiac arrest

will have different EtCO

parameters due to their underlying disease

ii. In patients with severe head injury with signs of herniation (unilateral dilated

pupil or decerebrate posturing), modest hyperventilation to EtCO

no less than

30 mmHg may be considered for a brief time

d. Tidal volume:

i. Ventilate with just enough volume to see chest rise, approximately 6–8 mL/kg

ideal body weight

ii. Over-inflation (e.g., excessive tidal volume) and overventilation (e.g., excessive

minute ventilation) are both undesirable and potentially harmful

e. Rate

i. Adult: 10–12 breaths/minute

ii. Child: 20–30 breaths/minute

iii. Infant: 20–30 breaths/minute

f. Continuously monitor EtCO

to guide tidal volume and minute ventilation

5. Non-invasive ventilation (NIV) should be considered early for severe respiratory distress or

impending respiratory failure

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a. NIV options include continuous positive airway pressure (CPAP), bilevel positive airway

pressure (BiPAP), bilevel nasal CPAP, and high flow oxygen by nasal cannula (HFNC)

b. NIV can also be used to improve oxygenation pre-intubation in some patients with

respiratory failure

6. Supraglottic airways (SGA): Consider the use of an appropriately sized SGA if BVM (with

OPA/NPA) alone is not effective in maintaining oxygenation and/or ventilation. This is

especially important in children as prehospital endotracheal intubation is an infrequently

performed skill in this age group and has not been shown to improve outcomes over

prehospital BVM or SGA

7. Endotracheal intubation

a. When less-invasive methods (two-person BVM, SGA placement) are ineffective or

inappropriate, consider endotracheal intubation to maintain oxygenation and/or

ventilation. Other indications may include potential airway obstruction, severe inhalation

burns, multiple traumatic injuries, altered mental status with loss of normal protective

airway reflexes

b. Optimize patient for first-pass success with pre-procedure resuscitation, preoxygenation,

positioning, sedatives and paralytics as indicated by patient presentation

i. A bougie may be a helpful adjunct to successful airway placement, especially when

video laryngoscopy is unavailable and the glottic opening is difficult to visualize with

direct laryngoscopy

ii. For experienced EMS clinicians, video laryngoscopy may enhance intubation success

rates and should be used when available

c. Monitor clinical signs, pulse oximetry, cardiac rhythm, blood pressure, and waveform

capnography for the intubated patient

d. For adults, the largest tube size possible should be placed in the patient to limit difficulty

with mechanical ventilation and high airway pressures. Absent significant airway swelling

or underlying anatomic abnormalities, initial tube size (internal diameter in millimeters)

for adult females should be 7.5, adult males 8.0. For pediatrics, cuffed tubes are now

recommended

8. Post-intubation management

a. Inflate endotracheal tube cuff with minimum air to seal airway. An ETT cuff

manometer can be used to measure and adjust the ETT cuff pressure to the

recommended 20 cmH

0 pressure

b. Confirm placement of advanced airway (endotracheal tube, SGA) with waveform

capnography (most reliable), absent gastric sounds, and bilateral breath sounds

c. Secure tube manually. Once proper position is confirmed, secure the tube with

tape, twill, or commercial device

i. Note measurement of tube at incisors or gum line and assess frequently for tube

movement/displacement using continuous waveform capnography and visual

inspection

ii. Cervical collar and/or cervical immobilization device may help reduce neck movement

and risk of tube displacement

d. Continuously monitor correct airway placement with waveform capnography during

treatment and transport, paying particular attention to reassessing after each

patient movement

e. Manual ventilation (see above for rate and tidal volume guidance)

f. Mechanical ventilation should be considered following advanced airway placement

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if available. See Mechanical Ventilation (Invasive) Guideline.

g. Intubated patients should be provided appropriate sedation with sedative or opioid

medications, and sedation titrated to an appropriate target level using RASS score

or similar scale

h. Consider PEEP adjustment to achieve oxygenation and ventilation goals (see above)

9. Gastric decompression can improve oxygenation and ventilation, so it should be

strongly considered in any patient with an advanced airway and positive pressure

ventilation

10. When patients cannot be oxygenated/ventilated effectively using the above

interventions, or when conventional airway approaches are impossible, surgical airway

management is a reasonable option if the clinician has competency in the procedure

and risk of death for not escalating airway management seems to outweigh the risk of a

procedural complication

11. Transport to the closest appropriate hospital for airway stabilization when respiratory

failure cannot be successfully managed in the prehospital setting

Patient Safety Considerations

1. Suctioning to limit aspiration is a priority, since it is associated with development of hospital

acquired pneumonia and related increases in ICU stay and mortality.

2. Avoid excessive pressures or tidal volumes during BVM ventilation. The goal is to avoid

barotrauma as well as overventilation and related reduction of venous return/preload/cardiac

output.

3. Routine use of sedation is not recommended for treatment of anxiety in patients on NIV.

Anxiety should be presumed due to hypoxia or inadequate minute ventilation and treated

primarily with ventilatory support.

4. Endotracheal intubation should only be used if less invasive methods do not meet patient care

goals.

5. Once a successful SGA placement or intubation has been performed, obstruction or

displacement of the tube can have further negative effects on patient outcome. Tubes should

be secured with either a commercial tube holder or tape.

6. Meticulous attention should be paid to avoiding hypoxia and hypotension during intubation

attempts to limit patient morbidity and mortality.

7. Waveform capnography should be placed prior to the first breath through an invasive airway

to confirm placement.

8. Drug Assisted Airway Management (DAAM) should be reserved for specialized clinicians on

operating within a comprehensive program with adequate resources, ongoing training and

quality assurance measures, and close EMS physician oversight.

9. Once initiated and patient is tolerating mask, DO NOT discontinue CPAP/BiPAP until patient is

on the emergency department stretcher and hospital CPAP/BiPAP is immediately available for

patient to be switched over, or physician is at bedside and requesting CPAP/BiPAP be

discontinued. Breaking the mask seal causes a significant decrease in airway pressures and

may lead to abrupt decompensation due to atelectasis and alveolar collapse.

10. If patient deteriorates on CPAP/BiPAP (e.g., worsened mental status, increasing EtCO

vomiting), remove CPAP/BiPAP and escalate airway management options as above.

11. If an endotracheal tube becomes dislodged, SGA should be strongly considered.

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12. Pediatric airway management requires appropriately sized tools and adjuncts based on

patient size/age. A method for determining appropriate sizing should be available to all EMS

clinicians.

a. Skill in BVM ventilation and NIV application should be emphasized in pediatrics.

b. SGA are reasonable primary and secondary adjuncts if needed.

c. Pediatric endotracheal intubation has unclear benefit in the prehospital setting.

d. Pediatric endotracheal tube placement and maintenance requires significant training to

achieve and maintain competency.

Notes/Educational Pearls

Key Considerations

1. Oxygen is a drug with an appropriate dose range and undesirable effects from both too much

and too little supplementation. Effective oxygenation meets the oxygen saturation (SpO

)

target set for that specific patient in the context of their acute and chronic medical

condition(s). Permissive hypoxia (SPO

≥ 90%) may be appropriate in patients with COPD or

other complex respiratory pathology

2. Adequate ventilation provides sufficient minute ventilation to meet the patient’s acute

respiratory and metabolic needs and is generally titrated to an EtCO

goal

3. Paramedics are less likely to attempt endotracheal intubation in children than adults with

cardiac arrest and are more likely to be unsuccessful when intubating children. Complications

such as malposition of the ET tube or aspiration can be nearly three times as common in

children as compared to adults

4. Continuous waveform capnography is an important adjunct in the monitoring of patients with

respiratory distress, respiratory failure, and those treated with positive pressure ventilation. It

should be used as the standard to confirm placement of all advanced airways. It can also be

helpful in the respiratory distress patient without an invasive airway to assess for causes of

respiratory distress, adequacy of ventilation, progression toward respiratory failure,

monitoring of BVM ventilation, as well as numerous other applications that provide insight

into acute metabolic and infectious disease processes. Continuous waveform capnography:

a. Should be used for patients with invasive airways for

initial verification of correct airway placement

ii.

continuous evidence of correct tube placement

iii.

to adjust ventilatory rate

1. to maintain EtCO

35–45 in most patients

2. to appropriately but not excessively hyperventilate patients with signs of

herniation only to maintain EtCO

30–35 (no lower than 30)

3. to gradually decrease EtCO

in chronically and acutely severely hypercarbic

patients including post-arrest

b. Is strongly encouraged in patients in cardiac arrest

to monitor quality of CPR

ii.

as an early indicator of ROSC (rapid increase of 10–15 in EtCO

)

iii.

to assist in evaluating prognosis for survival

c. Should be used in spontaneously breathing patients who are:

on NIV

ii.

in severe respiratory distress (e.g., receiving epinephrine, magnesium therapy)

d. In spontaneously breathing patients, waveform capnography can help with assessment of

critically ill patients, for example:

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assessment of adequacy of ventilation and change in ventilatory status in response to

treatment

ii.

differentiating between severe bronchospasm (shark fin waveform) and other causes

of respiratory distress (normal waveform, pulmonary edema)

iii.

hypotension due to sepsis or unclear cause (metabolic acidosis with/without

compensatory respiratory alkalosis)

iv.

status epilepticus to evaluate ventilatory and acid/base status

evaluation for acidosis in patients with altered mental status and potential diabetic

ketoacidosis (metabolic acidosis)

5. Bag-valve-mask (BVM) ventilation (for cardiac arrest patients see Cardiac Arrest Guideline):

a. Appropriately sized masks should completely cover the nose and mouth and maintain an

effective seal around the cheeks and chin

b. Ventilations should be delivered with only sufficient volume to achieve chest rise.

Overventilation is undesirable

In children, ventilating breaths should be delivered over one second, with a two

second pause between breaths

c. Ventilation rate:

Adult

1. Support spontaneous respirations if the patient is hypoventilating

2. For apnea, provide one breath every 6 seconds adjusting based on pulse oximetry

and digital capnometry or capnography (with the goal of 35–45 mmHg)

ii.

Pediatric – infant/child

1. Support spontaneous respirations if the patient is hypoventilating

2. For apnea, provide 1 breath every 2–3 seconds adjusting based on pulse

oximetry and digital capnometry or capnography (with the goal of 35–45 mmHg)

6. PEEP improves oxygenation or decreases risk of developing hypoxemia, by increasing

functional residual capacity (FRC), and tidal ventilation and may assist in meeting airway goals

by decreasing intrapulmonary shunting of blood and better matching perfused lung to

ventilated lung tissue, thus improving arterial oxygenation. It does not open fully collapsed

alveoli but re-expands partially collapsed ones. It does not decrease extravascular lung water

but redistributes it

a. Higher levels of PEEP are particularly useful in patients with acute respiratory distress

syndrome (ARDS)

b. PEEP should be increased slowly by 2–3 cmH

0 from 5 cmH

0 to a max of 15 cmH

0 closely

monitoring response and vital sign changes

c. Excessive PEEP over distends alveoli, increases dead space and work of breathing, reduces

lung compliance, and compresses alveolar capillaries, reducing oxygenation and risking

pulmonary barotrauma

d. Increased intrathoracic pressure can progressively decrease cardiac output and is most

notable when PEEP is greater than 15 cmH

0. The higher the level of PEEP (over 5 cmH

0),

the more likely the patient will experience a variety of adverse consequences, both

ventilatory and hemodynamic

7. Noninvasive ventilation (NIV) (e.g., CPAP or BiPAP):

a. NIV goals of therapy will vary based on patient presentation and history. More support

than is needed to relieve symptoms or “normal” is not necessarily better in these patients.

Goals of care may include:

Decreased air hunger

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ii.

SPO

of ≥ 94%. Chronic COPD patients tolerate hypoxia better, and an SPO

of 90%

may relieve their symptoms and be adequate

iii.

Normalization of respiratory rate (decreased tachypnea)

iv.

Normalization of EtCO

. This means a downward trend in a patient with increased

EtCO

. Patients who have end stage COPD may have chronically elevated EtCO

as high

as 50s–60s, and thus tolerate elevated EtCO

better so normalization may not be a

good target

b. The key to successful use of NIV in a patient who has not used it before is coaching and

explanation of the process and reassurance of the patient

c. For any patient on NIV, focus on maintaining a continuous mask seal is essential to

maximizing the positive impact of PEEP, particularly at higher levels. Breaking the circuit or

removing the mask should be meticulously avoided, as the significant atelectasis will occur

which will take time to reverse

d. Nebulized medications may be administered through a CPAP or BiPAP mask. A specialized

T-connector with a spring valve assembly is required to allow maintenance of positive

airway pressure

8. Orotracheal/Endotracheal intubation (ETI)

a. Checklist use and use of protocolized interventions to optimize the patient physically and

physiologically have been shown to both improve success rates of orotracheal intubation

as well as decrease peri-intubation complications. Preparation should also include a

promptly available plan for alternate airway placement if ETI unsuccessful.

b. Endotracheal tube sizes (cuffed tubes preferred in pediatrics)

Age

Size (mm)

Uncuffed

Size (mm)

Cuffed

Premature

2.5

Term to 3 months

3.0

3–7 months

3.5

3.0

7–15 months

4.0

3.5

15–24 months

4.5

3.5

2–15 years

[age(yrs.)/4]+4

[age(yrs.)/4]+3.5

>15 years

7.5 female 8.0 male

c. Approximate depth of insertion = (3) x (endotracheal tube size)

d. In addition to preoxygenation, apneic oxygenation (high-flow oxygen by nasal cannula)

may prolong the period before hypoxia during an intubation attempt

e. Positive pressure ventilation after intubation can decrease preload and subsequently lead

to hypotension

f. Significant attention should be paid to adequate preoxygenation to avoid peri-intubation

hypoxia and hypoxic cardiac arrest

g. Routine use of cricoid pressure is not recommended in pediatric or adult intubation

h. Prompt suctioning of soiled airways before intubation attempt may improve first pass

success and limit morbidity and mortality

i. Confirm successful placement with waveform capnography. Less optimal methods of

confirmation include bilateral chest rise, bilateral breath sounds, and maintenance of

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adequate oxygenation. Color change on EtCO

is less accurate than clinical assessment,

and wave-form capnography is superior. Misting observed in the tube is not a reliable

method of confirmation. Re-visualization with video laryngoscopy, when available, may

assist in confirming placement when unclear due to capnography failure or conflicting

information

j. Video laryngoscopy may be a useful tool for endotracheal intubation in the hands of a

practiced clinician

6. Manual vs. Mechanical ventilation: If mechanical ventilation is available, it is preferred to

manual ventilation due to the increased consistency of tidal volume and ventilatory rate, and

its ability to limit risk of overventilation. [See Mechanical Ventilation (Invasive) Guideline]

7. For patients being transferred from a hospital ventilator to a transport ventilator, the patient’s

current ventilator settings are generally a reasonable starting point if the patient is being

adequately oxygenated and ventilated based on pulse oximetry and capnography

8. Currently, there is limited experience with high-flow nasal cannula in the EMS environment, so

evidence-informed recommendations are not included in this guideline

9. Anxiety should be presumed due to hypoxia or inadequate minute ventilation and treated

primarily with ventilatory support. Routine use of sedation is not recommended for treatment

of anxiety in patients on NIV

Pertinent Assessment Findings

1. Ongoing assessment is critical when an airway device is in place.

2. Acute worsening of respiratory status or evidence of hypoxemia can be secondary to

displacement or obstruction of the airway device, pneumothorax, or equipment failure

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914001 – Airway

•

9914133 – Medical - Newborn/Neonatal Resuscitation

Key Documentation Elements

• Initial vital signs and physical exam

• Interventions attempted including the method of airway intervention, the size of equipment

used, and the number of attempts to achieve a successful result

• Indications for advanced airway management

• Subsequent vital signs and physical exam to assess for change after the interventions

• Occurrence of peri-intubation hypoxia (less than 90% SPO

), bradycardia (per age),

hypotension (SBP less than 90mmHg or lowest age-appropriate SBP) or cardiac arrest. The

peri-intubation period encompasses the time from sedative administration to up to 10

minutes post any invasive airway attempt

• Post-intubation with advanced airway, EtCO

value and capnograph should be documented

immediately after airway placement, with each patient movement (e.g., into and out of

ambulance), and at the time of patient transfer in the ED

• Recordings of video laryngoscopy may be useful for quality improvement purposes

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Performance Measures

• Percentage of clinicians that have received hands-on airway training (simulation or non-

simulation-based) for basic and advanced airway adjuncts and skills within the past year

• Percentage of patients with initial hypoxia who improve to target saturation of 94–98% by

arrival at hospital

• Percentage of patients with respiratory chief complaints for whom both oxygen saturation

(SpO

) and respiratory rate are measured and documented

• Rate of NIV use in respiratory distress (COPD, congestive heart failure (CHF)) patients with GCS

• Documentation of PEEP use with assisted ventilation

• Percentage of patients with advanced airway placement with capnographic verification of

correct placement within 1 minute

• Percentage of patients with advanced airway placement who have documentation of

waveform capnography for both initial confirmation and repeated verification of placement

during transport and at hospital arrival

• Percentage of intubated patients with endotracheal tube verified in proper position upon

turnover to receiving facility

• Rate of advanced airway (ETT or SGA) success without hypoxia or hypotension

• First pass success rate and number of intubation attempts

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Respiratory—01: Respiratory Assessment

References

1. Cabrini L, Landoni G, Baiardo Redaelli M, Saleh O, Votta CD, Fominskiy E, et al. Tracheal

intubation in critically ill patients: a comprehensive systematic review of randomized trials.

Crit Care. 2018;22(1):6

2. Carney N, Cheney T, Totten AM, Jungbauer R, Neth MR, Weeks C, et al. AHRQ Comparative

Effectiveness Reviews. Prehospital Airway Management: A Systematic Review. Rockville (MD):

Agency for Healthcare Research and Quality (US); 2021

3. Driver BE, Prekker ME, Klein LR, Reardon RF, Miner JR, Fagerstrom ET, et al. Effect of Use of a

Bougie vs Endotracheal Tube and Stylet on First-Attempt Intubation Success Among Patients

With Difficult Airways Undergoing Emergency Intubation: A Randomized Clinical Trial. JAMA.

2018;319(21):2179–89

4. “The Epic Project: Impact of Implementing the EMS Traumatic Brain Injury Treatment

Guidelines - Full Text View.” The EPIC Project: Impact of Implementing the EMS Traumatic

Brain Injury Treatment Guidelines - Full Text View - ClinicalTrials.gov.

https://www.clinicaltrials.gov/ct2/show/NCT01339702 . Accessed March 11 2022.

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Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care

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Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017;195(9):1253–63

6. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and

Treatment. JAMA. 2018;319(7):698–710

7. Fawcett VJ, Warner KJ, Cuschieri J, Copass M, Grabinsky A, Kwok H, et al. Pre-hospital

aspiration is associated with increased pulmonary complications. Surg Infect (Larchmt).

2015;16(2):159–64

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8. Fouche P, Stein C, Simpson P, Carlson J, Md MS, Doi S. Nonphysician Out-of-Hospital Rapid

Sequence Intubation Success and Adverse Events: A Systematic Review and Meta-Analysis.

Ann Emerg Med. 2017;70(4):449–59e20

9. George BP, Vakkalanka JP, Harland KK, Faine B, Rewitzer S, Zepeski A, et al. Sedation Depth is

Associated with Increased Hospital Length of Stay in Mechanically Ventilated Air Medical

Transport Patients: A Cohort Study. Prehosp Emerg Care. 2020;24(6):783–92

10. Gerber L, Botha M, Laher AE. Modified Two-Rescuer CPR With a Two-Handed Mask-Face Seal

Technique Is Superior To Conventional Two-Rescuer CPR With a One-Handed Mask-Face Seal

Technique. J Emerg Med. 2021

11. Gok PG, Ozakin E, Acar N, Karakilic E, Kaya FB, Tekin N, et al. Comparison of Endotracheal

Intubation Skills With Video Laryngoscopy and Direct Laryngoscopy in Providing Airway

Patency in a Moving Ambulance. J Emerg Med. 2021;60(6):752–9

12. Hope Kilgannon J, Hunter BR, Puskarich MA, Shea L, Fuller BM, Jones C, et al. Partial pressure

of arterial carbon dioxide after resuscitation from cardiac arrest and neurological outcome: A

prospective multi-center protocol-directed cohort study. Resuscitation. 2019;135:212–20

13. Ilia S, van Schelven PD, Koopman AA, Blokpoel RGT, de Jager P, Burgerhof JGM, et al. Effect of

Endotracheal Tube Size, Respiratory System Mechanics, and Ventilator Settings on Driving

Pressure. Pediatr Crit Care Med. 2020;21(1):e47–e51

14. Jarvis JL, Gonzales J, Johns D, Sager L. Implementation of a Clinical Bundle to Reduce Out-of-

Hospital Peri-intubation Hypoxia. Ann Emerg Med. 2018

15. Kopsaftis Z, Carson‐Chahhoud KV, Austin MA, Wood‐Baker R. Oxygen therapy in the pre‐

hospital setting for acute exacerbations of chronic obstructive pulmonary disease. Cochrane

Database of Systematic Reviews. 2020(1)

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Physiologically Difficult Airway: Consensus Recommendations From Society for Airway

Management. Anesth Analg. 2021;132(2):395–405

17. Krisciunas GP, Langmore SE, Gomez-Taborda S, Fink D, Levitt JE, McKeehan J, et al. The

Association Between Endotracheal Tube Size and Aspiration (During Flexible Endoscopic

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19. Losek JD, Bonadio WA, Walsh-Kelly C, Hennes H, Smith DS, Glaeser PW. Prehospital pediatric

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the Societe de Reanimation de Langue Francaise and the French Group for Pediatric Intensive

Care and Emergencies. Ann Intensive Care. 2019;9(1):115

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Failure Due to Cardiogenic Pulmonary Edema. Respir Care. 2020;65(9):1241–9

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Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.

2020;142(16_suppl_2):S366–s468

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cardiopulmonary resuscitation: A systematic review. Resuscitation. 2017;119:5–12

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scenario, supraglottic airway devices improve success and time to ventilation. Eur J Emerg

Med. 2015;22(5):374–6

Revision Date

March 11, 2022

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Respiratory Distress (includes Bronchospasm, Pulmonary Edema)

Patient Care Goals

1. Assure adequate oxygenation and ventilation

2. Recognize impending respiratory failure

3. Promptly identify and intervene for patients who require escalation of therapy

4. Deliver appropriate therapy by differentiating likely cause of respiratory distress

5. Alleviate respiratory distress

Patient Presentation

Inclusion Criteria

1. Patients aged 2 and older with respiratory distress due to disease processes including:

a. Asthma exacerbation

b. Chronic obstructive pulmonary disease (COPD) exacerbation

c. Wheezing/bronchospasm from suspected pulmonary infection (e.g., pneumonia, acute

bronchitis)

d. Pulmonary edema of cardiac (i.e., heart failure) or non-cardiac etiology

Exclusion Criteria

1. Respiratory distress related to acute trauma

2. Respiratory distress due to a presumed underlying cause that includes one of the following:

a. Anaphylaxis

b. Bronchiolitis (wheezing in patients less than 2 years of age)

c. Croup

d. Epiglottitis

e. Foreign body aspiration

f. Submersion/drowning

g. Lower airway obstruction from malignancy (very rare)

Patient Management

Assessment

1. History

a. Onset of symptoms

b. Concurrent symptoms (e.g., fever, cough, rhinorrhea, tongue/lip swelling, rash, labored

breathing, foreign body aspiration)

c. Usual triggers of symptoms (e.g., cigarette smoke, change in weather, upper respiratory

infections, exercise)

d. Sick contacts

e. Treatments prior to EMS: Oxygen, inhaler, nebulizer, other treatments, chronic or recent

steroids

f. Hospitalizations: Number of emergency department visits in the past year, number of

hospital admissions in the past year, number of ICU admissions (ever), previously

intubated (ever)

g. Family history of asthma, eczema, or allergies

2. Exam

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a. Full set of vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment), temperature, and O

saturation. Consider temperature and

waveform

capnography

b. Air entry (normal vs. diminished, prolonged expiratory phase)

c. Breath sounds (wheezes, crackles, rales, rhonchi, diminished, clear)

d. Skin color (pallor, cyanosis, mottling, normal) and temperature (febrile, diaphoretic)

e. Mental status (alert, tired, lethargic, unresponsive)

f. Signs of distress include:

i. Apprehension, anxiety, combativeness

ii. Hypoxia (less than 90% oxygen saturation)

iii. Intercostal/subcostal/supraclavicular retractions, accessory muscle use

iv. Grunting, stridor, inability to speak full sentences

v. Nasal flaring

vi. Cyanosis

Treatment and Interventions

1. Airway: See Airway Management Guideline for additional specifics

a. Give supplemental oxygen for dyspnea to a target of 94–98% saturation. Escalate from a

nasal cannula as needed to reach this goal

b. BVM ventilation should be utilized in children with respiratory failure

c. Non-invasive ventilation (NIV) should be administered for severe respiratory distress via

BVM, continuous positive airway pressure (CPAP) or bi-level positive airway pressure

(BiPAP)

d. If indicated, bronchodilators should be administered in line with NIV

2. Monitoring

a. Pulse oximetry and EtCO

should be routinely used as adjuncts to other forms of

monitoring in patients with respiratory complaints

b. Continuous cardiac monitoring may be indicated in patients with respiratory distress

associated with suspected acute or decompensated congestive heart failure (CHF) or

dysrhythmia

c. 12-lead EKG may be indicated to assess for dysrhythmia or ischemia, particularly in

patients with risk factors for coronary artery disease and/or presentation consistent with

CHF

3. IV Access and Fluids – IV access should be placed when IV medication administration is

indicated, or when there are clinical concerns of dehydration so that IV fluids can be

administered

4. Suspected bronchospasm, asthma, COPD:

a. Inhaled Medications

While albuterol 2.5 mg nebulized is usually sufficient for mild wheezing without

clinical distress, albuterol 5 mg nebulized (or 6 puffs metered dose inhaler) should be

administered to all patients in respiratory distress with signs of bronchospasm (e.g.,

known asthmatics, quiet wheezers). Repeat at this dose with unlimited frequency for

ongoing respiratory distress

ii.

Ipratropium 0.5 mg nebulized should be given up to 3 doses in conjunction with

albuterol

b. Steroids should be administered in the prehospital setting

PO steroid options for patients not critical enough to require IV placement include:

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1. Dexamethasone (0.6 mg/kg, maximum dose of 16 mg) PO solution or IV solution

given PO, or

2. Prednisolone/prednisone (1 mg/kg, maximum dose 60 mg) PO

ii.

IV steroid options for critically ill patients include:

1. Dexamethasone (0.6 mg/kg, maximum dose of 16 mg) IV/IM, or

2. Methylprednisolone (2 mg/kg, maximum dose 125 mg) IV/IM

iii.

Other steroids at equivalent doses may be given as alternatives

c. Magnesium sulfate (40 mg/kg IV, maximum dose of 2 g) over 10–15 minutes should be

administered for severe bronchoconstriction and concern for impending respiratory

failure. Consider decreased dose of 1 g IV for geriatric patients

d. Epinephrine (0.01 mg/kg of 1 mg/mL solution IM, maximum dose of 0.3 mg) should only

be administered for impending respiratory failure as adjunctive therapy when there are

no clinical signs of improvement with the above treatments

5. Adults with suspected pulmonary edema due to acute heart failure or fluid overload (such as

dialysis noncompliance):

a. Restoration of adequate oxygenation and ventilation should precede or be accomplished

simultaneously with other medication therapies below

CPAP/BiPAP: See Airway Management Guideline for goals of care and escalation of

interventions

b. SBP less than 100 mmHg

IV fluid bolus 250–500 mL

ii.

Consider vasopressor: Norepinephrine 0.02–2 mcg/kg/min

c. SBP less than 160 mmHg

Nitroglycerin

1. 0.4 mg SL, can repeat every 5 minutes for SBP greater than 100 mmHg

d. SBP >= 160 mmHg or MAP greater than 120

Nitroglycerin

1. 0.8 mg SL, can repeat every 5 minutes for SBP greater than 100 mmHg

2. Consider IV nitroglycerin infusion titrated to blood pressure

6. Suspected pulmonary edema due to other noncardiogenic causes (such as irritant inhalation,

abrupt opioid withdrawal). Provide supportive care to promote adequate oxygenation.

a. Inhaled Medications

While albuterol 2.5 mg nebulized is usually sufficient for mild wheezing without

clinical distress, albuterol 5 mg nebulized (or 6 puffs metered dose inhaler) should be

administered to patients in respiratory distress with signs of bronchospasm (e.g.,

known asthmatics, quiet wheezers). Repeat at this dose with unlimited frequency for

ongoing respiratory distress

ii.

Ipratropium 0.5 mg nebulized should be given up to 3 doses in conjunction with

albuterol

Patient Safety Considerations

1. Normal EtCO

(35–45 mmHg) with tachypnea and respiratory distress is an indicator of

impending respiratory failure

2. The use of nitrates should be avoided in any patient who has used a phosphodiesterase

inhibitor within the past 48 hours. Examples are sildenafil, vardenafil and tadalafil, which are

used for erectile dysfunction and pulmonary hypertension. Also avoid use in patients receiving

intravenous epoprostenol or treporstenil which are used for pulmonary hypertension

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3. Invasive airways do not improve bronchospasm. The airway should be managed in the least

invasive way possible. Supraglottic devices and endotracheal intubation should be considered

only if BVM ventilation fails

4. Positive pressure ventilation in the setting of bronchoconstriction, either via a supraglottic

airway or intubation, increases the risk of air trapping which can lead to pneumothorax and

cardiovascular collapse. These interventions should be reserved for situations of respiratory

failure

5. The following medications should not be administered to manage bronchospasm as there is

no evidence of patient benefit:

Inhaled magnesium sulfate

ii.

Heliox

Notes/Educational Pearls

1. The combination of ipratropium with albuterol may decrease the need for hospital admission

in certain patients

2. Magnesium sulfate may cause hypotension that will usually respond to a fluid bolus

3. Patient with acute heart failure and hypotension have high mortality

4. When assessing for cause of respiratory distress, CHF tends to be associated with lower levels

of EtCO

compared to COPD. EtCO

values that are extremely low and high are markers of

poor outcomes and need for intubation or ICU admission

Key Considerations

1. Nebulizer droplets can carry viral particles and other airborne pathogens, so additional PPE

should be considered, including placement of a surgical mask over the nebulizer (if feasible) to

limit droplet spread

2. Factors that have been shown to be associated with increased mortality from asthma include:

a. Severe asthma as evidenced by at least one of the following:

Prior near-fatal asthma (e.g., ICU admission or intubation/mechanical ventilation)

ii.

Prior admissions for asthma or repeated ED visits, particularly if in the last year

iii.

Heavy use of beta-agonist medications, or requiring three or more classes of asthma

medication

b. Together with one or more behavioral or psychosocial contributors:

Medication noncompliance

ii.

Alcohol or drug abuse

iii.

Obesity

iv.

Psychosis, depression, other psychiatric illness, or major tranquilizer use

Employment or income difficulties

vi.

Severe domestic, marital, or legal stressors

3. Single dose dexamethasone has been found equally effective as several days dosing of other

steroids, so dexamethasone is preferred over other po steroids

4. Acute heart failure is a common cause of pulmonary edema – other causes include:

a. Opioid overdose

b. High altitude exposure

c. Kidney failure or dialysis noncompliance

d. Lung damage caused by gases or severe infection

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5. Nitroglycerin reduces left ventricular filling pressure primarily via venous dilation. At higher

doses the drug variably lowers systemic afterload and increases stroke volume and cardiac

output

6. Pulmonary edema is more commonly a problem of volume distribution than total body fluid

overload, so administration of diuretics such as furosemide provide no immediate benefit for

most patients and can cause significant harm. Inducement of inappropriate diuresis can lead

to increased morbidity and mortality in patients with other disease processes such as

pneumonia and sepsis

7. Nitrates provide both subjective and objective improvement, and might decrease intubation

rates, incidence of MIs, and mortality. High-dose nitrates can reduce both preload and

afterload and potentially increase cardiac output and blood pressure

8. If available and trained, ultrasound is useful to distinguish pulmonary edema from other

causes of respiratory distress (including pneumothorax)

9. Pulmonary edema due to irritant gas inhalation (i.e., chlorine) generally is best managed by

supportive care and escalation of airway interventions as above once the patient is

appropriately decontaminated. Early poison center consultation should be strongly considered

for guidance

10. Pulmonary edema due to high altitude should be managed as described in Altitude Illness

Guideline

Pertinent Assessment Findings

1. Severe respiratory distress may manifest with hypoxia, altered mentation, diaphoresis, or

inability to speak more than 2–3 words

2. In the setting of severe bronchoconstriction, wheezing may not be heard. Patients with known

asthma with severe dyspnea should be empirically treated, even if wheezing is absent

A “shark fin” on waveform capnography suggests significant bronchospasm and obstructive

physiology

Etiology

of respiratory distress:

a. Bronchospastic etiology (e.g., asthma, COPD) is suggested by:

Wheezing on auscultation

ii.

“Shark fin” waveform capnograph or prolonged expiratory phase

iii.

History of asthma/COPD

b. Fluid overload etiology (e.g., CHF, pulmonary edema) is suggested by:

Jugular venous distention

ii.

Rales on auscultation

iii.

Peripheral edema

iv.

History of CHF, diuretic therapy, dialysis noncompliance, hypertension

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914137 – Pulmonary Edema/CHF

•

9914139 – Respiratory Distress/Asthma/COPD/Croup/Reactive Airway

Key Documentation Elements

Document key aspects of the exam at baseline and after each intervention:

• Respiratory rate

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• Oxygen saturation

• EtCO

/waveform shape

• Use of accessory muscles

• Breath sounds and quality

• Mental status

• Response to interventions

Performance Measures

• Use of pulse oximetry and capnography for patients with moderate-severe respiratory distress

(RR greater than age-appropriate normal, SPO

less than 90%)

• Percentage of patients with abnormal pulse oximetry, respiratory rate, EtCO

value with

normalization on final set of vital signs

• Time to administration of oxygen in hypoxic patients

• Time to bronchodilator administration in patients with wheezing

• Percentage of asthma/COPD patients receiving steroids and bronchodilators

• Time to improved SPO

and/or decreased respiratory rate

• Normalizing change in vital signs (pulse, blood pressure, respiratory rate, neurologic status

assessment) temperature, O

saturation, and capnography values with treatment

• Time to initiation of non-invasive positive pressure ventilation

• Number of CPAP/BiPAP patients who require intubation

• Documentation of blood pressure reassessment in patients receiving nitrates

References

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Revision Date

March 11, 2022

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Mechanical Ventilation (Invasive)

Patient Care Goals

1. Maintain adequate oxygenation

2. Maintain adequate minute ventilation and capnography targets based on patient

pathophysiology

3. Prevent or limit risk of short- and long-term invasive airway and ventilator-associated

complications including barotrauma, pneumothorax, aspiration, over-ventilation

Patient Presentation

Inclusion Criteria

Adult patients with invasive airway requiring mechanical ventilation

Exclusion Criteria

1. Interfacility transfer patients with established vent settings

2. Patients with suspected untreated pneumothorax or large airway injury

3. Patients in cardiac arrest

Patient Management

Assessment

1. Confirm airway placement with ventilation and auscultation over epigastrium and assess for

symmetric bilateral lung sounds

2. Verify that airway (ETT, SGA) is securely held in place (by holder or other method)

3. Assess oxygen delivery and confirm that FiO

meets patients' needs and maintains desired

oxygen saturation (SpO

)

a. If oxygen will be needed during transport calculate the duration of supply needed (O

tank

time (min) = tank pressure (psi) x tank conversion factor/flow rate (L/min)

4. Assess blood pressure to assure SBP greater than 90 mmHg or resuscitate to SBP >=90 mmHg

or MAP >=60 mmHg

5. Assess mental status, level of consciousness, Richmond Agitation Sedation Scale (RASS) or

similar sedation score

Treatment and Interventions

1. Set up ventilator and circuit, program initial ventilator settings as below. Suggested

general guidelines for adults with EMS initiation of mechanical ventilation:

a. Consider and modify based on any underlying acute or chronic lung pathology

(COPD, asthma, CHF)

b. Volume mode is generally preferred initially in adults

c. Select an appropriate ventilator mode: Assist Control (AC) is acceptable for most

patients

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i. Initial settings:

Tidal volume

6–8 mL/kg ideal

body weight

Go to ARDSNET table of height and Predicted Body

Weight and Tidal volumes. Use 6–8 mL/kg as a

starting point. Patients with known acidosis should

start with 9 mL/kg

Respiratory rate

12–14 (or 8–12)

breaths/min

Adjust for target minute ventilation based on EtCO

Inspiratory time

1 second

Adjust 0.7–1.2 seconds to maintain desired I:E ratio

(inspiration-expiration) ratio of 1:2 and patient

comfort

PEEP

5 cmH

FiO

60%

Titrate to achieve target O

saturation (94–98%)

Sensitivity

-2 cmH

ii. Set the heat moisture exchange (HME) at circuit Y.

iii. Plateau pressure (PPlat) goal is less than 30 cmH

Patient Safety Considerations

1. Ventilators have different capabilities and features. Users must be familiar with the device they

use and must be properly educated on its use and application in the specific population being

treated

2. Ensure that all vent alarms are set appropriately, and patient is continually monitored with pulse

oximetry and waveform capnography

a. Set all alarms that involve high pressure, low pressure, minute volume, and apnea

b. Plateau pressure (PPlat) goal is less than 30 cmH

c. Set high pressure alarm 10 cmH2O above resting PIP

d. Set low pressure alarm 5 cmH2O below resting PIP

e. Set low minute volume alarm 25% below resting minute volume

3. During transport of a critically ill patient only necessary adjustments should be made to the

ventilator. Focus on maintaining adequate oxygenation, minute volume and patient comfort.

4. An increase in the respiratory rate shortens the expiratory time. If changing rate, also check the I:E

ratio (the proportions of each breath cycle devoted to the inspiratory and expiratory phases) and

adjust the inspiratory time if necessary

5. The inspiratory time can be adjusted slightly to ensure greater patient comfort, however any

change in inspiratory time will affect the I:E ratio. Rarely should an inspiratory time be less than

0.7 for an adult

6. Assure proper sedation level for patient to tolerate ventilator

7. Assure patient does not have auto-PEEP

8. Asthmatics and patients with severe bronchoconstriction require different initial settings: for

example, PEEP of 0, FiO

100%, tidal volume 5 mL/kg, rate 10, I:E of 1:4 – 1:6 to allow full

exhalation and limit breath stacking/auto-PEEP. Hemodynamic instability may indicate increased

intrathoracic pressure and require either manual chest wall compression to promote full

exhalation or possibly needle chest decompression for pneumothorax

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Notes/Educational Pearls

Key Considerations

1. It is important to understand the patient's underlying pulmonary status to choose the

appropriate type of ventilation (volume or pressure) and mode (AC or SIMV most common)

a. Volume control ventilation is generally preferred initially in adults with compliant

lungs (PPlat less than 30) because of better control of minute ventilation

b. Pressure control ventilation can be used in patients with non-compliant lungs and

elevated PPlat

c. Assist Control (AC) mode is acceptable for most patients and provides best control

of minute ventilation. Synchronized Intermittent Mandatory Ventilation (SIMV) is an

alternative option

Pertinent Assessment Findings

1. Perform a pre-ventilator use inspection including a circuit check on the ventilator prior to

placing it on a patient

2. Assess values during transport, including:

a. Peak inspiratory pressure (PIP) Compare against baseline value to monitor for compliance

changes or obstruction in the circuit

b. Respiratory rate. Compare with baseline value, rapid increases could indicate leaks.

Overbreathing may require vent setting adjustment

c. Exhaled tidal volume. Compare against baseline, if extreme fluctuations, check for leaks in

circuit and in ET tube

d. Monitor the I:E ratio. 1:2 or 1:3 for normal lungs, longer E times may be needed for

patients with obstructive or restrictive lung disease

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

None noted

Key Documentation Elements

Documentation of ventilator settings and monitored values should include:

1. Ventilator Settings: Volume or pressure breaths; mode; respiratory rate; inspiratory time; tidal

volume or pressure, PEEP, FiO

; sensitivity

2. Patient Values (baseline and repeated): Peak inspiratory pressure (PIP); exhaled tidal volume;

respiratory rate; I:E ratio; minute volume; EtCO

; SPO

Performance Measures

None noted

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Adult Male Patients

Height

IBW kg

Lung-Protective

Resuscitative

Metabolic

6 ml/kg

10 ml/kg

8 ml/kg

Initial f

5'0"

300

500

400

5'1"

314

523

418

5'2"

328

546

437

5'3"

341

569

455

5'4"

355

592

474

5'5"

369

615

492

5'6"

383

638

510

5'7"

397

661

529

5'8"

410

684

547

5'9"

424

707

566

5'10"

438

730

584

5'11"

452

753

602

6'0"

466

776

621

6'1"

479

799

639

6'2"

493

822

658

6'3"

507

845

676

6'4"

521

868

694

6'5"

535

891

713

6'6"

548

914

731

Source: NIH-NHLBI ARDS Network

Adult Female Patients

Height

IBW kg

Lung-Protective

Resuscitative

Metabolic

6 ml/kg

10 ml/kg

8 ml/kg

Initial f

5'0"

273

455

364

5'1"

287

478

382

5'2"

301

501

401

5'3"

314

524

419

5'4"

328

547

438

5'5"

342

570

456

5'6"

356

593

474

5'7"

370

616

493

5'8"

383

639

511

5'9"

397

662

530

5'10"

411

685

548

5'11"

425

708

566

6'0"

439

731

585

6'1"

452

754

603

6'2"

466

777

622

6'3"

480

800

640

6'4"

494

823

658

6'5"

508

846

677

6'6"

521

869

695

Source: NIH-NHLBI ARDS Network

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References

1. NIH-NHLBI ARDS Network. Predicted Body Weight and Tidal Volume Charts. 2014.

2. Schauf, M. Respiratory emergencies, Airway Management and Ventilation. In: Pollak AN (Ed):

Critical Care Transport Second Edition. Jones &Bartlett Learning, Burlington, MA 2018.

Revision Date

March 11, 2022

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Tracheostomy Management

Aliases

None

Patient Care Goals

1. Meet airway management goals in a patient with a tracheostomy

a. Assure patent airway, understand how to troubleshoot tracheostomy in a patient with

respiratory distress

b. Assure adequate oxygenation and ventilation

Patient Presentation

Inclusion Criteria

Any adult or pediatric patient with an existing tracheostomy greater than 7 days post placement

and a mature stoma tract

Exclusion Criteria

Adult or pediatric patient with tracheostomy less than 7 days post placement (i.e., no mature

stoma tract)

Patient Management

Assessment

1. Evaluate patient respiratory status as per Airway Management Guideline

2. In a patient with respiratory distress, evaluate for DOPE:

a. Dislodgement or misplaced tracheostomy (e.g., decannulation)

i. Assess for subcutaneous air in the neck which may indicate the tracheostomy is not in

the trachea

ii. Directly visualize the tracheostomy and the stoma (i.e., remove anything obstructing

direct view of stoma including clothing/bandages/sponges etc.) to assure it remains

properly seated in the stoma

b. Obstruction or secretions in tracheostomy

i. Assure tracheostomy is patent. Especially in pediatric tracheostomy patients with

significant respiratory distress, plugging or dislodgement/decannulation of the

tracheostomy is the problem until proven otherwise

ii. Auscultate breath sounds, consider potential for plugging of large airways in patients

with significant respiratory distress

c. Pneumothorax

d. Equipment connection problems

3. As with any patient with respiratory distress, appropriate monitoring with pulse oximetry and

waveform capnography should be provided as per Airway Management Guideline

Treatment and Troubleshooting Interventions

1. In patient with mild respiratory distress and adequate oxygenation:

a. Suctioning/clearing obstruction:

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i. If the patient is not on a ventilator, remove any cap, filter, or speaking valve that may

be connected to the tracheostomy

ii. Provide passive oxygenation with high flow oxygen over nose/mouth and stoma to

avoid hypoxia during procedure

iii. Remove inner cannula if present

iv. If needed, use 1–3 mL sterile saline directly into the tracheostomy to loosen

secretions and help clear obstruction

v. Pass appropriately sized suction catheter through tracheostomy

vi. Once obstruction is cleared, assist ventilations as needed with BVM to tracheostomy

tube, provide passive oxygenation or return patient to ventilator if patient on chronic

ventilator via tracheostomy

2. In patient with significant/severe respiratory distress and/or inadequate oxygenation:

a. If patient on ventilator, remove from vent and attempt BVM ventilation

b. Suctioning/clearing obstruction:

i. If the patient is not on a ventilator, remove any cap, filter, or speaking valve that may

be connected to the tracheostomy

ii. Provide passive oxygenation with high flow oxygen over nose/mouth and stoma to

avoid hypoxia during procedure

iii. Remove inner cannula if present

iv. Attempt to pass appropriately sized suction catheter through tracheostomy

v. If needed, use 1–3 mL sterile saline directly into the tracheostomy to loosen

secretions and help clear obstruction

vi. If suction catheter will not pass, the tracheostomy needs to be changed emergently

due to obstruction. (See below)

vii. Once obstruction is cleared, assist ventilations as needed with BVM to tracheostomy

tube, provide passive oxygenation or return patient to ventilator if patient on chronic

ventilator via tracheostomy tube

c. Emergent tracheostomy change: determine size of tracheostomy needed from imprint on

existing tracheostomy flange/collar. If no replacement tracheostomy is available, an

endotracheal tube of the same size or smaller may be used

i. Ventilate or provide passive oxygenation during procedure. Attempt to ventilate from

the upper airway or direct high flow O

to stoma during attempts.

ii. Deflate cuff (if present)

iii. Remove ties and obstructed tracheostomy

iv. Immediately replace with new (lubricated) tracheostomy, remove obturator, and

begin BVM ventilation. Never use force. For difficult replacement, the following

strategies can be attempted:

a. Reposition patient with neck extended

b. Ensure proper lubrication and re-attempt approach at a 90-degree angle from

long axis of neck (i.e., from the side) to enter the stoma and then rotate back

along the long axis to complete insertion

c. Attempt reinsertion with a smaller sized tracheostomy or endotracheal tube

v. Confirm correct placement with waveform capnography, breath sounds, oxygen

saturation, chest rise

vi. Secure tracheostomy with tracheostomy ties or tube with appropriate holder

3. Consider use of humidified air or oxygen in any patient with a tracheostomy

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4. Cuff may need to be inflated to provide adequate oxygenation and ventilation when positive

pressure ventilation is required. However, cuff should never be inflated if positive pressure

ventilation is not being performed, or in patients with a Passy-Muir (teal colored) speaking

valve in place

Patient Safety Considerations

1. Especially in pediatric tracheostomy patients with significant respiratory distress, plugging or

dislodgement of the tracheostomy is the problem until proven otherwise. Signs and symptoms

of respiratory distress, cyanosis, ventilator alarms sounding, decreased level of consciousness,

decreased SpO

or cardiac arrest in patients with a tracheostomy, as well as bradycardia in

pediatric tracheostomy patients should be presumed due to a tracheostomy obstruction

2. Laryngectomy patients and some patients with congenital or surgical airway abnormalities

cannot be orally intubated. Patients with tracheostomy alone (e.g., for mechanical ventilation)

and no airway abnormalities should be able to be orally intubated

3. For recent tracheostomy patients who present with bleeding from the tracheostomy in the

early (up to 3 weeks) postoperative period, a tracheoinnominate arterial bleed is an

uncommon and life-threatening complication (0.7% incidence and a 90% mortality rate)

a. 50% of these patients present initially with a smaller sentinel bleed/hemoptysis which

appears to have stopped

b. Inflation of the tracheostomy balloon to the maximum is a potential temporizing measure

until definitive care can be provided, even overinflation may be needed. If the

tracheostomy is uncuffed, it can be replaced with a cuffed endotracheal tube and the

balloon maximally inflated

c. Any patient in the early postoperative period (within a month of surgery) with hemoptysis

or bleeding from a tracheostomy should be transported for evaluation, even if bleeding

has stopped

4. Prompt tracheostomy replacement is important. Delays allow for narrowing of the stoma and

can make recannulation more difficult

Notes/Educational Pearls

Key Considerations

1. Tracheostomy tube components

a. Outer cannula: the tracheostomy size is stamped on the collar

b. Inner cannula: not found in all tracheostomies

Not commonly used in pediatric patients

ii.

Removed by gently twisting a quarter turn to the left and pulling out

c. Balloon cuff: protects lower airway from secretions/blood from above, allows for better

mechanical ventilation

d. Collar: includes imprint of tube size and attachment for umbilical tape/tracheostomy ties

e. Obturator: stiffens and provides shape to tracheostomy tube to facilitate insertion. Must

be removed for ventilation

2. To determine the appropriate size suction catheter, double the size of the tracheostomy

(number on collar of tracheostomy tube)

3. A bougie may aid in the placement of an endotracheal tube into a mature stoma

4. An inner cannula may be required to ventilate through the tracheostomy tube

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5. Uncuffed and fenestrated cuffed tracheostomy tubes may not protect the patient from

aspiration

6. If transporting a patient with a tracheostomy either in an emergency or routine transport, the

patients home tracheostomy equipment (e.g., “Go bag”) should accompany them. The

equipment that needs to be at the bedside to ensure safety includes appropriately sized

French suction catheters, operating suction system, and spare tracheostomy tubes. Sterile

saline, sterile gloves and water-soluble medical lubrication packets should also be available.

Most tracheostomy patients will maintain a kit with these supplies to travel with

7. Inadvertent tracheostomy decannulation incidence is the second most frequent life-

threatening pediatric tracheostomy complication, occurring at rates of 0.35–15%, with the

vast majority occurring more than 7 days postoperatively

8. Tracheostomy obstruction can occur for several reasons, including mucus plugging,

abnormal/excess granulation tissue, tracheomalacia causing collapse of the tracheal wall

around the tube

9. Do not replace a heat moisture exchange (HME) filter cap if soiled or wet as it can impede

airflow

Pertinent Assessment Findings

1. Adequate oxygenation without respiratory distress suggests that the tracheostomy is patent

and functioning correctly

2. Inadequate oxygenation and ventilation, respiratory distress, air hunger in a patient with a

tracheostomy should first be presumed to be due to tracheostomy obstruction

3. Neck or chest crepitus on palpation suggests tracheostomy misplacement outside the trachea

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914001 – Airway

•

9914003 – Airway - Failed

•

9914005 – Airway - Obstruction/Foreign Body

Key Documentation Elements

• For any tracheostomy patient with respiratory distress, visual verification of correct location of

tracheostomy in the stoma and auscultation of breath sounds

• Continuous pulse oximetry and preferably continuous waveform capnography (or if

unavailable, repeated capnometry measurements) should be documented for every patient.

[eAirway.03: 4003015]

Performance Measures

None noted

References

1. Bontempo LJ, Manning SL. Tracheostomy Emergencies. Emergency medicine clinics of North

America. 2019;37(1):109–19

2. Dawson, D. (2014). Essential principles: tracheostomy care in the adult patient. Nurs Crit Care,

19(2), 63–72. doi:10.1111/nicc.12076

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3. Doherty, C., Neal, R., English, C., Cooke, J., Atkinson, D., Bates, L., . . . McGrath, B. A. (2018).

Multidisciplinary guidelines for the management of paediatric tracheostomy emergencies.

Anaesthesia, 73(11), 1400–1417. doi:10.1111/anae.14307

4. Fernandez-Bussy S, Mahajan B, Folch E, Caviedes I, Guerrero J, Majid A. Tracheostomy Tube

Placement: Early and Late Complications. J Bronchology Interv Pulmonol. 2015;22(4):357–64

5. Fuller C, Wineland AM, Richter GT. Update on Pediatric Tracheostomy: Indications, Technique,

Education, and Decannulation. Curr Otorhinolaryngol Rep. 2021:1–12

6. Hess DR, Altobelli NP. Tracheostomy tubes. Respiratory care. 2014;59(6):956–71; discussion 71–3

7. Kligerman MP, Saraswathula A, Sethi RK, Divi V. Tracheostomy Complications in the Emergency

Department: A National Analysis of 38,271 Cases. ORL J Otorhinolaryngol Relat Spec.

2020;82(2):106–14

8. Kohn, J., McKeon, M., Munhall, D., Blanchette, S., Wells, S., & Watters, K. (2019). Standardization

of pediatric tracheostomy care with "Go-bags". Int J Pediatr Otorhinolaryngol, 121, 154–156.

doi:10.1016/j.ijporl.2019.03.022

9. Mehta, K., Schwartz, M., Falcone, T. E., & Kavanagh, K. R. (2019). Tracheostomy Care Education for

the Nonsurgical First Responder: A Needs-Based Assessment and Quality Improvement Initiative.

OTO Open, 3(2), 2473974x19844993. doi:10.1177/2473974x19844993

10. Muller RG, Mamidala MP, Smith SH, Smith A, Sheyn A. Incidence, Epidemiology, and Outcomes of

Pediatric Tracheostomy in the United States from 2000 to 2012. Otolaryngol Head Neck Surg.

2019;160(2):332–8

11. Prickett, K., Deshpande, A., Paschal, H., Simon, D., & Hebbar, K. B. (2019). Simulation-based

education to improve emergency management skills in caregivers of tracheostomy patients. Int J

Pediatr Otorhinolaryngol, 120, 157–161. doi:10.1016/j.ijporl.2019.01.020

12. Sandler ML, Ayele N, Ncogoza I, Blanchette S, Munhall DS, Marques B, et al. Improving

Tracheostomy Care in Resource-Limited Settings. Ann Otol Rhinol Laryngol. 2020;129(2):181–90

13. Sterni LM, Collaco JM, Baker CD, Carroll JL, Sharma GD, Brozek JL, et al. An Official American

Thoracic Society Clinical Practice Guideline: Pediatric Chronic Home Invasive Ventilation. American

journal of respiratory and critical care medicine. 2016;193(8):e16–e35

14. Volsko TA, Parker SW, Deakins K, Walsh BK, Fedor KL, Valika T, et al. AARC Clinical Practice

Guideline: Management of Pediatric Patients With Tracheostomy in the Acute Care Setting.

Respiratory care. 2021;66(1):144–55

15. Walsh BK, Crotwell DN, Restrepo RD. Capnography/Capnometry During Mechanical Ventilation:

2011. Respiratory care. 2011;56(4):503–9

16. Watters KF. Tracheostomy in Infants and Children. Respiratory care. 2017;62(6):799–825

Revision Date

March 11, 2022

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Trauma

General Trauma Management

Aliases

None noted

Patient Care Goals

1. Rapid assessment and management of life-threatening injuries

2. Recognition of when to rapidly transport

3. Transport to the appropriate level of trauma care

4. Safe movement of patient to prevent worsening injury severity

Patient Presentation

Inclusion Criteria

1. Patients of all ages who have sustained an injury due to mechanical trauma, including:

a. Blunt injury

b. Penetrating injury

c. Blast

d. Burns

Exclusion Criteria

Not an acute traumatic injury

Patient Management

Initial Assessment

1. Primary survey (Use “MARCH” algorithm)

a. Massive Hemorrhage

i. Initial visual and body sweep to assess for penetrating wounds and severe life-

threatening hemorrhage [See Extremity Trauma/External Hemorrhage Management

Guideline]

b. Airway

i. Assess airway patency by asking the patient basic questions to assess for stridor and

ease of air movement

ii. Look for injuries that may lead to airway obstruction including unstable facial

fractures, expanding neck hematoma, blood or vomitus in the airway, facial

burns/inhalation injury

iii. Evaluate mental status for ability to protect airway (patients with a Glasgow Coma

Score (GCS) less than or equal to “8” are more likely to require airway protection)

c. Respiratory/Breathing

i. Assess respiratory rate and pattern

ii. Assess for tracheal deviation

iii. Assess symmetry of chest wall movement

iv. Listen bilaterally on lateral chest wall for breath sounds

d. Circulation

i. Assess blood pressure and heart rate

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e. Head injury/Hypothermia

i. Perform initial neurologic status assessment of GCS/AVPU (Alert, Verbal, Painful,

Unconscious) and pupillary size and responsiveness [See Appendix VII. Neurologic

Status Assessment and Head Injury Guideline]

ii. Assess for gross motor movement of extremities

iii. Evaluate for clinical signs of traumatic brain injury with herniation including:

1. Unequal pupils

2. Lateralizing motor signs

3. Posturing

iv. Prevent hypothermia

Immediate Treatment and Interventions

1. Massive or exsanguinating hemorrhage control

a. First stop severe external and extremity hemorrhage with extremity tourniquets or

appropriate wound packing with hemostatic gauze. Be sure to roll patient and examine

the back as well. [See Extremity Trauma/External Hemorrhage Management Guideline]

b. Utilize junctional tourniquets if needed for junctional area hemorrhage

2. Airway

a. If impending airway obstruction or altered mental status resulting in inability to maintain

airway patency, immediately ensure patent airway. [See Airway Management Guideline

and Spinal Care Guideline]

b. Consider airway adjuncts as appropriate avoiding nasal airway adjuncts in patents with

oral or other facial injuries. [See Airway Management Guideline]

3. Respiratory/Breathing

a. If absent or diminished breath sounds in a hypotensive trauma patient, especially those

with chest trauma and/or tracheal deviation, consider tension pneumothorax and perform

needle decompression of side without breath sounds or side opposite tracheal deviation;

may need second or third needle decompression on same side if there is a rush of air but

patient again has symptoms

b. For open chest wound, place semi-occlusive dressing

c. Monitor oxygen saturation (SpO

) and, if indicated, provide supplemental oxygen to

maintain SPO

greater than 94% and respiratory support if needed. [See Respiratory

Section]

4. Circulation

a. If pelvis is unstable, place pelvic binder or sheet to stabilize pelvis

b. Establish IV access if needed (large bore preferred)

c. Fluid resuscitation

i. Adults

1. If SBP greater than 90 mmHg and heart rate less than 120 BPM, no IV fluids

required

2. If SBP less than 90 mmHg or HR greater than 120 BPM, initiate resuscitation:

a. Blood products are recommended if available

b. If blood products not available, consider 500 mL bolus of IV fluid, repeat as

needed for persistent signs and symptoms of shock

If signs and symptoms of shock persist after a total of 2 L crystalloid bolus,

contact online medical direction

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c. Trauma resuscitation target SBP 90 mmHg (palpable radial pulse or alert

mental status)

d. Reassess SBP after bolus given

3. Head injury: target SBP greater than110 mmHg. Hypotension should be avoided to

maintain cerebral perfusion

ii. Pediatrics

1. If patient demonstrates tachycardia for age with signs of poor perfusion (low BP,

greater than 2-second capillary refill, altered mental status, hypoxia, weak pulses,

pallor, or mottled/cool skin), give 20 mL/kg crystalloid bolus and reassess. Repeat

as needed for persistent signs and symptoms of shock

a. If signs and symptoms of shock persist after a total of 60 mL/kg crystalloid

bolus, contact online medical direction

2. Target normal BP for age [See Appendix VIII. Abnormal Vital Signs]

d. Blood product administration may be considered based on local availability and protocols

e. Tranexamic acid (TXA) administration may be considered within three hours of injury and

signs of hemorrhagic shock

2. Disability/Head/Hypothermia

a. If clinical signs of traumatic brain injury [See Head Injury Guideline]

b. Avoid/treat hypothermia

i. Remove wet clothing

ii. Cover patient to warm and/or prevent further heat loss

3. NOTE: Patients with major hemorrhage, hemodynamic instability, penetrating torso trauma,

or signs of traumatic brain injury often require rapid surgical intervention. Minimize scene

time (goal is under 10 minutes) and initiate rapid transport to the highest level of care within

the trauma system

4. Repeat primary assessment or secondary assessment should be conducted en route to the

trauma center

5. Decisions regarding transport destination should be based on the ACS-COT 2022 National

Guideline for the Field Triage of Injured Patients

Secondary Assessment, Treatment, and Interventions

1. Assessment

a. Obtain medical history from patient or family including:

i. Allergies

ii. Medications

iii. Past medical and surgical history

iv. Last meal

v. Events leading up to the injury

b. Secondary survey: Head to toe physical exam including re-assessment of interventions

from primary survey

i. Head/Face

1. Palpate head and scalp and face and evaluate for soft tissue injury or bony

crepitus indicating injury to skull or facial bones

2. Assess for globe injury and subjective change in vision

3. See Facial/Dental Trauma Guideline

ii. Neck

1. Check for:

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a. Contusions

b. Abrasions

c. Hematomas

d. Jugular vein distention (JVD)

e. Tracheal deviation

2. Palpate for crepitus

3. Spinal assessment per Spinal Care Guideline

ii. Chest – See Initial Treatment

1. Palpate for instability/crepitus

2. Listen to breath sounds

3. Inspect for penetrating or soft tissue injuries

iii. Abdomen

1. Palpate for tenderness

2. Inspect for penetrating or soft tissue injuries

3. Cover eviscerated abdominal contents with moist dressings

iv. Pelvis

1. Inspect for penetrating or soft tissue injuries

2. Palpate once for instability by applying medial pressure on the iliac crests

bilaterally

v. Back

1. Maintain spinal alignment. Refer to Spinal Care Guideline

2. Inspect for penetrating or soft tissue injuries

vi. Neurologic status assessment [See Appendix VII. Neurologic Status Assessment]

1. Serial assessment of mental status

2. Gross exam of motor strength and sensation in all four extremities

vii. Extremities

1. Assess for fracture/deformity – See Extremity Trauma/External Hemorrhage

Management Guideline

2. Assess peripheral pulses/capillary refill

c. Additional treatment considerations

i. Maintain spine precautions per the Spinal Care Guideline

ii. Splint obvious extremity fractures per the Extremity Trauma/External Hemorrhage

Management Guideline

iii. Provide pain medication per the Pain Management Guideline

Patient Safety Considerations

1. Life-threatening injuries identified on primary survey should be mitigated immediately with

rapid transport to a trauma center

2. Monitor patient for deterioration over time with serial vital signs (pulse, blood pressure,

respiratory rate, neurologic status assessment) and repeat neurologic status assessment [See

Appendix VII. Neurologic Status Assessment]

a. Patients with compensated shock may not manifest hypotension until severe blood loss

has occurred

b. Patients with traumatic brain injury may deteriorate as intracranial swelling and

hemorrhage increase. [See Head Injury Guideline]

3. Anticipate potential for progressive airway compromise in patients with trauma to head and

neck

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Notes/Educational Pearls

Key Considerations

1. Optimal trauma care requires a structured approach to the patient emphasizing first control of

massive hemorrhage using MARCH (Massive hemorrhage, Airway, Respiratory/Breathing,

Circulation, Head injury/Hypothermia)

2. Target scene time less than 10 minutes for unstable patients or those likely to need surgical

intervention

3. Clinician training should include the ACS-COT 2022 National Guideline for the Field Triage of

Injured Patients

4. Frequent reassessment of the patient is important

a. If patient develops difficulty with ventilation, reassess breath sounds for development of

tension pneumothorax

b. If extremity hemorrhage is controlled with pressure dressing or tourniquet, reassess for

evidence of continued hemorrhage

c. If mental status declines, reassess ABCs (Airway, Breathing, Circulation) and repeat

neurologic status assessment [See Appendix VII. Neurologic Status Assessment]

5. Use structured communication tool for patient handoff to higher level care such as AT-MIST

a. Age

b. Time of incident or onset of symptoms

c. Mechanism

d. Injuries noted

e. Symptoms/Signs

f. Treatments provided

Traumatic Arrest: Withholding and Termination of Resuscitative Efforts

Resuscitative efforts should be withheld for trauma patients with the following:

1. Decapitation

2. Hemicorpectomy

3. Signs of rigor mortis or dependent lividity

4. Blunt trauma: apneic, pulseless, no organized cardiac activity on monitor

a. Note – Adult and Pediatric: Resuscitative efforts may be terminated in patients with

traumatic arrest who have no return of spontaneous circulation after 15–30 minutes of

resuscitative efforts, including airway management, evaluation/treatment for possible

tension pneumothorax, fluid bolus, and minimally interrupted CPR

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914207 – Injury - General Trauma Management

Key Documentation Elements

• Mechanism of injury

• Primary and secondary survey

• Serial vital signs including neurologic status assessments

• Scene time

• Procedures performed and patient response

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Performance Measures

• Monitor scene time for unstable patients

• Monitor appropriateness of procedures

• Monitor appropriate airway management

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

1. American College of Surgeons Committee on Trauma; American College of Emergency

Physicians Pediatric Emergency Medicine Committee; National Association of EMS

Physicians; American Academy of Pediatrics Committee on Pediatric Emergency Medicine,

Fallat ME. Withholding, or termination of resuscitation in pediatric out-of-hospital traumatic

cardiopulmonary arrest. Pediatrics. 2014;133(4): e1104.

2. Bickell WH, Wall MJ Jr., Pepe PE, et al. Immediate versus delayed fluid resuscitation for

hypotensive patients with penetrating torso injuries. N Engl J Med. 1994; 331:1105–9

3. Cullinane DC, Schiller HJ, Zielinski MD, et al. Eastern Association for the Surgery of Trauma

practice management guidelines for hemorrhage in pelvic fracture – update and systematic

review. J Trauma. 2011;71(6):1850–68

4. Deakin CD et al. Accuracy of the Advanced Trauma Life Support Guidelines for Predicting

Systolic Blood Pressure Using Carotid, Femoral, and radial Pulses: Observational Study. BMJ

2000. PMID: 10987771

5. Guidelines for the Field Triage of Injured Patients: Recommendations of the National Expert

Panel on Field Triage, 2011. Washington, DC: Centers for Disease Control and Prevention.

Morbidity and Mortality Weekly Report; 2012;61(RR01):1–20

6. Guidelines for the Management of Severe Traumatic Brain Injury, 4th Edition. Brain Trauma

Foundation, September 2016. Available at https://braintrauma.org/guidelines/guidelines-for-

the-management-of-severe-tbi-4th-ed#. Accessed March 11, 2022

7. Jason F Naylor, SP, Andrew D Fisher, SP, Michael D April, MC, Steven G Schauer, MC, An

analysis of radial pulse strength to recorded blood pressure in the Department of Defense

Trauma Registry, Military Medicine, 2020:185(11-12):e1903–e1907,

https://doi.org/10.1093/milmed/usaa197

8. Millin M, Galvagno SM, Khandker SR, et al. Withholding and termination of resuscitation of

adult cardiopulmonary arrest secondary to trauma: Resource document to the joint NAEMSP-

ACS (COT) position statements. J Trauma Acute Care Surg. 2013;75(3):459–67

9. Morrison C, Carrick M, Norman M, et al. Hypotensive resuscitation strategy reduces

transfusion requirements and sever postoperative coagulopathy in trauma patients with

hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma.

2011;70(3):652–63

10. Prehospital Trauma Life Support, 9th Edition. Burlington, MA: Jones & Bartlett; 2020

11. Poulton TJ et al. ATLS Paradigm Fails. Ann Emerg Med 1988. PMID: 3337405

12. Spaite DW, Bobrow BJ, Keim SM, et al. Association of Statewide Implementation of the

Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following

Traumatic Brain Injury. The Excellence in Prehospital Injury Care (EPIC) Study. JAMA Surg.

2019;154(7): e191152

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13. Tactical Combat Casualty Care (TCCC) Guidelines for Medical Personnel, 05 November 2020.

Available at https://deployedmedicine.com/content/40. Accessed March 11, 2022

14. Tactical Emergency Casualty Care (TECC) Guidelines for BLS/ALS Medical Providers. Current as

of March 2019. Available at https://www.c-tecc.org/images/4-

2019_TECC_ALS_BLS_Guidelines_.pdf. Accessed March 11, 2022

15. The CRASH-2 Collaborators. Effects of tranexamic acid on death, vascular occlusive events,

and blood transfusion in trauma patients with significant hemorrhage (CRASH-2): a

randomized, placebo-controlled trial. Lancet. 2010; 376:23–32

16. Topijian et al. Part 4: Pediatric Basic and Advanced Life Support: 2020 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular

Care. Circulation. 2020;142: S469–S523

17. Truhlar A, Deakin C, Soar J, et al. European resuscitation council guidelines for resuscitation

2015: section 4. Cardiac arrest in special circumstances. Resuscitation. 2015; 95:148–201

Revision Date

March 11, 2022

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Blast Injuries

Aliases

None noted

Patient Care Goals

1. Maintain patient and clinician safety by identifying ongoing threats at the scene of an

explosion

2. Identify multi-system injuries which may result from a blast, including possible toxic

contamination

3. Prioritize treatment of multi-system injuries to minimize patient morbidity

Patient Presentation

Inclusion Criteria

1. Patients exposed to explosive force. Injuries may include any or all the following:

a. Blunt trauma

b. Penetrating trauma

c. Burns

d. Pressure-related injuries (barotrauma)

e. Toxic chemical contamination

f. Chemical, biological, radiological, nuclear, and explosive devices, or agents

Exclusion Criteria

None noted

Patient Management

Assessment

1. Hemorrhage Control

a. Assess for and stop severe hemorrhage [See Extremity Trauma/External Hemorrhage

Management Guideline]

2. Airway

a. Assess airway patency

b. Consider possible thermal or chemical burns to the airway

3. Breathing

a. Evaluate the adequacy of respiratory effort, oxygenation, quality of lung sounds, and chest

wall integrity

b. Consider possible pneumothorax or tension pneumothorax (because of penetrating/blunt

trauma or barotrauma)

c. Continually reassess for blast lung injury

4. Circulation

a. Look for evidence of hemorrhage

b. Assess BP, pulse, skin color/character, and distal capillary refill for signs of shock

5. Disability

a. Assess patient responsiveness (e.g., AVPU) and level of consciousness (e.g., GCS) [See

Appendix VII: Neurologic Status Assessment]

b. Assess pupils

c. Assess gross motor movement of extremities

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6. Exposure

a. Rapid evaluation of entire skin surface, including back (log roll), to identify blunt or

penetrating injuries

Treatment and Interventions

1. Hemorrhage control:

a. Control any severe external hemorrhage [See Extremity Trauma/External Hemorrhage

Management Guideline]

2. Airway:

a. If thermal or chemical burn to the airway is suspected, early airway management is vital

b. Secure airway, utilizing airway maneuvers, airway adjuncts, supraglottic device, or

endotracheal tube [See Airway Management Guideline]

3. Breathing:

a. Administer oxygen as appropriate with a target of achieving 94–98% saturation.

b. Assist respirations as needed

c. Cover any open chest wounds with a semi-occlusive dressing

d. If the patient has evidence of tension pneumothorax, perform needle decompression

4. Circulation:

a. Establish IV access with two large bore IVs or IOs

i. Administer resuscitative fluids, per the General Trauma Management Guideline

ii. If the patient is burned, administer normal saline (NS) or lactated Ringer’s (LR) per the

Burns Guideline

5. Disability:

a. If evidence of head injury, treat per the Head Injury Guideline

b. Apply spinal precautions, per the Spinal Care Guideline

c. Monitor GCS during transport to assess for changes

6. Exposure:

a. Keep patient warm to prevent hypothermia

Patient Safety Considerations

1. Ensuring scene safety is especially important at the scene of an explosion

a. Always consider the possibility of subsequent explosions

b. Structural safety, possible toxic chemical contamination, the presence of poisonous

gasses, and other hazards might cause a delay in patient extraction

2. Remove patient from the scene as soon as is practical and safe

3. If the patient has sustained burns (thermal, chemical, or airway), consider transport to a

specialized burn center

Notes/Educational Pearls

Key Considerations

1. Scene safety is of paramount importance when responding to an explosion or blast injury

2. Patients sustaining blast injury may sustain complex, multi-system injuries, including blunt and

penetrating trauma, shrapnel, barotrauma, burns, and toxic chemical exposure

3. Consideration of airway injury, particularly airway burns, should prompt early and aggressive

airway management

4. Minimize IV fluid resuscitation in patients without signs of shock. Consider injuries due to

barotrauma

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a. Tension pneumothorax

Hypotension or other signs of shock associated with decreased or absent breath

sounds, jugular venous distension, and/or tracheal deviation

b. Tympanic membrane perforation resulting in deafness which may complicate the

evaluation of their mental status and their ability to follow commands

5. Primary transport to a trauma or burn center is preferable, whenever possible

Pertinent Assessment Findings

1. Evidence of multi-system trauma, especially:

a. Airway injury/burn

b. Barotrauma to lungs

c. Toxic chemical contamination

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914045 – Exposure - Explosive/Blast Injury

Key Documentation Elements

• Airway status and intervention

• Breathing status:

o Quality of breath sounds (equal bilaterally)

o Adequacy of respiratory effort

o Oxygenation

• Documentation of burns, including Total Burn Surface Area (TBSA) [See Burns Guideline]

• Documentation of possible toxic chemical contamination

Performance Measures

• Airway assessment and early and aggressive management

• Appropriate IV fluid management

• Transport to trauma or burn center

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

1. Explosions and Blast Injuries; A Primer for Clinicians. CDC.gov.

www.cdc.gov/masstrauma/preparedness/primer.pdf. Accessed March 11, 2022

2. Mathews ZR, Koyfman A. Blast Injuries. J Emerg Med. 2015 Oct;49(4):573–87. doi:

10.1016/j.jemermed.2015.03.013. Epub 2015 Jun 10. PMID: 26072319.

3. Plurad DS. Blast injury. Mil Med. 2011 Mar;176(3):276–82. doi: 10.7205/milmed-d-10-00147.

PMID: 21456353.

Revision Date

March 11, 2022

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Burns

Aliases

None noted

Patient Care Goals

Minimize tissue damage and patient morbidity from burns

Patient Presentation

1. Patient may present with:

a. Airway – stridor, hoarse voice

b. Mouth and nares – redness, blisters, soot, singed hairs

c. Breathing – rapid, shallow, wheezes, rales

d. Skin – Estimate Total Burn Surface Area (TBSA) and depth (partial vs. full thickness)

e. Associated trauma – blast, fall, assault

Inclusion Criteria

Patients sustaining thermal burns

Exclusion Criteria

Electrical, chemical, and radiation burns [See Toxins and Environmental Section]

Special Transport Considerations

1. Transport to most appropriate trauma center when there is airway or respiratory

involvement, or when significant trauma or blast injury is suspected

2. Consider air ambulance transportation for long transport times or airway management needs

beyond the scope of the responding ground medic

3. Consider transport directly to burn center if partial or full thickness burns (TBSA) greater than

10% and/or involvement of hands/feet, genitalia, face, and/or circumferential burns

Scene Management

1. Assure crew safety:

a. Power off

b. Electrical lines secure

c. Gas off

d. No secondary devices

e. Hazmat determinations made

f. Proper protective attire including breathing apparatus may be required

Patient Management

Assessment

1. Circumstances of event – Consider:

a. Related trauma in addition to the burns

b. Inhalation exposures such as carbon monoxide (CO) and cyanide (CN)

c. Pediatric or elder abuse

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2. Follow ABCs (Airway, Breathing, Circulation) of resuscitation per the General Trauma

Management Guideline

3. If evidence of possible airway burn, consider aggressive airway management

4. Consider spinal precautions for those that qualify per the Spinal Care Guideline

5. Estimate TBSA burned and depth of burn

a. Use “Rule of 9’s” [See burn related tables in Appendix VI. Burn and Burn Fluid Charts]

b. First-degree/superficial burns (skin erythema only) are not included in TBSA calculations

6. Document pain scale

Treatments and Interventions

1. Stop the burning

a. Remove wet clothing (if not stuck to the patient)

b. Remove jewelry

c. Leave blisters intact

2. Minimize burn wound contamination

a. Cover burns with dry dressing or clean sheet

b. Do not apply gels or ointments

3. Monitor SPO

, EtCO

and cardiac monitor

4. High flow supplemental oxygen for all burn patients rescued from an enclosed space

5. Establish IV access, avoid placement through burned skin

6. Evaluate respiratory status in patients with circumferential thoracic burns due to the risk for

ventilatory compromise and potential need for escharotomy

7. Evaluate distal circulation in circumferentially burned extremities due to increased risk of

circulatory compromise and potential need for escharotomy

8. Consider early management of pain and nausea/vomiting

9. Initiate fluid resuscitation – Use lactated Ringer’s or normal saline

a. If patient in shock:

i. Consider other cause, such as trauma or cyanide toxicity

ii. Administer IV fluid per the Shock Guideline

b. If patient not in shock:

i. Begin fluids based on estimated TBSA [See Appendix VI. Burn and Burn Fluid Charts as

appropriate to patient weight]

ii. Pediatric patients weighing less than 40 kg, use length-based tape for weight estimate

and follow

c. For persons over 40 kg, the initial fluid rate can also be calculated using the “Rule of 10”:

i. Calculate the TBSA (round to nearest 10%)

ii. Multiply TBSA x 10 = initial fluid rate (mL/hr) {for persons between 40–80 kg}

iii. Add 100 mL/hr for every 10 kg of body weight over 80 kg

10. Prevent systemic heat loss and keep the patient warm

Special Treatment Considerations

1. If blast mechanism, treat per the Blast Injury Guideline

2. Airway burns can rapidly lead to upper airway obstruction and respiratory failure. After

performing the appropriate airway management measures, the administration of nebulized

epinephrine, bronchodilators, nebulized n-acetylcystine, and nebulized heparin, if available,

can be considered to reduce edema of the laryngeal and pulmonary tissues and airway

occlusion from secretions and blood.

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3. Have a high index of suspicion for cyanide poisoning in a patient with depressed GCS,

respiratory difficulty, and cardiovascular collapse in the setting of an enclosed-space fire. Give

the antidote (hydroxocobalamin), if available, in this circumstance

4. Particularly in enclosed-space fires, carbon monoxide toxicity is a consideration and pulse

oximetry may not be accurate [See Carbon Monoxide/Smoke Inhalation Guideline]

5. For specific chemical exposures (cyanide, hydrofluoric acid, other acids, and alkali) [See

Topical Chemical Burn Guideline]

6. Consider decontamination and notification of receiving facility of potentially contaminated

patient (e.g., methamphetamine (meth) lab incident)

7. Burns that involve significant sloughing or loss of skin can result in uncontrolled heat loss.

These patients should be monitored closely for the development of hypothermia and

appropriate preventative measures should be taken

Notes/Educational Pearls

1. Onset of stridor and change in voice are sentinel signs of potentially significant airway burns,

which may rapidly lead to airway obstruction or respiratory failure.

2. If the patient is in shock within one hour of burn, it is not from the burn. Evaluate the patient

carefully for associated trauma or cyanide toxicity.

3. If the patient is not in shock, the fluid rates recommended above will adequately maintain

patient’s fluid volume.

4. Pain management is critical in acute burns.

5. End-tidal capnography (EtCO

) monitoring may be particularly useful to monitor respiratory

status in patients receiving significant doses of narcotic pain medication.

6. Cardiac monitor is important in electrical burns and chemical inhalations.

7. TBSA is calculated only based on percent of second- and third-degree burns – First

degree/superficial burns are not included in this calculation

Quality Improvement

Burn trauma is relatively uncommon. Clinicians should receive regular training on burn assessment and

management.

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914085 – Injury - Burns-Thermal

Key Documentation Elements

• Initial airway status

• Total volume of fluid administered

• Body surface area of second- and third-degree burns (TBSA)

• Pulse and capillary refill exam distally on any circumferentially burned extremity

• Pain scale documentation and pain management

Performance Measures

• Patient transported to most appropriate hospital, preferably a burn center

• Pain scale documented and pain appropriately managed

• Airway assessment and management appropriately documented

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• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

1. American Burn Association. Advanced Burn Life Support (ABLS) Handbook; 2011

2. Chung K, Salinas J, Renz E, et al. Simple derivation of the initial fluid rate for the resuscitation

of severely burned adult combat casualties: in Silico validation of the rule of ten. J Trauma.

2010;69 Suppl 1: S49–54

3. Dries DJ, Endorf FW. Inhalation injury: epidemiology, pathology, treatment strategies. Scand J

Trauma Resusc Emerg Med. 2013; 21:31

4. Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J

Burn Care Res. 2007; 28(1):80-83

5. Fluid Rate charts (based on Parkland formula) and TBSA diagrams courtesy of the University of

Utah Burn Center; 2014. As presented in Appendix VI. Burn and Burn Fluid Charts

6. Hettiaratchy S, Papini R. Initial management of a major burn: II— assessment and

resuscitation. BMJ. 2004;329(7457):101–103. doi:10.1136/bmj.329.7457.101

7. McIntire AM, Harris SA, Whitten JA, et al. Outcomes Following the Use of Nebulized Heparin

for Inhalation Injury (HIHI Study). J Burn Care Res 2017; 38:45-52

8. Miller AC. Influence of nebulized unfractionated heparin and N-acetylcysteine in acute lung

injury after smoke inhalation injury. J Burn Care Res. 2009; 30:249–256

Revision Date

March 11, 2022

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Crush Injury/Crush Syndrome

Aliases

Compartment syndrome Crush

Patient Care Goals

1. Recognizing traumatic crush injury mechanism

2. Minimize systemic effects such as rhabdomyolysis, hyperkalemia, acute kidney injury

Patient Presentation

Inclusion criteria

Traumatic crush mechanism of injury

Non-traumatic injuries that may cause compartment syndrome include prolonged immobilization,

prolonged compression of the torso/limbs, electrical injury, or burns

Exclusion criteria

None noted

Patient Management

Assessment

1. Identify any severe hemorrhage

2. Assess airway, breathing, and circulation

3. Evaluate for possible concomitant injury (e.g., fractures, solid organ damage, or spinal injury)

4. Monitor for development of compartment syndrome (pain out of proportion to clinical exam,

tense swelling, pain with passive stretch, muscle weakness, absent pulses, parasthesias)

Treatment and Interventions

1. The treatment of crushed casualties should begin as soon as they are discovered

2. If severe hemorrhage is present, see Extremity Trauma/External Hemorrhage Management

Guideline

3. Establish IV access. IV fluids should be administered prior to releasing the crushed body part.

Administer 1000 mL normal saline (NS) bolus. Avoid lactated Ringer’s solution as it contains

potassium. Crush injury without adequate fluid resuscitation develops into crush syndrome

4. For significant crush injuries or prolonged entrapment of an extremity, consider sodium

bicarbonate 1 mEq/kg (maximum dose of 50 mEq) IV bolus over 5 minutes

5. Attach cardiac monitor. Obtain/interpret 12-lead EKG, if available. Carefully monitor for

dysrhythmias or signs of hyperkalemia before and immediately after release of pressure and

during transport (e.g., peaked T waves, wide QRS, lengthening QT interval, loss of P wave)

6. For pain control, consider analgesics [See Pain Management Guideline]

7. Consider the following post extrication

a. Continued resuscitation with normal saline (500–1000 mL/hr for adults, 10 mL/kg/hr for

children)

b. If EKG suggestive of hyperkalemia or if findings of hyperkalemia, administer IV fluids and

consider administration of:

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i. Calcium chloride – 1 gm IV/IO over 5 minutes, ensure IV patency and do not exceed 1

mL per minute (Pediatric: 10% 20 mg/kg, max 1 g, IV.IO over 5 minutes.

ii. Calcium gluconate – 3 gm IV/IO over 5 minutes with constant cardiac monitoring

(Pediatric: 10% 50 mg/kg (0.5 mL/kg), max 2 gram, IV over 5 minutes

c. If not already administered, for significant crush injuries with EKG suggestive of

hyperkalemia, administer sodium bicarbonate 1 mEq/kg (max dose of 50 mEq) IV bolus

over 5 minutes

d. If EKG suggestive of hyperkalemia, consider albuterol 5 mg via small volume nebulizer (can

be repeated if no response is seen)

Patient Safety Considerations

Scene safety for both rescuers and patients are of paramount importance.

Notes/Educational Pearls

1. Causes of mortality in untreated crush syndrome:

a. Immediate

i. Severe head injury

ii. Traumatic asphyxia

iii. Torso injury with damage to intrathoracic or intra-abdominal organs

b. Early

i. Sudden release of a crushed extremity may result in reperfusion syndrome (acute

hypovolemia, electrolyte abnormalities, and subsequent lethal arrhythmia)

ii. Hyperkalemia (potassium is released from injured muscle cells)

iii. Hypovolemia/shock

c. Late

i. Acute kidney injury (from release of toxins from injured muscle cells)

ii. Coagulopathy and hemorrhage

iii. Sepsis

Key Considerations

1. Rapid extrication and evacuation to a definitive care facility (trauma center preferred)

2. A patient with a crush injury may initially present with very few signs and symptoms. Maintain

a high index of suspicion for any patient with a compressive mechanism of injury

3. A fatal medical complication of crush syndrome is hyperkalemia. Suspect hyperkalemia if T-

waves become peaked, QRS becomes prolonged (greater than 0.12 seconds), absent P wave,

prolonged QTc, or sine wave. Continue fluid resuscitation through extrication and transfer to

hospital

Pertinent Assessment Findings

1. Mental status/Glasgow Coma Scale (GCS)

2. Evaluation for fractures and potential compartment syndrome development (neurovascular

status of injured extremity)

3. Examination of spine

4. Evidence of additional trauma, potentially masked by with other painful injuries

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914089 – Injury - Crush Syndrome

Key Documentation Elements

• Time of tourniquet application, if applied

• Neurovascular status of any crushed extremity

• EKG findings consistent with hyperkalemia

• Amount of IV fluid administered

Performance Measures

• Initiation of fluid resuscitation prior to extrication

• EKG/monitor to monitor for dysrhythmias or changes related to hyperkalemia

• Treatment of hyperkalemia if evidence is noted on EKG

References

1. Better OS. The crush syndrome revisited (1940–1990). Nephron. 1990; 55:97–103

2. Jagodzinski N, Weerasinghe C, Porter K. Crush injuries and crush syndrome – a review.

Trauma. 2010; 12:69–88

3. Sever MS, Vanholder R, Lameire N. Management of crush-related injuries after disasters. N

Engl J Med. 2006;354(10):1052–63

4. Smith J, Greaves I. Crush injury and crush syndrome: a review. J Trauma. 2003;54(5): S226–30

Revision Date

March 11, 2022

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Extremity Trauma/External Hemorrhage Management

Aliases

None noted

Patient Care Goals

1. Minimize blood loss from extremity hemorrhage

2. Avoid hemorrhagic shock due to extremity hemorrhage

3. Minimize pain and further injury due to fractures, dislocations, or soft-tissue injuries

Patient Presentation

Inclusion Criteria [Refer to Crush Injury and Crush Syndrome Guideline]

1. Traumatic extremity hemorrhage (external hemorrhage) due to blunt or penetrating injury

2. Known or suspected extremity fractures or dislocations

Exclusion Criteria

None noted

Patient Management

Assessment

1. Assess degree of extremity/external bleeding/blood loss

2. Vascular status of extremity:

a. Pallor

b. Pulse

c. Capillary refill and skin temperature

3. Evaluate for obvious deformity, shortening, rotation, or instability

4. Neurologic status of extremity:

a. Sensation to light touch

b. Distal movement of extremity

Treatments and Interventions

1. Manage bleeding:

a. Expose the wound and apply direct pressure to bleeding site, followed by a pressure

dressing

b. If direct pressure/pressure dressing is ineffective or impractical:

If the bleeding site is amenable to tourniquet placement, apply a commercial

tourniquet to extremity:

1. Tourniquet should be placed 2–3 inches proximal to wound, not over a joint, and

tightened until bleeding stops and distal pulse is eliminated

2. If bleeding continues, place a second tourniquet proximal to the first

3. For thigh wounds, consider placement of two tourniquets, side-by-side, and

tighten sequentially

c. Wound packing:

i. Indications: Groin/axillary (“junctional”) injury or any limb wound with persistent

bleeding despite direct pressure and/or application of commercial tourniquet(s)

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ii. Materials: hemostatic gauze, regular gauze, or any available material

iii. Procedure: pack tightly and fully to the depth of the wound until bleeding stops (may

require significant packing for deep, large wounds), then apply direct pressure and/or

pressure dressing; do not remove packing to assess bleeding

1. Pack around (do not remove) bone fragments or foreign objects

d. Junctional tourniquets may be considered for groin or axillary wounds, if available

e. Consider tranexamic acid (TXA) for injury associated with hemorrhagic shock if within

three hours of injury

2. Manage pain [See Pain Management Guideline]

a. Pain management should be strongly considered for patients with tourniquets and

suspected fractures

b. Do not loosen tourniquet to relieve pain

3. Stabilize suspected fractures/dislocations:

a. Strongly consider pain management before attempting to move a suspected fracture

b. If distal vascular function is compromised, gently attempt to restore normal anatomic

position, and reassess perfusion status

c. Use splints as appropriate to limit movement of suspected fracture

d. Elevate extremity fractures above heart level whenever possible to limit swelling

e. Apply ice/cool packs to limit swelling in suspected fractures or soft tissue injury, but do

not apply ice directly to bare skin

f. Reassess distal neurovascular status after any manipulation or splinting of

fractures/dislocations

g. Dress open wounds associated with fractures with saline-moistened gauze

4. Remove wet or blood-soaked clothing and use measures to prevent heat loss

5. Remove jewelry and potentially constricting clothing from the injured limb

6. Do not remove impaled foreign bodies

Patient Safety Considerations

1. If improvised tourniquet has been placed by bystander, reassess, and consider placing

commercial tourniquet proximal to it

2. If tourniquet is placed:

a. Ensure that the tourniquet is sufficiently tight to occlude the distal pulse

b. Ensure that the tourniquet is well marked and visible, and that all subsequent clinicians

are aware of the presence of the tourniquet

c. Do not cover the tourniquet with clothing or dressings

3. Mark the time of tourniquet placement prominently on the patient and in the patient care

report

4. Without removing the tourniquet or dressing, reassess frequently for signs of ongoing or

renewed bleeding, such as:

a. Blood soaking through dressing

b. Bleeding distal to tourniquet

Notes/Educational Pearls

Key Considerations

1. Tourniquets should be applied to bare skin, 2–3 inches proximal to the wound

2. Tourniquet should be reassessed at every stage of patient movement to ensure ongoing

hemorrhage control.

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3. Survival is markedly improved when a tourniquet is placed before shock develops

4. Properly-applied tourniquets in conscious patients are painful – treat pain with analgesics, but

do not loosen a tourniquet to relieve discomfort

5. Arterial pressure points may not be effective in controlling hemorrhage; however, may help

slow bleeding while tourniquet is applied

6. Amputated body parts should be transported with patient for possible re-implantation

a. It should remain cool but dry

b. Place the amputated part in a plastic bag

c. Place the bag with the amputated part on ice in a second bag

d. Do not let the amputated part come into direct contact with the ice

7. Pediatric considerations:

a. External hemorrhage control to prevent shock is critical in infants and young children, due

to their relatively small blood volume

b. Most commercial tourniquets can be used effectively on children over 2 years of age

c. Stretch-wrap-tuck elastic-type tourniquets can be used on any age patient

d. Direct pressure and wound packing may be more suitable for infants and young children

e. Consult with local online medical direction regarding use of traction splints for femur

fractures in young children, to avoid risk of possible nerve damage

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914083 – Injury - Bleeding/Hemorrhage Control

•

9914097 – Injury - Extremity

Key Documentation Elements

• Vital signs and vascular status of extremity after placement of tourniquet, pressure dressing,

packing, and/or splint

• Time of tourniquet placement

• Documentation of signs/symptoms of possible compartment syndrome

Performance Measures

• Proper placement of tourniquet (location, cessation of bleeding)

• Proper marking and timing of tourniquet placement and notification of tourniquet placement

to subsequent EMS clinicians and ED personnel

• Appropriate splinting and padding of fractures

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

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Graphic 1. Prehospital External Hemorrhage Control Protocol

* Use of tourniquet for extremity hemorrhage is strongly recommended if sustained direct pressure

is ineffective or impractical; Use a commercially produced, windlass, pneumatic, or ratcheting

device, which has been demonstrated to occlude arterial flow and avoid narrow, elastic, or bungee-

type devices; Utilize improvised tourniquets only if no commercial device is available; Do not

release a properly applied tourniquet until the patient reaches definitive care

# Apply a topical hemostatic agent, in combination with direct pressure, for wounds in anatomic

areas where tourniquets cannot be applied and sustained direct pressure alone is ineffective or

impractical; Only apply topical hemostatic agents in a gauze format that support wound packing;

Only utilize topical hemostatic agents which have been determined to be effective and safe in a

standardized laboratory injury model

Source: Bulger et al. 2014

References

1. Bedri H, Ayoub H, Engelbart J, Lilienthal M, Galet C, Skeete D. Tourniquet application for

bleeding control in a rural trauma system: outcomes and implications for prehospital

providers. Prehos Emerg Care. 2021; DOI: 10.1080/10903127.2020.1868635

2. Bulger E et al. An evidence-based prehospital guideline for external hemorrhage control:

American College of Surgeons Committee on Trauma. Prehosp Emerg Care. 2014;18(2):163–73

3. Charlton NP, et al. Pediatric Tourniquet Types: First Aid New TF SR. CoSTR.ILCOR.org

[Internet]. Available from: https://costr.ilcor.org/document/pediatric-tourniquet-types-first-

aid-new-tf-sr. Accessed March 11, 2022

4. Cornelissen M, Brandwijk A, Schoonmade L, Giannakopoulos G, van Oostendorp S, Geeraedts

L. The safety and efficacy of improvised tourniquet in life-threatening hemorrhage: A

systematic review. European Journal of Trauma and Emergency Surgery. 2020; 46:531–538

5. Cunningham A, Auerbach M, Cicero M, Jafri M. Tourniquet usage in prehospital care and

resuscitation of pediatric trauma patients – Pediatric Trauma Society position statement. J

Trauma Acute Care Surg. 2018;85(4):665–667

6. Doyle G, Taillac P. Tourniquets: a review of current use with proposals for expanded

prehospital use. Prehosp Emerg Care. 2008;12(2):241–56

7. Kelly JR, Levy MJ, Reyes J, Anders J. Effectiveness of the combat application tourniquet for

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arterial occlusion in young children. JTACS. 2020;88(5):644–647

8. Kragh J, Littrel ML, Jones JA, et al. Battle casualty survival with emergency tourniquet use to

stop limb bleeding. J Emerg Med. 2011;41(6):590–7

9. Leonard J, Aietlow J, Morris D, et al. A multi-institutional study of hemostatic gauze and

tourniquets in rural civilian trauma. J Trauma Acute Care Surg. 2016;81(3):441–4

10. Mawhinney A and Kirk S. A systematic review of the use of tourniquets and topical

haemostatic agents in conflicts in Afghanistan and Iraq. J R Nav Med Serv. 2015;101(2):147–54

11. Meusnier J, Dewar C, Mavrovi E, et al. Evaluation of two junctional tourniquets used on the

battlefield: Combat Ready Clamp® versus SAM® Junctional Tourniquet. J Spec Oper Med. 2016;

16:41–6

12. Peng H. Hemostatic agents for prehospital hemorrhage control: a narrative review. Military

Med Res. 2020; 7:13. DOI: 10.1186/x40779-020-00241

13. Prehospital Trauma Life Support, 9th Edition. Burlington, MA: Jones & Bartlett; 2021

14. Snyder CL. Bleeding Children. Pediatrics. May 2019;143(5):1–2

15. Snyder D, Schoelles K. Efficacy of prehospital application of tourniquets and hemostatic

dressings to control traumatic external hemorrhage [Internet]. National Highway Traffic

Safety Administration. Retrieved from: https://www.ems.gov/pdf/research/Studies-and-

Reports/Prehospital_Applications_Of_Tourniquest_And_Hemostatic_Dressings.pdf. Accessed

March 11, 2022

16. Van Oostendorp S, Tan E, Geeraedts L. Prehospital control of life-threatening truncal and

junctional haemorrhage is the ultimate challenge in optimizing trauma care: a review of

treatment options and their applicability in the civilian trauma setting. Scand J Trauma Resusc

Emerg Med. 2016;24(1):110

17. Watters J, Van P, Hamilton G, et al. Advanced hemostatic dressings are not superior to gauze

for care under fire scenarios. J Trauma. 2011;70(6):1413–9

Revision Date

March 11, 2022

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Facial/Dental Trauma

Aliases

None noted

Patient Care Goals

1. Preservation of a patent airway

2. Preservation of vision

3. Preservation of dentition

Patient Presentation

Inclusion Criteria

Isolated facial injury, including trauma to the eyes, nose, ears, midface, mandible, dentition

Exclusion Criteria

1. General Trauma [See General Trauma Management Guideline]

2. Burn trauma [See Burns Guideline]

Patient Management

Assessment

1. Overall trauma assessment

2. ABCs (Airway, Breathing, Circulation) with particular focus on ability to keep airway patent

a. Stable midface

b. Stable mandible

c. Stable dentition (poorly anchored teeth require vigilance for possible aspiration)

3. Bleeding (which may be severe – epistaxis, oral trauma, facial lacerations)

4. Patient medications with focus on blood thinners/anti-platelet agents

5. Cervical spine pain or tenderness [See Spinal Care Guideline]

6. Mental status assessment for possible traumatic brain injury [See Head Injury Guideline]

7. Gross vision assessment

8. Dental avulsions

9. Any tissue or teeth avulsed should be collected, if possible

10. Specific re-examination geared toward airway and ability to ventilate adequately

Treatment and Interventions

1. Administer oxygen as appropriate with a target of achieving 94–98% saturation. Use EtCO

help monitor for hypoventilation and apnea

2. IV access, as needed, for fluid or medication administration

3. Pain medication per the Pain Management Guideline

4. Avulsed tooth:

a. Avoid touching the root of the avulsed tooth. Do not wipe off tooth

b. Pick up at crown end. If dirty, rinse off under cold water for 10 seconds

c. Place in milk or saline as the storage medium. Alternatively, an alert and cooperative

patient can hold tooth in mouth using own saliva as storage medium

5. Eye trauma:

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a. Place eye shield for any significant eye trauma

b. If globe is avulsed or enucleated, do not put back into socket. Cover eye socket with moist

saline dressings and then place eye shield over it

6. Mandible unstable:

a. Expect patient cannot spit/swallow effectively and have suction readily available

b. Preferentially transport sitting up with emesis basin/suction available (in the absence of a

suspected spinal injury.) [See Spinal Care Guideline]

7. Epistaxis: squeeze nose (or have patient do so) for 10–15 minutes continuously

8. Nose/ear avulsion:

a. Recover tissue, if possible

b. Transport with tissue wrapped in dry sterile gauze in a plastic bag placed on ice

c. Severe ear and nose lacerations can be addressed with a protective moist sterile dressing

Patient Safety Considerations

1. Frequent reassessment of airway

2. Maintenance of a patent airway is the highest priority; therefore, conduct cervical spine

assessment for field clearance (per Spinal Care Guideline) to enable transport sitting up for

difficulty with bleeding, swallowing, or handling secretions

Notes/Educational Pearls

Key Considerations

1. Airway may be compromised because of fractures or bleeding

2. Lost teeth not recovered on scene may be in the airway

3. After nasal fractures, epistaxis may be posterior and may not respond to direct pressure over

the nares with bleeding running down posterior pharynx, potentially compromising airway

4. Protect avulsed tissue and teeth

a. Avulsed teeth may be successfully re-implanted if done so in a very short period after

injury

b. Use moist sterile dressing for ear and nose cartilage

5. For penetrating eye injuries, do not remove foreign bodies. Splint in place. Cover uninjured

eye or ask patient to close eye to prevent conjugate movement of injured eye

6. Consider administration of antiemetics to prevent increases in intraocular pressure due to

nausea and vomiting in penetrating and blunt trauma to the eye [See Nausea - Vomiting

Guideline]

Pertinent Assessment Findings

1. Unstable facial fractures that can abruptly compromise airway

2. Loose teeth and retro-pharynx bleeding

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914057 – Injury - Facial Trauma

•

9914099 – Injury - Eye

•

9914205 – General - Dental Problems

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Key Documentation Elements

• Airway patency and reassessment

• Degree and location of hemorrhage

• Mental status (GCS or AVPU)

• Technique used to transport tissue or teeth

• Eye exam documented, when applicable

• Assessment and management of cervical spine

• Patient use of anticoagulant medications

Performance Measures

• Appropriate airway management and satisfactory oxygenation

• Eye shield applied to eye trauma

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

1. Bord S, Linden J. Trauma to the globe and orbit. Emerg Med Clin N Am. 2008;26(1):97–123

2. Mordini L, Lee P, Lazaro R, Biagi R, Gianetti L. Sport and dental traumatology: Surgical

solutions and prevention. Dent J (Basel) 2021;9(3):33

3. Patel P, Stanton D, Granquist E. Common dental and orofacial trauma: evaluation and

management. Med Clin N Am. 2014;98(6):1261–79

Revision Date

March 11, 2022

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Head Injury

Aliases

None noted

Patient Care Goals

1. Limit disability and mortality from head injury by limiting secondary brain injury through

a. Promoting adequate oxygenation and preoxygenating to protect against unanticipated

deterioration

b. Promoting good cerebral perfusion and avoid hypotension

c. Preventing hypocapnia (by avoiding hyperventilation and overventilation)

Patient Presentation

Inclusion Criteria

Adult or pediatric patient with blunt or penetrating head injury – loss of consciousness or amnesia

not required

Exclusion Criteria

None noted

Patient Management

Assessment

1. Maintain cervical stabilization [See Spinal Care Guideline]

2. Primary survey per the General Trauma Management Guideline

3. Monitoring:

a. Continuous pulse oximetry

b. Frequent systolic and diastolic blood pressure measurement

c. Initial neurologic status assessment [See Appendix VII. Neurologic Status Assessment] and

reassessment with any change in mentation

d. Moderate/severe head injury: apply continuous waveform EtCO

, if available

4. Secondary survey pertinent to isolated head injury:

a. Head: Gently palpate skull to evaluate for depressed or open skull fracture

b. Eyes:

i. Evaluate pupil size and reaction to light to establish baseline

ii. Reassess pupils if decrease in mentation

c. Nose/mouth/ears: evaluate for blood/fluid drainage

d. Face: evaluate for bony stability

e. Neck: palpate for cervical spine tenderness or deformity

f. Neurologic:

i. Perform neurologic status assessment (GCS or AVPU)

ii. Evaluate for focal neurologic deficit: motor and sensory

Treatment and Interventions

NOTE: These are not necessarily the order they are to be done, but are grouped by conceptual areas

1. Airway:

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a. Administer high-flow oxygen via NRB (non-rebreather) as a precaution against

unanticipated deterioration

b. If patient unable to maintain airway, consider oral airway (nasal airway should not be used

with significant facial injury or possible basilar skull fracture)

c. BVM (bag-valve-mask) ventilation if high flow oxygen (HFO)/non-rebreather (NRB)

inadequate to maintain good airway and/or oxygenation

d. Place supraglottic airway or perform endotracheal intubation or if BVM ventilation

ineffective in maintaining oxygenation or if airway is continually compromised.

Endotracheal intubation (ETI)/supraglottic airway (SGA) should only be used in systems

that have continuous EtCO

monitoring

2. Breathing:

a. For patients who cannot maintain adequate oxygenation with HFO/NRB, BVM ventilation

(15 years old or older: 10 breaths per minute; 2–14 years old: 20 breaths per minute; less

than 2 years old: 25 breaths per minute) with gentle manual bagging. Consider flow-

controlled bags and ventilation rate timers to help prevent hyper-/overventilation

b. SGA placement or ETI should only be performed if BVM ventilation fails to maintain

adequate oxygenation. With advanced airways, manage with a target EtCO

of 40 (normal

range 35–45 mmHg)

c. Do not induce hypocapnia through hyper-/overventilation

3. Circulation:

a. Wound care

i. Control bleeding with direct pressure if no suspected open skull injury

ii. Moist sterile dressing to any potential open skull wound

iii. Cover an injured eye with moist saline dressing and place cup over it

b. Moderate/severe closed head injury

i. Blood pressure: avoid hypotension

1. Adult (age greater than 10 years): maintain SBP greater than or equal to 110

mmHg

2. Pediatric: maintain SBP:

a. Age less than 1 month: greater than 60 mmHg

b. Age 1–12 months: greater than 70 mmHg

c. Age 1–10 years: greater than 70 + 2x age in years

c. Closed head injury

i. Administer normal saline (NS)/lactated Ringer’s (LR) fluid boluses to maintain SBP

above threshold. Do not wait until after the patient is already hypotensive—prevent

hypotension

d. Do not delay transport to initiate IV access

4. Disability:

a. Evaluate for other causes of altered mental status — check blood glucose during transport

b. Spinal assessment and management, per Spinal Care Guideline

c. Perform and trend neurologic status assessment (GCS or AVPU scale)

i. Early signs of deterioration:

1. Confusion

2. Agitation

3. Drowsiness

4. Vomiting

5. Severe headache

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d. Severe head injury – Elevate head of bed 30 degrees

5. Transport destination specific to head trauma

a. Preferential transport to highest level of care within trauma system:

i. GCS 3–13, P (pain) or U (unresponsive) on AVPU scale

ii. Penetrating head trauma

iii. Open or depressed skull fracture

Patient Safety Considerations

1. Do not hyperventilate patients: Maintain all patients in EtCO

range of 35–45 mmHg

2. Assume concomitant cervical spine injury in patients with moderate/severe head injury

3. Geriatric Consideration: Elderly patients with ankylosing spondylitis or severe kyphosis should

be padded and immobilized in a position of comfort and may not tolerate a cervical collar

4. Pediatric Consideration: Children have disproportionately larger heads. When securing

pediatric patients to a spine board, the board should have a recess for the head, or the body

should be elevated approximately 1–2 cm to accommodate the larger head size and avoid

neck flexion when immobilized

Notes/Educational Pearls

Key Considerations

1. Head injury severity guideline:

a. Mild: GCS 14–15/AVPU = (A)

b. Moderate: GCS 9–13/AVPU = (V)

c. Severe: GCS 3–8/AVPU = (P) or (U)

2. Important that clinicians be specifically trained in accurate neurologic status assessment [See

Appendix VII. Neurologic Status Assessment]

3. If endotracheal intubation or invasive airways are used, continuous waveform capnography is

required to document proper tube placement and assure proper ventilation rate and minute

volume (preventing both hyperventilation [too fast] and overventilation [too much])

4. Herniation is difficult to diagnose in the prehospital setting. Hyperventilation results in

vasoconstriction which further decreases blood flow to the brain and worsens the secondary

brain injury.

Pertinent Assessment Findings

1. Neurologic status assessment findings

2. Pupils

3. Trauma findings on physical exam

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914101 – Injury - Head

Key Documentation Elements

• High-flow oxygen with non-rebreather (NRB) mask

• Airway status and management

• EtCO

monitored and documented for all traumatic brain injury (TBI) patients with advanced

airway and strict avoidance of hyperventilation, overventilation, and hypocapnia)

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• Neurological status with vitals: AVPU, GCS

• Exams: Neurological and Mental Status Assessment pre- and post-treatment

Performance Measures

• No oxygen desaturation less than 90%

• No hypotension:

o Adults: less than 110 mmHg

o Pediatrics:

▪ Age less than 1 month: less than 60 mmHg

▪ Age 1–12 months: less than 70 mmHg

▪ Age 1–10 years: less than 70 + 2x age in years

• Assess the patient’s blood pressure prior to the administration of any medication that may

cause hypotension.

• EtCO

target 40 mmHg (range 35–45 mmHg). Meticulous prevention of hypocapnia in all

patients

• Triage to the appropriate level hospital within the local trauma system

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

1. Ambrosi PB, Valença MM, Azevedo-Filho H. Prognostic factors in civilian gunshot wounds

to the head: a series of 110 surgical patients and brief literature review. Neurosurg Rev.

2012;35(3):429–35; discussion 435–6

2. Badjatia N, Carney N, Crocco TJ, et al; Brain Trauma Foundation; BTF Center for Guidelines

Management. Guidelines for prehospital management of traumatic brain injury 2

edition. Prehosp Emerg Care. 2008;12 Suppl 1: S1–52

3. Berlot G, La Fata C, Bacer B, et al. Influence of prehospital treatment on the outcome of

patients with severe blunt traumatic brain injury: a single-centre study. Eur J Emerg Med.

2009;16(6):312–17

4. Davis DP, Koprowicz KM, Newgard CD, et al. The relationship between out-of-hospital

airway management and outcome among trauma patients with Glasgow Coma Scale

scores of 8 or less. Prehosp Emerg Care. 2011;15(2):184–92

5. Dumont TM, Visioni AJ, Rughani AI, Tranmer BI, Crookes B. Inappropriate prehospital

ventilation in severe traumatic brain injury increases in-hospital mortality. J Neurotrauma.

2010 Jul;27(7):233–41

6. Franschman G, Peerdeman SM, Andriessen TM, et al; Amsterdam Lifeliner: Analysis of

Results and Methods--Traumatic Brain Injury (ALARM-TBI) Investigators. Effect of

secondary prehospital risk factors on outcome in severe traumatic brain injury in the

context of fast access to trauma care. J Trauma. 2011;71(4):826–32

7. Gaither JB, Spaite DW, Bobrow BJ, et al: Impact of Implementing the Prehospital

Traumatic Brain Injury Treatment Guidelines: The Excellence In Prehospital Injury Care for

Children (EPIC4Kids) Study. Ann Emerg Med. 2021:77(2):139–153. DOI:

10.1016/j.annemergmed.2020.09.435. NIH Manuscript System ID: NIHMSID:1654418;

PubMed PMID:33187749

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8. Haut ER, Kalish BT, Cotton BA, et al. Prehospital intravenous fluid administration is

associated with higher mortality in trauma patients: a National Trauma Data Bank

analysis. Ann Surg. 2011;253(2):371–7

9. Jagoda AS, Bazarian JJ, Bruns JJ Jr, et al; American College of Emergency Physicians;

Centers for Disease Control and Prevention. Clinical policy: neuroimaging and decision

making in adult mild traumatic brain injury in the acute setting. Ann Emerg Med.

2008;52(6):714–48

10. Kleinman ME, Chameides L, Schexnayder SM, et al. Part 14: pediatric advanced life

support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation

and emergency cardiovascular care. Circulation. 2010;122: S876–908

11. Reed D. Adult Trauma Clinical Practice Guidelines: Initial Management of Closed Head

Injury in Adults: 2

Edition. New South Wales Institute of Trauma and Injury Management;

2011

12. Roberts I, Schierhout G. Hyperventilation therapy for acute traumatic brain injury.

Cochrane Database Syst Rev. 1997;(4):CD000566

13. Spaite DW, Bobrow BJ, Keim SM, et al: Association of Statewide Implementation of the

Prehospital Traumatic Brain Injury Treatment Guidelines With Patient Survival Following

Traumatic Brain Injury: The Excellence In Prehospital Injury Care (EPIC) Study. JAMA Surg.

2019;154(7): e191152. doi:10.1001/jamasurg.2019.1152. NIH Manuscript System ID:

NIHMSID: 1663161; PubMed PMID: 31066879; PMCID: PMC6506902

14. Stocchetti N, Maas AIR, Chieregato A, van der Plas AA. Hyperventilation in head injury a

review. Chest. 2005;127(5):1812–27

15. Zebrack M, Dandoy C, Hansen K, Scaife E, Mann NC, Bratton SL. Early resuscitation of

children with moderate-to-severe traumatic brain injury. Pediatrics. 2009;124(1):56–64

Revision Date

March 11, 2022

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High Threat Considerations/Active Shooter Scenario

Aliases

None noted

Definitions

• Hot Zone/Direct Threat Zone: an area within the inner perimeter where active threat and

active hazards exists.

• Warm Zone/Indirect Threat Zone: an area within the inner perimeter where security and

safety measures are in place. This zone may have potential hazards, but no active hazards

exist.

Patient Care Goals

1. Assess scene

2. Mitigating further harm

3. Accomplish mission with minimal additional injuries

Patient Presentation

Inclusion Criteria

High threat environment – when greater than normal conditions exist that could cause threat to

clinician or patient

Exclusion Criteria

No significant threat exists to clinician or patient allowing for the performance of routine care

Patient Management

Assessment, Treatment, and Interventions

1. Hot Zone/Direct Threat care considerations:

a. Mitigate threat as able to minimize risk to patients and clinicians, move to a safer position

and recognize that threats are dynamic and may be ongoing, requiring continuous

assessment of threat

b. Defer in depth medical interventions if engaged in ongoing direct threat (e.g., active

shooter, unstable building collapse, improvised explosive device, hazardous material

threat)

c. Triage should be deferred to when no longer in a hot zone/direct threat care zone

d. Prioritization for extraction is based on resources available and the situation encountered

e. Encourage patients to provide self-first aid or instruct uninjured bystanders to provide aid

f. Consider hemorrhage control:

i. Tourniquet application is the primary “medical” intervention to be considered in Hot

Zone/Direct Threat Zone. Tourniquet choice should be guided by expected ability to

perform in the desired patient population (pediatrics)

ii. Consider instructing patient to apply direct pressure to the wound if no tourniquet

available (or application is not feasible)

iii. Consider quickly placing or directing patient to be placed in position to protect airway,

if not immediately moving patient

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2. Warm Zone/Indirect Threat care considerations:

a. Maintain situational awareness

b. Ensure safety of both responders and patients by rendering equipment and environment

safe (firearms, vehicle ignition)

c. Conduct primary survey, per the General Trauma Management Guideline, and initiate

appropriate life-saving interventions

i. Hemorrhage control

1. Tourniquet

2. Wound packing if feasible

ii. Maintain airway and support ventilation [See Airway Management Guideline]

d. Maintain body temperature and prevent hypothermia

e. Do not delay patient extraction and evacuation for non-life-saving interventions

f. Consider establishing a casualty collection point if multiple patients are encountered

g. Unless in a fixed casualty collection point, triage in this phase of care should be limited to

the following categories:

i. Uninjured and/or capable of self-extraction

ii. Deceased/expectant

iii. All others

Patient Safety Considerations

1. Anticipate unique threats based on situation

2. During high threat situations, clinician safety should be considered in balancing the risks and

benefits of patient treatment

Notes/Educational Pearls

Key Considerations

1. In high threat situations clinician and patient safety will need to be simultaneously considered

2. During high threat situations, an integrated response with other public safety entities may be

warranted

3. Risks taken and threats to responder safety must be weighed in relations to the expected

benefit to patient safety and outcome

4. During these situations, maintaining communications and incident management concepts may

be crucial to maximizing efficiency and mitigating dangers

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

None noted

Key Documentation Elements

• Traditional documentation may not be appropriate during Hot Zone/Direct Threat and Warm

Zone/Indirect Threat care

• Documentation of key intervention should be relayed:

o Time of tourniquet application

o GCS for patients with suspected head injury

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References

1. Callaway DW, Smith ER, Cain J, et al. The Committee for Tactical Emergency Casualty Care (C-

TECC): evolution and application of TCCC guidelines to civilian high threat medicine. J Spec

Oper Med. 2011;11(3):104–122

2. Hartford Consensus. Facs.org. https://www.facs.org/about-acs/hartford-consensus. Accessed

March 11, 2022

3. Kelly JR, Levy MJ, Reyes J, Anders J. Effectiveness of the combat application tourniquet for

arterial occlusion in young children. J Trauma Acute Care Surg. 2020 May;88(5):644–647

4. TCCC-MP Guidelines and Curriculum. NAEMT.org http://www.naemt.org/education/TCCC/

guidelines_curriculum. Accessed March 11, 2022

5. TECC Guidelines. C-TECC.org. https://www.c-tecc.org/images/content/TECC_Guidelines_-

_JUNE_2015_update.pdf. Committee for Tactical Emergency Casualty Care. Accessed March

11, 2022

Revision Date

March 11, 2022

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Spinal Care

(Adapted from an evidence-based guideline created using the National Prehospital Evidence-Based

Guideline Model Process)

Aliases

None noted

Patient Care Goals

1. Select patients for whom spinal motion restriction (SMR) is indicated

2. Minimize secondary injury to spine in patients who have, or may have, an unstable spinal

injury

3. Minimize patient morbidity from the unnecessary use of immobilization devices

Patient Presentation

Inclusion criteria

Traumatic mechanism of injury

Exclusion criteria

None noted

Patient Management

Assessment

1. Assess the scene to determine the mechanism of injury

a. Mechanism alone should not determine if a patient requires spinal motion restriction –

however, mechanisms that have been associated with a higher risk of injury are:

i. Motor vehicle crashes (including automobiles, all-terrain vehicles, and snowmobiles)

ii. Axial loading injuries to the spine

iii. Falls greater than 10 feet

2. Assess the patient in the position found for findings associated with spine injury:

a. Mental status

b. Neurologic deficits

c. Spinal pain or tenderness

d. Any evidence of intoxication

e. Other severe injuries, particularly associated torso injuries

Treatment and Interventions

1. Place patient in cervical collar and initiate spinal motion restriction in adults if there are any of

the following:

a. Patient complains of midline neck or spine pain

b. Any midline neck or spinal tenderness with palpation

c. Any abnormal mental status (including extreme agitation)

d. Focal or neurologic deficit

e. Any evidence of alcohol or drug intoxication

f. Another severe or painful distracting injury

g. Torticollis in children

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h. A communication barrier that prevents accurate assessment

i. If none of the above apply, patient may be managed without a cervical collar

2. Patients with penetrating injury to the neck should not be placed in a cervical collar or other

spinal precautions regardless of whether they are exhibiting neurologic symptoms or not.

Doing so can lead to delayed identification of injury or airway compromise and has been

associated with increased mortality

3. If extrication is required:

a. From a vehicle: After placing a cervical collar, if indicated, children in a booster seat and

adults should be allowed to self-extricate. For infants and toddlers already strapped in a

car seat with a built-in harness, extricate the child while strapped in his/her car seat

b. Other situations requiring extrication: A, preferably padded, long board may be used for

extrication, using the lift and slide (rather than a logroll) technique

4. Helmet removal

a. If a football helmet needs to be removed, it is recommended to remove the face mask

followed by manual removal (rather than the use of automated devices) of the helmet

while keeping the neck manually immobilized — occipital and shoulder padding should be

applied, as needed, with the patient in a supine position to maintain neutral cervical spine

positioning

b. Evidence is lacking to provide guidance about other types of helmet removal

5. Do not transport patients on rigid long boards unless the clinical situation warrants long board

use. An example of this may be facilitation of immobilization of multiple extremity injuries or

an unstable patient where removal of a board will delay transport and/or other treatment

priorities. In these situations, long boards should ideally be padded or have a vacuum mattress

applied to minimize secondary injury to the patient

6. Patients should be transported to the nearest appropriate facility, in accordance with the

American College of Surgeons Committee on Trauma (ACS COT) 2022 National Guideline for

the Field Triage of Injured Patients

7. Patients with severe kyphosis or ankylosing spondylitis may not tolerate a cervical collar.

These patients should be immobilized in a position of comfort using towel rolls or sandbags

Patient Safety Considerations

1. Be aware of potential airway compromise or aspiration in immobilized patient with

nausea/vomiting or with facial/oral bleeding

2. Excessively tight immobilization straps can limit chest excursion and cause hypoventilation

3. Prolonged immobilization on spine board can lead to ischemic pressure injuries to skin

4. Prolonged immobilization on spine board can be very uncomfortable for patient

5. Children are abdominal breathers therefore immobilization straps should go across chest and

pelvis and not across the abdomen

6. Children have disproportionately larger heads. When securing pediatric patients to a spine

board, the board should have a recess for the head or the body should be elevated

approximately 1–2 cm to accommodate the larger head size and avoid neck flexion when

immobilized

7. In an uncooperative patient, avoid interventions that may promote increased spinal

movement

8. The preferred position for all patients with spine management is flat and supine. There are

three circumstances under which raising the head of the bed to 30 degrees may be

considered:

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a. Respiratory distress

b. Suspected severe head trauma

c. Promotion of patient compliance

Notes/Educational Pearls

Key Considerations

1. Evidence is lacking to support or to refute the use of manual stabilization prior to spinal

assessment in the setting of a possible traumatic injury when the patient is alert with

spontaneous head/neck movement. Clinicians should not manually stabilize these alerts and

spontaneously moving patients since patients with pain will self-limit movement and forcing

immobilization in this scenario may unnecessarily increase discomfort and anxiety

2. Certain populations with musculoskeletal instability may be predisposed to cervical spine

injury. However, evidence does not support or refute that these patients should be treated

differently than those who do not have these conditions. These patients should be treated

according to the Spinal Care Guideline like other patients without these conditions

3. Pediatric considerations:

a. Age alone should not be a factor in decision-making for prehospital spine care, yet the

patient’s ability to reliably be assessed at the extremes of age should be considered.

Communication barriers with infants/toddlers or elderly patients with dementia may

prevent the clinician from accurately assessing the patient

b. There is no evidence that children experience non-contiguous multilevel injuries. The

existing evidence suggests that the rate of contiguous multilevel injuries is exceedingly low

at 1%

c. Because of variation in head size to body ratio, consider additional padding under the

shoulders to avoid excessive cervical spine flexion

4. Spinal precautions should be considered a treatment or preventive therapy

5. Patients who are likely to benefit from immobilization should undergo this treatment

6. Patients who are not likely to benefit from immobilization, who have a low likelihood of spinal

injury, should not be immobilized

7. Ambulatory patients may be safely immobilized on gurney with cervical collar and straps and

will not generally require a spine board. The role for standing take downs is extremely limited,

e.g., extrication of a patient with a high likelihood of a spinal cord injury from a large body of

water. Ambulatory patients may have a collar applied and walked to the EMS gurney

8. Reserve long spine board use for the movement of patients whose injuries limit ambulation

and who meet criteria for the use of spinal precautions. Remove from the long board as soon

as is practical

Pertinent Assessment Findings

1. Mental status

2. Normal neurologic examination

3. Evidence of intoxication

4. Evidence of multiple traumas with other severe injuries

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914073 – General - Spinal Precautions/Clearance

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•

9914107 – Injury - Spinal Cord

Key Documentation Elements

• Patient complaint of neck or spine pain

• Spinal tenderness

• Mental status/GCS

• Neurologic examination

• Evidence of intoxication

• Documentation of multiple trauma

• Documentation of mechanism of injury

• Document patient capacity with:

o All barriers to patient care in the NEMSIS element “Barriers to Patient Care”

(eHistory.01—required of all software systems)

o Exam fields for Mental Status and Neurological Assessment

o Vitals for Level of Responsiveness and Glasgow Coma Scale

o Alcohol and drug use indicators

• Patient age

• Patient who is underage and not emancipated: legal guardian name, contact, and relationship

Performance Measures

• Percentage of patients with high-risk mechanisms of injury and/or signs or symptoms of

cervical spine injury who are placed in a cervical collar

• Percentage of patients without known trauma who have a cervical immobilization device

placed (higher percentage creates a negative aspect of care)

• Percentage of trauma patients who are transported on a long backboard (target is a low

percentage)

• Percentage of patients with a cervical spinal cord injury or unstable cervical fracture who did

not receive cervical collar

• National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

o Pediatrics—03: Documentation of Estimated Weight in Kilograms

o Trauma—01: Pain Assessment of Injured Patients

References

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transport team and ED staff regarding the prehospital assessment of air medically evacuated

scene patients. Air Med J. 2006;25(4):165–9

6. Brown JB, Bankey PE, Sangosanya AT, Cheng JD, Stassen NA, Gestring ML. Prehospital spinal

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7. Bureau of Emergency Medical Services. State of New Hampshire Patient Care Protocols.

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8. Burton JH, Dunn MG, Harmon NR, Hermanson TA, Bradshaw JR. A statewide, prehospital

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14. Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury.

1996;27(9):647–9

15. Decoster LC, Burns MF, Swartz EE, et al. Maintaining neutral sagittal cervical alignment after

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2012;37(8):654–9

16. Del Rossi G, Heffernan TP, Horodyski M, Rechtine GR. The effectiveness of extrication collars

tested during the execution of spine-board transfer techniques. Spine J. 2004;4(6):619–23

17. Del Rossi G, Horodyski MH, Conrad BP, Di Paola CP, Di Paola MJ, Rechtine GR. The 6-plus-

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18. Del Rossi G, Horodyski M, Conrad BP, Dipaola CP, Dipaola MJ, Rechtine GR. Transferring

patients with thoracolumbar spinal instability: Are there alternatives to the log roll maneuver?

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19. Del Rossi G, Rechtine GR, Conrad BP, Horodyski M. Are scoop stretchers suitable for use on

spine-injured patients? Am J Emerg Med, 2010 28(7), 751–756

20. Dixon, M, O'Halloran J, Cummins NM. Biomechanical analysis of spinal immobilisation during

prehospital extrication: a proof of concept study. Emerg Med J. 2014;31(9):745–9

21. Domeier RM, Frederiksen SM, Welch K. Prospective performance assessment of an out-of-

hospital protocol for selective spine immobilization using clinical spine clearance criteria. Ann

Emerg Med. 2005;46(2):123–31

22. Domeier RM, Swor RA, Evans RW, et al. Multicenter prospective validation of prehospital

clinical spinal clearance criteria. J Trauma. 2002;53(4):744–50

23. Edlich RF, Mason SS, Vissers RJ, et al. Revolutionary advances in enhancing patient comfort on

patients transported on a backboard. Am J Emerg Med. 2011;29(2):181–6

24. Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine

motion during extrication. J Emerg Med. 2013;44(1):122–7

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25. Hale DF, Fitzpatrick CM, Doski JJ, et al. Absence of clinical findings reliably excludes unstable

cervical spine injuries in children 5 years or younger. J Trauma Acute Care Surg. 2015; 78:943–

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27. Hauswald M, Hsu M, Stockoff C. Maximizing comfort and minimizing ischemia: a comparison

of four methods of spinal immobilization. Prehosp Emerg Care. 2000;4(3):250–2

28. Hauswald M, Ong G, Tandberg D, Omar Z. Out-of-hospital spinal immobilization: its effect on

neurologic injury. Acad Emerg Med. 1998;5(3):214–9

29. Haut ER, Kalish BT, Efron DT, et al. Spine immobilization in penetrating trauma: More harm

than good? J Trauma. 2010;68(1):115–20; discussion 120–1

30. Hemmes B, Poeze M, Brink PR. Reduced tissue-interface pressure and increased comfort on a

newly developed soft-layered long spineboard. J Trauma. 2010;68(3):593–8

31. Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI. Validity of a set of clinical criteria to

rule out injury to the cervical spine in patients with blunt trauma. National Emergency X-

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32. Hostler D, Colburn D, Seitz SR. A comparison of three cervical immobilization devices. Prehosp

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33. Huerta C, Griffith R, Joyce SM. Cervical spine stabilization in pediatric patients: evaluation of

current techniques. Ann Emerg Med. 1987;16(10):1121–6

34. Kim EG, Brown KM, Leonard JC, Jaffe DM, Olsen CS, Kuppermann N. Variability of prehospital

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35. Kolb JC, Summers RL, Galli RL. Cervical collar-induced changes in intracranial pressure. Am J

Emerg Med. 1999;17(2):135–7

36. Kwan I, Bunn F. Effects of prehospital spinal immobilization: a systematic review of

randomized trials on healthy subjects. Prehosp Disaster Med. 2005;20(1):47–53

37. Leonard JC, Mao J, Jaffe DM. Potential adverse effects of spinal immobilization in children.

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38. Leonard JC, Kuppermann N, Olsen C, et al. Factors associated with cervical spine injury in

children after blunt trauma. Ann Emerg Med. 2011;58(2):145–55

39. Leonard JC, Kuppermann N, Olsen C, Babcock-Cimpello L, Brown K, Mahajan P, et al. Factors

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40. Leonard JC, Jaffe DM, Olsen CS, Kuppermann N. Age- related differences in factors associated

with cervical spine injuries in children. Acad Emerg Med. 2015; 22:1–6

41. Leonard JR, Jaffe DM, Kuppermann N, Olsen C, Leonard JC. Cervical spine injury patterns in

children. Pediatrics. 2014:133(5): e1179–e1188

42. Lin HL, Lee WC, Chen CW, et al. Neck collar used in treatment of victims of urban motorcycle

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43. Lovell ME, Evans JH. A comparison of the spinal board and the vacuum stretcher, spinal

stability and interface pressure. Injury. 1994;25(3):179–80

44. Luscombe MD, Williams, JL. Comparison of a long spinal board and vacuum mattress for spinal

immobilisation. Emerg Med J. 2003;20(5):476–8

45. March JA, Ausband SC, Brown, LH. Changes in physical examination caused by use of spinal

immobilization. Prehosp Emerg Care. 2002;6(4):421–4

46. McGuire RA, Degnan G, Amundson GM. Evaluation of current extrication orthoses in

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immobilization of the unstable cervical spine. Spine (Phila Pa 1976). 1990;15(10):1064–7

47. Mohseni S, Talving P, Branco BC, et al. Effect of age on cervical spine injury in pediatric

population: a National Trauma Data Bank review. J Pediatr Surg. 2011;46(9):1771–6

48. National Association of EMS Physicians/American College of Surgeons Committee on Trauma.

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Emerg Care. 2013; 17:392–3

49. Nypaver M, Treloar D. Neutral cervical spine positioning in children. Ann Emerg Med.

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population: a systematic review of the literature. J Neurotrauma. 2011;28(8):1515–24

52. Peery CA, Brice J, White WD. Prehospital spinal immobilization and the backboard quality

assessment study. Prehosp Emerg Care. 2007;11(3):293–7

53. Pieretti-Vanmarcke R, Velmahos GC, Nance ML, et al. Clinical clearance of the cervical spine in

blunt trauma patients younger than 3 years: a multi-center study of the American Association

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57. Rhee P, Kuncir EJ, Johnson L, et al. Cervical spine injury is highly dependent on the mechanism

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58. Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory

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60. Shah MI, Kamin R, Freire J, Jaeger E, Lobo C, Sholl JM. An evidence-based guideline for

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Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg.

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emergency removal of football helmets using two techniques. Prehosp Emerg Care.

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65. Theodore N, Hadley MN, Aarabi B, et al. Prehospital cervical spinal immobilization after

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Spine Rule by paramedics. Ann Emerg Med. 2009;54(5):663-71. e1

67. Vanderlan WB, Tew BE, McSwain NE Jr. Increased risk of death with cervical spine

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immobilisation in penetrating cervical trauma. Injury. 2009;40(8):880–3

68. Vanderlan WB, Tew BE, Seguin CY, et al. Neurologic sequelae of penetrating cervical trauma.

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69. Velopulos, C. G., Shihab, H. M., Lottenberg, L., Feinman, M., Raja, A., Salomone, J., & Haut, E.

R. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice

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of Trauma and Acute Care Surgery, 2018, 84(5), 736-744.

70. Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR. A prospective

multicenter study of cervical spine injury in children. Pediatrics. 2001;108(2): e20

71. Werman HA, White LJ, Herron H, et al. Clinical clearance of spinal immobilization in the air

medical environment: a feasibility study. J Trauma. 2008;64(6):1539–42

72. White CC IV, Domeier RM, Millin MG. EMS spinal precautions and the use of the long

backboard – resource document to the position statement of the National Association of EMS

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2013; 17:392–3

73. White CC, Domeier RM, Millin MG. EMS spinal precautions and the use of the long

backboard—resource document to the position statement of the National Association of EMS

Physicians and the American College of Surgeons Committee on Trauma. Prehosp Emerg Care.

2014;18(2):306–314

Revision Date

March 11, 2022

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Trauma Mass Casualty Incident

Aliases

Disaster

Mass casualty incident (MCI)

Trauma triage for multiple casualties overwhelming EMS resources

Patient Care Goals

1. Save life and limb for greatest number given resources available

2. Triage and transport most critical requiring immediate in-hospital care first

Patient Presentation

Inclusion Criteria

Trauma MCI overwhelming immediately available resources

Exclusion Criteria

Routine EMS response for non-MCI for trauma

Patient Management

Special circumstances may occur in any incident in which the resources of the emergency medical services

are overwhelmed by the number and severity of casualties.

Triage and Treat

1. Ensure scene safety for EMS clinicians

2. Senior EMS clinician rapidly assesses scene and assigns roles and responsibilities to EMS

personnel

3. Sort patients using a locally agreed upon MCI triage process such as SALT (Sort, Assess,

Lifesaving Interventions, Treatment/Transport), START/JUMP-START (Simple Triage and Rapid

Transport), MUCC (Model Uniform Core Criteria), etc.

4. Identify those in need of immediate life-saving intervention

5. Triage categories are recommended and should be guided by local protocols: immediate,

delayed, minimal, expectant, dead

6. Triage new patients as identified

7. Re-triage frequently for duration of MCI

8. Immediate life-saving interventions for immediate patients

a. Treat hemorrhage with tourniquets, direct pressure with assistance from other patients or

other devices

b. Ensure patent airway by opening airway and using rapid adjuncts

c. Decompress tension pneumothorax

d. Use autoinjector antidotes if needed

Transport

1. First transport immediate patients

a. Those requiring immediate in-hospital care for life and limb, particularly surgical care

(suspected torso hemorrhage, uncontrollable junctional or extremity hemorrhage)

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b. Those with injuries temporized that required immediate transport (received airway

intervention, decompressed tension pneumothorax, effective tourniquets for extremity

hemorrhage or amputations)

2. Second, transport delayed patients

a. Continue to re-triage continuously

b. Continue life-saving interventions

c. Initiate urgent required therapy

3. Assess minimal patients for appropriate transport decision

Patient Safety Considerations

1. Ensure patients remain in safe area

2. Re-assess scene safety as incident progresses as needed

Notes/Educational Pearls

Key Considerations

1. The most experienced EMS clinician should perform triage.

2. Another experienced EMS clinician should be assigned to immediate patient area and perform

life-saving interventions as well as continuous triage.

3. Prioritize patients within immediate group for transport.

4. If available, another EMS clinician should be assigned to delayed area and perform urgent

interventions if patient condition changes. Continuously triage and prioritize within the

delayed patient group for transport.

5. Patient triage category may change with subsequent triage. If need for up-triage occurs,

perform life-saving interventions, and move patient to appropriate triage area (delayed or

immediate).

6. EMS system leaders within a defined area should work collaboratively to agree upon a

common triage tool.

7. Evidence is limited on the highest performing triage tool. Available evidence suggests that the

SALT triage tool was most likely to correctly triage adult emergency department patients, but

all tested triage tools demonstrated relatively high rates of under triage.

Pertinent Assessment Findings

None noted

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

None noted

Key Documentation Elements

• Document pertinent patient information per local EMS protocol when able and before

transport

Performance Measures

• Rapidly triage, treat and transport immediate life-threatening injuries

• Maintain scene safety for EMS clinicians and patients

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• Continue triage and treat for all patients until relieved, until all patients transported or

dispositioned, and until incident completion

References

1. Courtney H. McKee, Robert W. Heffernan, Brian D. Willenbring, Richard B. Schwartz, J. Marc Liu,

M. Riccardo Colella & E. Brooke Lerner (2020) Comparing the Accuracy of Mass Casualty Triage

Systems When Used in an Adult Population, Prehospital Emergency Care 2019, 24:4, 515–

524, DOI: 10.1080/10903127.2019.1641579

2. Model Uniform Core Criteria for Mass Casualty Triage, Disaster Med Public Health Prep. 2011

Jun;5(2):125–8

3. SALT Mass Casualty Triage Concept Endorsed by the American College of Emergency Physicians,

American College of Surgeons Committee on Trauma, American Trauma Society, National

Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and

Territorial Injury Prevention Directors Association. Disaster Medicine and Public Health

Preparedness. 2008; Vol2(4): 245–6

Revision Date

March 11, 2022

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Toxins and Environmental

Poisoning/Overdose Universal Care

Aliases

Exposure Overdose Poison

Toxin

Patient Care Goal

1. Remove patient from hazardous environment. Decontaminate to remove continued sources

of absorption, ingestion, inhalation, or injection

2. Identify intoxicating agent by toxidrome or appropriate environmental testing

3. Assess risk for organ impairments (heart, brain, kidney)

4. Identify antidote or mitigating agent

5. Treat signs and symptoms in effort to stabilize patient

Patient Presentatio

1. Inclusion (suspect exposure) Criteria Presentation may vary depending on the concentration

and duration of exposure. Signs and symptoms vary, and may include, but are not limited to,

the following:

a. Absorption:

i. Nausea

ii. Vomiting

iii. Diarrhea

iv. Altered mental status

v. Abdominal pain

vi. Rapid heart rate

vii. Dyspnea

viii. Wheezing

ix. Seizures

x. Arrhythmias

xi. Respiratory depression

xii. Sweating

xiii. Tearing

xiv. Defecation

xv. Constricted/dilated pupils

xvi. Rash

xvii. Burns to the skin

b. Ingestion:

i. Nausea

ii. Vomiting

iii. Diarrhea

iv. Altered mental status

v. Abdominal pain

vi. Rapid or slow heart rate

vii. Dyspnea

viii. Seizures

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ix. Arrhythmias

x. Respiratory depression

xi. Chemical burns around or inside the mouth

xii. Abnormal breath odors

c. Inhalation:

i. Nausea

ii. Vomiting

iii. Diarrhea

iv. Altered mental status

v. Abnormal skin color

vi.

Dyspnea

vii.

Seizures

viii.

Burns to the respiratory tract

ix.

Stridor

Sooty sputum

xi.

Known exposure to toxic or irritating gas

xii.

Respiratory depression

xiii.

Sweating

xiv.

Tearing

xv.

Constricted/dilated pupils

xvi.

Dizziness

d. Injection:

i. Local pain

ii. Puncture wounds

iii. Reddening skin

iv. Local edema

v. Numbness

vi. Tingling

vii. Nausea

viii. Vomiting

ix. Diarrhea

x. Altered mental status

xi. Abdominal pain

xii. Seizures

xiii. Muscle twitching

xiv. Hypoperfusion

xv.

Respiratory depression

xvi.

Metallic or rubbery taste

2. Toxidromes (constellations of signs and symptoms that add in the identification of certain

classes of medications and their toxic manifestations). These toxidrome constellations

may be masked or obscured in poly pharmacy events due to counteracting effects of the

toxins

a. Anticholinergic

i. Red as a beet (flushed skin)

ii. Dry as a bone (dry skin)

iii. Mad as a hatter (altered mental status)

iv. Blind as a bat (mydriasis)

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v. Hot as a pistol (hyperthermia)

vi. Full as a flask (urinary retention)

vii. "Tacky" like a pink flamingo (tachycardia and hypertension)

b. Cholinergic (DUMBELS)

DUMBELS is a mnemonic used to describe the signs and symptoms of

acetylcholinesterase inhibitor agent poisoning. All patient age groups are included

where the signs and symptoms exhibited are consistent with the toxidrome of

DUMBELS

i. Diarrhea

ii. Urination

iii. Miosis/Muscle weakness

iv. Bronchospasm/Bronchorrhea/Bradycardia (the killer Bs)

v. Emesis

vi. Lacrimation

vii. Salivation/Sweating

c. Opioids

Respiratory depression

ii.

Miosis (pinpoint pupils)

iii.

Altered mental status

iv.

Decreased bowel sounds

Sedative Hypnotic

i. Central nervous system depression

ii. Ataxia (unstable gait or balance)

iii. Slurred speech

iv. Normal or depressed vital signs (pulse, blood pressure, respiratory rate, neurologic

status assessment)

Stimulants (Sympathomimetic)

i. Tachycardia, tachydysrhythmias

ii. Hypertension

iii. Diaphoresis

iv. Delusions/paranoia

v. Seizures

vi. Hyperthermia

vii. Mydriasis (dilated pupils)

Serotonin Syndrome (presentation with at least three of the following)

i. Agitation

ii. Ataxia

iii. Diaphoresis

iv. Diarrhea

v. Hyperreflexia

vi. Mental status changes

vii. Myoclonus

viii. Shivering

ix. Tremor

x. Hyperthermia

xi. Tachycardia

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Exclusion Criteria

None noted

Patient Managemen

Assessment

Make sure the scene is safe. Use environmental Carbon Monoxide (CO) detector on

"first in" bag if possible

Consider body substance isolation (BSI) or appropriate PPE

Assess ABCD and, if indicated, expose patient for assessment and then re-cover to

assure retention of body heat

Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

temperature, and O

saturation including temperatur

Attach cardiac monitor and examine rhythm strip for arrhythmias (consider 12-lead EKG)

Check blood glucose level

onitor pulse oximetry and end-tidal capnography (EtCO

) for respiratory

decompensation

Perform carboxyhemoglobin device assessment, if available

When

indicated, identify specific medication taken (including immediate

release vs sustained release), time of ingestion, dose, and quantity. When

appropriate, bring all medications (prescribed and not prescribed) found in the

environment

10.

Obtain an accurate ingestion history (as patient may become unconscious before arrival at

the emergency department (ED)):

a. Time of ingestion or exposure

b. Route of exposure

c. Quantity of medication or toxin taken (safely collect all possible medications or

agents)

d. Alcohol or other intoxicant tak

11.

If bringing in exposure agent, consider the threat to yourself and the destination facility

12.

Obtain pertinent cardiovascular history and other prescribed medications

13.

Check for needle marks, paraphernalia, bites, bottles, or evidence of agent

involved in exposure, self-inflicted injury, or trauma

14.

Law enforcement should have checked for weapons and drugs, but you may need

to re- check

15.

Obtain any other pertinent patient history

16.

Perform remainder of physical examination

Treatment and Intervention

Assure a patent airway

dminister oxygen as appropriate with a target of achieving 94–98% saturation, and if

there is hypoventilation noted, support breathing

Initiate IV access for infusion of treatment medication and/or lactated Ringer's or

normal saline if indicated, and obtain blood samples if EMS management might

change based upon the value (e.g., glucose, lactate, cyanide)

Consider fluid bolus (20 mL/kg) if evidence of hypoperfusion

Administration of appropriate antidote or mitigating medication (refer to

specific agent guideline if not listed below)

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a. Acetaminophen overdose:

i. Consider activated charcoal without sorbitol (1 g/kg) PO only if within the

first hour of ingestion and prolonged transport to definitive care

ii. Based on suspected quantity and timing, consider acetylcysteine (pediatric

and adult), if available

1. Loading dose is acetylcysteine 150 mg/kg IV; mix in 200 mL of dextrose

5% in water (D5W) and infuse over 1 hr

2. After loading dose, give acetylcysteine 50 mg/kg IV in 500 mL D5W over 4

hrs.

3. If IV is not available, acetylcysteine 140 mg/kg PO

iii. If risk of rapidly decreasing mental status, do not administer oral agents

b. Aspirin overdose:

i. Consider activated charcoal without sorbitol (1 gm/kg) PO only if within the first

hour of ingestion

1. As ASA is erratically absorbed, charcoal is highly recommended to be

administered early

2. If altered mental status or risk of rapid decreasing mental status from

polypharmacy, do not administer oral agents including activated

charcoal

ii. In salicylate poisonings, let the patient breathe on their own, even if

tachypneic, until there is evidence of decompensation or dropping oxygen

saturation. Acid/base disturbances and outcomes worsen when the patient

is manually ventilated

c. Benzodiazepine overdose:

i. Respiratory support

ii. Consider fluid challenge (20 mL/kg) for hypotension

iii. Consider vasopressors after adequate fluid resuscitation (1–2 liters of

crystalloid in adult) for the hypotensive patient

d. Caustic substances ingestion (i.e., acids and alkali):

i. Evaluate for airway compromise secondary to spasm or direct injury

associated with oropharyngeal burns

e. Dystonia (symptomatic), extrapyramidal signs or symptoms, or mild allergic reactions

Consider administration of diphenhydramine

Adult

diphenhydramine 25–50 mg IV or IM

2. Pediatric: diphenhydramine 1–1.25 mg/kg IVP/IO or IM (maximum

single dose of 25 mg)

f. Monoamine oxidase inhibitor overdose (symptomatic, e.g., MAOI;

isocarboxazid, phenelzine, selegiline, tranylcypromine)

onsider administration of midazolam for temperature control

ii. Adult and Pediatric: Midazolam 0.1 mg/kg in 2 mg increments slow IV push over

one to two minutes per increment with maximum single dose 5 mg — reduce

by 50% for patients 69 years old or older

g. Opiate overdose, treat per the Opioid Poisoning/Overdose Guideline

h. Oral ingestion unknown poisoning:

there is a risk of rapidly decreasing mental status or for petroleum-

based ingestions, do not administer oral agents

ii. Consider administration of activated charcoal without sorbitol (1 g/kg)

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PO particularly if it is within the first 1 hour after ingestion (including

acetaminophen) and there will be prolonged transport to definitive

care.

iii. Patients who have ingested medications with extended release or

delayed absorption may also be administered activated charcoal

i. Selective serotonin reuptake inhibitors (SSRls)

i. Consider early airway management

ii. Treat arrhythmias following Advanced Cardiac Life Support (ACLS) guidelines

iii.

Aggressively control hyperthermia with cooling measures

iv. Consider fluid challenge (20 mL/kg) for hypotension

v. Consider vasopressors after adequate fluid resuscitation (1–2 liters of

crystalloid in adult) for the hypotensive patient [See Shock Guideline ]

vi. For agitation, consider midazolam

1. Adult: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to

two minutes per increment with maximum single dose 5 mg

Reduce by 50% for patients 69 years or older

2. Pediatric: midazolam 0.1 mg/kg in 2 mg increments slow IV push over

one to two minutes per increment with maximum single dose 4 mg or

midazolam 0.2 mg/kg IN to maximum single dose of 10 mg

vii. For seizures, treat per Seizures Guideline

j. Tricyclic Antidepressant (TCA)/Sodium Channel Blocker Overdose:

i. Consider early airway management

ii. If widened QRS (100 msec or greater), consider sodium bicarbonate 1–2

mEq/kg IV, this can be repeated as needed to narrow QRS and improve blood

pressure

iii. Consider fluid challenge (20 mL/kg) for hypotension

iv. Consider vasopressors after adequate fluid resuscitation (1–2 liters of

crystalloid) for the hypotensive patient [See Shock Guideline]

v. For agitation, consider midazolam

1. Adult: midazolam 0.1 mg/kg in 2 mg increments slow IV push over one to

two minutes per increment with maximum single dose 5 mg

Reduce by 50% for patients 69 years or older

2. Pediatric: midazolam 0.1 mg/kg in 2 mg increments slow IV push over

one to two minutes per increment with maximum single dose 4 mg or

midazolam 0.2 mg/kg IN to maximum single dose of 10 mg

vi. For seizure, treat per Seizures Guideline

Patient Safety Consideration

Scene/environmental safety for patient and clinician

a. Consider environmental carbon monoxide monitor use

Monitor patient airway, breathing, pulse oximetry, EtCO

for adequate ventilation as they may

change over time

Repeat vital signs often

Monitor level of consciousness

Monitor EKG with special attention to rate, rhythm, QRS and QT duration

Maintain or normalize patient temperature

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The regional poison center should be engaged as early as reasonably possible to aid in

appropriate therapy and to track patient outcomes to improve knowledge of toxic effects. The

national 24-hour toll-free telephone number to poison control centers is (800) 222- 1222,

and it is a resource for free, confidential expert advice from anywhere in the United States

Notes/Educational Pearl

Key Consideration

Each toxin or overdose has unique characteristics which must be considered in

individual protocols

tivated charcoal (which does not bind to all medications or agents) is still a useful

adjunct in the serious-agent, enterohepatic, or extended-release agent poisoning if the

patient does not have the potential for rapid alteration of mental status or

airway/aspiration risk. Precautions should be taken to avoid or reduce the risk of

aspiration

Ipecac is not recommended for any poisoning or toxic ingestion — the manufacturer

has stopped production of this medication

Flumazenil is not indicated in a suspected benzodiazepine overdose as it can precipitate

refractory/intractable seizures if the patient is a benzodiazepine dependent patient

Pertinent Assessment Findings

Frequent reassessment is essential as patient deterioration can be rapid and catastrophic

Quality Improvemen

Associated NEMSIS Protocol(s) (eProtocol.01

)

(for additional information, go to www.nemsis.org)

•

9914135—General - Overdose/Poisoning/Toxic Ingestion

Key Documentation Element

•

Repeat evaluation and documentation of signs and symptoms as patient clinical conditions

may deteriorate rapidly

•

Identification of possible etiology of poisoning

•

Initiating measures on scene to prevent exposure of bystanders when appropriate/indicated

•

Time of symptoms onset and time of initiation of exposure-specific treatments

Performance Measure

•

Early airway management in the rapidly deteriorating patient

•

Accurate exposure history

o Time of ingestion/exposur

o Route of exposure

o Quantity of medication or toxin taken (safely collect all possible mediations or agents)

cohol or other intoxicant taken

•

Appropriate protocol selection and management

•

Multiple frequent documented reassessments

Reference

1. Boyer EW, Shannon MS. The serotonin syndrome. N Engl J M ed. 2005; 352:1112–20

2. Bruccoleri RE, Burns MM. A Literature Review of the Use of Sodium Bicarbonate for the

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Poisoning/Overdose Universal Care 259

Version 3.0

Treatment of QRS Widening. J Med Toxicol. 2016 Mar;12(1):121-9. doi: 10.1007/s13181-

015-0483-y. PMID: 26159649; PMCID: PMC4781799

3. Cushing TA. Selective Serotonin Reuptake Inhibitor Toxicity

https://emedicine.medscape.com/article/821737-overview. Updated April 24, 2018.

Accessed March 11, 2022

4. Gresham C. Benzodiazepine toxicity treatment and management.

http://emedicine.medscape.com/article/813255-treatment#d10. Updated January 23,

2020. Accessed March 11, 2022

5. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank's

Toxicologic Emergencies, 10

Edition. China: McGraw -Hill Education; 2015.

http://accessemergencymedicine.mhmedical.com/book.aspx?bookID=1163

Accessed

March 11, 2022

6. Lemyze M, Masse J, Queva C, Huchette D. Cardiac effect of sodium bicarbonate in sodium-

channel blocker poisoning. Intensive Care Med. 2016 Apr;42(4):588-590. doi:

10.1007/s00134-015-4122-5

7. Spiller H. A prospective evaluation of the effect of activated charcoal before N-

Acetyl cysteine in acetaminophen overdose. Ann of Emerg Med. 1994;23(3):519 -23

8. Tsai V. Tricyclic Antidepressant Toxicity.

http://emedicine.medscape.com/article/819204-overview. Updated May 19, 2020.

Accessed March 11, 2022

9. Wolf S. Clinical policy: critical issues in the management of patients presenting to the

emergency department with acetaminophen overdose. Ann of Emerg M ed.

2007;50(3):292– 313

Revision Date

March 11, 2022

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Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates)

Exposure

Aliases

Acetylcholinesterase inhibitor Carbamate Insecticide

Nerve agent Organophosphate Pesticide

Weapons of mass destruction (WMD)

Patient Care Goal

1. Rapid recognition of the signs and symptoms of confirmed or suspected

acetylcholinesterase inhibitor (AChEI) agents such as carbamates, nerve agents, or

organophosphates exposure followed by expeditious and repeated administration

of atropine, the primary antidote

2. Carbamates and organophosphates are commonly active agents in commercial

insecticides

3. Accidental carbamate exposure rarely requires treatment

Patient Presentatio

Inclusion Criteri

1. DUMBELS is a mnemonic used to describe the signs and symptoms of acetylcholinesterase

inhibitor agent poisoning. All patient age groups are included where the signs and symptoms

exhibited are consistent with the toxidrome of DUMBELS

a. Diarrhea

rination

c. Miosis/Muscle weakness

d. Bronchospasm/Bronchorrhea/Bradycardia (the killer Bs)

e. Emesis

f. Lacrimation

alivation/

weating

Exclusion Criteria

None noted

Patient Managemen

Don the appropriate PPE

Remove the patient's clothing and wash the skin with soap and warm wate

a. Acetylcholinesterase inhibitor agents can be absorbed through the skin

b. Contaminated clothing can provide a source of continued exposure to the toxin

Rapidly assess the patient's respiratory status, mental status, and pupillary status

Administer the antidote atropine immediately for confirmed or suspected

acetylcholinesterase inhibitor agent exposure

Administer oxygen as appropriate with a target of achieving 94–98% saturation and

provide airway management

Establish intravenous access (if possible)

Apply a cardiac monitor (if available)

The heart rate may be normal, bradycardic, or tachycardic

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Clinical improvement should be based upon the drying of secretions and easing

of respiratory effort rather than heart rate or pupillary response

10.

Continuous and ongoing patient reassessment is critical

Assessment

1. Acetylcholinesterase inhibitor agents are highly toxic chemical agents and can rapidly

be fatal

2. Patients with low-dose chronic exposures may have a more delayed presentation

of symptoms

3. Antidotes (atropine and pralidoxime) are effective if administered before circulation fails

4. The patient may develop:

a. Miosis (pinpoint pupils)

b. Bronchospasm

c. Bradycardia

Vomiting

e. Excessive secretions in the form of

Tearing

ii.

Salivation

iii.

Rhinorrhea

iv.

Diarrhea

Urination

vi.

Bronchorrhea

5. Penetration of an acetylcholinesterase inhibitor agent into the central nervous system

(CNS) will cause:

a. Headache

b. Confusion

c. Generalized muscle weakness

d. Seizures

e. Lethargy or unresponsiveness

6. Estimated level of exposure based upon signs and symptoms

ild

Miosis alone (while this is a primary sign in vapor exposure, it may not be

present is all exposures)

ii.

Miosis and severe rhinorrhea

b. Mild to moderate (in addition to symptoms of mild exposure

)

Localized swelling

ii.

Muscle fasciculations

iii.

Nausea and vomiting

iv.

Weakness

Shortness of breath

c. Severe (in addition to symptoms of mild to moderate exposure

)

Unconsciousness

ii.

Convulsions

iii.

Apnea or severe respiratory distress requiring assisted ventilation

iv.

Flaccid paralysis

7. Onset of symptoms can be immediate with an exposure to a large amount of

the acetylcholinesterase inhibitor

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a. There is usually an asymptomatic interval of minutes after liquid exposure before

these symptoms occur

b. Effects from vapor exposure occur almost immediately

8. Signs and symptoms with large acetylcholinesterase inhibitor agent exposures (regardless

of route)

a. Sudden loss of consciousness

b. Seizures

c. Copious secretions

d. Apnea

e. Death

9. Obtain an accurate exposure history (as patient may become unconscious before arrival at

the ED:

a. Time of ingestion or exposure

b. Route of exposure

c. Quantity of medication or toxin taken (safely collect all possible medications or agents)

Alcohol

or other intoxicant taken

e. Pertinent cardiovascular history or other prescribed medications for underlying disease

10. The patient can manifest any of the signs and symptoms of the toxidrome based on the

route of exposure, agent involved, and concentration of the agent

a. Vapor exposures will have a direct effect on the eyes and pupils causing miosis

b. Patients with isolated skin exposures will have normally reactive pupils

c. Certain acetylcholinesterase inhibitor agents can place the patient at risk for both

a vapor and skin exposure

Treatment and Interventions (See dosing tables)

1. Medications:

a. Atropine

i. Atropine is the primary antidote for organophosphate, carbamate, or nerve

agent exposures, and repeated doses should be administered liberally to

patients who exhibit signs and symptoms of exposure or toxicity

ii. Atropine may be provided in multi-dose vials, pre-filled syringes, or auto-

injectors

b. Pralidoxime chloride (2-PAM)

i. Pralidoxime chloride is a secondary treatment and should be given concurrently

to reactivate acetylcholinesterase

ii. Pralidoxime chloride may be provided in a single dose vial, pre-filled syringes, or

auto-injector

iii. Auto-injectors typically contain 600 mg of pralidoxime chlorid

iv. To be beneficial to the victim, a dose of pralidoxime chloride should be

administered shortly after the nerve agent or organophosphate poisoning as it

has minimal clinical effect if administration is delayed

c. Benzodiazepines

i. Benzodiazepines are administered as an anticonvulsant for those patients who

exhibit seizure activity [See Seizures Guideline for doses and routes of

administration]

ii. Lorazepam, diazepam, and midazolam are the most frequently used

benzodiazepines in the prehospital setting; midazolam may have the fastest

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onset of action

iii. Benzodiazepines may be provided in multi-dose or single-dose vials, pre-filled

syringes, or auto-injectors

iv. CANA® (Convulsive Antidote Nerve Agent) is a commercially available auto-

injector that contains 10 mg of diazepam

d. Duodote

commercially available auto-injector of nerve agent/organophosphate

antidote

ii. Duodote® is one auto-injector that contains 2.1 mg of atropine and 600 mg of

pralidoxime chloride

e. ATNAA® (Antidote Treatment Nerve Agent Auto-injector)

auto-injector of nerve agent/organophosphate antidote that is typically in

military supplies

ii. ATNAA® is one auto-injector that contains 2.1 mg of atropine and 600 mg of

pralidoxime chloride

iii. ATNAA® may be seen in civilian supplies assets when Duodote® is unavailable or

in short supply

f. CHEMPACK

i. Federal cache of nerve agent antidotes that is managed by the Centers for

Disease Control and Prevention (CDC) and offered to states that voluntarily

agree to maintain custody and security of CHEMPACK assets

ii.

These

are forward-deployed at sites determined by states that are part of the

program such as hospitals and EMS centers

iii.

Deployment

of CHEMPACKs is reserved for events where the nerve

agent/organophosphate exposure will deplete the local or regional supply of

antidotes

iv. There are two types of CHEMPACK containers:

1. EMS Containers: CHEMPACK assets for EMS contain a large portion of auto-

injectors for rapid administration of antidotes by EMS clinicians of all levels

of licensure/certification. They contain enough antidote to treat roughly

454 patients

2. Hospital Containers: CHEMPACK assets contain a large portion of multidose

vials and powders for reconstitution — they contain enough antidote to

treat roughly 1,000 patients

2. Medication Administration

a. Atropine, in large and potentially multiple doses, is the antidote for an

acetylcholinesterase inhibitor agent poisoning

b. Atropine should be administered immediately followed by repeated doses

until the patient' s secretions resolve

c. Pralidoxime chloride (2-PAM) is a secondary treatment and, when possible,

should be administered concurrently with atropine

d. The stock of atropine and pralidoxime chloride available to EMS clinicians is

usually not sufficient to fully treat the victim of an acetylcholinesterase inhibitor

agent exposure; however, EMS clinicians should initiate the administration of

atropine and, if available, pralidoxime chloride

e. Seizures should be treated with benzodiazepines. There is some emerging

evidence that, for midazolam, the intranasal route of administration may be

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preferable to the intramuscular route. However, intramuscular absorption

may be more clinically efficacious than the intranasal route in the presence of

significant rhinorrhea

f. The patient should be emergently transported to the closest appropriate medical

facility as directed by medical direction

3. Recommended Doses (See dosing tables)

The medication dosing tables that are provided below are based upon the severity of

the clinical signs and symptoms exhibited by the patient. There are several imperative

factors to note:

a. For organophosphate or severe acetylcholinesterase inhibitor agent exposure, the

required dose of atropine necessary to dry secretions and improve the respiratory

status may exceed 20 mg. Atropine should be administered rapidly and repeatedly

until the patient's clinical symptoms diminish. Atropine must be given until the

acetylcholinesterase inhibitor agent has been metabolized.

b. Because Duodote® auto-injectors contain pralidoxime chloride, they should not

be used for additional dosing of atropine beyond the recommended

administered dose of pralidoxime chloride

c. All the medications below can be administered intravenously in the same doses

cited for the intramuscular route. However, due to the rapidity of onset of signs,

symptoms, and potential death from acetylcholinesterase inhibitor agents,

intramuscular administration is highly recommended to eliminate the inherent

delay associated with establishing intravenous access

d. The antidotes can be administered via the intraosseous route. However, due to

the rapidity of onset of signs, symptoms, and potential death from

acetylcholinesterase inhibitor agents, intramuscular administration remains the

preferable due to the inherent delay associated with establishing intraosseous

access and the limited use of this route of administration for other medications

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Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure 265

Version 3.0

Table 1. Mild Acetylcholinesterase Inhibitor Agent Exposure

Patient

Atropine Dose (Weight) IM or via

Auto-injector

Infant:

0–2

years of age

0.05 mg/kg IM or via auto-injector

(i.e., 0.25 and/or 0.5 mg auto-injector(s))

Child:

3–7 years of age

(13–25 kg)

1 mg IM or via auto-injector

(i.e., one 1 mg or two 0.5 mg auto-injectors)

Child:

8–14 years of age

(26–50 kg)

2 mg IM or via auto-injector

(i.e., one 2 mg or two 1 mg auto-injectors)

Adolescent/Adult

2 mg IM or via auto-injector

Pregnant Women

2 mg IM or via auto-injector

Geriatric/Frail

1 mg IM or via auto-injector

Adapted from: U.S. Department of Health and Human Services, ASPR,

National Library of Medicine, Chemical Hazards Emergency Medical

Management: Nerve Agents— Prehospital Management,

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93

Table 2. Mild to Moderate Acetylcholinesterase Inhibitor Agent Exposure

Patient

(Weight)

Atropine Dose

IM or via Auto-injector

Pralidoxime Chloride Dose IM

or via 600 mg Auto-injector

Infant:

0–2

years of age

0.05 mg/kg IM or via auto-injector

(i.e., 0.25 mg and/or 0.5 mg auto-

injector)

15 mg/kg IM

Child:

3–7

years of age

(13–25 kg)

1 mg IM or via auto-injector

(i.e., one 1 mg auto-injector or two 0.5

mg auto-injectors)

15 mg/kg IM

One auto-injector (600 mg)

Child:

8–14 years of age

(26–50 kg)

2 mg IM or via auto-injector

(i.e., one 2 mg auto-injector or two 1

mg auto-injectors)

15 mg/kg IM

One auto-injector (600 mg)

Adolescent/ Adult

2–4 mg IM or via auto-injector

600 mg IM

One auto-injector (600 mg)

Pregnant Women

2–4 mg IM or via auto-injector

600 mg IM

One auto-injector (600 mg)

Geriatric/Frail

2 mg IM or via auto-injector

10 mg/kg IM

One auto-injector (600 mg)

Adapted from:

U.S. Department of Health and Human Services, ASPR, National Library of Medicine,

Chemical Hazards Emergency Medical Management: Nerve Agents— Prehospital Management,

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93

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Version 3.0

Table 3. Severe Acetylcholinesterase Inhibitor Agent Exposure

Patient

(Weight)

Atropine Dose

IM or via 600 mg Auto-injector

Pralidoxime Chloride Dose

IM or via Auto-injector

Infant:

0–2

years of age

0.1 mg/kg IM or via auto-injector

(i.e., 0.25 mg and/or 0.5 mg auto-

injector)

45 mg/kg IM

Child:

3–7

years of age

(13–25 kg)

0.1 mg/kg IM

2 mg via auto-injector

.e., one 2 mg auto-injector or four

0.5 mg auto-injectors)

45 mg/kg IM OR

One auto-injector (600 mg)

Child:

8–14

years of age

(26–50 kg)

4 mg IM or via auto-injector

(i.e.,

two 2 mg auto-injectors or four

1 mg auto-injectors

)

45 mg/kg IM OR

Two auto-injectors (1200 mg)

Adolescent:

years of age

or olde

6 mg IM or via auto-injector

(i.e., three 2 mg auto-injectors)

Three auto-injectors (1800 mg)

Adult

6 mg IM or via auto-injector

(i.e., three 2 mg auto-injectors)

Three auto-injectors (1800 mg)

Pregnant

Women

6 mg IM or via auto-injector

(i.e., three 2 mg auto-injectors)

Three auto-injectors (1800 mg)

Geriatric/Frail

2–4 mg IM or via auto-injector

(i.e., one to two 2 mg auto-injectors)

25 mg/kg IM

two to three auto-injectors

(1200 mg–1800 mg)

Adapted from: U.S. Department of Health and Human Services, ASPR, National Library of Medicine,

Chemical Hazards Emergency Medical Management: Nerve Agents— Prehospital Management,

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93

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Version 3.0

Table 4. Guidance for the Treatment of Seizures Secondary to Acetylcholinesterase Inhibitor Agent Exposure

Patient

Diazepam

Midazolam

Infant

(0–2

y/o

)

0.2–0.5 mg/kg IM

Repeat q 2–5 minutes

0.2 mg/kg IM

Repeat

prn in 10 minutes

0.2–0.5 mg/kg IV q 15–30 minutes

May repeat twice as needed

May repeat dose once

Total maximum dose: 5 m

Total maximum dose: 0.4 mg/k

Child

(3–13

y/o)

0.2–0.5 mg/kg

Repeat q 2–5 minutes

0.2 mg/kg IM

Not to exceed 10 mg

Repeat prn in 10 minutes

0.2–0.5 mg/kg IV q 15–30 minutes

May repeat dose twice if needed

May repeat dose once

Total maximum dose: 5 mg if less than 5 years

Total maximum dose: 0.4 mg/kg

Not to exceed 20 mg

Total maximum dose: 10 mg if age 5 years or older

1 CANA® auto-injector

Adolescent:

y/o

olde

2–3 CANA® auto-injectors

0.2 mg/kg IM

Total

maximum dose of 10 mg

Repeat prn in 10 minutes

5–10 mg IV q 15 minutes

May repeat dose once

Total maximum dose: 30 mg

Total maximum dose: 20 mg

Adult

2–3 CANA® auto-injectors

10 mg IM

Repeat prn in 10 minutes

5–10 mg IV q 15 minutes

May repeat dose once

Total maximum dose: 30 mg

Total maximum dose: 20 mg

Pregnant

Women

2–3 CANA® auto-injectors

10 mg IM

Repeat prn in 10 minutes

5–10 mg IV q 15 minutes

May repeat dose once

Total maximum dose: 30 mg

Total maximum dose: 20 mg

Geriatric

2–3 CANA® auto-injectors

10 mg IM

Repeat prn in 10 minutes

5–10 mg IV q 15 minutes

May repeat dose once

Total maximum dose: 30 mg

Total maximum dose: 20 mg

Adapted from:

U.S. Department of Health and Human Services, ASPR, National Library of Medicine, Chemical

Hazards Emergency Medical Management: Nerve Agents — Prehospital Management,

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93

Patient Safety Consideration

Continuous and ongoing patient reassessment is critical

Clinical response to treatment is demonstrated by the drying of secretion and the easing

of respiratory effort

Initiation of and ongoing treatment should not be based upon heart rate or

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Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure 268

Version 3.0

pupillary response

Precautions for pralidoxime chloride administration:

a. Although Duodote® and ATNAA® contains atropine, the primary antidote for an

acetylcholinesterase inhibitor agent poisoning, the inclusion of pralidoxime chloride in

the auto-injector can present challenges if additional doses of atropine are warranted

by the patient condition and other formulations of atropine are unavailable:

Pediatrics: an overdose of pralidoxime chloride may cause profound

neuromuscular weakness and subsequent respiratory depression

ii.

Adults: Especially for the geriatric victim, excessive doses of pralidoxime

chloride may cause severe systolic and diastolic hypertension, neuromuscular

weakness, headache, tachycardia, and visual impairment

iii.

Geriatrics: victim who may have underlying medical conditions, particularly

impaired kidney function or hypertension, the EMS clinician should consider

administering the lower recommended adult dose of intravenous pralidoxime

chloride

Considerations during the use of auto-injectors

a. If an auto-injector is administered, a dose calculation prior to administration is

not necessary

b. For atropine, additional auto-injectors should be administered until secretions diminish.

c. Mark 1 kits, Duodote® and ATNAA® have not been approved for pediatric use by the Food

and Drug Administration (FDA), but they can be considered for the initial treatment for

children of any age with severe symptoms of an acetylcholinesterase inhibitor agent

poisoning especially if other formulations of atropine are unavailable

d. Pediatric Atro-Pen® auto-injectors are commercially available in a 0.25 mg auto-

injector (yellow) and a 0.5 mg auto-injector (red). Atro-Pen® auto-injectors are

commercially available in a 1 mg auto-injector (blue) and a 2 mg auto-injector (green)

e. A pralidoxime chloride 600 mg auto-injector may be administered to an infant

that weighs greater than 12 kg

Notes/Educational Pearls

Key Consideration

Clinical effects of acetylcholinesterase inhibitor agents

a. The clinical effects are caused by the inhibition of the enzyme

acetylcholinesterase which allows excess acetylcholine to accumulate in the

nervous system

b. The excess accumulated acetylcholine causes hyperactivity in muscles, glands,

and nerves

Organophosphates Insecticides

a. Can be legally purchased by the general public

b. Organophosphate pesticides penetrate tissues and bind to the patient's body fat

producing a prolonged period of illness and ongoing toxicity even during aggressive

treatment

Nerve agents

a. Traditionally classified as weapons of mass destruction (WMD)

b. Not readily accessible to the general public

c. Extremely toxic and rapidly fatal with any route of exposure

d. GA (tabun), GB (sarin), GD (soman), GF, and VX are types of nerve agents and are WMDs

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Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure 269

Version 3.0

e. Nerve agents can persist in the environment and remain chemically toxic for

a prolonged period of tim

Pertinent Assessment Findings

The signs and symptoms exhibited with the toxidrome of DUMBELS [See Patient Presentation—

Inclusion Criteria]

Quality Improvemen

Associated NEMSIS Protocol(s) (eProtocol.01

)

(for additional information, go to www.nemsis.org)

•

9914047—Exposure - Nerve Agents

Key Documentation Element

•

Time to recognize initial signs and symptoms

•

Number of repeated doses of atropine required for the secretions diminish and respirations to

improve

•

Patient reassessments

•

Patient responses to therapeutic interventions

•

Measures taken to decontaminate the patient

•

Measures taken to protect clean environments from contamination

Performance Measure

• Ability of the EMS system to rapidly locate additional and adequate antidote assets

• Ability of the EMS system to rapidly deploy additional and adequate antidote assets

• Survival rates of victims

• Complication rates from the toxin

• Complication rates from the antidotes

• Long-term clinical sequelae of the victims

Reference

Barkin RM, Rosen P, Seidel JS, Caputo GL, Jaffe DM. Pediatric Emergency Medicine: Concepts

and Clinical Practice. St Louis, MO: Mosby; 1992:490–1

Burillo-Putze G, Nogue Xarau SN. In Tintinalli JE, ed. Tintinalli's Emergency Medicine, 8

Edition. McGraw-Hill Education; 2016:1318–21

Eddelston M, Buckley NA, Eyer P, Dawson AH. Management of acute

organophosphorus poisoning. Lancet. 2008;371(9612):597–607

Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank's

Toxicologic Emergencies, 10

Edition. China: McGraw -Hill Education; 2015

Horowitz BZ, Hendrickson RG. Chemical disasters. In Tintinalli JE, ed. Tintinalli's

Emergency Medicine, 8

Edition. McGraw-Hill Education; 2016:44–5

Marx JA et al. Rosen's Emergency Medicine: Concepts and Clinical Practice.

2014:825-6,2057-60,2476-7

Nelson LS. Goldfrank’s Toxicologic Emergencies, 10th Edition. China: McGraw -Hill

Education; 2015:1450–76

Nerve Agents—Prehospital Management. Chemm.nlm.nih.gov.

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Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure 270

Version 3.0

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93 Updated April

28, 2017. Accessed August 27, 2017

Silbergleit R, Lowenstein D, Durkalski V, Conwit R; Neurological Emergency Treatment Trials

(NETT) Investigators. RAMPART (Rapid Anticonvulsant Medication Prior to Arrival Trial): a

double-blind randomized clinical trial of the efficacy of intramuscular midazolam versus

intravenous lorazepam in the prehospital treatment of status epilepticus by paramedics.

Epilepsia. 2011 Oct;52(8):45–7. doi: 10.1111/j.1528–1167.2011. 03235.x. PMID: 21967361

Revision Date

March 11, 2022

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Radiation Exposure 271

Version 3.0

Radiation Exposure

Aliases

None noted

Patient Care Goals

1. Prioritize identification and treatment of immediately life-threatening medical conditions and

traumatic injuries above any radiation-associated injury

2. Identify and appropriately treat acute radiation injury

3. Reduce risk for contamination of personnel while caring for patients potentially or known to

be contaminated with radioactive material

Patient Presentatio

Inclusion Criteri

1. Patients who have been acutely exposed to ionizing radiation from accidental environmental

release of a radioactive source

2. Patients who have been acutely exposed to ionizing radiation from a non-accidental

environmental release of a radioactive source

3. Patients who have been contaminated with material emitting ionizing radiation

Exclusion Criteria

1. Patients exposed to normal doses of ionizing radiation from medical imaging studies

2. Patients exposed to normal doses of ionizing radiation from therapeutic medical procedures

Patient Managemen

Assessment

1. Don standard PPE capable of preventing skin exposure to liquids and solids (gown and gloves),

mucous membrane exposure to liquids and particles (face mask and eye protection), and

inhalational exposure to particles (N95 face mask or respirator)

2. Identification and treatment of life-threatening injuries and medical problems takes priority

over decontamination

3. Do not eat or drink any food or beverages while caring for patients with radiation injuries until

screening completed for contamination and appropriate decontamination if needed

4. Use caution to avoid dispersing contaminated materials

5. Provide appropriate condition-specific care for any immediately life-threatening injuries or

medical problems

Treatment and Intervention

f patient experiences nausea, vomiting, and/or diarrhe

a. Provide care, per Nausea-Vomiting Guideline

b. Document the time gastrointestinal symptoms starte

If seizure occurs:

a. Consider a primary medical cause or exposure to possible chemical agents unless

indicators for a large whole-body radiation dose (greater than 20 Gy (Gray)), such as

rapid onset of vomiting, are present

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Radiation Exposure 272

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b. Treat per Seizures Guideline

Patient Safety Consideration

Treat life-threatening medical problems and traumatic injuries prior to assessing for and treating

radiation injuries or performing decontamination

Notes/Educational Pearl

Key Consideration

Irradiated patients pose no threat to medical clinicians

Contaminated patients pose very little threat to medical clinicians who use appropriate PPE

including N95 masks or respirators, gloves, gowns, and face and eye protection

Sources of radiation

a. Legal

Industrial plants

ii.

Healthcare facilities that provide radiologic services

iii.

Nuclear power plants

iv.

Mobile engineering sources (i.e., construction sites that are installing cement)

b. Illegal

Weapons of mass destruction

ii.

"Dirty bomb" design to contaminate widespread areas

Physiology of radiation poisoning

c. Contamination: Poisoning from direct exposure to a radioactive source,

contaminated debris, liquids, or clothing where radiation continues to be emitted

from particles on surface

d. Exposure: Poisoning from radioactivity, in the form of ionizing rays,

penetrating through the bodily tissues of the patien

Common types of radioactivity that cause poisonin

e. Gamma rays

Highest frequency of ionizing rays

ii.

Penetrates the skin deeply

iii.

Causes the most severe radiation toxicity

f. Beta rays: can penetrate up to 1 cm of the skin's thicknes

g. Alpha rays

Lowest frequency of ionizing rays

ii.

Short range of absorptio

iii.

Dangerous only if ingested or inhaled

h. Radioactive daughters

Products of decay of the original radioactive substance

ii.

Can produce gamma and beta rays (i.e., uranium decays into a series of radon

daughters)

In general, trauma patients who have been exposed to or contaminated by radiation

should be triaged and treated based on the severity of their conventional injurie

A patient who is contaminated with radioactive material (i.e., flecks of radioactive

material embedded in their clothing and skin) generally poses a minimal exposure risk to

medical personnel, although should not be placed in a contained space before

decontaminatio

EMS clinicians may be asked to assist public health agencies in the distribution and

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Radiation Exposure 273

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administration of potassium iodide in a mass casualty incident involving radiation release

or exposu

Stages of Radiation Sicknes

i. Prodromal: nausea, vomiting, diarrhea, fatigue, fever, agitation, starting hours up to

4 days after initial exposure

j. Latent: May last up to four weeks (this is the maximum period for

immunocompromise due to radiation exposure); however, time span may be less as

dose of radiation exposure increases. Symptoms include anorexia, fever, weakness,

bleeding, diarrhea, potentially altered mental status after two to three wee

k. Recovery: may take weeks to months

Pertinent Assessment Findings

1. Treatment of life-threatening injuries or medical conditions takes priority over

assessment for contamination or initiation of decontaminatio

2. Time to nausea and vomiting is a reliable indicator of the received dose of ionizing

radiation. The more rapid the onset of vomiting, the higher the whole-body dose of

radiation

3. Tissue burns are a late finding (weeks following exposure) of ionizing radiation injury.

If burns are present acutely, they are from a thermal or chemical mechanism

4. Seizures may suggest acute radiation syndrome if accompanied by early vomiting. If

other clinical indicators do not suggest a whole-body dose of greater than 20 Gy,

consider other causes of seizure

5. Delayed symptoms (days to weeks after exposure or contamination)

a. Skin burns with direct contact with radioactive source

b. Skin burns or erythema from ionizing rays

c. Fever

d. Bone marrow suppression presenting as:

immunosuppression

ii.

Petechiae

e. Spontaneous internal and external bleeding

Quality Improvemen

Associated NEMSIS Protocol(s) (eProtocol.01

)

(for additional information, go to www.nemsis.org)

•

9914049—Exposure - Radiologic Agents

Key Documentation Element

•

Duration of exposure to the radioactive source or environment

•

Distance (if able to be determined) from the radioactive source (if known)

•

Time of onset of vomiting

Performance Measure

• Use of appropriate PPE

• Use of dosimetry by EMS clinician

• Scene measurements of radioactivity

Reference

1. Center for Disease Control and Prevention, Emergency Preparedness and Response,

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Radiation Exposure 274

Version 3.0

Specific Hazards: Radiation, 2013

2. Cone DC, Koenig KL. Mass casualty triage in the chemical, biological, radiological, or nuclear

environment. Eur J Emerg M ed;12(6): 287– 302

3. Marx JA et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 2010 1937–1939

4. Radiation Emergency Assistance Center/Training Site (REAC/TS) Training Site.

Orise.orau.gov. https://orise.orau.gov/reacts/. Accessed August 28, 2017

5. The Medical Aspects of Radiation Incidents https://orise.orau.gov/reacts/documents/medical-

aspects-of-radiation-incidents.pdf. Revised January 2017. Accessed August 28, 2017

Revision Date

March 11, 2022

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Topical Chemical Burn 275

Version 3.0

Topical Chemical Burn

Aliases

Chemical Burn

Patient Care Goal

Rapid recognition of a topical chemical burn

Initiation of emergent and appropriate intervention and patient transport

Patient Presentatio

Inclusion Criteri

Patients of all ages who have sustained exposure to a chemical that can cause a

topical chemical burn may develop immediate or in some cases a delayed clinical

presentation

Agents that are known to cause chemical burns include alkalis, acids, mustard agent,

and lewisite

Exclusion criteri

None noted

Patient Managemen

Don the appropriate PPE

Remove the patient's clothing, if necessary

Contaminated clothing should preferably be placed in double bags

If deemed necessary and manpower resources permit, the patient should be transported by

EMS clinicians who did not participate in the decontamination process, and in an emergency

response vehicle that has not been exposed to the chemical

Information regarding the chemical should be gathered while on scene including materials

safety data sheet if available

Communicate all data regarding the chemical to the receiving facility

Assessment

1. Clinical effects and severity of a topical chemical burn is dependent upon:

a. Class of agent (alkali injury or acid injury)

b. Concentration of the chemical the (higher the concentration, the greater the risk

of injury

)

c. pH of the chemical

Alkali-increased risk with pH greater than or equal to 11

ii.

Acid-increased risk with pH less than or equal to 3

d. Onset of bur

Immediate

ii.

Delayed (e.g., hydrofluoric acid)

2. Calculate the estimated total body surface area that is involved

Prevent further contamination

4. Special attention to assessment of ocular or oropharyngeal exposure — evaluate for

airway compromise secondary to spasm or direct injury associated with oropharyngeal

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burns

5. Some acid and alkali agents may manifest systemic effects

Treatment and Intervention

1. If dry chemical contamination, carefully brush off solid chemical prior to flushing the site

as the irrigating solution may activate a chemical reaction

wet chemical contamination, flush the patient's skin (and eyes, if involved) with

copious amounts of water or normal saline

3. Provide adequate analgesia per the Pain Management Guideline

4. Consider the use of topical anesthetic eye drops (e.g., tetracaine) for chemical burns of

the eye

For

eye exposure, administer continuous flushing of irrigation fluid to eye — Morgan lens

may facilitate administration

6. Early airway intervention for airway compromise or bronchospasm associated with

oropharyngeal burns

7. Take measures to minimize hypothermia

8. Initiate intravenous fluid resuscitation if necessary to obtain hemodynamic stability

Hydrofluoric Acid

Hydrofluoric acid (HF) is a highly corrosive substance that is primarily used for automotive

cleaning products, rust removal, porcelain cleaners, etching glass, cleaning cement or brick, or

as a pickling agent to remove impurities from various forms of steel. Hydrofluoric acid readily

penetrates intact skin and there may be underlying tissue injury. It is unlikely that low

concentration HF will cause an immediate acid-like burn however there may be delayed onset

of pain to the exposed area. Higher concentration HF may cause immediate pain as well as

more of a burn appearance that can range from mild erythema to an obvious burn. An oral or

large dermal exposure can result in significant systemic hypocalcemia with possible QT

prolongation and cardiovascular collapse

For all patients in whom a hydrofluoric acid exposure is confirmed or suspected:

Vigorou

sly irrigate all affected areas with water or normal saline for a minimum of

15 minutes

b. Apply a cardiac monitor for oral or large dermal exposures significant HF exposures

c. Apply calcium preparation:

Calcium prevents tissue damage from hydrofluoric acid

ii.

Topical calcium preparations:

1. Commercially manufactured calcium gluconate gel

2. If commercially manufactured calcium gluconate gel is not available, a

topical calcium gluconate gel preparation can be made by combining 150 mL

(5 ounces) of a sterile water-soluble gel (e.g., Surgilube® or KY® jelly) with

one of the following:

35 mL of calcium gluconate 10% solution

10 g of calcium gluconate tablets (e.g., Tums®)

3.5 g calcium gluconate powder or

3. If calcium gluconate is not available, 10 mL of calcium chloride 10%

solution in 150 mL in sterile water-soluble gel (e.g., Surgilube® or KY® jelly)

4. Apply generous amounts of the calcium gluconate gel to the exposed skin

sites to neutralize the pain of the hydrofluoric acid

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Leave in place for at least 20 minutes then reassess

This can be repeated as needed

5. Hydrofluoric acid exposure is very painful. Calcium gel is the foundation of

pain control. While intravenous pain medications may be less effective, they

should be added to calcium gel to assist with pain control. Hydrofluoric acid

exposure typically causes pain out of proportion to the visible dermal effects.

Minimal skin changes may exist with substantial exposures

fingers are involved, apply the calcium gel to the hand, squirt additional

calcium gel into a surgical glove, and then insert the affected hand into the

glove

7. For patients who have ingested hydrofluoric acid or who have a large dermal

exposure consider intravenous calcium gluconate, 1–2 grams of 10%

solution, as symptomatic hypocalcemia can precipitate rapidly as manifest

by muscle spasms, seizures, hypotension ventricular arrhythmias, and QT

prolongation

Patient Safety Consideration

1. Don PPE

2. Take measures to prevent the patient from further contamination through decontamination

3. Take measures to protect the EMS clinician and others from contamination

4. Do not attempt to neutralize an acid with an alkali or an alkali with an acid as an exothermic

reaction will occur and cause serious thermal injury to the patient

5. Expeditious transport or transfer to a designated burn center should be considered for burns

that involve a significant percentage of total body surface area or burns that involve the eyes,

face, hands, feet, or genitals

Notes/Educational Pearl

Key Consideration

IV fluid resuscitation should be guided by patient age, percentage of body surface area

involved in burn, body habitus and calculated by the Parkland Formula [See Appendix

VI. Burn and Burn Fluid Charts]

Since

the severity of topical chemical burns is largely dependent upon the type,

concentration, and pH of the chemical involved as well as the body site and surface area

involved, it is imperative to obtain as much information as possible while on scene about

the chemical substance by which the patient was exposed. The information gathering

process will often include:

a. Transport of the sealed container of the chemical to the receiving facilit

b. Transport of the original or a copy of the Material Safety Data Sheet (MSDS) of

the substance to the receiving facility

c. Contacting the reference agency to identify the chemical agent and assist

in management (e.g., CHEMTREC®)

Inhalation of HF should be considered in any dermal exposure involving the face and neck

or if clothing is soaked in the product

Decontamination is critical for both acid and alkali agents to reduce injury — removal of

chemicals with a low pH (acids) is more easily accomplished than chemicals with a high

pH (alkalis) because alkalis tend to penetrate and bind to deeper tissues

Some chemicals will also manifest local and systemic signs, symptoms, and bodily damage

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Pertinent Assessment Findings

1. An estimate of the total body surface area that is involved

2. Patient response to therapeutic interventions

3. Patient response to fluid resuscitation

4. Patient response to analgesia

Quality Improvemen

Associated NEMSIS Protocol(s) (eProtocol.01

)

(for additional information, go to www.nemsis.org)

•

9914213—Injury - Topical Chemical Burn

Key Documentation Element

•

Burn site

•

Body surface area involved

•

Identification of the chemical

•

Reported or measured pH of the chemical

•

Acquisition and transfer of MSDS, chemical container, or other pertinent

substance information to the receiving the facility

Performance Measure

•

Accu

rate (overtriage/undertriage) triage of patients to designated burn centers

•

Early

recognition of a topical chemical burn with appropriate treatment

•

Early

recognition of hydrofluoric acid burns followed by expeditious initiation of

treatment with calcium gluconate and/or calcium chloride and appropriate analgesia

•

Measu

res taken to prevent further contamination

Reference

1. American Heart Association. Advanced Pediatric Life Support. Jones & Bartlett Learning LLC;

2013

2. Ferng M, Gupta R, Bryant SM. Hazardous Brick Cleaning. J Emergency Medicine.

2009;37(3):305–7

3. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s

Toxicologic Emergencies, 10

Edition. China: McGraw-Hill Education; 2015

4. Marx JA et al. Rosen's Emergency Medicine: Concepts and Clinical Practice, 2010 769–770

5. O'Sullivan SB, Schmitz TJ. Physical Rehabilitation, 5

Edition. F.A. Davis; 2007: 1098

6. Recommended Medical Treatment for hydrofluoric Acid Exposure. Morristown,

NJ: Honeywell Performance Materials and Technologies; October 2012

7. Tintinalli JE, ed. Tintinalli's Emergency Medicine, 9th Edition. McGraw-Hill Education; 2021:35–

40, 1391–96

Revision Date

March 11, 2022

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Stimulant Poisoning/Overdose

Aliases

Amphetamines Bath Salts Cocaine

Ice Methamphetamine Phencyclidine (PCP)

Stimulant

Patient Care Goal

Identify intoxicating agent

Protect organs at risk for injury such as heart, brain, liver, kidney

Determine if there is an antidote

Treat the symptoms, which may include severe tachycardia and hypertension, agitation,

hallucinations, chest pain, seizure, and arrhythmia

Patient Presentatio

Inclusion Criteria

achycardia/tachydysrhythmias

Hypertension

Diaphoresis

elusions/paranoia

Seizures

Hyperthermia

ydriasis (dilated pupils)

Stimulant/hallucinogenic (with stimulant properties) agents

a. Cocaine

b. Amphetamine/methamphetamine

c. Phencyclidine (PCP) (hallucinogen)

d. Bupropion

e. Synthetic stimulant drugs of abuse (some having mixed properties)

f. Ecstasy

g. Methamphetamine

h. Khat or Synthetic cathinones (“bath salts”)

i. “Spice”

j. “K2”

k. Synthetic THC

Exclusion Criteria

None note

Patient Management

Assessment

1. Begin with the ABCDs:

Airway is patent

Breathing is oxygenating

Circulation is perfusing

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Version 3.0

Disability/neuro/mental status

Treat any compromise of these parameters

Ask about chest pain and difficulty breathing

2. Vital signs including temperature for hyperthermia

3. Apply a cardiac monitor and examine rhythm strip for arrhythmias

4. Check blood glucose level

5. Monitor EtCO

for respiratory decompensation

6. Check a 12-lead EKG when possible

7. Check for trauma, self-inflicted injury

8. Law enforcement should have checked for weapons and drugs, but you may need to

repeat the inspection

Treatment and Interventions

IV access for any fluids and meds

Give fluids for poor perfusion; cool fluids for hyperthermia [See Shock

Guideline and Hyperthermia/Heat Exposure Guideline]

Treat chest pain as acute coronary syndrome (ACS) and follow ST-Elevation Myocardial

Infarction (STEMI) Guideline if there is EKG is consistent with STEMI

Consider treating shortness of breath as atypical ACS

a. Administer oxygen as appropriate with a target of achieving 94–98% saturation

Consider soft physical management devices especially if law enforcement has been

involved in getting patient to cooperate [See Agitated or Violent Patient/Behavioral

Emergency Guideline ]

Consider medications to reduce agitation and other significant sympathomimetic findings,

preferably benzodiazepines, for the safety of the patients and clinicians. The administration

of ketamine should be considered for delirium with agitated behavior. This may improve

behavior and compliance [See Agitated or Violent Patient/Behavioral Emergency Guideline

]

a. If haloperidol or droperidol is used, maintain cardiac monitoring (or obtain 12-lead EKGs)

for QT-interval prolongation if feasible

Consider prophylactic use of antiemetic:

a. Adult: administer ondansetron 4–8 mg SLOW IV over 2–5 minutes or 4–8 mg IM or

8 mg orally disintegrating tablet

b. Pediatric: Administer ondansetron 0.15 mg/kg SLOW IV over 2–5 minutes

c. Do not use promethazine if haloperidol or droperidol are to be or have been given.

They all increase QT prolongation, but ondansetron has less seizure risk

If hyperthermia suspected, begin external cooling (e.g., cold or ice packs to axilla/groin)

Patient Safety Considerations

Apply the least amount of physical management devices that are necessary to protect the

patient and the clinicians [See Agitated or Violent Patient/Behavioral Emergency

Guideline ]

Assessment for potential weapons or additional drugs is very important since these

items can pose a threat not just to the patient but also to the EMS crew

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Stimulant Poisoning/Overdose 281

Version 3.0

Notes/Educational Pearls

Key Considerations

Recognition and treatment of hyperthermia (including sedatives to decrease

heat production from muscular activity) is essential as many deaths are

attributable to hyperthermia

If law enforcement has placed the patient in handcuffs, this patient needs ongoing

physical security for safe transport. Have law enforcement in back of ambulance for the

handcuffed patient or make sure proper non-handcuff physical management devices are

in place before law enforcement leaves and ambulance departs from scene

If patient has signs and symptoms of ACS, consider giving nitroglycerin sublingual (SL)

q (quaque, every) 3–5 minutes if SBP greater than 100 mmHg and until pain resolves

(if range not desired, use q 3 minutes)

a. Vasospasm is often the problem in this case as opposed to a fixed coronary artery lesion

b. Consider administration of benzodiazepines as if to treat anxiety

Maintaining IV access, cardiac monitor, and SPO

/EtCO

monitors are key to being able

to catch and intervene decompensations in a timely manner

a. If agitated, consider restraining the patient to facilitate patient assessment and

lessen likelihood of vascular access or monitor displacements

Cocaine has sodium channel blocking effects and can cause significant cardiac

conduction abnormalities with a widened QRS. Treatment is with sodium bicarbonate

similar to a tricyclic antidepressant. Check a 12-lead EKG to assess for these

complications

Pertinent Assessment Findings

1. History is as important as the physical examination.

2. If the patient is on psychiatric medication, but has failed to be compliant, this fact alone puts

the patient at higher risk for the adverse outcome of delirium with agitated behavior

3. If the patient is found naked, this may elevate the suspicion for stimulant use or abuse. These

substances increase the risk for sudden death secondary to delirium with agitated behavior.

Neuroleptic malignant syndrome or serotonin syndrome can present with similar signs and

symptoms

4. If polypharmacy is suspected, hypertension and tachycardia are expected hemodynamic

findings secondary to increased dopamine release. Stimulus reduction from benzodiazepines,

anti-psychotics, and ketamine will improve patient's vital signs and behavior

5. Be prepared for the potential of cardiovascular collapse as well as respiratory arrest

6. If a vasopressor is needed, epinephrine or norepinephrine is recommended over dopamine

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914225—Medical - Stimulant Poisoning/Overdose

Key Documentation Elements

•

Reason for psychologic and physical management procedures used and neurologic/circulatory

exams with device use

•

Reason for medications selected

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Stimulant Poisoning/Overdose 282

Version 3.0

•

Documentation of QT interval when antiemetic medications, haloperidol, or droperidol is used

and result conveyed to ED staff

Performance Measures

•

Recognition and treatment of hyperthermia

•

Recognition of need for monitoring cardiovascular and respiratory status of patient with

stimulant toxicity

•

ACS evaluation and treatment considered for chest pain and shortness of breath

•

Respiratory compromise quickly recognized and treated

•

Cardiovascular compromise quickly recognized and treated

•

Patient and medics did not suffer any harm

•

Access and monitoring were not lost during transport

References

1. Kupas, D, Wydro, G, Tan, D, Kamin, R, Harrell, A, Wang, A, NASEMSO Position Paper

2020 Clinical Care and Restraint of Agitated or Combative Patients by Emergency

Medical Services Practitioners https://nasemso.org/wp-content/uploads/Clinical-

Care-and-Restraint-of-Agitated-or-Combative-Patients-by-Emergency-Medical-

Services-Practitioners.pdf. Accessed March 11, 2022

2. Warrcik BJ, Hill M, Hekman K, et al. A 9-state analysis of designer stimulant, "bath

salt, " hospital visits reported to poison control centers. Ann Emerg Med.

2013;62(3):244–51

3. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task

Force, American College of Emergency Physicians; September 10, 2009

Revision Date

March 11, 2022

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Cyanide Exposure 283

Version 3.0

Cyanide Exposure

Aliases

Blood agent Cyanide Hydrogen cyanide

Patient Care Goal

emove patient from toxic environment

2. Assure adequate ventilation, oxygenation, and correction of hypoperfusion

Patient Presentation

Cyanide is a colorless gas or white crystal which binds to the ferric ion in cells, blocking the enzyme

cytochrome oxidase, thus preventing the use of oxygen by the cell's mitochondria, leading to cellular

hypoxia. While it has a characteristic "bitter almond smell”, genetically only 40% of the population can

smell it

Inclusion Criteria

Depending on its form, cyanide can enter the body through inhalation, ingestion, or

absorption through the skin. Cyanide should be suspected in occupational or other smoke

exposures (e.g., firefighting), industrial accidents, natural catastrophes, suicide and

murder attempts, chemical warfare, and terrorism (whenever there are multiple

casualties of an unclear etiology). Non-specific and early signs of cyanide exposure

(inhalation, ingestion, or absorption) include the following signs and symptoms: anxiety,

vertigo, weakness, headache, tachypnea, nausea, dyspnea, vomiting, and tachycardia

High concentrations of cyanide will produce:

a. Markedly altered level of consciousness, including rapid collapse

b. Seizures

c. Respiratory depression or respiratory arrest

d. Cardiac dysrhythmias (other than sinus tachycardia)

The rapidity of onset is related to the severity of exposure (inhalation or ingestion) and

may be dramatic with immediate effects that include early hypertension with subsequent

hypotension, sudden cardiovascular collapse or seizure/coma, and rapid death

Exclusion Criteria

None noted

Patient Management

Assessment

1. Remove patient from toxic environment

2. Assess ABCDs and, if indicated, expose the patient, and then re-cover the patient to

assure retention of body heat

3. Assess vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

including temperature and pulse oximetry (which may not correlate with tissue

oxygenation in cyanide/smoke exposure)

4. Attach a cardiac monitor and examine rhythm strip for arrhythmias

a. Perform a 12-lead EKG

5. Check blood glucose level

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Cyanide Exposure 284

Version 3.0

6. Monitor pulse oximetry and EtCO

7. Monitor patient for signs of hypoxia (pulse oximetry less than 94%) and

respiratory decompensation regardless of pulse oximetry reading

8. Identify the specific agent of exposure, time of ingestion/inhalation, and quantity/timing

of exposure

9. Obtain patient history including cardiovascular history and prescribed medication

10. Obtain other pertinent patient history

11. Perform physical exam

Treatment and Interventions

There is no widely available, rapid, confirmatory cyanide blood test. Many hospitals will not

be able to rapidly assess cyanide levels. Therefore, treatment decisions must be made on the

basis of clinical history and signs and symptoms of cyanide intoxication. For the patient with

an appropriate history and manifesting one or more significant cyanide exposure signs or

symptoms, treat with:

100% oxygen via non-rebreather mask, CPAP, or bag valve mask

Collect a pre-treatment blood sample in the appropriate tube for lactate and cyanide levels, if

feasible

Administer one of the following medication regimes

a. Hydroxocobalamin (the preferred agent)

Adult: Administer hydroxocobalamin

Initial dose is 5 g administered over 15 minutes slow IV

Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with

200 mL of LR, NS, or D5W (25 mg/mL) and administered at 10–15

mL/minute

An additional 5 g dose may be administered with medical consultation.

ii.

Pediatric: Administer hydroxocobalamin 70 mg/kg (reconstitute concentration is

25 mg/mL)

Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with

200 mL of LR, NS, or DSW (25 mg/mL) and administered at 10–15

mL/minute

Maximum single dose is 5 g

Sodium thiosulfate

i. Adult: Sodium thiosulfate 12.5 g IVF (50 mL of 25% solution)

ii. Pediatric: Sodium thiosulfate 0.5 g/kg IV (2 mL/kg of 25% solution)

4. If seizure, treat per Seizures Guideline

Patient Safety Considerations

In the event of multiple casualties, be sure to wear appropriate PPE during rescue evacuation

from the toxic environment

If the patient ingests cyanide, it will react with the acids in the stomach generating hydrogen

cyanide gas. Be sure to maximize air circulation in closed spaces (ambulance) as the patient's

gastric contents may contain hydrogen cyanide gases when released with vomiting or belching

Do not use nitrites in conjunction with suspected carbon monoxide poisoning as it worsens

the hemoglobin oxygen carrying capacity even more than carbon monoxide (CO)

Hydroxocobalamin is only agent safe for treatment of cyanide poisoning in pregnant patients

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Notes/Educational Pearls

Key Considerations

Pulse oximetry accurately reflects serum levels of oxygen but does not accurately reflect

tissue oxygen levels therefore should not be relied upon in possible cyanide and/or

carbon monoxide toxicity

After hydroxocobalamin has been administered, pulse oximetry levels are no longer

accurate and skin, tears, and urine will all turn red. This flushing should not be interpreted

as an allergic reaction

If the patient ingests cyanide, it will react with the acids in the stomach generating

hydrogen cyanide gas. Be sure to maximize air circulation in closed spaces (ambulance) as

the patient's gastric contents may contain hydrogen cyanide gases when released with

vomiting or belching

Amyl nitrite and sodium nitrite are no longer being used and no longer available

in commercial kits

Pertinent Assessment Findings

Early and repeated assessment is essential

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914043—Exposure - Cyanide

Key Documentation Elements

•

Repeat evaluation and documentation of signs and symptoms as the patient's clinical

condition may deteriorate rapidly

•

Identification of possible etiology of poisoning

•

Time of symptom onset and time of initiation of exposure-specific treatments

•

Therapy and response to therapy

Performance Measure

• Early airway management in the rapidly deteriorating patient

• Accurate exposure history

o Time of ingestion/exposure

o Route of exposure

o Quantity of medication or toxin taken (safely collect all possible medications or agents)

o Alcohol or other intoxicant taken

• Appropriate protocol selection and management

• Multiple frequent documented reassessments

References

Amyl Nitrite—Medical Countermeasures Database. Chemm.nlm.nih.gov.

https://wwwn.cdc.gov/TSP/MMG/MMGDetails.aspx?mmgid=523&toxid=93. Accessed

March 11, 2022

Bebarta VS, Tanen DA, Lairet J, Dixon PS, Valtier S, Bush A. Hydroxocobalamin and

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Cyanide Exposure 286

Version 3.0

sodium thiosulfate versus sodium nitrite and sodium thiosulfate in the treatment of

acute cyanide toxicity in a swine (Sus scrota) model. Ann Emerg Med. 2010; 55(4):345–

Cyanide Poisoning. UpToDate.com. https://www.uptodate.com/contents/cyanide-

poisoning?source=search_result&search=cyanide%20and%20pulse%20oximetry&selecte

dTitle=3~150. Updated September 28, 2016. March 11, 2022

Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank's

Toxicologic Emergencies, 10

Edition. China: McGraw-Hill Education; 2015

Marraffa JM, Cohen V, Howland MA. Antidotes for toxicological emergencies: a

practical review. Am J Health Syst Pharm. 2012;69(3):199–212

Meridian Cyanokit (package insert). Semoy, France: Merck Sante.

https://www.meridianmeds.com/sites/default/files/pi/CYANOKIT_PI.pdf. Accessed

March 11, 2022

Roderique EJ, Gebre-Giorgis AA, Stewart DH, Feldman MJ, Pozez AL. Smoke inhalation

injury in a pregnant patient: a literature review of the evidence and current best

practices in the setting of a classic case. J Burn Care Res. 2012; Sep-Oct;33(5):624–33

Shepherd G, Velez LI. Role of hydroxocobalamin in acute cyanide poisoning.

Ann Pharmacotherapy. 2008;42(5):661–9

Thompson JP, Marrs TC. Hydroxocobalamin in cyanide poisoning. Clin Toxicol (Phila).

2012;50(10):875–85

Revision Date

March 11, 2022

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Beta Blocker Poisoning/Overdose 287

Version 3.0

Beta Blocker Poisoning/Overdose

Aliases

Anti-hypertensive

Patient Care Goals

1. Reduce GI absorption of oral agents with some form of binding agent (activated charcoal)

especially for extended release

2. Early airway protection is required as patients may have rapid mental status deterioration

3. Assure adequate ventilation, oxygenation, and correction of hypoperfusion

Patient Presentation

Beta blocker or beta-adrenergic antagonist medication to reduce the effects of epinephrine/adrenaline

Inclusion Criteria

Patients may present with:

Bradycardia

Hypotension

Altered mental status

Weakness

Shortness of breath

Possible seizures

Hypoglycemia

Beta blocker agent examples:

Acebutolol hydrochloride (Sectral®)

Atenolol (Tenormin®)

Betaxolol hydrochloride (Kerlone®)

Bisoprolol fumarate (Zebeta®)

Carteolol hydrochloride (Cartrol®)

Esmolol hydrochloride (Brevibloc®)

Metoprolol (Lopressor®, Toprol XL®)

Nadolol (Corgard®)

Nebivolol (Bystolic®)

Penbutolol sulfate (Levatol®)

Pindolol (Visken®)

I. Propranolol (lnderal®, lnno Pran®)

m. Timolol maleate (Blocadren®)

n. Sotalol hydrochloride (Betapace®)

Alpha/beta-adrenergic blocking agents’ examples:

Carvedilol (Coreg®)

Labetalol hydrochloride (Trandate®, Normodyne®)

Exclusion Criteria

None noted

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Beta Blocker Poisoning/Overdose 288

Version 3.0

Patient Management

Assessment

1. Assess ABCDs and if indicated expose and then cover to assure retention of body heat

2. Vital signs which include temperature

3. Apply a cardiac monitor, examine rhythm strip for arrhythmias, and consider obtaining a 12-

lead EKG

4. Check blood glucose level

5. Monitor pulse oximetry and EtCO

for respiratory decompensation

6. Identify specific medication taken (noting immediate release vs. sustained release

formulations), time of ingestion, and quantity

7. Pertinent cardiovascular history or other prescribed medications for underlying disease

8. Patient pertinent history

9. Patient physical

Treatment and Interventions

1. Consider activated charcoal without sorbitol (1 g/kg) PO only if within the first hour of

ingestion, if indicated per the time of ingestion. If risk of rapid decreasing mental status, do

not administer oral agent without adequately protecting the airway

a. If risk of rapid decreasing mental status, do not administer oral agent

without adequately protecting the airway

2. Check blood glucose level on all patients but especially on pediatric patients as beta-

blockers can cause hypoglycemia in pediatric population

3. Consider atropine sulfate for symptomatic bradycardia

a. Adult: Atropine 1 mg IV q 5 minutes to maximum of 3 mg

b. Pediatric: Atropine 0.02 mg/kg (0.5 mg maximum) q 5 minutes, maximum total dose

1 mg

4. Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia

5. For symptomatic patients with cardiac effects (e.g., hypotension, bradycardia) consider:

a. Adult: Glucagon initial dose 5 mg IVP — this can be repeated in 5–10 minutes for a

total of 10 mg

b. Pediatric:

i. Glucagon 1 mg IVP (25–40 kg) every 5 minutes as necessary

ii. Glucagon 0.5 mg IVP (less than 25 kg) q 5 minutes as necessary

6. Consider vasopressors after adequate fluid resuscitation (1–2 liters of crystalloid) for

the hypotensive patient [See Shock Guideline for pediatric vs. adult dosing]

7. Consider transcutaneous pacing if refractory to initial pharmacologic interventions

8. If seizure, treat per Seizures Guideline

9. If widened QRS (100 msec or greater), consider sodium bicarbonate 1–2 mEq/kg IV. This

can be repeated as needed to narrow QRS

Patient Safety Considerations

Transcutaneous pacing may not always capture nor correct hypotension when capture is

successful

Aspiration of activated charcoal can cause airway management to be nearly impossible. Do

not administer activated charcoal to any patients that may have a worsening mental status

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Beta Blocker Poisoning/Overdose 289

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Notes/Educational Pearls

Key Considerations

Pediatric Considerations

a. Pediatric patient may develop hypoglycemia from beta blocker overdose therefore it

is important to perform glucose evaluation

b. A single pill can kill a toddler. It is very important that a careful assessment

of medications the toddler could have access to is done by EMS and all

suspect medications should be brought into the ED

Glucagon has a side effect of increased vomiting at these doses and

ondansetron prophylaxis may be considered

Atropine may have little or no effect (likely to be more helpful in mild overdoses) —

the hypotension and bradycardia may be mutually exclusive, and the blood pressure

may not respond to correction of bradycardia

Propranolol crosses the blood brain barrier and can cause altered mental status,

seizure, and widened QRS similar to TCA toxicity

Pertinent Assessment Findings

Certain beta-blockers, such as acebutolol and propranolol, may increase QRS duration

Certain beta-blockers, such as acebutolol and pindolol, may produce tachycardia and

hypertension

Sotalol can produce increase in QTc interval and ventricular dysrhythmias

Frequent reassessment is essential as patient deterioration can be rapid and catastrophic

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914215—Medical - Beta Blocker Poisoning/Overdose

Key Documentation Elements

•

Repeat evaluation and documentation of signs and symptoms and vital signs as patient clinical

conditions may deteriorate rapidly

•

Identification of possible etiology of poisoning

•

Time of symptoms onset and time of initiation of exposure-specific treatment

•

Therapy and response to therapy

Performance Measures

• Early airway management in the rapidly deteriorating patient

• Accurate exposure history

o Time of ingestion/exposure

o Route of exposure

o Quantity of medication or toxin taken (safely collect all possible mediations or agents)

o Alcohol or other intoxicant taken

• Appropriate protocol selection and management

• Multiple frequent documented re-assessments

• Blood glucose checks (serial if long transport, especially in children)

• Good evaluation of the EKG and the segment intervals

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Beta Blocker Poisoning/Overdose 290

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References

1. Boyd R, Ghosh A. Towards evidence-based emergency medicine: best BETs from the

Manchester Royal Infirmary. Glucagon for the treatment of symptomatic beta

blocker overdose. Emerg Med J. 2003;20 (3): 266–7

2. Hepherd G. Treatment of poisoning caused by beta-adrenergic and calcium-

channel blockers. Am J Health Syst Pharm. 2006;63(19):1828–35

3. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s

Toxicologic Emergencies, 10

Edition. China: McGraw -Hill Education; 2015

4. Kerns W 2

Management of beta-adrenergic blocker and calcium channel

antagonist toxicity. Emerg Med Clin N Am. 2007 ;25(2):309– 31

5. Marraffa JM, Cohen V, Howland MA. Antidotes for Toxicological Emergencies. Am J

Health Syst Pharm. 2012 ;69(3):19 9–212

6. Review. Erratum in. Am J Health Syst Pharm. 2008;65(17):1592

7. Wax PM. b-Blocker ingestion: an evidence-based consensus guideline for out-of-

hospital management. Clinical Toxicology. 2005; 43:131–46

Revision Date

March 11, 2022

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Bites and Envenomation 291

Version 3.0

Bites and Envenomation

Aliases

Stings

Patient Care Goals

Bites, stings, and envenomations can come from a variety of insects, marine, and terrestrial animals.

Assure adequate ventilation, oxygenation, and correction of hypoperfusion. Provide pain control

which also may include external interventions to reduce pain

Patient Presentation

Inclusion Criteria

Bites, stings, and envenomations can come from a variety of marine and terrestrial

animals and insects causing local or systemic effects

Patients may present with toxin specific reactions which may include:

Site pain

Swelling

Muscle pain (hallmark of black widow spider bites)

Erythema

Discoloration

Bleeding

Nausea

Abdominal pain

Hypotension

Tachycardia

Tachypnea

I. Muscle incoordination

Confusion

Anaphylaxis/allergic reactions

There is a spectrum of toxins or envenomations and limited EMS interventions that will

have any mitigating effect on the patient in the field

The critical intervention is to get the patient to a hospital that has access to

the antivenin if applicable

Exclusion Criteria

None noted

Patient Management

Assessment

1. Assess ABCDs and if indicated expose and then cover to assure retention of body heat

2. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) which

include temperature

3. Apply a cardiac monitor, examine rhythm strip for arrhythmias, and consider obtaining a 12-

lead EKG

4. Check blood glucose Level

5. Monitor pulse oximetry and EtCO

for respiratory decompensation

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Bites and Envenomation 292

Version 3.0

6. Patient pertinent history

7. Patient physical with special consideration to area of envenomation especially crotalid bite

Treatment and Interventions

1. Consider an IV fluid bolus (normal saline or lactated Ringer's) 20 mL/kg up to 2 liters

2. Consider vasopressors after adequate fluid resuscitation for the hypotensive patient

[for adult vs. pediatric dosing, see Shock Guideline]

3. If seizure, treat per Seizures Guideline

4. Specific therapy for select bites, stings, or envenomation

Envenomations that are known to antivenom readily available in the USA include

black widow spider, bark scorpions, crotalid snakes (rattlesnake, copperhead) and

coral snakes

i. For these envenomations, consider transport to a hospital that has access to

antivenom, if feasible

Jellyfish

i. As there is a significant variety and diversity of jellyfish, it is important to be

familiar with the species and the appropriate treatment for your local aquatic

creatures

ii. Generally, scrape off any remaining tentacles or nematocysts, then immerse

affected body part in hot water (113°F/45°C). Vinegar may be used to reduce pain

due to deactivation of the nematocysts remaining in the skin except for stings

from certain species of jellyfish (i.e., Physalia, a species found in Australian

waters) which may have nematocysts activated by vinegar (acetic acid). Vinegar

may also activate the nematocysts of sea nettles and is not recommended after

this type of jellyfish exposure

Lionfish, scorpionfish, stingray:

i. Immerse affected body part in hot water to reduce the pain associated with the

toxin

5. Provide adequate analgesia per the Pain Management Guideline

Patient Safety Considerations

1. Do NOT:

Apply tourniquets, tight Ace®/crepe bandage, or constricting bands above or below

the site of the envenomation

Incise and/or suction wound to remove toxin

Apply cold packs or immerse the effect extremity in ice water (cryotherapy)

2. EMS clinicians should not try to capture the marine or terrestrial animal or insect

3. If the organism has been killed, beware that many dead insect, marine, or fanged animals

can continue to bite or sting with venom and should be safely placed in a hard sided and

closed container for future identification

4. Patient may still have an imbedded stinger, tooth, nematocyst, or barb which may

continue to deliver toxin if left imbedded. Consider safe removal without squeezing the

toxin delivery apparatus

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Notes/Educational Pearls

Key Considerations

Vinegar has potential to increase pain associated with jellyfish sting as it can increase

nematocyst discharge in certain species. Clinicians must be familiar with endemic species

and how to best address exposure

Pertinent Assessment Findings

Assess for signs and symptoms of local and systematic impact of the suspected toxin

Patient may still have an imbedded stinger, tooth, nematocysts, or barb which may continue

to deliver toxin if left imbedded

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

• 9914079—Injury - Bites and Envenomations-Land

• 9914081—Injury - Bites and Envenomations-Marine

Key Documentation Elements

• It is helpful to accurately describe the suspect bite or sting source without risking patient or

EMS clinician

• Only transport source animal or insect if can be done safely in a hard-sided container

• Repeat evaluation and documentation of signs and symptoms as patient clinical conditions

may deteriorate rapidly

• Time of symptoms onset and time of initiation of exposure-specific treatments

• Therapy and response to therapy

Performance Measures

•

Offending organism was managed appropriately without secondary exposure

•

Appropriate and timely definitive treatment was provided

•

Appropriate pain management

References

1. Aacharya RP, Gastmans C, Denier Y. Emergency department tri age: an ethical analysis.

BMC Emerg Med. 2011 ;11 :16

2. American College of Medical Toxicology, American Academy of Clinical Toxicology,

American Association of Poison Control Centers, European Association of Poison Control

Centres, International Society on Toxinology, Asia Pacific Association of Medical

Toxicology. Pressure immobilization after North American crotalinae snake envenomation.

J Med Toxicol. 2011;7 (4): 3 22–3

3. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank' s

Toxicologic Emergencies, 10

Edition. China: McGraw -Hill Education; 2015

4. Lavonas EJ, Ruha AM, Banner W, et al. Unified treatment algorithm for the management

of crotaline snakebite in the United States: results of evidence-informed consensus

workshop. BMC Emerg Med. 2011; 11:2

5. Prestwich H, Jenner R. Best evidence topic report. Treatment of jellyfish stings in UK

coastal waters: vinegar or sodium bicarbonate? Emerg Med J. 2007;24 (9):6 64

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6. Ward N. Evidence-based treatment of jellyfish stings in North America and Hawaii.

Ann Emerg Med. 2012; 60(4):399–414.

7. Weinstein SA, Dart RC, Stables A. Envenomations: an overview of clinical toxinology for

the primary care physician. Am Fam Physician. 2009;80(8):793–802

Revision Date

March 11, 2022

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Calcium Channel Blocker Poisoning/Overdose

Aliases

Anti-hypertensive

Patient Care Goals

1. Reduce GI absorption of oral agents with some form of binding agent (activated charcoal)

especially for extended release

2. Early airway protection is required as patients may have rapid mental status deterioration

3. Assure adequate ventilation, oxygenation, and correction of hypoperfusion

Patient Presentation

Calcium channel blockers interrupt the movement of calcium across cell membranes. Calcium

channel blockers are used to manage hypertension, certain rate-related arrhythmias, prevent

cerebral vasospasm, and angina pectoris. Patients may present with:

Bradycardia

Hypotension

Decreased AV nodal conduction

Cardiogenic shock

Hyperglycemia

Inclusion Criteria

Patients who have may have taken/been administered calcium channel blockers

a. Calcium channel blocker examples:

i. Amlodipine (Norvasc®)

ii. Diltiazem (Cardizem®, Tiazac®)

iii. Felodipine

iv. lsradipine

v. Nicardipine

vi. Nifedipine (Adalat CC®, Afeditab CR®, Procardia®)

vii. Nisoldipine (Sular®)

viii. Verapamil (Calan®, Verelan®)

Exclusion Criteria

None noted

Patient Management

Assessment

1. Assess ABCDs and, if indicated, expose, and then cover to assure retention of body heat

2. Vital signs including temperature

3. Apply a cardiac monitor, examine rhythm strip for arrhythmias, and consider obtaining a 12-

lead EKG

4. Check blood glucose level

5. Monitor pulse oximetry and EtCO

for respiratory decompensation

6. Identify specific medication taken (noting immediate release vs. sustained release

formulations), time of ingestion, and quantity

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7. Pertinent cardiovascular history or other prescribed medications for underlying disease

8. Patient pertinent history

9. Physical exam

Treatment and Interventions

1. Consider activated charcoal without sorbitol (1 g/kg) PO only if within the first hour of

ingestion, if indicated per the time of ingestion. If risk of rapid decreasing mental status,

do not administer oral agent without adequately protecting the airway

2. Consider atropine sulfate for symptomatic bradycardia

a. Adult: atropine 1 mg IV q 5 minutes to maximum of 3 mg

b. Pediatric: atropine 0.02 mg/kg (0.5 mg maximum) q 5 minutes, maximum total dose 1 mg

3. Consider calcium gluconate or calcium chloride

a. Calcium gluconate

i. Adult: Calcium gluconate 2–6 g slow IVP over 10 minutes

ii. Pediatric: Calcium gluconate 60 mg/kg IVP over 10 minutes

b. Calcium chloride

i. Adult: Calcium chloride 0.5–1 g slow IVP (50 mg/minute)

ii. Pediatric: Calcium chloride 20 mg/kg (0.2 mL/kg) slow IVP over 10 minutes (50

mg/mL) Maximum dose 1 g or 10 mL (Calcium gluconate is preferred as Calcium

chloride has increased risk of tissue damage in pediatrics)

4. Consider IV fluid bolus (normal saline or lactated Ringer's) 20 mL/kg up to 2 liters

5. Consider vasopressors after adequate fluid resuscitation for the hypotensive patient

[See Shock Guideline for adult vs. pediatric dosing]

6. If atropine, calcium, and vasopressors have failed in the symptomatic bradycardia

patient, consider:

a. Adult: Glucagon 5 mg IVP, then 1 mg q 5 minutes IVP (may require 5–15 mg to see

effect)

b. Pediatric:

i. Glucagon 1 mg IVP (25–40 kg); q 5 minutes as necessary

ii. Glucagon 0.5 mg IVP (less than 25 kg); q 5 minutes as necessary

7. Consider transcutaneous pacing if refractory to initial pharmacologic interventions

8. If seizure, consider midazolam (benzodiazepine of choice). [See Seizures Guideline for adult vs.

pediatric dosing]

Patient Safety Considerations

Transcutaneous pacing may not always capture nor correct hypotension when capture is

successful.

Notes/Educational Pearls

Key Considerations

While most calcium channel blockers cause bradycardia, dihydropyridine class calcium

channel blockers (e.g., nifedipine, amlodipine) can cause a reflex tachycardia (torsade de

pointes) early in the ingestion. The patient can become bradycardic as the intoxication

worsens

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The avoidance of administering calcium chloride or calcium gluconate to a patient on cardiac

glycosides (e.g., digoxin) as this may precipitate toxicity and associate fatal arrhythmias is felt

to be a historical belief and not supported

Glucagon has a side effect of increased vomiting at these doses and ondansetron prophylaxis

should be considered

A single pill can kill a toddler. It is very important that a careful assessment of medications the

toddler could have access to is done by EMS and suspect medications brought into the ED

Calcium channel blockers can cause many types of rhythms that can range from sinus

bradycardia to complete heart block

Hyperglycemia is the result of the blocking of L-type calcium channels in the pancreas. This

can help differentiate these ingestions from beta-blockers. There may also be a relationship

between the severity of the ingestion and the extent of the hyperglycemia

Atropine may have little or no effect (likely to be more helpful in mild overdoses)

a. Hypotension and bradycardia may be mutually exclusive, and the blood pressure

may not respond to correction of bradycardia

Pertinent Assessment Findings

Close monitoring of EKG changes and dysrhythmias

Serial frequent assessments are essential as these patients often have rapid deterioration with

profound hypotension

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914217—Medical - Calcium Channel Blocker Poisoning/Overdose

Key Documentation Elements

•

Repeat evaluation and documentation of signs and symptoms as patient clinical conditions

may deteriorate rapidly

•

Identification of possible etiology of poisoning

•

Time of symptoms onset and time of initiation of exposure-specific treatments

•

Therapy and response to therapy

Performance Measures

• Early airway management in the rapidly deteriorating patient

• Accurate exposure history

o Time ingestion/exposure

o Route of exposure

o Quantity of medication or toxin taken (safely collect all possible mediations or agents)

o Alcohol or other intoxicant taken

• Appropriate protocol selection and management

• Multiple frequent documented reassessments

References

Ashraf M, Chaudhary K, Nelson J, Thompson W. Massive overdose of sustained-

release verapamil: a case report and review of literature. Am J Med Sci.

1995;310(6):258–63

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Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s

Toxicologic Emergencies, 10

Edition. China: McGraw-Hill Education; 2015

Levine M. Critical care management of verapamil and diltiazem overdose with a focus

on vasopressors: a 25-year experience at a single center. Ann Emerg Med.

2013;62(3):252–8

Levine M, Boyer EW, Pozner CN, et al. Assessment of hyperglycemia after calcium

channel blocker overdoses involving diltiazem or verapamil. Crit Care Med.

2007;35(9):2071–5

Levine M, Nikkanen H, Pallin DJ. The effects of intravenous calcium in patient are

with digoxin toxicity. J Emerg Med. 2011;40(1);41–6

Marraffa JM, Cohen J, Howland MA. Antidotes for toxicological emergencies. Am J

Health Syst Pharm. 2012;69(3):199–212

Olsen KR, Erdman AR, Woolf AD, et al. Calcium channel blocker ingestion: an evidence-

based consensus guideline for out-of-hospital management. Clin Toxicol (Phila).

2005;(7):797–822

Olsen K. What is the best treatment for acute calcium channel blocker overdose? Ann

Emerg Med. 2013;62(3):259–61

Shepherd G. Treatment of poisoning caused by beta-adrenergic and calcium-channel

blockers. Am J Health Syst Pharm. 2006;63(19):1828–35. Review. Erratum in: Am J Health

Syst Pharm. 2008;65(17):1592

10.

St-Onge M, Anseeuw K, Cantrell FL, et al. Experts consensus recommendations for the

management of calcium channel blocker poisoning in adults. Crit Care Med. 2017;45(3):

e306–15

11.

St-Onge M, Dubé PA, Gosselin S, et al. Treatment for calcium channel blocker poisoning: a

systematic review. Clin Toxicol (Phila). 2014;52(9):926–44

Revision Date

March 11, 2022

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Carbon Monoxide/Smoke Inhalation

Aliases

Patient Care Goals

Remove patient from toxic environment.

Assure adequate ventilation, oxygenation, and correction of hypoperfusion.

Consider use of environmental carbon monoxide (CO) monitors on "first in" bags to assist in

detection of occult CO toxicity.

Patient Presentation

Carbon monoxide is a colorless, odorless gas which has a high affinity for binding to red cell hemoglobin,

thus preventing the binding of oxygen to the hemoglobin, leading to tissue hypoxia (although pulse

oximetry may appear to be normal). A significant reduction in oxygen delivery to tissues and organs occurs

with carbon monoxide poisoning. Carbon monoxide is also a cellular toxin which can result in delayed or

persistent neurologic sequelae in significant exposures. With any form of combustion (fire/smoke [e.g.,

propane, kerosene, or charcoal stoves or heaters], combustion engines [e.g., generators, lawn mowers,

motor vehicles, home heating systems]), carbon monoxide will be generated. People in a fire may also be

exposed to cyanide from the combustion of some synthetic materials. Cyanide toxicity may need to be

considered in the hemodynamically unstable patient removed from a fire.

Inclusion Criteria

Patients exposed to carbon monoxide may present with a spectrum of symptoms:

a. Mild intoxication:

Nausea

ii.

Fatigue

iii.

Headache

iv.

Vertigo

Lightheadedness

b. Moderate to severe:

Altered mental status

ii.

Tachypnea

iii.

Tachycardia

iv.

Convulsion

Cardiopulmonary arrest

Exclusion Criteria

None noted

Patient Management

Assessment

Remove patient from toxic environment

Assess ABCDs and, if indicated, expose patient and re-cover to assure retention of body heat

Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

temperature, and O

saturation, and EtCO

if available

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Apply a cardiac monitor, examine rhythm strip for arrhythmias, and obtain a 12-lead EKG if

available

Check blood glucose level

Monitor pulse oximetry and EtCO

for respiratory decompensation

Patient pertinent history

Patient physical examination

Treatment and Interventions

100% oxygen via non-rebreather mask or high flow oxygen by nasal cannula (HFNC) or CPAP or

bag valve mask or advanced airway as indicated

If seizure, treat per Seizures Guideline

Consider transporting patients with severe carbon monoxide poisoning directly to a facility

with hyperbaric oxygen capabilities if feasible and patient does not meet criteria for other

specialty care (e.g., trauma or burn)

Patient Safety Considerations

1. Consider affixing a carbon monoxide detector to an equipment bag that is routinely taken into

scene (if it signals alarm, don appropriate respiratory protection and exit scene) to assist with

detection of occult CO toxicity

2. Remove patient and response personnel from potentially hazardous environment as soon as

possible

3. Provide instruction to the patient, the patient's family, and other appropriate bystanders to

not enter the environment (e.g., building, car) where the carbon monoxide exposure occurred

until the source of the poisoning has been eliminated

4. Do not look for cherry red skin coloration as an indication of carbon monoxide poisoning, as

this is an unusual finding

5. CO oximeter devices may yield inaccurate low/normal results for patients with CO poisoning.

All patients with probable or suspected CO poisoning should be transported to the nearest

appropriate hospital based on their presenting signs and symptoms

Notes/Educational Pearls

Key Considerations

Pulse oximetry is inaccurate due to the carbon monoxide binding with hemoglobin

As maternal carboxyhemoglobin levels do not accurately reflect fetal carboxyhemoglobin

levels, pregnant patients are more likely to be treated with hyperbaric oxygen

Consider cyanide toxicity if carbon monoxide poisoning is from a fire

Pertinent Assessment Findings

Early and repeat assessment of patient's mental status and motor function are extremely

useful in determining response to therapy and the need for hyperbaric therapy

Identification of possible etiology of poisoning

Time of symptom onset and time of initiation of exposure-specific treatment

Response to therapy

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914167—Exposure - Carbon Monoxide

•

9914173—Exposure - Smoke Inhalation

Key Documentation Elements

•

If using an environmental carbon monoxide detector, record the level detected

•

Evidence of soot or burns around the face, nares, or pharynx

•

Early and repeat assessment of patient's mental status and motor function are

extremely useful in determining response to therapy and the need for hyperbaric

therapy

•

Accurate exposure history

Time of ingestion/exposure

Route of exposure

Quantity of medication or toxin taken (safely collect all possible mediations or agents)

Alcohol or other intoxicant taken

•

Signs and symptoms of other patients encountered at same location if present

Performance Measures

•

Early airway management in the rapidly deteriorating patient

•

Accurate exposure history

Time of ingestion/exposure

Route of exposure

Quantity of medication or toxin taken (safely collect all possible mediations or agents)

Alcohol or other intoxicant taken

•

Appropriate protocol selection and management

•

Multiple frequent documented reassessments

References

Buckley NA, Juurlink DN, Isbister G, Bennett MH, Lavonas EJ. Hyperbaric oxygen for

carbon monoxide poisoning. Cochrane Database Syst Rev. 2011 Apr 13;(4): CD002041

Clinical Policy: Critical Issues in the Evaluation and Management of Adult Patients

Presenting to the Emergency Department with Acute Carbon Monoxide Poisoning. ACEP

Clinical Policies Subcommittee (Writing Committees) on Carbon Monoxide Poisoning,

American College of Emergency Physicians; Ann Emerg Med. 2017;69:98–107

Hampson N. Practice Recommendations: the diagnosis, management, and prevention

of carbon monoxide poisoning. Am J Respir Crit Care Med. 2012;186(11):1095–101

High Flow Nasal Cannula is superior than CPAP in carbon monoxide poisoning

Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s

Toxicologic Emergencies, 10

Edition. China: McGraw-Hill Education; 2015

Hampson NB. Pulse oximetry in severe carbon monoxide poisoning.

Chest. 1998;114(4):1036–41

Jones A. Recent advances in the management of poisoning. Ther Drug Monit. 2002;24(1):150–

Karaman K, Golcuk Y, Yıldırım B, Acar E. Am J Emerg Med. 2020 Oct 2: S0735-6757(20)30879-2.

doi: 10.1016/j.ajem.2020.09.084. Bahadır Caglar

, Suha Serin

, Gokhan Yilmaz

, Alper

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Torun

, Ismet Parlak The Impact of Treatment with Continuous Positive Airway Pressure on

Acute Carbon Monoxide Poisoning Prehosp Disaster Med. 2019 Dec;34(6):588–591. doi:

10.1017/S1049023X19005028. Epub 2019 Oct 22. PMID: 31637993

Touger M, Birnbaum A, Wang J, Chou K, Pearson D, Bijur P. Performance of the RAD-57

pulse co-oximeter compared with standard laboratory carboxyhemoglobin

measurement. Ann Emerg Med. 2010;56(4):382–8

Revision Date

March 11, 2022

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Opioid Poisoning/Overdose

Aliases

Carfentanil Dilaudid® Drug abuse

Fentanyl Heroin Hydrocodone

Hydromorphone Methadone Morphine

Opiate Opioid Overdose

Oxycodone Oxycontin® Percocet®

Percodan® U-47700 Vicodin®

Patient Care Goals

1. Rapid recognition and intervention of a clinically significant opioid poisoning or overdose

2. Prevention of respiratory and/or cardiac arrest

Patient Presentation

Inclusion Criteria

Patients exhibiting decreased mental status, and respiratory depression of all age groups with

known or suspected opioid use or abuse. Lack of miosis (pinpoint pupils) is not a reliable sign for

ruling out opioid exposure, although its presence is consistent with such exposure

Exclusion Criteria

Patients with altered mental status exclusively from other causes (e.g., head injury, or

hypoglycemia)

Patient Management

Don the appropriate PPE. Note that opioids have minimal vapor pressure and do not pose an

exposure risk to rescuers unless aerosolized or ingested

Therapeutic interventions to support the patient's airway, breathing, and circulation should be

initiated prior to the administration of naloxone

If possible, identify specific medication taken (including immediate release versus sustained

release) time of ingestion, and quantity

Obtain and document pertinent cardiovascular history or other prescribed medications for

underlying disease

Be aware that unsecured hypodermic needles may be on scene if the intravenous route may

have been used by the patient, and that there is a higher risk of needle sticks during the

management of this patient population which may also have an increased incidence of blood-

borne pathogens

Naloxone, an opioid antagonist, should be considered for administration to patients with

respiratory depression in a confirmed or suspected opioid overdose

Naloxone administration via the intravenous route provides more predictable bioavailability

and flexibility in dosing and titration

Naloxone administration via the intranasal or intramuscular routes or as a nebulized solution

provide additional options of medication delivery

If naloxone was administered to the patient prior to the arrival of EMS, obtain the dose and

route through which it was administered and, if possible, bring the devices containing the

dispensed naloxone with the patient along with all other medications on scene

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Assessment

Assess the patient's airway, breathing, circulation, and mental status

Support the patient's airway by positioning, oxygen administration, and ventilator assistance

with a bag valve mask if necessary

Assess the patient for other etiologies of altered mental status including hypoxia (pulse

oximetry less than 94%), hypoglycemia, hypotension, and traumatic head injury

Legally prescribed opioids are also manufactured as an adhesive patch for transdermal

absorption, and if found, should be removed from the skin

Treatments and Interventions

1. Critical resuscitation (opening and/or maintaining the airway, provision of oxygen,

ensuring adequate circulation) should be performed prior to naloxone administration

2. If the patient has respiratory depression from a confirmed or suspected opioid

overdose, consider naloxone administration

a. The administration of the initial dose or subsequent doses can be incrementally

titrated until respiratory depression is reversed

3. Naloxone can be administered via the IV, IM, IN, or ETT routes. As the ETT route is not very

effective, its use should be reserved for dire circumstances with a patient in extremis with no

other choice

a. Adults: The typical initial adult dose ranges between 0.4–2 mg IV, IM, up to a dose of 4 mg

IN or 5 mg ETT

b. Pediatrics: The pediatric dose of naloxone is 0.1 mg/kg IV, IM, IN, or ETT

i. Maximum dose of 2 mg IV, IM, or ETT

ii. Maximum dose of 4 mg IN

4. Naloxone can be administered via the IV, IM, IN, or ETT routes. As the ETT route is not very

effective, its use should be reserved for dire circumstances with a patient in extremis with no

other choice

a. Adults: The typical initial adult dose ranges between 0.4–2 mg IV, IM, up to a dose

of 4 mg IN or 5 mg ETT

b. Pediatrics: The pediatric dose of naloxone is 0.1 mg/kg IV, IM, IN, or ETT

i. Maximum dose of 2 mg IV, IM, or ETT

ii. Maximum dose of 4 mg IN

c. Naloxone provided to laypersons and non-medical first responders via public access

programs or prescriptions may be provided as a pre-measured dose in an auto-injector or

nasal spray or as a pre-measured, but variable, dose and/or concentration in a needleless

syringe with a mucosal atomization device (MAD) on the hub

d. Naloxone auto-injectors contain 0.4 mg/0.4 mL or 2 mg/0.4 mL

i. The cartons of naloxone auto-injectors prescribed to laypersons contain two

naloxone auto-injectors and one trainer

e. Naloxone nasal spray is manufactured in a single-use bottle that contains 4 mg/0.1 mL

f. For the intranasal route when naloxone is administered via a needleless syringe

(preferably with MAD on the hub), divide administration of the dose equally

between the nostrils to a maximum of 1 mL per nostril

g. The administration of naloxone can be titrated until adequate respiratory effort

is achieved if administered with a syringe IV, IM, IN, or ETT

h. Naloxone has no benefit in the treatment of cardiac arrest. Do not delay other

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interventions such as chest compressions and ventilations

5. High-potency opioids [See Key Considerations] may require higher and/or more

frequently administered doses of naloxone to reverse respiratory depression and/or to

maintain adequate respirations

6. Regardless of the doses of naloxone administered, airway management with provision

of adequate oxygenation and ventilation is the primary goal in patients with confirmed

or suspected opioid overdose

Patient Safety Considerations

1. Clinical duration of naloxone

a. The clinical opioid reversal effect of naloxone is limited and may end within an hour

whereas opioids often have a duration of 4 hours or longer

b. Monitor the patient for recurrent respiratory depression and decreased mental status

2. Opioid withdrawal

a. Patients with altered mental status secondary to an opioid overdose may become agitated

or violent following naloxone administration due to opioid withdrawal therefore the goal

is to use the lowest dose as possible to avoid precipitating withdrawal

b. Be prepared for this potential scenario and take the appropriate measures in advance to

ensure and maintain scene safety

3. EMS clinicians should be prepared to initiate airway management before, during, and after

naloxone administration and to provide appropriate airway support until the patient has

adequate respiratory effort

Notes/Educational Pearls

Key Considerations

The essential feature of opioid overdose requiring EMS intervention is

respiratory depression or apnea, managed by ventilation followed by naloxone

Some opioids have additional toxic effects (i.e., methadone can produce QT

prolongation and tramadol can produce seizures)

Overuse and abuse of prescribed and illegal opioids has led to an increase in accidental

and intentional opioid overdoses

Opioid combinations:

a. Some opioids are manufactured as a combination of analgesics with acetaminophen,

acetylsalicylic acid (aspirin), or other substances

b. In the scenario of an overdose, there is a potential for multiple drug toxicities

c. Examples of opioid combination analgesics:

Vicodin® is a combination of acetaminophen and hydrocodone

ii.

Percocet® is a combination of acetaminophen and oxycodone

iii.

Percodan® is a combination of aspirin and oxycodone

iv.

Suboxone® is a combination of buprenorphine and naloxone

High-potency opioids:

a. Fentanyl is 50–100 times more potent than morphine. It is legally manufactured in an

injectable and oral liquid, tablet, and transdermal (worn as a patch) forms however much

of the fentanyl adulterating the heroin supply are illegal fentanyl analogs such as acetyl

fentanyl

b. Carfentanil is 10,000 times more potent than morphine

It is legally manufactured in a liquid form; however, a powder or tablet is the

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most common form of this drug that is illegally produced

ii.

In the concentration in which it is legally manufactured (3 mg/mL), an

intramuscular dose of 2 mL of carfentanil will sedate an elephant

c. Synthetic opioids (i.e., W-18 are 10,000 times more potent than morphine) many

synthetic opioids are not detectable by routine toxicology screening assays

The IN route has the benefit of no risk of needle stick to the clinician

Patients with opioid overdose from fentanyl or fentanyl analogs may rapidly exhibit

chest wall rigidity and require positive end expiratory pressure (PEEP), in addition to

multiple and/or larger doses of naloxone, to achieve adequate ventilation

Pertinent Assessment Findings

1. The primary clinical indication for the use of opioid medications is analgesia

2. In the opioid overdose scenario, signs and symptoms include:

a. Miosis (pinpoint pupils)

b. Respiratory depression

c. Decreased mental status

3. Additional assessment precautions:

a. The risk of respiratory arrest with subsequent cardiac arrest from an opioid overdose

as well as hypoxia (pulse oximetry less than 94%), hypercarbia, and aspiration may be

increased when other substances such as alcohol, benzodiazepines, or other

medications have also been taken by the patient

b. Pediatric Considerations: The signs and symptoms of an opioid overdose may also be

seen in newborns who have been delivered from a mother with recent or chronic

opioid use. Neonates who have been administered naloxone for respiratory

depression due to presumed intrauterine opioid exposure may be narcotic dependent

and should be monitored closely for seizures

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914219—Medical - Opioid Poisoning/Overdose

Key Documentation Elements

•

Rapid and accurate identification of signs and symptoms of opioid poisoning

•

Airway management

•

Pulse oximetry (oxygen saturation) and, if available, capnometry or capnography

•

Blood glucose assessment

•

Naloxone dose and route of administration

•

Clinical response to medication administration

•

Number of doses of naloxone to achieve a clinical response

Performance Measures

• Clinical improvement after prehospital administration of naloxone

• The performance and ongoing assessment of airway management

• Frequency of patients who develop adverse effects or complications (recurrent respiratory

depression or decreased mental status, aspiration pneumonia or pulmonary edema)

• Number of patients who refuse transport following naloxone administration

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References

1. American College of Medical Toxicology and the American Academy of Clinical

Toxicology, Preventing Occupational Fentanyl and Fentanyl Analog Exposure to

Emergency Responders,

https://www.acmt.net/_Library/Positions/Fentanyl_PPE_Emergency_Responders_.pdf.

Accessed March 11, 2022

2. Burns G, DeRienz RT, Baker DD, Casavant M, Spiller HA. Could chest wall rigidity be a

factor in rapid death from illicit fentanyl abuse? Clin Toxicol. 2016;54(5):420–3

3. Drugs@FDA: FDA Approved Drug Products. FDA.gov.

https://www.accessdata.fda.gov/scripts/cder/daf/. New Drug Application (NDA)

#208411. Accessed March 11, 2022

4. Drugs@FDA: FDA Approved Drug Products. FDA.gov.

https://www.accessdata.fda.gov/scripts/cder/daf/. New Drug Application (NDA)

#209862. Accessed March 11, 2022

5. Fentanyl: Preventing Occupational Exposure to Emergency Responders. Atlanta, GA:

Centers for Disease Control and Prevention, the National Institute for Occupational

Safety and Health; Updated November 28, 2016

6. Hoffman RS, Howland MA, Lewin NA, Nelson LS, Goldfrank LR. Goldfrank’s

Toxicologic Emergencies, 10

Edition. China: McGraw-Hill Education; 2015

7. Marx JA et al. Rosen’s Emergency Medicine: Concepts and Clinical Practice, 2014 2052–2056

8. Nelson, LS et al. Goldfrank’s Toxicologic Emergencies, 2014, 559–578

9. Title 21 United States Code (USC) Controlled Substance Act, Section 812. Springfield, VA:

US Department of Justice, Drug Enforcement Administration

Revision Date

March 11, 2022

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Airway Respiratory Irritants

Aliases

Airway injury Chemical respiratory Injury

Respiratory injury Respiratory irritant Toxic inhalation

Patient Care Goals

Rapid recognition of the signs and symptoms of confirmed or suspected airway respiratory irritants

Patient Presentation

Inclusion Criteria

Inhalation of a variety of gases, mists, fumes, aerosols, or dusts may cause irritation or injury

to the airways, pharynx, lung, asphyxiation, or other systemic effects

Inhaled airway/respiratory irritant agents will interact with the mucous membranes, upper

and lower airways based on solubility, concentration, particle size, and duration of exposure

The less soluble and smaller the particle size of the agent the deeper it will travel into the

airway and respiratory systems the inhaled toxic agent will go before reacting with adjoining

tissues thus causing a greater delay in symptom onset

Signs and Symptoms

1. As the type, severity and rapidity of signs and symptom onset depends on agent, water

solubility, concentration, particle size, and duration of exposure, the below signs and

symptoms are often overlapping and escalating in severity

2. Many airways and respiratory irritant agents have "warning properties" such as identifiable or

unpleasant smells or irritation to eyes or airways

3. Some agents do not have clear warning properties and will often have delayed onset of any

sign or symptom:

a. Unusual odor/smell

b. Tearing or itchy eyes

c. Burning sensation and burns to the nose, pharynx, and respiratory tract

d. Sneezing

e. General excitation

f. Cough

g. Chest tightness

h. Nausea

i. Shortness of breath/dyspnea

j. Wheezing

k. Stridor

l. Dyspnea on exertion

m. Dizziness Upper

n. Change in voice

o. Airway obstructions include laryngospasm and laryngeal edema

p. Pulmonary edema (non-cardiogenic)

q. Seizures

r. Cardiopulmonary arrest

4. High water solubility/highly irritating (oral/nasal and pharynx, particle size greater than

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10 micrometers)

a. Acrolein

b. Ammonia

c. Chloramine

d. Ethylene oxide

e. Formaldehyde

f. Hydrogen chloride

g. Methyl bromide

h. Sodium azide

i. Sulfur dioxide

5. Intermediate water solubility (bronchus and bronchiole, particle size 5–10 micrometers)

a. Chlorine

6. Low water solubility/less irritating (alveolar, particle size less than 5 micrometers)

a. Cadmium fume

b. Fluorine

c. Hydrogen sulfide (rotten egg odor; olfactory fatigue)

d. Mercury fume

e. Mustard gas (also delayed blistering skin manifestations)

f. Nickel carbonyl

g. Ozone

h. Phosgene

7. Asphyxia agents (two categories)

a. Oxygen deprivation below 19.5% oxygen atmosphere ("simple asphyxiants")

Any gas that reduces oxygen fraction or displaces oxygen from the inspired air

Argon

ii.

Carbon dioxide

iii.

Ethane

iv.

Helium

Methane

vi.

Natural gas (e.g., heptane, propane)

vii.

Nitrogen

viii.

Nitrogen dioxide (delayed symptom onset)

b. Chemical interfering with oxygen delivery of utilization ("chemical asphyxiants")

Carbon monoxide [See Carbon Monoxide/Smoke Exposure Guideline]

ii.

Cyanide [See Cyanide Exposure Guideline]

iii.

Hydrogen sulfide

8. Inhalants of abuse

a. These agents or substances are a diverse class of substances that include

volatile solvents, aerosols, and gases

b. These chemicals are intentionally inhaled to produce a state that resembles

alcohol intoxication with initial excitation, drowsiness, lightheadedness, and

agitation

c. Users of these inhaled agents are often called huffers, sniffers, baggers, or

snorters

i. These individuals often present after inhaling an aerosol or gas with a loss of

consciousness and the presence of the aerosol can or residue/paint around or in

the mouth, nose, and oral pharynx

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d. Common household products that are used as inhalants of abuse

Volatile solvents

Paint remover

Degreasers

Dry-cleaning fluids

Gasoline

Lighter fluid

Correction fluid

Felt tip markers

Glue

ii.

Cosmetic/paint spray

Deodorant spray

Vegetable oil spray

Fabric protector spray

Spray paint

iii.

Propellants/asphyxiants/nitrous oxide

Propane gas

Balloon tanks (helium)

Computer keyboard cleaner

Ether

Halothane

Chloroform

Butane

Propane

Whipped cream dispensers

9. Riot Control Agents [See Riot Control Agent Guideline]

10. A prototype agent is identified with each region of the effected airway respiratory track

for mild to moderate exposures, as severe concentrated exposures of many of these

agents overlap in signs and symptoms — the deeper the symptoms are in the respiratory

track and the slower the rate of symptom onset the less water soluble the airway

respiratory irritant

a. Nasal and oral pharynx irritation: highly water-soluble agents (ammonia)

b. Bronchial irritation (chlorine)

c. Acute pulmonary edema/deep alveolar injury: poorly water soluble (phosgene)

d. Direct neurotoxin (hydrogen sulfide)

e. Asphyxia agent with additional symptoms (nitrogen dioxide — Silo Filler's disease)

f. Inhalants of abuse (volatile solvents, cosmetics/paints,

propellants/asphyxiants/nitrous oxide)

g. Riot control agents [See Riot Control Agent Guideline]

h. Anticholinesterase inhibitors [See Acetylcholinesterase Inhibitors Guideline]

11. Ammonia

a. Immediate detection of unique sharp smell

b. Nasal pharyngeal burning/irritation sensation

c. Ocular tearing and irritation

d. Sneezing

e. Altered mental status — sleepy to agitated

f. Cough

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g. Shortness of breath

h. Chest tightness

i. Bronchospasm wheezing

j. Change in voice

k. Upper airway obstruction includes laryngospasm and laryngeal edema

l. Corneal burns or ulcers

Skin burns

Pharyngeal, tracheal, bronchial burns

Dyspnea/tachypnea

High concentrations and or protracted exposure may develop non-cardiac

pulmonary edema

Esophageal burns

12. Chlorine

a. All the above (ammonia)

b. Increased likelihood of the following

Bronchiole burns

ii.

Bronchospasm wheezing

iii.

Non-cardiac pulmonary edema develops within 6–24 hours of higher

exposures

13. Phosgene

a. Often have none of the above symptoms for first half hour to several hours then

are much milder until more severe lower respiratory tract symptoms develop

i. Only warning is report of "fresh mowed hay" odor

ii. Mild airway irritation or drying

iii. Mild eye irritation

iv. Fatigue

v. Chest tightness

vi. Dyspnea/tachypnea

vii. Significant delay up to 24 hours for

Exertional dyspnea

Bronchospasm wheezing

Hypoxia

Severe non-cardiac pulmonary edema

Cardiopulmonary arrest

14. Hydrogen sulfide — A direct neurotoxin and is rapidly absorbed through lung

generating systemic effects

a. Distinctive rotten egg smell which rapidly causes olfactory fatigue/loss of sense of smell

b. Cough

c. Shortness of breath

d. Rapid alternations in cognition or consciousness

e. Bronchiole and lung hemorrhage/hemoptysis

f. Non-cardiac pulmonary edema

g. Hydrogen sulfide is known as the "knock down" gas because of near immediate

and sudden loss of consciousness with high concentrations

h. Asphyxia

i. Death

15. Nitrogen dioxide (also called Silo Filler's disease)

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a. Heavier than air displacing oxygen from low lying areas and closed spaces causing

direct asphyxia

b. Low concentrations may cause

Ocular irritation

ii.

Cough

iii.

Dyspnea/tachypnea

iv.

Fatigue

c. High concentrations:

i. Altered mental status including agitation

ii. Cyanosis

iii. Vomiting

iv. Dizziness

v. Loss of consciousness

vi. Cardiopulmonary arrest

16. Inhalants of abuse (i.e., felt tip markers, spray paint)

a. Physical presences of paint or residue on individual from the inhaled agent

b. Slurred speech

c. Altered mental status (excitation, drowsiness to unconsciousness)

d. Loss of consciousness

e. Cardiac dysrhythmias

f. Cardiopulmonary arrest

Patient Management

Don appropriate PPE — respiratory protection critical

Remove patient from the toxic environment

a. Remove the patient's clothing that may retain gases or decontaminate if liquid or

solid contamination

b. Flush irrigated effected/burned areas

Rapidly assess the patient's respiratory status, mental status, and oxygenation

Administer (humidified if available) oxygen

Establish intravenous access (if possible)

Apply a cardiac monitor (if available)

Continuous and ongoing patient reassessment is critical

Assessment

1. Make sure the scene is safe as many gases are heavier than air and will build up in low lying

areas. This is especially true of hydrogen sulfide and it's "knock down" effect of the initial

unprotected responder and subsequence casualties associated with unprotected rescuers

attempting to safe the first downed responder

2. Consider BSI or appropriate PPE

3. Remove patient from toxic environment

4. Decontaminate

5. Assess ABCD and if indicated, expose the patient, and then cover the patient to assure

retention of body heat

6. Vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment) which

include temperature

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7. Place cardiac monitor and examine rhythm strip for arrhythmia potentials (consider 12-lead

EKG)

8. Check blood glucose Level

9. Monitor pulse oximetry and EtCO

for respiratory decompensation

10. Perform carboxyhemoglobin and cyanide device assessment, if available

11. Identify specific suspected agent if possible

12. Pertinent cardiovascular history or other prescribed medications for underlying disease

13. Patient pertinent history

14. Patient physical examination

Treatment and Interventions

1. Assure a patent airway

2. Administer (humidified if available) oxygen and if hypoventilation, toxic inhalation,

or desaturation noted, support breathing

a. Maintain the airway and assess for airway burns, stridor, or airway edema and if

indicated, perform intubation early (recommendation to avoid supraglottic airways

— cricothyrotomy may be required in rare severe cases

b. Non-invasive ventilation techniques

Use continuous CPAP, BiPAP, intermittent positive pressure breathing (IPPB),

HFNC, and/or bilevel nasal CPAP for severe respiratory distress or impending

respiratory failure

ii.

Use bag-valve-mask (BVM) ventilation in the setting of hypoventilation,

respiratory failure, or arrest

3. While albuterol 2.5 mg nebulized is usually sufficient for mild wheezing without clinical

distress, albuterol 5 mg nebulized (or 6 puffs metered dose inhaler) should be

administered to all patients in respiratory distress with signs of bronchospasm either by

basic life support BLS or ALS clinicians. This medication should be repeated at this dose

with unlimited frequency for ongoing distress

4. lpratropium 0.5 mg nebulized should be given up to 3 doses, in conjunction with albuterol

5. Initiate IV access for infusion of lactated Ringer's or normal saline and obtain blood

samples in effort to record pre-treatment levels, e.g., via point-of-care testing, associated

with EMS management (e.g., glucose, lactate, cyanide)

6. Fluid bolus (20 mL/kg) if evidence of hypoperfusion

7. If the patient is experiencing significant pain, administer IV/IO analgesics

a. Morphine sulfate 0.1 mg/kg IV or IO

b. Fentanyl 1 mcg/kg IV or IO

8. Eye irrigation early

9. Treat topical chemical burns [See appropriate Toxins and Environmental

Section guideline(s)]

10. In severe respiratory irritation, in particular hydrogen sulfide, with altered mental status and

no improvement with removal from the toxic environment, administer oxygen (humidified if

available) as appropriate with a target of achieving 94–98% saturation. Consider consultation

for transfer to a tertiary care hospital. If carbon monoxide is a confirmed or suspected

element of the inhalant, a facility with hyperbaric oxygen capabilities is preferred

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Medication Administration

If wheezing is present, consider administering inhaled albuterol (2.5–5 mg) as nebulized, or

four to eight puffs metered dose inhaler

lpratropium 0.5 mg nebulized should be given in conjunction with albuterol, up to three doses

Patient Safety Considerations

Generally, speaking to patients with exposure to highly soluble airway/respiratory irritants you

will find that they have self-extricated due to the warning properties such as the smell,

rapidity of onset of irritation, and other symptoms

The less soluble agents may generate only an odor (e.g., mowed hay smell for Phosgene) and

will have delayed serious symptoms such as acute pulmonary edema, hypoxia, and shortness

of breath with minimal exertion

Notes/Educational Pearls

Key Considerations

Airway respiratory irritants can exacerbate underlying reactive airway diseases (e.g.,

asthma, chronic obstructive pulmonary disease (COPD)) and precipitate or exacerbate

bronchospasm, respiratory distress, and hypoxia

As patients may be off gassing (particularly hydrogen sulfide and hydrogen cyanide) in the

back of the transport vehicle, it is important to have adequate ventilation of the patient

compartment

Removal from the toxic environment, oxygen (humidified if available), general supportive

therapy, bronchodilators, respiratory support, and rapid transport are core elements of

care as there are no specific antidotes for any of these inhaled agents except for heavy

metals that may be chelated in-hospital after agent identification

Hydrogen sulfide causes the cells responsible for the sense of smell to be stunned into

inaction and therefore with a very short exposure will shut down and the exposed victim

will not perceive the smell, yet the victim continues to absorb the gas as it is still present

Inhaled agents have become popular as a means of committing suicide. If there is some

form of suicide signage, hoses, or buckets of substances visible as you arrive at the

vehicle or residence, immediately retreat to well ventilated area and don self-contained

breathing apparatus (SCBA) before opening the vehicle or making entry as these gases

may be highly concentrated and potentially lethal to EMS responders

Household bathroom, kitchen, and oven cleaners when mixed can generate various

airway respiratory irritants (ammonia, chloramine, and chlorine gas releases are

particularly common). A very common exposure is to chloramine, a gas liberated when

bleach (hypochlorite) and ammonia are combined. Chloramine then hydrolyzes in the

distal airways and alveoli to ammonia and hypochlorous acid

Sudden sniffing death can result from a single use of inhalant of abuse

a. Some inhalants can cause cardiac arrest due to dysrhythmias from irritated

myocardium

b. This syndrome most often is associated with abuse of butane, propane, and effects

of the chemicals in the aerosols

Pertinent Assessment Findings

1. Patient may describe a specific odor (chlorine swimming pool smell, ammonia smell,

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fresh mowed hay smell [phosgene]) which may be helpful but should not be relied upon

as the human nose is a poor discriminator of scent

2. Respiratory distress (retractions, wheezing, stridor)

3. Decreased oxygen saturation

4. Skin color

5. Neurologic status assessment

6. Reduction in work of breathing after treatment

7. Improved oxygenation after breathing

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914033—Exposure - Airway/Inhalation Irritants

•

9914139—Medical - Respiratory Distress/Asthma/COPD/Reactive Airway

Key Documentation Elements

•

Document key aspects of the exam to assess for a change after each intervention:

o Respiratory rate

o Oxygen saturation

o Use of accessory muscles or tracheal tugging

o Breath sounds

o Air entry/stridor

o Mental status

o Color

o Reduction of burning sensation in airway/pharynx

Performance Measures

•

Clinical improvement in patient and response to therapy

•

Survival rates of victims

•

Long term sequelae of the victims

•

No EMS clinicians injured while managing these incidents

References

Ainsile G. Inhalational injuries produced by smoke and nitrogen dioxide. Respir Med. 1993;

87:169–74

Arwood R, Hammond J, Ward GG. Ammonia inhalation. J Trauma. 1985; 25:444–7

Baydala L, Canadian Paediatric Society, First Nations, Inuit and Métis Health

Committee. Inhalant Abuse. Paediatr Child Health. 2010;15(7):443–8

Chenuel B, Sonobe T, Haouzi P. Effects of infusion of human methemoglobin

solution following hydrogen sulfide poisoning. Clin Toxicol (Phila). 2015;53(2):93–

101

Chlorine Toxicity. Emedicine.medscape.com. http://www.emedicine.com/emerg/

topic851.htm Updated Dec 11, 2015. Accessed March 11, 2022

D’Alessandro A, Kuschner W, Wong H, et al. Exaggerated responses to chlorine

inhalation among persons with nonspecific airway hyperreactivity. Chest. 1996;

109:331–7

Douglas WW, Hepper NGG, Colby TV. Silo-filler’s disease. Mayo Clin Proc. 1989; 64:291–304

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Fuller DC, Suruda AJ. Occupationally related hydrogen sulfide deaths in the United

States from 1984 to 1994. J Occup Environ Med. 2000;42(9):939–42

Gorguner M, Akgun M. Acute Inhalation Injury. Eurasian J Med. 2010;42(1):28–35

10.

Guloglu C, Kara IH, Erten PG. Acute accidental exposure to chlorine gas in the Southeast

of Turkey: a study of 106 cases. Environ Res. 2002; 88:89–93

11.

Haouzi P, Chenuel B, Sonobe T. High-dose hydroxocobalamin administered after H2S

exposure counteracts sulfide poisoning induced cardiac depression in sheep. Clin Toxicol

(Phila). 2015 Jan;51(1): 28–36

12.

Hydrogen Sulfide Toxicity. Emedicine.medcape.com. http://www.emedicine.com/emerg/

topic258.htm Updated December 29, 2016. Accessed March 11, 2022

13.

Issley S, Lang E. Ammonia Toxicity. Emedicine.medscape.com.

http://www.emedicine.com/emerg/topic846.htm Updated December 29, 2015. Accessed

March 11, 2022

14.

Leduc D, Gris G, Lheureux P, et al. Acute and long-term respiratory damage

following inhalation of ammonia. Thorax. 1992; 47:755–7

15.

Lim SC, Yang JY, Jang AS, et al. Acute lung injury after phosgene inhalation. Korean J

Intern Med. 1996; 11:87–92

16.

Mowry JB, Spyker DA, Brooks DE, Zimmerman A, Schauben JL. 2015 Annual Report of the

American Association of Poison Control Centers' National Poison Data System (NPDS):

33rd Annual Report. Clin Toxicol (Phila). 2016;(10):924–1109

17.

Newman LS, Gottschall EB. Toxic Inhalational Lung Injury. In: Albert RK, Spiro SG, Jett JR, ed.

Clinical Respiratory Medicine. 2nd Edition. Philadelphia, PA: Mosby; 2004:759–64

18.

Noltkamper D, Burgher SW. Toxicity Phosgene 2006. Available at:

https://www.ncbi.nlm.nih.gov/books/NBK537213/. Accessed March 11, 2022

19.

Phosgene Toxicity. Emedicine.medscape.com.

https://www.ncbi.nlm.nih.gov/books/NBK537213/. Accessed March 11, 2022

20.

Reiffenstein RJ, Hulbert WC, Roth SH. Toxicology of hydrogen sulfide. Ann Rev

Pharmacol Toxicol. 1992; 32:109–34

21.

Sams RN, Carver HW 2nd, Catanese C, Gilson T. Suicide with hydrogen sulfide. Am J

Forensic Med Pathol. 2013;34(2):81–2

22.

Truscott A. Suicide fad threatens neighbors, rescuers. CMAJ. 2008 Aug 12;179(4):312–3

23.

Weinberger B, Laskin DL, Heck DE, et al. The toxicology of inhaled nitric oxide. Toxicol Sci.

2001; 59:5–16

Revision Date

March 11, 2022

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Riot Control Agents

Aliases

Chemical crowd control agents 2-Chloroacetophenone (CN, Mace®)

Harassing agents Incapacitating agents

Lacrimators o-chlorobenzylidene malononitrile (CS)

Oleoresin capsicum (OC, pepper spray) Tear gas

Patient Care Goals

Address side effects of exposed individuals

Decontamination of affected individuals

Minimize effect to clinician

Patient Presentation

Inclusion Criteria

Exposure to identifiable agents that are not intended to cause significant injury or fatality

Exclusion Criteria

Exposure to chlorine, phosgene, ammonia, or other agents that are intended to cause

significant injury or fatality

Exposure to an unknown agent

Patient Management

Assessment

1. Assess scene safety: evaluate for hazards to EMS personnel, patient, bystanders

a. Determine riot control agent being used

b. Don appropriate PPE

c. Determine number of patients

2. Note symptoms exhibited by the exposed individual

3. Examine as appropriate to complaints

Treatment and Interventions

Move affected individuals from contaminated environment into fresh air if possible

Remove contaminated clothing as able

Have patient remove contact lenses if appropriate

Irrigation with water or saline may facilitate resolution of symptoms and is recommended for

decontamination of dermal and ocular exposure

If patient is in respiratory distress, go to Respiratory Section

If patient is wheezing, go to Bronchospasm Guideline

For persistent pain of the eye or skin, go to Topical Chemical Burn Guideline

Exposed individuals who are persistently symptomatic warrant further evaluation and

treatment per local standards

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Patient Safety Considerations

Toxicity is related to duration of exposure and concentration of agent used (exposure in non-

ventilated space)

Patients with pre-existing pulmonary conditions (e.g., asthma, COPD) may be prone to more

severe respiratory effects

Traumatic injury may result when exposed individuals are in proximity to the device used to

disperse the riot control agent (e.g., hose/stream under pressure, riot control agent projectile,

grenade)

Notes/Educational Pearls

Key Considerations

CN, CS, and OC are the most encountered riot control agents

CN, CS, and OC have a high safety ratio. All three have a high median lethal

concentration (LCt50) and a low median effective concentration (ECt50)

Toxicity is related to time of exposure and concentration of agent used (exposure in

non-ventilated space)

Symptoms that may be experienced after exposure:

a. Eyes: tearing, pain, conjunctivitis, blurred vision

b. Nose/mouth/throat: rhinorrhea, burning/pain, trouble swallowing, drooling

c. Lungs: chest tightness, coughing, choking sensation, wheezing, dyspnea

d. Skin: burning, redness, dermatitis

e. GI: nausea and vomiting are rare and may be posttussive

Symptoms begin within seconds of exposure, are self-limited and are best treated by

removing patient from ongoing exposure. Symptoms frequently decrease over time (15–

45 minutes) after exposure ends

Pertinent Assessment Findings

1. Riot control agent used

2. Symptoms of exposed

3. Lung sounds

4. Evidence of other traumatic injuries

Quality Improvement

Key Documentation Elements

•

Type of riot control agent if known

•

Symptoms being treated

•

Treatment provided

•

Response to treatment

Performance Measures

•

Riot control agent identified before making patient contact and providing treatment

•

PPE used by responders

•

Affected individuals removed from ongoing exposure

•

Contaminated clothing and contact lenses removed as able

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References

1. Barry JD, Hennessy R, McManus JG Jr. A randomized controlled trial comparing

treatment regimens for acute pain for topical oleoresin capsaicin (pepper spray)

exposure in adult volunteers. Prehosp Emerg Care. 2008 Oct–Dec;12(4):432–7

2. Dimitroglou Y, Rachiotis G, Hadjichristodoulou C. Exposure to the Riot Control Agent CS

and Potential Health Effects: A Systematic Review of the Evidence. Int. J. Environ. Res.

Public Health 2015, 12(2), 1397–1411

3. Menezes RG, Hussain SA, Rameez MA, Kharoshah MA, Madadin M, Anwar N,

Senthilkumaran S, Chemical crowd control agents. Med Leg J. 2016 Mar;84(1):22–

4. Riot-control agents. Army.mil. https://medcoe.army.mil/borden-field-mgt-of-cb-

casualities. Accessed March 11, 2022

5. Riot control agents. Fas.org.

https://fas.org/nuke/guide/usa/doctrine/army/mmcch/RiotAgnt.htm. Accessed August 29,

2017

6. Riot control agents/tear gas. CDC.gov. https://emergency.cdc.gov/agent/riotcontrol/

factsheet.asp. Accessed March 11, 2022

7. Schep LJ, Slaughter RJ, McBride DI. Riot control agents: the tear gases CN, CS and OC- a

medical review. J R Army Med Corps. 2015 Jun;161(2):94–9. http://jramc.bmj.com/

content/161/2/94.long. Epub 2013 Dec 30. Accessed March 11, 2022

Revision Date

March 11, 2022

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Hyperthermia/Heat Exposure

Aliases

Heat cramps Heat edema Heat exhaustion

Heat stroke Heat syncope Hyperthermia

Definitions

1. Heat Cramps: are muscle cramps usually in the legs and abdominal wall. Patient temperature

is normal

2. Heat Exhaustion: has both salt and water depletion usually of a gradual onset. As it progresses

tachycardia, hypotension, elevated temperature, and very painful cramps occur. Symptoms of

headache, nausea, and vomiting occur. Heat exhaustion can progress to heat stroke

3. Heat Stroke: occurs when the cooling mechanism of the body ceases due to temperature

overload and/or electrolyte imbalances. Patient core temperature is usually greater than

104°F. When no thermometer is available, it is distinguished from heat exhaustion by altered

level of consciousness, seizures, or coma

4. Heat Syncope: transient loss of consciousness with spontaneous return to normal mentation,

attributable to heat exposure

Patient Care Goals

1. Cooling and rehydration

2. Mitigate high-risk for decompensation

3. Mitigate high-risk for agitation and uncooperative behavior

Patient Presentation

Inclusion Criteria

1. Heat cramps

2. Heat exhaustion

3. Heat stroke

4. Heat syncope

5. Heat edema

6. Stimulant drug abuse

7. Delirium with agitated behavior [See Agitated or Violent Patient/Behavioral Emergency

Guideline]

Exclusion Criteria

1. Fever from infectious or inflammatory conditions

2. Malignant hyperthermia

3. Serotonin syndrome

4. Neuroleptic malignant syndrome

Patient Management

Assessment

1. Patient Assessment:

a. Age

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b. Oral intake

c. Medications

Alcohol

Illicit drugs

Overdose

Withdrawal risk

2. Environmental Assessment:

a. Ambient temperature and humidity

b. Exertion level

c. Length of time at risk

d. Attire (clothing worn)

e. Confined space

i. Pediatric Considerations: Children left in cars who show signs of altered mental

status and elevated body temperature should be presumed to have hyperthermia

3. Associated Symptoms:

a. Cramps

b. Headache

c. Orthostatic symptoms

d. Nausea

e. Weakness

f. Mental status changes, including

i. Confusion

ii. Coma

iii. Seizures

iv. Psychosis

4. Vital signs:

a. Core temperature: usually 104°F or greater (if thermometer available)

b. Skin:

i. Flushed and hot

ii. Dry or sweaty

iii. Signs of first or second degree burns from sun exposure

c. Other signs of poor perfusion/shock

Treatment and Interventions

1. Move victim to a cool area and shield from the sun or any external heat source

2. Remove as much clothing as is practical and loosen any restrictive garments

3. If alert and oriented, give small sips of cool liquids

4. If altered mental status, check blood glucose level

5. Manage airway as indicated

6. Place on cardiac monitor and record ongoing vital signs (pulse, blood pressure, respiratory

rate, neurologic status assessment)

7. If core temperature is greater than 104°F (40°C) or if altered mental status is present,

begin active cooling by:

a. Ice bath immersion provides the most rapid cooling mechanism

b. If ice bath immersion is not available, consider the following:

i. Tarp-assisted cooling with oscillation

ii. Rotating ice water-soaked towels or sheets

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iii. Continually misting the exposed skin with tepid water while fanning the victim

iv. Truncal ice packs may be used, but are less effective than evaporation

v. DO NOT apply wet cloths or wet clothing, as they may trap heat and prevent

evaporative cooling

c. If shivering occurs during cooling and prevents effective cooling, benzodiazepines

may be considered:

i. Adult:

Midazolam

a. 2.5 mg IV/IN, may repeat once in 5 minutes

b. 5 mg IM may repeat once in 10 minutes

Lorazepam

a. 1 mg IV, may repeat once in 5 minutes

b. 2 mg IM, may repeat once in 10 minutes

c. Diazepam – 2 mg IV, may repeat once in 5 minutes

ii. Pediatric:

Midazolam (single maximum dose 1 mg)

a. 0.5 mg/kg IV, maximum single dose 2 mg, may repeat once in 10 minutes

b. 0.2 mg/kg IN/IM, maximum single dose 10 mg

c. NOTE: a 5 mg/mL concentration is recommended for IN/IM

administration

Lorazepam (single maximum dose 1 mg)

a. 0.1 mg/kg IV/IM

Diazepam

a. 0.1 mg/kg IV (maximum single dose 2.5 mg)

b. May repeat once, for maximum total IV/IM dose 5 mg

c. 0.5 mg/kg PR (maximum single dose 10 mg)

d. May repeat once for maximum total PR dose 20 mg

8. Cooling efforts should continue until the patient's temperature is less than 102.2°F

(39°C) or, if continuous temperature monitoring is not available, until the patient

demonstrates improvement in mental status

9. Establish IV access for patients suffering from heat stroke — give cool fluids at 20

mL/kg boluses and reduce to 10 mL/kg/hr boluses when vitals are stable

10. Monitor for arrhythmia and cardiovascular collapse [See Cardiovascular Section]

11. Treat seizures, per the Seizures Guideline

12. All patients suffering from life threatening heat illness (including heat stroke) should

be transported to the hospital

Patient Safety Considerations

Consider use of physical securing devices [See Agitated or Violent Patient/Behavioral Emergency

Guideline] to protect vascular access sites.

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Notes/Educational Pearls

Key Considerations

Patients at risk for heat emergencies include neonates, infants, geriatric patients,

and patients with mental illness

Contributory risk factors may come from:

a. Prescription and over-the-counter herbal supplements

b. Cold medications

c. Heart medications

d. Diuretics

e. Psychiatric medications

f. Drug abuse

g. Accidental or intentional drug overdose

Heat exposure can occur either due to increased environmental temperatures or

prolonged exercise or a combination of both

a. Environments with temperature greater than 90°F and humidity greater than 60% present

the most risk

Heat stroke is associated with cardiac arrhythmias independent of drug

ingestion/overdose Heat stroke has also been associated with cerebral edema

For patients with signs and symptoms of heat stroke, rapid cooling takes priority over

other interventions (e.g., cardiac monitoring, IV access)

Do not forget to look for other causes of altered mental status such as low blood glucose

level, or, in the proper circumstances (i.e., endurance exercise events), consider exercise

associated hyponatremia (EAH), especially in the patient with altered mental status,

normal blood glucose, and normal temperature

Controversy: shivering may occur while treating heat stroke

a. It is uncertain how harmful shivering is to heat stroke patients

b. Cooling should be continued until the above temperature and mental status goals

are met

c. Treat shivering as above

d. Research does not demonstrate the value of one benzodiazepine over another

in shivering patients or any value of other medications

Hyperthermia not from environmental factors has a differential that includes the following:

a. Fever and delirium

b. Hyperthyroid storm

c. Delirium tremens (DTs)

d. CNS lesion or tumor

e. Adverse drug event: neuroleptic malignant syndrome, malignant hyperthermia

f. Mental status changes without hyperthermia in the correct circumstances could be

exercise associated hyponatremia

There is no evidence supporting EMS obtaining orthostatic vital signs as a clinical indicator

Pertinent Assessment Findings

1. Warning signs: fever, altered mental status

2. Blood glucose level for AMS

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Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914027—Environmental - Heat Exposure/Heat Exhaustion

•

9914029—Environmental - Heat Stroke/Heat Exposure

Key Documentation Elements

• Patient assessment includes all types of medication/drug use and detailed past medical

history

• Environmental assessment performed

• Cooling interventions considered and implemented

• Decision-making regarding securing devices

• Decision-making regarding monitoring ABCs (Airway, Breathing, Circulation)

Performance Measures

•

Blood glucose level obtained

•

Fluids given for hypotension

•

Attempts to reduce core temperature

•

Time from arrival at scene to when active cooling by immersion is started

•

All decompensations during EMS care reviewed

•

National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

Hypoglycemia—01: Treatment Administered for Hypoglycemia.

• Measure of patients who received treatment to correct their hypoglycemia

Pediatrics—03: Documentation of Estimated Weight in Kilograms

References

Belval, L., Casa, D., Adams, W., Chiampas, G., Holschen, J., Hosokawa, Y., Jardine, J., Kane, S.,

Labotz, M., Lemieux, R., McClaine, K., Nye, N., O'Connor, F., Prine, B., Raukar, N., Smith, M.

and Stearns, R., 2022. Consensus Statement- Prehospital Care of Exertional Heat Stroke.

Bouchama A, Knochel JP. Heat Stroke. NEJM. 2002;346(25):1978–88

Bouchama A, Dehbi M, Chaves-Carballo E. Cooling and hemodynamic

management in heatstroke: practical recommendation. Crit Care Lond Engl.

2007;11(3): R54

Brugger H, Bouzat P, Pasquier M, Mair P, Fieler J, Darocha T, Blancher M, de

Riedmatten M, Falk M, Paal P, Strapazzon G, Zafren K, Brodmann Maeder M. Cut-off

values of serum potassium and core temperature at hospital admission for

extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective

multi-centre study. Resuscitation. 2019;139:222–229. doi:

10.1016/j.resuscitation.2019.04.025

Epstein, Y., Yanovich, R. “Heatstroke” N Engl J Med 2019;380:2449-59. https://

www.nejm.org/doi/pdf/10.1056/NEJMra1810762?articleTools=true. Accessed March

11, 2022

Heled Y, Rav-Acha M, Shani Y et al. The “Golden Hour” for heatstroke treatment. Mil Med,

2004 169(3)184–186

Lipman G, Eifling K, Ellis MA, et. al. Wilderness Medical Society practice guidelines for

the prevention and treatment of heat-related illness. Wilderness Environ Med.

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2013;24(4):351–61

Luhring, K. E., Butts, C. L., Smith, C. R., Bonacci, J. A., Ylanan, R. C., Ganio, M. S., &

McDermott, B. P. (2016). Cooling Effectiveness of a Modified Cold-Water Immersion Method

After Exercise-Induced Hyperthermia. Journal of athletic training, 51(11), 946–951.

https://doi.org/10.4085/1062-6050-51.12.07. Accessed March 11, 2022

Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B,

Wanscher M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-

an update: The content of this review is endorsed by the International Commission

for Mountain Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg

Med. 2016;24:111. doi: 10.1186/s13049-016-0303-7

10.

ROBERT GAUER, MD, BRYCE K. MEYERS, DO, MPH, Heat Related Illnesses. Am Fam

Physician. 2019 Apr 15;99(8):482–489

11.

The Futility of Orthostatic Measurements. Lifeinthefastlane.com. https://litfl.com/

the-futility-of-orthostatic-measurements/. Published January 14, 2014. Accessed

March 11, 2022

12.

Vicario SJ, Okabajue R, Haltom T. Rapid cooling in classic heatstroke treatment: effect

on mortality rates. Am J Emerg Med. 1986;4(5):394–8

Revision Date

March 11, 2022

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Hypothermia/Cold Exposure

Aliases

Cold induced injuries Frost bite Hypothermia

Patient Care Goal

aintain hemodynamic stability

2. Prevent further heat loss

3. Rewarm the patient in a safe manner

4. Appropriate management of hypothermia induced cardiac arrest

5. Prevent loss of limbs

Patient Presentation

1. Patients may suffer from hypothermia due to exposure to a cold environment (increased heat

loss) or may suffer from a primary illness or injury that, in combination with cold exposure

(heat loss in combination with decreased heat production), leads to hypothermia

2. Patients may suffer systemic effects from cold (hypothermia) or localized effects (i.e.,

frostbite)

3. Patients with mild hypothermia will have normal mental status, shivering, and may have

normal vital signs while patients with moderate to severe hypothermia will manifest mental

status changes, eventual loss of shivering and progressive bradycardia, hypotension, and

decreased respiratory status

4. Patients with frostbite will develop numbness involving the affected body part along with a

"clumsy" feeling along with areas of blanched skin — later findings include a "woody"

sensation, decreased or loss of sensation, bruising or blister formation, or a white and waxy

appearance to affected tissue

Inclusion Criteria

Patients suffering systemic or localized cold injuries.

Exclusion Criteria

Patients without cold exposure

Patients with cold exposure but no symptoms referable to hypothermia or frostbite

Patient Management

Assessment

1. Patient assessment should begin with attention to the primary survey, looking for

evidence of circulatory collapse and ensuring effective respirations

a. The patient suffering from moderate or severe hypothermia may have

severe alterations in vital signs including weak and extremely slow pulses,

profound hypotension, and decreased respirations

b. The rescuer may need to evaluate the hypothermic patient for a pulse for

longer than the normothermic patient (up to 60 seconds)

2. History: along with standard SAMPLE — type history, additional patient history

should include:

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a. Attention to any associated injury or illness

b. Duration of cold exposure

c. Ambient temperature

d. Treatments initiated before EMS arrival

3. There are several means to categorize the severity of hypothermia based on either core

body temperature readings or clinical evaluation. If possible and reliable, EMS clinicians

should perform core body temperature measurements and categorize patients into one

of the three follow levels of hypothermia:

a. Mild: 32.1°–35°C/89.8°–95°F

b. Moderate: 28.1°–32°C/82.5°–89.7°F

c. Severe: 24°–28°C/75.2°–82.4°F

d. Profound: less than 24°C (75.2°F)

4. Equally important is the patient's clinical presentation and the signs or symptoms the

patient is experiencing — the above temperature-based categorization should be

balanced against these clinical findings

a. Mild: vital signs not depressed; normal mental status; shivering is preserved;

body maintains the ability to attempt to control temperature

b. Moderate/Severe: progressive bradycardia, hypotension, and decreased respirations,

alterations in mental status with eventual coma, shivering will be lost in moderate

hypothermia (generally between 30°–31°C (86°-87.8°F), and general slowing of bodily

functions; the body loses the ability to thermo-regulate

Treatment and Interventions

1. Maintain patient and rescuer safety

2. Manage airway per the Airway Management Guideline

3. Mild hypothermia:

a. Remove the patient from the environment and prevent further heat loss by removing

wet clothes and drying skin, insulate from the ground, shelter the patient from wind

and wet conditions, and insulate the patient with dry clothing or a hypothermia

wrap/blanket. Cover the patient with a vapor barrier and, if available, move the patient

to a warm environment

b. Hypothermic patients have decreased oxygen needs and may not require

supplemental oxygen

i. If oxygen is deemed necessary, it should be warmed to a maximum

temperature between 40°–42°C (104°–108°F) and humidified if possible

c. Provide beverages or foods containing glucose if feasible and patient is awake and

able to manage airway independently

d. Vigorous shivering can substantially increase heat production — shivering should

be fueled by caloric replacement

e. Consider field-rewarming methods such as placement of large heat packs or heat

blankets (chemical or electric if feasible) to the anterior chest or wrapped around the

patient's thorax if large enough — forced air warming blankets (e.g., Bair Hugger®)

can be an effective field rewarming method if available

f. Monitor frequently — if temperature or level of consciousness decreases, refer to

severe hypothermia

g. Consider IV access

i. Indications for IV access and IV fluids in the mildly hypothermic patient are

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similar to those of the non-hypothermic patient

ii. IV fluids, if administered, should be warmed, ideally to 42°C (107.6°F)

iii. Bolus therapy is preferable to continuous drip

h. If alterations in mental status, consider measuring blood glucose and treat as

indicated (treat per Hypoglycemia Guideline or Hyperglycemia Guideline) and assess

for other causes of alterations of mentation

i. Transport to a hospital capable of rewarming the patient

4. Moderate or severe hypothermia:

a. Perform ABCs (Airway, Breathing, Circulation), pulse checks for patients suffering

hypothermia should be performed for 60 seconds, and obtain core temperature, if

possible, for patients exhibiting signs or symptoms of moderate/severe hypothermia

i. Core temperatures can be measured by esophageal probe, if one is available, the

patient's airway is secured, and the clinician has been trained in its insertion and

use.

ii. Rectal temperatures may also be used, with caution to avoid worsening the

hypothermia by undressing the patient (e.g., done in a warm environment such as

a heated ambulance)

iii. If neither esophageal nor rectal thermometers are available, an epitympanic field

thermometer with an isolating ear cap may be used, but is generally less accurate

b. Manage airway as needed

i. Care must be taken not to hyperventilate the patient as hypocarbia may reduce

the threshold for ventricular fibrillation in the cold patient

ii. Indications and contraindications for advanced airway devices are similar in the

hypothermic patient as in the normothermic patient

c. Prevent further heat loss by removing the patient from the environment and removing

wet clothes and drying skin, insulate from the ground, shelter the patient from wind

and wet conditions, and insulate the patient with dry clothing or a hypothermia

wrap/blanket. Cover the patient with a vapor barrier and, if available, move the patient

to a warm environment

d. Initiate field-rewarming methods such as placement of large heat packs or heat

blankets (chemical or electric if feasible) to the anterior chest or wrapped around the

patient's thorax if large enough

i. Chemical or electrical heat sources should never be applied directly to the skin

ii. Use a barrier between the skin and heat source to prevent burns

iii. Forced air warming blankets (e.g., Bair Hugger®) can be an effective field

rewarming method if available

e. Handle the patient gently

i. Attempt to keep the patient in the horizontal position, especially limiting motion

of the extremities to avoid increasing return of cold blood to the heart

ii. Once in a warm environment, clothing should be cut off (rather than removed

by manipulating the extremities)

iii. Move the patient only when necessary, such as to remove the patient from the

elements

f. Apply cardiac monitor or AED if available

g. Establish IV and provide warmed isotonic crystalloid bolus. Repeat as necessary

h. If alterations in mental status, consider measuring blood glucose and treat as

indicated (treat per Hypoglycemia Guideline or Hyperglycemia Guideline) and assess

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for other causes of alterations of mentation

i. Transport as soon as possible to a hospital capable of resuscitation. If cardiac arrest

develops consider transport to a center capable of extracorporeal circulation (ECMO)

or cardiopulmonary bypass (if feasible)

j. Warm the patient compartment of the ambulance to at least 24°C (75.2°F) during

transport

5. Frost bite:

a. If the patient has evidence of frostbite, and ambulation/travel is necessary for

evacuation or safety, avoid rewarming of extremities until definitive treatment is

possible. Additive injury occurs when the area of frostbite is rewarmed then

inadvertently refrozen. Only initiate rewarming if refreezing is absolutely

preventable

i. If rewarming is feasible and refreezing can be prevented use circulating warm

water (37°–39°C/98.6°–102°F) to affected body part, thaw injury completely. If

warm water is not available, rewarm frostbitten parts by contact with non-

affected body surfaces. Do not rub or cause physical trauma.

ii. After rewarming, cover injured parts with loose sterile dressing. If blisters are

causing significant pain, and the clinician is so trained, these may be aspirated,

however, should not be de-roofed. Do not allow injury to refreeze. Treat per the

Pain Management Guideline.

Patient Safety Considerations

1. Given the additive effects of additional cold stress, the patient should be removed from the

cold environment as soon as operationally feasible

2. In patients suffering from moderate to severe hypothermia, it is critical to not allow these

patients to stand or exercise as this may cause circulatory collapse

3. Devices that self-generate heat (e.g., heat packs) that are being utilized during the rewarming

process should be wrapped in a barrier to avoid direct contact with the skin and to prevent

burns. Available evidence suggests that heat packs with peak temperatures above 45°C

(113°F) are most likely to cause burns. In patients who are unresponsive, or unable to

recognize a developing injury, please check the area in which the heating pad is placed

regularly to ensure no tissue damage occurs.

Notes/Educational Pearls

Key Considerations

Considerations in cardiac arrest

1. The following are contraindications for initiation of resuscitation in the hypothermic patient:

a. Obvious fatal injuries (such as decapitation)

b. The patient exhibits signs of being frozen (such as ice formation in the airway)

c. Chest wall rigidity such that compressions are impossible

d. Danger to rescuers or rescuer exhaustion

e. Avalanche victims buried for 35 minutes or longer with airway obstruction by ice

or snow

2. Fixed and dilated pupils, apparent rigor mortis, and dependent lividity may not

be contraindication for resuscitation in the severely hypothermic patient

3. The mainstay of therapy in severe hypothermia and cardiac arrest should be

effective chest compressions and attempts at rewarming. Chest compressions

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should be provided at the same rate as in normothermic patients

4. The temperature at which defibrillation should first be attempted in the severely

hypothermic cardiac arrest victim and the number of defibrillation attempts is unclear.

There are different approaches regarding resuscitation of the hypothermic arrest

patient

a. Per the American Heart Association (AHA), if the patient has a shockable rhythm

(VF/VT), defibrillation should be attempted. It is reasonable to continue defibrillation

attempts per AHA protocols concurrently with rewarming strategies

b. The state of Alaska's 2014 guidance on management of hypothermic patients in

cardiac arrest advises that defibrillation should be attempted once, followed by 2

minutes of chest compressions, then rhythm and pulse checks

If defibrillation is unsuccessful and the patient's core temperature is less than

30°C (86°F), do not make further attempts at defibrillation until the core

temperature has increased to greater than 30°C (86°F)

ii.

Continue CPR and attempt to rewarm the patient

c. An alternate strategy, per the Wilderness Medical Society's accidental hypothermia

guideline, suggests that if the patient's core temperature is below 30°C (86°F),

attempt defibrillation once, then wait until the patient has been rewarmed at least

1°–2°C or to 30°C (86°F) before attempting additional shocks. It is noted that the

likelihood of successful defibrillation increases with every one-degree increase in

temperature

d. If defibrillation is unsuccessful and the patient's core temperature is greater than

30°C (86°F), follow guidelines for normothermic patients

e. If available monitors reveal asystole, CPR alone is the mainstay of therapy

f. If monitoring reveals an organized rhythm (other than VF or VT) and no pulses

are detected, do not start CPR, but continue to monitor

While this may represent pulseless electrical activity (PEA), this may also

represent situations in which the patient's pulses are not detectable but remain

effective due to decreased metabolic needs

ii.

In the case of PEA, the rhythm will deteriorate rapidly to asystole, in which case, CPR

should be initiated

iii.

Given the potential to cause VF with chest compressions, the Alaska guidance

offers that it is better to maintain effective cardiac activity than to start CPR and

cause VF

5. Manage the airway per standard care in cardiac arrest victims [See Cardiac Arrest Guideline]

a. In the absence of advanced airways, ventilate the patient at the same rate as

a normothermic patient

b. If the patient has an advanced airway, ventilate at half the rate recommended for

a normothermic patient to prevent hyperventilation. If EtCO

is available, ventilate

to maintain normal EtCO

levels

6. There is little evidence to guide use of medications in severe hypothermia with cardiac

arrest, however 2010 AHA updates to advanced cardiac life support recommend use of

vasopressors according to standard ACLS protocols while the 2014 Alaska guidelines and

the Wilderness Medical Society's accidental hypothermia guideline for the management of

hypothermic patients advises medications should be withheld until the patient's core

temperature is greater than 30°C (86°F)

a. Above 30°C (86°F), intervals between medication provision should be doubled until the

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patient reaches 35°C (95°F), at which time, normal medication intervals may be

adopted

7. Upon ROSC, treat per Adult Post-ROSC Care Guideline

8. Patients with severe hypothermia and arrest may benefit from resuscitation even after

prolonged downtime, and survival with intact neurologic function has been observed

even after prolonged resuscitation

a. Patients should not be considered deceased until rewarming has been attempted

9. If a hypothermic patient clearly suffered cardiac arrest and subsequently became

hypothermic afterward with prolonged down time between arrest and rescue, there is

no rationale for initiating resuscitation and warming the patient

Pertinent Assessment Findings

1. Identification of associated traumatic injuries (when present)

2. Identification of localized freezing injuries

3. Patient core temperature (when available)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914023 – Environmental - Cold Exposure

•

9914025 – Environmental - Frostbite/Cold Injury

•

9914031 – Environmental - Hypothermia

Key Documentation Elements

• Duration of cold exposure

• Ambient temperature and recent range of temperatures

• Rewarming attempts or other therapies performed prior to EMS arrival

• Patient use of alcohol/drugs

Performance Measures

•

Patient core temperature and means of measurement (when available)

•

Presence of cardiac dysrhythmias

•

Documentation of associated trauma (when present)

•

Blood glucose level obtained

•

National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

Hypoglycemia—01: Treatment Administered for Hypoglycemia

Trauma—01: Pain Assessment of Injured Patients

References

1. Alaska Emergency Medical Services. State of Alaska Cold Injury Guidelines – 2014.

Anchorage, AK: Department of Health and Social Services, Division of Public Health; July

15, 2014.

2. Brown DJ, Brugger H, Boyd J, Paal P. Accidental Hypothermia. NEJM. 2012;367(2):1930–8

3. Casa DJ, DeMartini JK, Bergeron MF, Csillan D, Eichner ER, Lopez RM, Ferrara MS,

Miller KC, O'Connor F, Sawka MN, Yeargin SW. National Athletic Trainers' Association

Position Statement: Exertional Heat Illnesses. J Athl Train. 2015 Sep;50(9):986-1000.

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doi: 10.4085/1062-6050-50.9.07. Erratum in: J Athl Train. 2017 Apr;52(4):401. PMID:

26381473; PMCID: PMC4639891

4. Dow, Jennifer MD, MHA Giesbrecht, Gordon G. PhD Danzl, Daniel F. MD Zafren, Ken

MD Bennett, Brad L. PhD Grissom, Colin K. MD

Https://pubmed.ncbi.nlm.nih.gov/31326282/ December 1, 2019.

5. McIntosh SE, Hamonko M, Freer L, et al. Wilderness Medical Society guidelines for

the prevention and treatment of frostbite. Dec 1,

2019.https://www.wemjournal.org/issue/S1080-6032(19)X0006-X

6. Venden Hoek et al. Part 12: cardiac arrest in special situations. 2010 American Heart

Association guidelines for cardiopulmonary resuscitation and emergency

cardiovascular care. Circulation. 2010;122;(18 Suppl 3): S829–61.

7. Panchal et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart

Association Guidelines for Cardiopulmonary Resuscitation and Emergency

Cardiovascular Care. Circulation. 2020;142:S366–S468.

8. Brugger H, Bouzat P, Pasquier M, Mair P, Fieler J, Darocha T, Blancher M, de

Riedmatten M, Falk M, Paal P, Strapazzon G, Zafren K, Brodmann Maeder M. Cut-off

values of serum potassium and core temperature at hospital admission for

extracorporeal rewarming of avalanche victims in cardiac arrest: A retrospective

multi-centre study. Resuscitation. 2019;139:222–229. doi:

10.1016/j.resuscitation.2019.04.025

9. Paal P, Gordon L, Strapazzon G, Brodmann Maeder M, Putzer G, Walpoth B, Wanscher

M, Brown D, Holzer M, Broessner G, Brugger H. Accidental hypothermia-an update:

The content of this review is endorsed by the International Commission for Mountain

Emergency Medicine (ICAR MEDCOM). Scand J Trauma Resusc Emerg Med.

2016;24:111. doi: 10.1186/s13049-016-0303-7

Revision Date

March 11, 2022

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Drowning

Aliases

Fatal drowning Immersion Near-drowning

Non-fatal drowning Submersion

Patient Care Goal

1. Rapid assessment and management of life-threatening injuries

2. Rescue from the water-based environment

3. Transport patients suffering from drowning for hospital evaluation unless field arrest

resuscitation termination guidelines apply.

Patient Presentati

Inclusion Criter

Patients suffering from drowning or drowning events independent of presence or absence of

symptoms

Exclusion Criteria

When protocol is inapplicable.

Patient Managemen

Assessment

1. History should include circumstances leading to the submersion, details of mechanism of

injury, time under water

2. Primary survey should include aggressive airway management and restoration of adequate

oxygenation and ventilation. Unlike the CAB strategy used in standard cardiac arrest, patients

suffering cardiac arrest from drowning require an ABCs (Airway, Breathing, Circulation)

approach with prompt airway management and supplemental breathing

3. History, mechanism of injury and exam should include consideration of possible c-spine injury.

Manage c-spine if evaluation suggests injury to the cervical spine

4. Assess for other associated injury such as injury to the head or dive-related emergency

Treatment and Intervention

Ensure scene safety for patient and rescuers. Remove patient from water as soon

as possible

a. Practice the safest water rescue technique possible, given circumstances on scene

b. Evacuate to land or a watercraft as soon as possible

c. If there is a delay to accessing shore or a rescue boat, initiate in-water basic life support

consisting of ventilation only

Manage airway per the Airway Management Guideline

Follow Cardiac Arrest Guideline as indicated with consideration of ABCs (Airway,

Breathing, Circulation) strategy for drowning victims in cardiac arrest

a. Initiate 5 rescue breaths followed by 30 chest compressions

b. After the initial 5 breaths, use ratio of 30 compressions to 2 breaths

If mechanism or history suggest cervical spine injury, manage c-spine, per the Spinal

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Care Guideline

Monitor vital signs (pulse, blood pressure, respiratory rate, neurologic status assessment)

including oxygen saturations

If O

saturations are less than 92%, administer oxygen as appropriate with a target of

achieving 94–98% saturation. Consider positive pressure ventilation in patients with

signs or symptoms of respiratory difficulty

Consider hypothermia, treat per

Hypothermia/Cold Exposure Guideline

the victim was involved in underwater diving and uncertainty exists regarding the

most appropriate therapy, consider contacting medical direction and discussing need

for hyperbaric treatment. Include discussion regarding:

a. Submersion time

b. Greatest depth achieved

c. Ascent rate

d. Gas mix

Establish IV access

10.

Fluid bolus as indicated

11.

Advanced airway management as indicated. Consider CPAP in awake patients with

respiratory distress

12.

ardiac monito

Patient Safety Consideration

1. Avoidance of hyperoxygenation of the drowning victim

2. Rescuer safety considerations

Notes/Educational Pearl

Key Consideration

The World Health Organization definition of drowning is " the process of

experiencing respiratory impairment from submersion/immersion in liquid

Drowning is further defined in the following categories:

a. Non-fatal drowning: patients rescued from drownin

b. Fatal drowning: any death, acutely or subacutely, resulting from drownin

Submersion refers to situations in which the patient's airway is underwater. Immersion

refers to situations in which the patient's body is in water, but the patient's airway

remains out of the wat

Pediatric Considerations:

a. Drowning is a common cause of death in children

b. Risk factors for drowning include male gender, age less than 14 years old, alcohol

use, lack of supervision, and risky behavior

Rescue efforts should be coordinated between all responding agencies to ensure patient

is rapidly accessed and removed from the water

Initiation of in-water ventilations may increase survival. In-water chest compressions are

futil

The European Resuscitation Council recommends five initial breaths be provided to

the drowning victim

a. The initial ventilations may be more difficult to achieve as water in the airways

may impede alveolar expansio

b. If cardiac arrest after 5 rescue breaths, refer to Cardiac Arrest Guideline.

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Active efforts to expel water from the airway (by abdominal thrusts or other means)

should be avoided as they delay resuscitative efforts and increase the potential for

vomiting and aspiration

Long-standing teaching has suggested that rescuers should always assume c-spine injury

in victims of drowning

a. The 2010 American Heart Association update on special circumstances in cardiac arrest

notes that routine c-spine precautions in all victims of drowning is likely unnecessary

unless the mechanism or injury, history, or physical exam suggests a cervical spine

injury

echanisms of injury highly suggestive of cervical spine injury include diving,

water skiing, surfing, or watercraft accidents

10.

Uncertainty exists regarding survival in cold water drowning; however, recent

literature suggests the following:

a. If water temperature is less than 43°F (6°C) and the patient is submerged with

evidence of cardiac arres

i. Survival is possible for submersion time less than 90 minutes and resuscitative

efforts should be initiated

ii. Survival is not likely for submersion time greater than 90 minutes and clinicians

may consider not initiating resuscitation or termination of resuscitation on scene

b. If water temperature is greater than 43°F (6°C) and the patient is submerged

with evidence of cardiac arrest:

i. Survival is possible for submersion time less than 30 minutes and resuscitative

efforts should be initiated

ii. Survival is not likely for submersion time greater than 30 minutes and clinicians

may consider not initiating resuscitation or termination of resuscitation on scene

11.

Patients may develop subacute respiratory difficulty after drowning and therefore all

victims of drowning should be transported for observation

12.

Decompression illness may have a variety of presentations depending on system affected

(e.g., skin, joint(s), pulmonary, neurologic), and can occur even when a diver does not

exceed dive table limits

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914091 – Injury - Diving Emergencies

•

9914093 – Injury - Drowning/Near Drowning

Key Documentation Elements

• Mechanism of injury or history suggesting cervical spine injury

• Submersion time

• Water temperature

• Activities leading to drowning

• Consider a standardized data collection metrics such as the Utstein drowning data reporting

elements

Performance Measures

• Recognition and appropriate care of pulmonary/respiratory complaints

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• Cervical spine management when appropriate

• Adherence to Cardiac Arrest (VF/VT/Asystole/PEA) Guideline

References

Harris M. ABC of resuscitation, near drowning. BMJ. 2003;327(7427):1336–8

Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of

data from drowning: The “Utstein Style.” Circulation. 2003;108(20):2565–74

Layon J, Modell JH. Drowning, update 2009. Anesthesiology. 2009;110(6):1390–401

Olshaker J. Submersion. Emerg Med Clin N Am. 2004;22(2):357–67

Perkins, Olasveengen et al. BLS Task Force March 15, 2021, Resuscitation

https://costr.ilcor.org/document/drowning-tfsr-costr Drowning BLS Systematic Review.

Accessed March 11, 2022

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med.

2012;366(22):2102–10

Vanden Hoek T, Morrison LJ, Shuster M, et al. Part 12: Cardiac arrest in special

situations. 2010 American Heart Association guidelines for cardiopulmonary

resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):

S829–61

Revision Date

March 11, 2022

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Dive (SCUBA) Injury/Accidents

Aliases

Barotrauma Bends Squeeze

Patient Care Goal

1. Rapid assessment and management of life-threatening injuries

2. Rescue from the water-based environment

3. Transport patients suffering from self-contained underwater breathing apparatus (SCUBA)

diving injury/illness for hospital evaluation and consideration of repressurization/hyperbaric

oxygen therapy (HBOT)

Patient Presentatio

Inclusion Criteri

Patients with history of recent (within 48 hours) SCUBA diving activity who are exhibiting potential

signs and/or symptoms of dive related illness/injury, regardless of dive table compliance. NOTE:

SCUBA-related complications may occur anywhere, particularly when divers travel by air within

24-hours of diving

Exclusion Criteria

Patients without history of recent (within 48 hours) SCUBA diving exposure

Patient Managemen

Assessment

1. History should include circumstances leading to the complaint, details of mechanism of injury,

time under water, depth of dive, compliance with dive tables/decompression stops, gas

mixture used, and water temperature (if available)

2. Be alert for signs of barotrauma (pulmonary barotrauma, arterial gas embolism,

pneumothorax, pneumomediastinum, ear/sinus/dental barotrauma, dysrhythmias, skin

mottling or erythema, neurologic signs and symptoms etc.) and/or decompression sickness

(joint pain, mental status change, other neurologic symptoms including paralysis) or nitrogen

narcosis (confusion, intoxication).

3. Assess for other associated injury such as injury to the head or spine (if mechanism and

symptoms suggest), marine envenomation, hypothermia, or other injury

Treatment and Intervention

If a SCUBA accident includes associated drowning/near-drowning [See Drowning Guideline ]

Manage airway as indicated and provide 100% oxygen

If air embolism suspected, place in left lateral recumbent position (patient lying with the

left side down, knees drawn upward, and flat

)

a. Trendelenburg position is sometimes recommended to help trap the air in the

dependent right ventricle, and may be useful if a central venous catheter is being

used to withdraw the air, but this position may increase cerebral edema

Monitor vital signs including oxygen saturations and cardiac rhythm (if possible)

minister oxygen as appropriate with a target of achieving 94–98% saturation

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a. Use positive pressure ventilation (e.g., CPAP) carefully in patients for whom

pulmonary barotrauma is a consideration [See Airway Management Guideline] and if

signs or symptoms of tension pneumothorax are present perform needle decompression

Patients with symptoms suspicious for decompression illness, should be placed

on supplemental oxygen regardless of saturations to enhance washout of inert

gasses

Assess for hypothermia, treat per

Hypothermia/Cold Exposure Guideline

Consider contacting medical direction and discussing need for hyperbaric treatment and

primary transport to facility with hyperbaric oxygen therapy (HBOT) capability — include

discussion regarding factors such as submersion time, greatest depth achieved, ascent

rate, and gas mix

Establish IV access

10.

Fluid bolus as indicated

Patient Safety Consideration

1. If the patient is still in the water, seek safest and most rapid means of removal safe (within

your scope of training) while minimizing risk of further injury

2. Seek assistance early for special rescue/extrication and transportation needs

3. Check for multiple patients (e.g., group dive table calculation error(s) or contaminated dive

gases)

Notes/Educational Pearl

Key Consideration

Rescue efforts should be coordinated between all responding agencies to ensure that the

patient is rapidly accessed and safely removed from the water if diver unable to do so

themselves

If air medical transport is necessary, the patient should be transported with the cabin

pressurized to lowest possible altitude. If an unpressurized aircraft is used (i.e., most

helicopter emergency medical services (HEMS)), patient should be flown at the lowest safe

altitude possible

Decompression illness may have a variety of presentations depending on system affected

(e.g., skin, joint(s), pulmonary, neurologic)

SCUBA accidents/incidents can result in a variety of issues, including barotrauma, air

embolism and decompression illness

Decompression illness may have a variety of presentations depending on system affected

(e.g., skin, joint(s), pulmonary, neurologic), and can occur even when a diver does not exceed

dive table limits

Do not attempt to disassemble, turn off, or modify any of the dive equipment. The dive

computer may provide a clue about the patient’s exposure to depth

Pertinent Assessment Findings

1. Vital signs findings

2. Neurologic status assessment findings

3. Respiratory assessment findings (i.e., oxygen saturation, respiratory rate)

4. Subcutaneous emphysema

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Quality Improvemen

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914091

– Injury - Diving Emergencies

•

9914211

– Injury - SCUBA Injury/Accidents

Key Documentation Element

•

Water temperature, if available

•

Dive history

o Number of dives in recent history (days)

o "Bottom time" in dives

o Dive profiles

o Maximum depth

o Rate of ascent

o Safety stops utilized if any

o Dive gas (i.e., air vs. mixed gases such as Nitrox, Heliox or Trimix)

•

Timing of onset of symptoms

•

History of altitude exposure after diving (air travel)

•

Any associated injuries or exposures

Performance Measur

•

Recognition and appropriate care of pulmonary/respiratory complaints

•

Patient transported to nearest appropriate facility (HBOT if available and indicated)

•

Need for HBOT recognized and communicated to receiving facility if indicated

References

Chandy D, Weinhouse GL. Complications of SCUBA diving. Post TW, ed. UpToDate. Waltham,

MA: UpToDate. (Accessed March 15, 2021)

Doolette DJ, Mitchell SJ. Recreational technical diving part 2: decompression from

deep technical dives. Diving Hyperb Med. 2013;43(2):96–104

FAA Aeronautical Information Manual—Decompression Sickness after Scuba

Diving.

https://www.faa.gov/air_traffic/publications/atpubs/aim_html/chap8_section_1.

html. Accessed March 11, 2022

Fock A, Harris R, Slade M. Oxygen exposure and toxicity in recreational technical divers. Diving

Hyperb Med. 2013;43(2):67–71

Fock AW. Analysis of recreational closed-circuit rebreather deaths 1998–2010. Diving

Hyperb Med. 2013;43(2):78–85

Gordy S, Rowell S. Vascular Air Embolism. Int J Crit Iln Inj Sci. 2013;3(1):73–6

Madden D, Lozo M, Dujic Z, Ljubkovic M. Exercise after SCUBA diving increases the

incidence of arterial gas embolism. J Appl Physiol (1985). 2013;115(5):716–22

Mitchell SJ, Doolette DJ. Recreational technical diving part 1: an introduction to

technical diving methods and activities. Diving Hyperb Med. 2013;43(2):86–93

Muth C-M, Tetzlaff K. [Scuba diving and the heart. Cardiac aspects of sport scuba diving]. Herz.

2044;29(4):406–13

10.

Sykes O, Clark JE. Patent foramen ovale and scuba diving: a practical guide for physicians

on when to refer for screening. Extrem Physiol Med. 2013;2(1):10

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11.

Türkmen N, Okan A, Selçuk C, Bülent E, Murat SG, Umit NG. Scuba diver deaths due to

air embolism: two case reports. Soud Lék. 2013;58(2):26–8

12.

Vann RD, Gerth PJ, Denoble CF, Pieper CF, Thalmann ED. Experimental trials to assess

the risks of decompression sickness in flying after diving. Undersea Hyberb Med. 2004

Winter;3(4):431–44

13.

Winkler BE, Muth CM, Kaehler W, Froeba G, Georgieff M, Koch A. Rescue of drowning

victims and divers: Is mechanical ventilation possible underwater? A pilot studies.

Diving Hyperb Med. 2013;43(2):72–7

Revision Date

March 11, 2022

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Altitude Illness 341

Version 3.0

Altitude Illness

Aliases

Acute mountain sickness (AMS) Altitude sickness

High altitude cerebral edema (HACE) High altitude pulmonary edema (HAPE)

Definitions

Acute mountain sickness: Headache plus one or more of the following: anorexia, nausea

or vomiting, fatigue or weakness, dizziness or lightheadedness or difficulty sleeping. (In

infants and young children, symptoms include pallor, fussiness, vomiting, decreased

appetite, poor sleep, decreased playfulness.) These symptoms must occur in the setting

of recent arrival to high altitude (generally considered greater than 5000 – 7000 feet)

High altitude pulmonary edema (HAPE): Progressive dyspnea, cough, hypoxia, and

weakness in high altitude environments (considered greater than 8000 feet). (In infants

and young children, symptoms again include pallor, fussiness, vomiting, decreased

appetite, poor sleep, decreased playfulness.) Patients may or may not exhibit new

symptoms if acute mountain sickness precedes symptoms of HAPE

High altitude cerebral edema (HACE): Heralded by mental status changes in patients with

symptoms of acute mountain sickness including altered mentation, ataxia, or stupor and

progressing to coma. Typically seen in high altitude environments (greater than 8000 feet)

Feet to meters conversion reference:

Patient Care Goals

1. Improve oxygenation through a combination of descent and supplemental O

2. Safe but rapid transport from the high-altitude environment to a lower altitude environment

Patient Presentation

Inclusion Criteria

1. Patients suffering from altitude illness, including

a. Acute mountain sickness

b. High altitude pulmonary edema

c. High altitude cerebral edema

Exclusion Criteria

When protocol is inapplicable.

Feet

Meters

8000 ft

Approximately

2400 m

7000 ft

Approximately

2100 m

5000 ft

Approximately

1500 m

1000 ft

Approximately

300 m

500 ft

Approximately

150 m

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Patient Management

Assessment

Assessment should target the signs and symptoms of altitude illness but should also consider

alternate causes of these symptoms

Treatment and Interventions

1. Ensure scene safety for rescuers

2. Stop ascent

a. Patients with acute mountain sickness only may remain at their current altitude

and initiate symptomatic therapy

b. Patients with HACE or HAPE should initiate descent

3. Perform ABCs (Airway, Breathing, Circulation) and manage airway as necessary

4. Administer supplemental oxygen, if available, with goal to keep oxygen saturations 90%

5. Descend to lower altitude. Descent is the mainstay of therapy and is the definitive

therapy for all altitude related illnesses. Descent should be initiated as soon as scene

conditions permit

a. If severe respiratory distress is present and pulmonary edema is found on

exam, clinician should start positive pressure ventilation

b. Establish IV and perform fluid bolus with goal to maintain systolic BP greater than 90

mmHg

c. Monitor cardiac rhythm

6. Descent should always be the primary treatment strategy for patients suffering from

altitude illness, especially patients suffering from HACE and HAPE. If decent is not

possible, or if medical direction permits, the EMS clinician may consider the following

possible therapies — portable hyperbaric chambers are effective for the management of

severe altitude illness. However, they should not be used in lieu of decent, only as an

alternative should descent be unfeasible.

a. Acute mountain sickness

Ibuprofen or acetaminophen for pain [See Pain Management Guideline]

ii.

Ondansetron 4 mg IV, PO, or sublingual every 6 hours for vomiting [See Nausea-

Vomiting Guideline]

iii.

Acetazolamide: up to 250 mg PO twice a day

1. Pediatric dosing is 2.5 mg/kg to a maximum of 125 mg, given twice a day

2. Acetazolamide speeds acclimatization and therefore helps in treating acute

mountain sickness

iv.

Dexamethasone 4 mg IM, IV, or PO q 6 hours until symptoms resolve

1. Pediatric dosing is 0.15 mg/kg IM, IV, or PO q 6 hours; maximum single dose is 4

mg.

2. Dexamethasone helps treat the symptoms of acute mountain sickness and

may be used as an adjunctive therapy in severe acute mountain sickness when

the above measures alone do not ameliorate the symptoms. In these

circumstances, patients should also initiate descent, as dexamethasone does

not facilitate acclimatization

b. HACE: All therapies listed below should be considered as adjunctive to descent.

Descent should always be the primary treatment modality

Dexamethasone: 8 mg IM, IV, or PO once followed by 4 mg q 6 hours

1. Pediatric dosing: 0.15 mg/kg/dose every 6 hours

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2. Dexamethasone helps treat the symptoms of HACE and should be initiated in

HACE. In these circumstances, patients should also initiate descent

ii.

Consider use of acetazolamide at the above dosing

HAPE: All therapies listed below should be considered as adjunctive to descent.

Descent should always be the primary treatment modality

i. Nifedipine: Adult 30 mg ER (extended-release) PO twice a day. Pediatric: 0.5 mg/kg

(max single dose 20 mg), extended-release PO every 8 hours

ii. If nifedipine is not available:

iii. Tadalafil: 10 mg PO twice daily may be used

i. Sildenafil: 50 mg PO three times a day may be used

ii. Multiple pulmonary vasodilators should not be used concurrently

Patient Safety Considerations

The high-altitude environment is inherently dangerous. Rescuers must balance

patient needs with patient safety and safety for the responders

Rapid descent by a minimum of 500–1000 feet is a priority, however rapidity of

descent must be balanced by current environmental conditions and other safety

considerations

Notes/Educational Pearls

Key Considerations

Patients suffering from altitude illness have exposed themselves to a dangerous

environment. By entering the same environment, clinicians are exposing themselves to

the same altitude exposure. Be vigilant in looking for symptoms of altitude illness

amongst rescuers

Descent of 500–1000 feet is often enough to see improvements in patient conditions

Patients with HAPE are suffering from non-cardiogenic pulmonary edema and may

benefit from positive pressure ventilation via either bag assisted ventilation, CPAP, or

other means of positive pressure ventilation

Patients suffering from altitude illness are commonly dehydrated and require IV fluids —

once resuscitation is complete and the patient requires no further fluid boluses, maintain

IV fluids at 125 mL/hr

HAPE is the most lethal of all altitude illnesses

Consider alternate causes of symptoms of AMS — the symptoms of AMS may be caused

by alternate etiologies such as carbon monoxide poisoning (in patients cooking within

enclosed areas), dehydration, exhaustion, hypoglycemia, hyponatremia

Children with the following are at greater risk for altitude illness:

a. Those with a concurrent upper or lower respiratory tract infection or otitis media.

b. Full term infants less than 6 weeks of age, or preterm infants less than 46 weeks post

conceptual age

c. Congenital heart disease

d. Down syndrome, especially those with obstructive sleep apnea

e. Those with bronchopulmonary dysplasia (BPD), cystic fibrosis, sickle cell anemia,

severe scoliosis, and neuromuscular diseases

f. Premature infants beyond 46-weeks with a history of oxygen requirement, PBD or

pulmonary hypertension

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g. Children who live at high altitude when they descend to lower altitude, then return

home are at risk for HAPE

Pertinent Assessment Findings

1. Consider airway management needs in the patient with severe alteration in mental status

2. HAPE will present with increasing respiratory distress and rales on exam

3. HACE will present with mental status changes, ataxia, and progressing to coma

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914021 – Environmental - Altitude Sickness

Key Documentation Elements

•

Patient's itinerary, including starting altitude, highest altitude gained and rate of ascent

•

Presence (or absence) of prophylaxis against altitude (including medications such as

acetazolamide, sildenafil)

•

Total altitude descended

Performance Measures

•

Mechanism of treatment for acute mountain sickness, HACE, or HAPE

•

Medical decision-making regarding treatment choice (i.e., weather, inability to descend)

References

1. Barry P, et al. Clinical review: altitude illness. BMJ, 2003

2. Bartsch P, Swenseon ER. Acute high-altitude illness. N Engl J Med. 2013; 368:2294–302

3. Gallagher SA, Hackett PH. High-altitude illness. Emerg Med Clin N Am. 2004;22(2):329–55

4. Gallagher SA, Hackett P. Acute Mountain sickness and high-altitude cerebral edema. Post

TW, ed. UpToDate. Waltham, MA: UpToDate. (Accessed March 15, 2021)

5. Hackett P, Gallagher. High altitude disease: unique pediatric considerations. Post TW, ed.

UpToDate. Waltham, MA: UpToDate. (Accessed March 15, 2021)

6. Imray C, Wright A, Subudhi A, Roach R. Acute Mountain sickness: pathophysiology,

prevention and treatment. Prog Cardiovasc Dis. 2010;52(6):467–84

7. Jackson Hole Fire/EMS. Operations Manual: Altitude illness. Jackson Hole, WY:

Teton County

8. Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society consensus

guidelines for the prevention and treatment of acute altitude illness. Wilderness

Environ Med. 2010;25(4 Suppl): S4–14

9. Luks AM, McIntosh SE, Grissom CK, et al. Wilderness Medical Society Practice guidelines

for the prevention and treatment of acute altitude illness: 2014 update. Wilderness

Environ Med. 2014;25(4 Suppl): S4–14

10. West JB. High-altitude medicine. Am J Respir Crit Care Med. 2012;186(12):1229–37

Revision Date

March 11, 2022

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Conducted Electrical Weapon Injury (i.e., TASER®) 345

Version 3.0

Conducted Electrical Weapon Injury (i.e., TASER®)

Aliases

Tased

Patient Care Goals

1. Manage the condition that triggered the application of the conducted electrical weapon with

special attention to patients meeting criterion for delirium with agitated behavior [See

Agitated or Violent Patient/Behavioral Emergency Guideline ]

2. Ensure patient is appropriately secured or restrained with assistance of law enforcement to

protect the patient and clinicians [See Agitated or Violent Patient/Behavioral Emergency

Guideline]

3. Perform comprehensive trauma and medical assessment for injuries (e.g., from falls or

altercations or concomitant medical issues)

4. If discharged from a distance, up to two single barbed darts (13 mm length) should be located

a. Do not remove barbed dart from sensitive areas (head, neck, hands, feet, or

genitals)

Patient Presentation

Inclusion Criteria

1. Patient received either a weapon’s direct-contact discharge or struck by the barbed dart of a

conducted electrical weapon

2. Patient may have sustained fall or physical confrontation trauma

3. Patient may be under the influence of toxic substances and or may have underlying medical or

psychiatric disorder

Exclusion Criteria

None noted

Patient Management

Assessment

1. Once patient has been appropriately secured or restrained with assistance of law

enforcement, perform primary and secondary assessment including 3-lead EKG, pulse

oximeter, and consider 12-lead EKG

2. Evaluate patient for evidence of delirium with agitated behavior manifested by varied

combination of agitation, reduced pain sensitivity, elevated temperature, persistent

struggling, or hallucinosis

Treatment and Interventions

1. Make sure patient is appropriately secured with assistance of law enforcement to protect the

patient and staff. Consider psychologic management medications if patient struggling against

physical devices and may harm themselves or others

2. Some EMS agencies treat all barbed darts as a foreign body and leave them for physician

removal while others allow EMS or law enforcement to remove barbed darts except for

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sensitive areas (head, neck, hands, feet, or genitals). Follow local protocols, including those of

law enforcement for evidence collection and retention.

3. Treat medical and traumatic injury

Patient Safety Considerations

1. Before removal of the barbed dart, make sure the cartridge has been removed from the

conducted electrical weapon

2. Patient should not be restrained in the prone, face down, or hog-tied position as respiratory

compromise is a significant risk

3. The patient may have underlying pathology before being tased (refer to appropriate

guidelines for managing the underlying medical/traumatic pathology)

4. Perform a comprehensive assessment with special attention looking for signs and symptoms

of active medical decompensation

5. Transport the patient to the hospital

6. EMS clinicians who respond for a conducted electrical weapon patient should not perform a

"medical clearance" for law enforcement to then take the patient to a nonmedical facility

Notes/Educational Pearls

Key Considerations

1. Conducted electrical weapon can be discharged in three fashions:

a. Direct contact without the use of the darts

b. A single dart with addition contact by direct contact of weapon

c. From a distance up to 35 feet with two darts

2. The device delivers 19 pulses per second with an average current per pulse of 2.1

milliamps which, in combination with toxins/drugs, patient's underlying diseases,

excessive physical exertion, and trauma, may precipitate arrhythmias. Thus, consider

cardiac monitoring and 12-lead EKG assessment

3. Drive Stun is a direct weapon two-point contact which is designed to generate pain and

not incapacitate the subject. Only local muscle groups are stimulated with the Drive Stun

technique

Pertinent Assessment Findings

1. Thoroughly assess the patient for trauma as the patient may have fallen from standing or

higher

2. Ascertain if more than one TASER® cartridge was used (by one or more officers, in effort

to identify total number of possible darts and contacts)

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914203 – Injury - Conducted Electrical Weapon (e.g., Taser)

Key Documentation Elements

•

If darts removed, document the removal location in the patient care report

•

Physical exam trauma findings

•

Cardiac rhythm and changes

•

Neurologic status assessment findings

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Performance Measures

•

Comprehensive patient documentation as this is a complex patient

•

Abnormal findings or vital signs were addressed

•

Patient received cardiac monitoring and/or 12-lead EKG evaluation

•

If indicated, review for appropriate securing technique

References

1. Ho JD, Dawes DM, Buttman LL, Moscati RM, Janchar TA, Miner JR. Prolonged TASER use

on exhausted humans does not worsen markers of acidosis. Am J Emerg Med.

2009;27(4):413–8

2. Ho JD, Dawes DM, Cole JC, et al. Corrigendum to ‘‘lactate and pH evaluation in exhausted

humans with prolonged TASER X26 exposure or continued exertion.’’ Forensic Sci Int.

2009;190(1–3):80–6

3. Ho JD, Dawes DM, Cole JB, Hottinger JC, Overton KG, Miner JR. Lactate, and pH evaluation

in exhausted humans with prolonged TASER X26 exposure or continued exertion. Forensic

Sci Int. 2009;190(1–3):80–6

4. Ho JD, Dawes DM, Nelson RS, et al. Acidosis and catecholamine evaluation following

simulated law enforcement ‘‘use of force’’ encounters. Acad Emerg Med. 2010;17(7):

e60–8

5. Ho JD, Dawes DM, Nystrom PC, et al. Markers of acidosis and stress in a sprint versus

a conducted electrical weapon. Forensic Sci Int. 2013;233(1–3):84–9

6. Kroll MW, Adamec J, Wetli CV, Williams HE. Fatal traumatic brain injury with electrical weapon

falls. J Forensic Legal Med. 2016; 43:12–19

7. Kroll MW, Ritter MB, Kennedy EA, Silverman NK, et al. Eye injuries from electrical weapon

probes: Incidents, prevalence and legal implications. J Forensic Legal Med. 2018; 55:52–57

8. Kroll MW, Ritter MB, Kennedy EA, Siegal NK, et al. Eye injury from electrical weapon probes:

Mechanisms and treatment. Am J Emerg Med. 2018; 37:427–432

9. Kunz SN, Calkins HG, Adamec J, Kroll MW. Adrenergic and metabolic effects of electrical

weapons: review and meta-analysis of human data. Intl J Legal Med. 2018; 132:1469–1475

10. Kunz SN, Calkins H, Adamec J, Kroll MW. Cardiac and skeletal muscle effects of electrical

weapons: a review of human and animal studies. Forens Sci Med Pathol. 2018; 14:358–366

11. Kunz SN, Adamec J. A comparative brief on conducted electrical weapon safety. Wien Med

Wochenschr 2019; 169:185–192

12. Pinto DS, Clardy PF. Environmental and weapon-related electrical injuries. Uptodate.com

[Internet]. January 22, 2020. Accessed March 31, 2021

13. Stevenson R, Drummond-Smith I. Medical Implications of Conducted Electrical Devices in Law

Enforcement. J Forens Leg Med. Published online June 10, 2020;73:101948

14. Vilke G, Chan T, Bozeman WP, Childers R. Emergency Department Evaluation After Conducted

Energy Weapon Use: Review of the Literature for the Clinician. J Emerg Med. 2019;57(5):740–

746

15. White Paper Report on Excited Delirium Syndrome. ACEP Excited Delirium Task

Force, American College of Emergency Physicians; September 10, 2009

Revision Date

March 11, 2022

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Electrical Injuries

Aliases

Electrical burns Electrocution

Patient Care Goals

1. Prevent additional harm to patient

2. Identify life threatening issues such as dysrhythmias and cardiac arrest

3. Identify characteristics of electrical source to communicate to receiving facility

(voltage, amperage, alternating current [AC] versus direct current [DC])

4. Understand that deep tissue injury can be far greater than external appearance

5. Have high index of suspicion for associated trauma due to patient being thrown

6. Determine most appropriate disposition for the patient as many will require burn

center care and some may require trauma center care

Patient Presentation

Inclusion Criteria

Exposure to electrical current (AC or DC).

Exclusion Criteria

None noted

Patient Management

Assessment

1. Verify scene is secure. The electrical source must be disabled prior to assessment

2. Perform primary survey with specific focus on dysrhythmias or cardiac arrest—apply a

continuous cardiac monitor and obtain 12-lead EKG as soon as feasible

3. Identify all sites of burn injury. If the patient became part of the circuit, there will be an

additional site near the contact with ground. Electrical burns are often full thickness and

involve significant deep tissue damage, and there may be multiple burn sites

4. Assess for potential associated trauma and note if the patient was thrown from contact point.

If patient has altered mental status, assume trauma was involved and treat accordingly

5. Assess for potential compartment syndrome from significant extremity tissue damage

6. Determine characteristics of source if possible (AC or DC, voltage, amperage, time of injury)

Treatment and Interventions

1. Identify dysrhythmias or cardiac arrest — even patients who appear dead (particularly dilated

pupils) may have good outcomes with prompt intervention [see appropriate guideline for

additional information and patient assessment/treatment]

2. Apply spinal motion restriction if associated trauma suspected [See Trauma Section]

3. Apply dry dressing to any wounds

4. Remove constricting clothing and jewelry since additional swelling is possible

5. Administer IV fluid resuscitation. Remember that external appearance will underestimate the

degree of tissue injury but that electrical injuries do not generally require as much fluid as

thermal burn injuries

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6. Electrical injuries may be associated with significant pain, treat per Pain Management

Guideline

7. Electrical injury patients should be taken to a burn center whenever possible since these

injuries can involve considerable tissue damage

8. When there is significant associated trauma, this takes priority, if local trauma resources and

burn resources are not in the same facility

Patient Safety Considerations

1. Verify no additional threat to patient

2. Shut off electrical power

3. Move patient to shelter if electrical storm activity still in area

Notes/Educational Pearls

Key Considerations

Electrical current causes injury through three main mechanisms:

a. Direct tissue damage, altering cell membrane resting potential, and eliciting tetany

in skeletal and/or cardiac muscles

b. Conversion of electrical energy into thermal energy, causing massive tissue

destruction and coagulative necrosis

c. Mechanical injury with direct trauma resulting from falls or violent muscle contraction

Anticipate atrial and/or ventricular dysrhythmias as well as cardiac arrest

The mortality related to electrical injuries is impacted by several factors:

a. Route current takes through the body- current traversing the heart has

higher mortality

b. Type of current (AC vs. DC)

i. AC is more likely to cause cardiac dysrhythmias while DC is more likely to cause

deep tissue burns however either type of current can cause any injury

ii. DC typically causes one muscle contraction while AC can cause repeated

contractions

iii. Both types of current can cause involuntary muscle contractions that do not

allow the victim to let go of the electrical source

iv. AC is more likely to cause ventricular fibrillation while DC is more likely to cause

asystole

c. The amount of current impacts mortality more than the voltage

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Current level

(Milliamperes)

Probable Effect on Human Body of 120 V, 60 Hz AC for 1 second

1mA

Perception level. Slight tingling sensation. Still dangerous if wet

conditions.

5mA

Slight shock felt; not painful but disturbing. Average individual can let

go.

However, strong involuntary reactions to shocks in this range may lead

to injuries.

6mA–16mA

Painful shock, begin to lose muscular control.

Commonly referred to as the freezing current or "let-go" range.

17mA–99mA

Extreme pain, respiratory arrest, severe muscular contractions.

Individual cannot let go. Death is possible.

100mA–

2000mA

Ventricular fibrillation (uneven, uncoordinated pumping of the heart).

Muscular contraction and nerve damage begins to occur.

Death is likely.

> 2,000mA

Cardiac arrest, internal organ damage, and severe burns. Death is

probable.

Source: https://www.osha.gov/SLTC/etools/construction/electrica!_incidents/eleccurrent.html

Pertinent Assessment Findings

1. Identification of potential trauma concomitant with electrical injury

2. Presence of cardiac dysrhythmias

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914095 – Injury - Electrical Injuries

Key Documentation Elements

•

Characteristics of electrical current

•

Downtime if found in cardiac arrest

•

Positioning of the patient with respect to the electrical source

•

Accurate description of external injuries

•

Document presence or absence of associated trauma

Performance Measures

•

Confirmation of scene safety

•

Documentation of electrical source and voltage if known

•

Documentation of cardiac monitoring

•

Documentation of appropriate care of associated traumatic injuries

•

National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

Trauma—01: Pain Assessment of Injured Patients

References

1. Electrical Injuries. Emedicince.medscape.com.

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http://emedicine.medscape.com/article/433682-overview. Updated February 8, 2017.

Accessed March 11, 2022

2. Pham TN, Gibran NS. Thermal and electrical injuries. Surg Clin North Am. 2007;87(1)

:185– 206

3. Price TG, Cooper MA. Electrical and lightning injuries. In Hockenberger R, ed.

Rosen's Emergency Medicine, 9th Edition. 2009

Revision Date

March 11, 2022

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Lightning/Lightning Strike Injury

Aliases

Lightning burn

Patient Care Goals

1. Identify patient(s) as lightning strike victim(s)

2. Move to safe area

3. Initiate immediate resuscitation of cardiac arrest victim(s), within limits of mass casualty care,

also known as "reverse triage"

4. Cardiac monitoring during transport

5. Treat associated traumatic injuries

Patient Presentation

Lightning strikes may happen in a variety of environmental conditions

Most commonly they occur in outdoor or wilderness circumstances

Golf courses, exposed mountains or ledges and farms/fields all present conditions

that increase risk of lightning strike, when hazardous meteorological conditions exist

Lacking bystander observations or history, it is not always immediately apparent

that patient has been the victim of a lightning strike

Subtle findings such as injury patterns might suggest lightning injury

Inclusion Criteria

Patients of all ages who have been the victim of lightning strike injury

Exclusion Criteria

No recommendations

Patient Management

Assessment

1. Respiratory

a. Apnea

b. Agonal respirations

c. Respiratory paralysis

2. Cardiovascular

a. Dysrhythmias

b. Transient hypertension

3. Neurologic

a. Seizures

b. Confusion

c. Paralysis

d. Paraplegia

e. Vertigo/dizziness

f. Paresthesias

g. Amnesia

h. Memory deficits

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i. Anxiety

j. Fixed/dilated pupils possible (autonomic dysfunction)

4. Skin

a. Ferning or fern-like superficial skin burn ("Lichtenberg figures")

b. Vascular instability may result in cool, mottled extremities

c. Frequent first and/or second-degree burns

d. Third degree burns less common

5. Patient may be in full cardiopulmonary arrest or have only respiratory arrest, as injury is

a result of DC current

6. May have stroke-like findings as a result of neurologic insult

7. May have secondary traumatic injury as a result of overpressurization, blast or missile injury

8. Fixed/dilated pupils may be a sign of neurologic insult, rather than a sign of

death/impending death. Should not be used as a solitary, independent sign of death for the

purpose of discontinuing resuscitation in this patient population

Treatment and Interventions

1. Assure patent airway — if in respiratory arrest only, manage airway as appropriate

2. If in cardiopulmonary arrest, treat per Cardiac Arrest Guideline

3. Consider IV initiation — avoid initiation through burned skin

4. Monitor EKG. Be alert for potential arrhythmias. Consider 12-lead EKG, when available

5. Consider early pain management for burns or associated traumatic injury [See Pain

Management Guideline]

Patient Safety Considerations

Recognize that repeat strike is a risk. Patient and rescuer safety is paramount

Victims do not carry or discharge a current, so the patient is safe to touch and treat

Notes/Educational Pearls

Key Considerations

Lightning strike cardiopulmonary arrest patients have a high rate of successful

resuscitation, if initiated early, in contrast to general cardiac arrest statistics

There may be multiple victims

If multiple victims, cardiac arrest patients whose injury was witnessed or thought to be

recent should be treated first and aggressively (reverse from traditional triage

practices)

a. Patients suffering cardiac arrest from lightning strike initially suffer a combined

cardiac and respiratory arrest

b. Return of spontaneous circulation may precede resolution of respiratory arrest

c. Patients may be successfully resuscitated if provided proper cardiac and

respiratory support, highlighting the value of "reverse triage"

It may not be immediately apparent that the patient is a lightning strike victim

Injury pattern and secondary physical exam findings may be key in identifying patient as

a victim of lightning strike

Lightning strike is a result of very high voltage, very short duration DC current exposure

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Pertinent Assessment Findings

1. Presence of thermal or non-thermal burns

2. Evidence of trauma

3. Evidence of focal neurologic deficits

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01) (for additional information, go to www.nemsis.org)

•

9914209 – Injury - Lightning/Lightning Strike

Key Documentation Elements

•

Initial airway status

•

Initial cardiac rhythm

•

Neurologic exam (initial and repeat)

•

Associated/secondary injuries

•

Pain scale documentation/pain management

Performance Measures

•

Cardiopulmonary issues addressed early and documented appropriately

•

Patient transported to closest appropriate facility

•

Pain scale documented and treated per guidelines (when appropriate)

•

National EMS Quality Alliance (NEMSQA) Performance Measures (for additional information,

see www.nemsqa.org)

Trauma—01: Pain Assessment of Injured Patients

References

1. Anderson DR, Gillberg JM, Torrey JW, Koneru JN. Lightning induced inappropriate ICD

shock: an unusual case of electromagnetic interference. Pacing Clin Electrophysiol.

2012;35(6): e159–62

2. Arnoldo BD, Purdue GF. The diagnosis and management of electrical injuries. Hand Clin.

2009;25(4):469–79

3. Blumenthal R. Secondary missile injury from lightning strike. Am J Forensic Med Pathol.

2012;33(1):83–5

4. Blumenthal R, Jandrell IR, West NJ. Does a sixth mechanism exist to explain lightning

injuries? Investigating a possible new injury mechanism to determine the cause of

injuries related to close lightning flashes. Am J Forensic Med Pathol. 2012;33(3):222–6

5. Brunner FX. [Bilateral tympanic membrane perforation caused by a lightning accident]. HNO.

1984;32(10):429–30

6. Centers for Disease Control and Prevention (CDC). Lightning-associated deaths –

United States, 1980–1995. MMWR Morb Mortal Wkly Rep. 1998 May 22;47(19):391–

7. Cherington M, Kurtzman R, Krider EP, Yarnell PR. Mountain medical mystery:

unwitnessed death of a healthy young man, caused by lightning. Am J Forensic Med

Pathol. 2001;22(3):296–8

8. Cooper MA. Emergent care of lightning and electrical injuries. Semin Neurol.

1995;15(3):268–78

9. Cooper MA. A fifth mechanism of lightning injury. Acad Emerg Med. 2002;9(2):172–4

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10. Davis C, Engeln A, Johnson E, et al; Wilderness Medical Society. Wilderness Medical

Society practice guidelines for the prevention and treatment of lightning injuries.

Wilderness Environ Med. 2012;23(3):260–9

11. Davis C, Engeln A, Johnson E, et al; Wilderness Medical Society Practice Guidelines for the

Prevention and Treatment of Lightning Injuries: 2014 Update - Wilderness &

Environmental Medicine (wemjournal.org) https://doi.org/10.1016/j.wem.2014.08.011.

Accessed March 11, 2022

12. Desai BK, Fairclough R. A case of a speech impediment following a near lightning strike. Int

J Emerg Med. 2011; 4:60

13. Dronacahrya L, Poudel R. Lightning induced atrial fibrillation. Kathmandu Univ Med

J (KUMJ). 2008;6(24):514–5

14. Duclos PJ, Sanderson LM, Klontz KC. Lightning-related mortality, and morbidity in Florida.

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15. Dundon BK, Puri R, Leong DP, Worthley MI. Takotsubo cardiomyopathy following lightning

strike. BMJ. 2008; 25:460–1

16. Fontanarosa PB. Electrical shock and lightning strike. Ann Emerg Med. 1993;22(2 Pt 2):378–87

17. Forster SA, Silva IM, Ramos MLC, Gragnani A, Ferreira LM. Lightning burn – review and case

report. Burns. 2013;39(2): e8–12

18. Gluncić I, Roje Z, Gluncić V, Poljak K. Ear injuries caused by lightning: report of 18 cases. J

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19. Guardiola B, Planella M, Ferreruela M, Velasco J, Pérez-Bárcena J, Llompart-Pou JA. [Brain

injury secondary to lightning strike]. Med Intensiva. 2013;37(5):367–8

20. Haraldsson PO, Bergstedt M. [Unconsciousness and persistent tinnitus caused by lightning

injury to the ear during telephoning]. Läkartidningen. 1983;80(19):2024

21. Hinkelbein J, Spelten O, Wetsch WA. [Lightning strikes and lightning injuries in prehospital

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22. Jefferiss WR. Three cases of lightning-stroke. Br Med J. 1876;1(786):102

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24. Kleinschmidt-DeMasters, BK. Neuropathology of lightning-strike injuries. Semin Neurol.

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experience. Burns. 2004;30(7):691–5

26. Kubilius D, Rimdeika R. Simultaneous lightning injury in a group of people: case report. Burns.

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27. Lane JR. Clinical lecture on injuries from lightning. Br Med J. 1872;2(605):114–6

28. Leiria TLL, Pires LM, Kruse ML, de Lima GG. Struck by lightning: a case of nature-induced pre-

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29. Levy DR, Akiyama T. Lightning-induced ventricular fibrillation. Cardiology J. 2007;14(1):91–4

30. Lichtenberg R, Dries D, Ward K, Marshall W, Scanlon P. Cardiovascular effects of lightning

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34. Modayil PC, Lloyd GW, Mallik A, Bowdler DA. Inner ear damage following electric current and

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2002;39(6):660–4

Revision Date

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I. Author, Reviewer and Staff Information 357

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APPENDICES

I. Author, Reviewer and Staff Information

Authors

Co-Principal Investigators

Carol A. Cunningham, MD

State Medical Director

Ohio Department of Public Safety, Division of EMS

Associate Professor of Emergency Medicine, Northeast Ohio Medical University

Department of Emergency Medicine, Cleveland Clinic Akron General

Richard Kamin, MD

EMS Program Director

Associate Professor of Emergency Medicine

University of CT Health Center

Medical Director

Connecticut Department of Health, Office of EMS

Workgroup Authors

Gail H. Bradley, MD,

Medical Director, Bureau of EMS and Trauma System

Arizona Department of Health Services

Sabina Braithwaite, MD, MPH, NRP

Professor of Emergency Medicine, Washington University in St Louis

Medical Director, AirEvac Lifeteam Missouri / Arkansas

Missouri State EMS Medical Director

Jon Burstein, MD

State EMS Medical Director

Office of EMS, MA Dept of Public Health

M. Riccardo Colella, DO, MPH

Professor and Chief, Division of EMS Medicine

Department of Emergency Medicine

Medical College of Wisconsin

Toni K. Gross, MD, MPH

Chief, Pediatric Emergency Medicine, Children’s Hospital New Orleans

Professor of Pediatrics, Tulane University School of Medicine

Clinical Associate Professor of Pediatrics, LSU Health Sciences Center New Orleans

Douglas F. Kupas, MD

Commonwealth EMS Medical Director

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Bureau of EMS

Pennsylvania Department of Health

Professor of Emergency Medicine

Lewis Katz School of Medicine at Temple University

David Lehrfeld, MD

Medical Director

Oregon Health Authority

Emergency Medical Services & Trauma Systems

Michael Levy, MD

Chief Medical Officer Anchorage Areawide EMS, Anchorage Alaska

Medical Director for Emergency Programs State of Alaska

Affil Assoc Prof WWAMI School of Health Univ of Alaska Anchorage

George Lindbeck, MD

Associate Professor of Emergency Medicine

Director, Emergency Medical Services Fellowship

University of Virginia

Sharon Malone, MD

Medical Director

Emergency Medical Task Force (EMTF-2)

Medical Director for North Central Texas Trauma Advisory Council (NCTTRAC)

Julian Mapp MD, MBA, MPH

Assistant Research Director

WellSpan Health

Tom McGinnis, MHA, EMT-P

Chief, EMS Division

California EMS Authority

Kyle N. Remick, MD

EMS Committee

American College of Surgeons – Committee on Trauma

Professor of Surgery

Uniformed Services University School of Medicine

Curtis Sandy, MD

EMS Director

Portneuf Medical Center

Chair Idaho EMS Physician Commission

J. Matthew Sholl, MD, MPH

Associate Professor

Director, Division of EMS

Department of Emergency Medicine

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Maine Medical Center

Tufts University School of Medicine

State Medical Director, Maine EMS

Maine Department of Public Safety

Peter P. Taillac, MD

Clinical Professor

University of Utah School of Medicine

State EMS Medical Director

Utah Bureau of EMS and Preparedness

Utah Department of Health

Lynn White, MS

National Director of Research and Evidence Based Practice

Global Medical Response

Contributing Authors

Jennifer Anders, MD

Johns Hopkins Children's Center

Noah Bernhardson, MD

Medical Director

Southeast Fire Department

Lorin Browne, DO

Children's Wisconsin - Milwaukee Hospital

Patricia Casey, RN, NRP

STARS Program

SSM Health Cardinal Glennon Children’s Hospital

Mark Cicero, MD

Yale New Haven Children's Hospital

Shea Duerring, MD

University of Alabama at Birmingham

Greg Faris, MD

Riley Hospital for Children

Jennifer Fishe, MD

UF Health Jacksonville

Peter Fischer, MD, MS, NRP

Associate Professor

College of Medicine - Memphis

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Department of Surgery

Division of Trauma/Surgical Critical Care

Susan Fuchs, MD

Lurie Children's Hospital

Marianne Gausche-Hill, MD

LA County EMS

Andrew Hogan, MD

UT Southwestern Medical Center

Steven Laffey, MD

Professor of Pediatrics

Director of Clinical Operations – Pediatric Emergency Medicine

SSM Health Cardinal Glennon Children’s Hospital

Suzan Mazor, MD

Seattle Children's Hospital

Ronna Miller, MD

UT Southwestern Medical Center

Stacey Noel, MD

C. S. Mott Children's Hospital

Karen O'Connell, MD

Children's National Medical Center

Lara Rappaport, MD

Denver Health

David Rayburn, MD

Children's Hospital New Orleans

Lauren Riney, DO

Cincinnati Children's Hospital

Michael Schauf, MD

Neonatal/Pediatric Transport Team, Albany Medical Center, New York

Air Med Air Ambulance, Birmingham, Alabama

Manish Shah, MD

Texas Children's Hospital

Jeffery Siegler, MD, EMT-P

EMS Physician

Assistant Professor

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Department of Emergency Medicine

Washington University School of Medicine

Jessica Wall, MD

Seattle Children's Hospital

Caleb Ward, MD

Children's National Medical Center

Elizabeth Weinstein, MD

Riley Hospital for Children

Technical Reviewers

William Heuser, PharmD, MS, BCCCP, EMT-P, FP-C

Research Coordinator/Assistant Professor

Hofstra Northwell

School of Nursing and Physician Assistant Studies

Timothy T. Pieh, MD

Medical Director, Emergency Medicine

Maine General Medical Center

Amy Raubenolt, MD, MPH, MEd

EMS Medical Director

Cleveland Clinic Akron General

Associate Professor of Emergency Medicine

Northeast Ohio Medical University

James C. Suozzi, DO, NRP

Associate Medical Director/EMS

Cheshire Medical Center/Dartmouth Hitchcock – Keene NH

Medical Director, New Hampshire Bureau of EMS

Kate Zimmerman, DO

Associate State EMS Medical Director

Department of Emergency Medicine

Maine Medical Center

Key Federal Partners for Project

Jon Krohmer, MD

Director, Office of Emergency Medical Services

National Highway Traffic Safety Administration

Theresa Morrison-Quinata

Division of Child, Adolescent and Family Health (DCAFH) Maternal and Child Health Bureau

Health Resources and Services Administration

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Max Sevareid

Office of Emergency Medical Services

National Highway Traffic Safety Administration

Alternate Cooperative Agreement Project Manager

Gamunu Wijetunge

Office of Emergency Medical Services

National Highway Traffic Safety Administration

Cooperative Agreement Project Manager

Project Staff

Andy Gienapp

Program Manager

Guidelines Project Manager

National Association of State EMS Officials

Alisa Williams

Program Manager

Guidelines Project Technical Writer/Editor

National Association of State EMS Officials

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II. Universal Documentation Guideline

Aliases

NEMSIS, Documentation

Patient Care Goals

1. Support continuity of patient care and continuous performance improvement (CPI) of

patient care through meeting minimum documentation standards for all EMS events where

a patient was encountered

2. This guideline defines minimum standards and inclusions used and referenced throughout

this document under the “Quality Improvement” section of each guideline

3. The National EMS Information System (NEMSIS) submission requirements, state and local

EMS systems, and EMS billing reimbursement services will have more extensive minimum

requirements that exceed this guideline (For additional information, go to www.nemsis.org)

4. This guideline can be used as a starting point for systems looking to more formally define

documentation requirements

Patient Presentation

Inclusion Criteria

All EMS events where a patient was encountered, and one or more clinical guideline was used to

determine patient treatment and/or disposition.

Exclusion Criteria

None noted

Toolkit for Key Categories of Data Elements

Incident Demographics

1. Incident Demographics include the type of incident, location, time, dispatch information,

response resources and patient/incident disposition of the EMS event

a. This information will always apply and be available, even if the responding unit never

arrives on scene (is cancelled) or never makes patient contact

b. Incident demographics are important for filtering incident types and outcomes when

doing CPI reviews, providing aggregate descriptive data, and billing for reimbursement

2. Minimum Incident Demographic Fields include:

a. Incident Times

i. eTimes.03—Unit Notified by Dispatch Date/Time (NEMSIS mandatory)

ii. eTimes.05—Unit En Route Date/Time (Unit responding)

iii. eTimes.06—Unit Arrived on Scene Date/Time (If arrived)

iv. eTimes.07—Arrived at Patient Date/Time (If patient contact made)

v. eTimes.09—Unit Left Scene Date/Time (Unit Transporting Time, if applicable)

vi. eTimes.11—Patient Arrived at Destination Date/Time (If applicable)

vii. eTimes.13—Unit Back in Service Date/Time (NEMSIS mandatory)

b. eResponse.05—Type of Service Requested (i.e., 911 vs interfacility)

c. eResponse.07—Primary Role of the Unit (i.e., Transport or non-transport)

d. eDispatch.01—Complaint Reported by Dispatch (Dispatch reason from EMD)

e. Crew Responding:

i. eCrew.01—Crew Member ID (Crew name or license # depending on software)

ii. eCrew.02—Crew Member Level (License level for this call)

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iii. eCrew.03—Crew Member Response Role (i.e., Primary or secondary care giver)

f. eScene.09—Incident Location Type

i. Used for multiple purposes, including CARES (Cardiac Arrest Registry to Enhance

Survival)

g. Response Modes (e.g., lights and sirens)

i. eResponse.23—Response Mode to Scene

ii. eResponse.24—Additional Response Mode Descriptors

h. Delays:

i. eResponse.09—Type of Response Delay

ii. eResponse.10—Type of Scene Delay

Patient Demographics and Medical History

Patient demographics in this section include the minimum information required for CPI review

and do not include protected health information (PHI) or patient identifiable information. Local

systems may require additional PHI to support EMS reimbursement and link local level CPI

reviews to specific incidents or outcome data.

1. Minimum Patient Demographic and History Fields include:

a. ePatient.13—Gender

b. ePatient.15—Age

c. ePatient.16—Age Units

d. eHistory.06—Medication Allergies

e. eHistory.07—Environmental/Food Allergies

f. eHistory.08—Medical/Surgical History

g. eHistory.12—Current Medications

h. eHistory.17—Alcohol/Drug Use Indicators

i. eHistory.01—Barriers to Patient Care

j. eExam.01—Estimated Body Weight in Kilograms

k. eExam.02—Length-based Tape Measure

Patient Complaints and Symptoms

1. Patient and situational history for this EMS event generally addresses issues leading up to

EMS being requested and include patient complaints, SAMPLE history, signs or symptoms,

barriers and confounders, onset times, and trauma and cardiac arrest historical information

2. Patient Complaints, Signs and Symptoms, and Key Related Times:

a. eSituation.02—Possible Injury

b. Patient Complaint Group

i. eSituation.03—Complaint Type

ii. eSituation.04 – Complaint

iii. eSituation.05—Duration of Complaint

iv. eSituation.06—Time Units of Duration of Complaint

c. eSituation.07—Chief Complaint Anatomic Location

d. eSituation.08—Chief Complaint Organ System

e. Signs and Symptoms

i. eSituation.01—Date/Time of Symptom Onset

ii. eSituation.09—Primary Symptom [Single Choice]

iii. eSituation.10—Other Associated Symptoms [Choose All that Apply]

f. eSituation.18—Date/Time Last Known Well (Stroke/CVA)

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Situational History for this EMS Event

3. SAMPLE History

NOTE: Although many assessment guidelines refer to this history mnemonic, many electronic

patient care report (ePCR) systems do not collect this information in a tool organized

specifically in this group, but rather throughout the EMS record in the appropriate areas to

the topics

a. Symptoms

i. eSituation.09—Primary Symptom

AND

ii. eSituation.10—Other Associated Symptoms

b. Allergies

i. eHistory.06—Medication Allergies

AND

ii. eHistory.07—Environmental/Food Allergies

a. Medications

i. eHistory.12—Current Medications

b. Past medical and surgical history

i. eHistory.08—Medical/Surgical History

c. Last Oral Intake

i. eHistory.19—Last Oral Intake (if software configured to collect)

and/or

ii. eNarrative.01—Patient Care Report Narrative

d. Events leading to activation of EMS

i. eSituation.17—Patient Activity

and/or

ii. eNarrative.01—Patient Care Report Narrative

4. Barriers and Situational Confounders

a. eHistory.01—Barriers to Patient Care

b. eHistory.17—Alcohol/Drug Use Indicators

5. Stroke

a. eSituation.18—Date/Time Last Known Well (Stroke/CVA)

6. Trauma History and Situation

a. eSituation.02—Possible Injury (Yes/No—based on mechanism, not listing an actual

injury)

b. eInjury.01—Cause of Injury

i. Known to clinicians as Mechanism of Injury; values are from ICD-10

ii. Intent is included where possible in ICD-10, but is no longer a separate field as it was

in NEMSIS v2

c. eInjury.03—Trauma Center Criteria (per the ACS-COT 2022 National Guideline for Field

Triage of Injured Patients)

d. eInjury.04—Vehicular, Pedestrian, or Other Injury Risk Factor (per the ACS-COT 2022

National Guideline for Field Triage of Injured Patients)

e. eInjury.07—Use of Occupant Safety Equipment

f. Destination Pre-Arrival Alerts (e.g., trauma alerts)

i. eDisposition.24—Destination Team Pre-Arrival Alert or Activation

ii. eDisposition.25—Date/Time of Destination Pre-Arrival Alert or Activation

7. Cardiac Arrest History and Situation

NOTE: The following fields meet the needs of Utstein Criteria reports and many of the fields

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in CARES. CARES has additional custom fields that may be available from your software

vendor.

a. eArrest.01—Cardiac Arrest [Yes/No]

b. eArrest.02—Cardiac Arrest Etiology

c. eArrest.03—Resuscitation Attempted By EMS

d. eArrest.04—Arrest Witnessed By

e. eArrest.05—CPR Care Provided Prior to EMS Arrival

f. eArrest.06—Who Provided CPR Prior to EMS Arrival

g. eArrest.07—AED Use Prior to EMS Arrival

h. eArrest.08—Who Used AED Prior to EMS Arrival

i. eArrest.09—Type of CPR Provided

j. eArrest.11—First Monitored Arrest Rhythm of the Patient

k. eArrest.12—Any Return of Spontaneous Circulation

l. eArrest.14—Date/Time of Cardiac Arrest

m. eArrest.15—Date/Time Resuscitation Discontinued

n. eArrest.16—Reason CPR/Resuscitation Discontinued

o. eArrest.17—Cardiac Rhythm on Arrival at Destination

p. eArrest.18—End of EMS Cardiac Arrest Event

q. eScene.02—Other EMS or Public Safety Agencies at Scene

r. eScene.03—Other EMS or Public Safety Agency ID Number

s. eScene.04—Type of Other Service at Scene

Clinician Impressions and Incident/Patient Disposition

1. Clinician Impressions (Clinician Field Working Diagnosis)

a. eSituation.11—Clinician's Primary Impression [Single Choice]

i. The word “Primary” causes a great deal of understandable confusion with this field,

this should be the diagnosis of the most acute (primary) problem NOT NECESSARILY

THE FIRST problem that was wrong with the patient, or their initial complaint

b. eSituation.12—Clinician's Secondary Impressions [Choose all that Apply]

2. Incident/Patient Disposition

a. eSituation.13—Initial Patient Acuity (Intended to be prior to EMS care)

b. eDisposition.19—Final Patient Acuity (Intended to be after EMS care)

c. eDisposition.12—Incident/Patient Disposition

d. eDisposition.16—EMS Transport Method

e. Transport Mode (i.e., use of lights and sirens)

i. eDisposition.17—Transport Mode from Scene

ii. eDisposition.18—Additional Transport Mode Descriptors

f. eDisposition.01—Destination/Transferred To, Name

i. Intended by NEMSIS to be the destination facility or the Agency transferred to,

although many ePCR systems only collect this as the destination facility because of

the complexity of mixing facilities and services in the same field

Assessments and Exams

1. Exams

By definition, use of NEMSIS eExam fields is optional; they are, however, available for both

state and local EMS system use.

a. Many systems do not require use of these fields as they can be time-consuming to

enter, often too detailed (i.e., there is no value for whole arm, it would need to be

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entered as shoulder, upper arm, elbow, forearm and wrist with separate exam findings

for each component, meaning a single exam finding of paralysis for an arm would take

ten steps to enter) and the same information is often reflected in the clinician’s

narrative.

b. However, there is some utility in targeted use of these fields for certain situations such

as stroke, spinal exams, and trauma without needing to enter all the fields in each

record.

2. Capacity Assessment Group

This can be used to support documentation of patient capacity for refusal of care and/or

transport, participation in advanced spinal assessments, or support for treatment decisions

by EMS clinicians. NOTE: The Capacity Assessment Group does not provide a legal definition

of capacity and should not be used as such. It is intended only to assist the EMS clinician in

documenting the most basic exam and history findings in order to determine capacity. Many

additional factors must be considered when determining capacity including the situation,

patient medical history, medical conditions, and consultation with medical direction.

a. Barriers and situational confounders [Both only single entry]

i. eHistory.01—Barriers to Patient Care

ii. eHistory.17—Alcohol/Drug Use Indicators

b. Glasgow Coma Score (GCS) Vitals Group [see Vitals section] [serial entries allowed]

c. eVitals.26—Level of Responsiveness (AVPU) [serial entries allowed]

d. eExam.19—Mental Status Assessment [serial entries allowed]

e. eExam.20—Neurological Assessment [serial entries allowed]

3. Stroke Assessments

a. Initial Vitals

b. eSituation.18—Date/Time Last Known Well (Stroke/CVA)

c. Stroke Score Group

d. eExam.19—Mental Status Assessment

e. eExam.20—Neurological Assessment (Speech, facial droop, arm drift, unilateral

weakness)

f. eVitals.31—Reperfusion Checklist (May not apply if service area does not use due to lack

of consensus on a standard reperfusion checklist, or acceptance by EMS if used)

4. Spinal Injury/Exam

a. Capacity Assessment Group

b. Back and Spine Assessment Group

i. eExam.13—Back and Spine Assessment Finding Location

ii. eExam.14—Back and Spine Assessment

c. Extremity Assessment Group

i. eExam.15—Extremity Assessment Finding Location

ii. eExam.16—Extremities Assessment

5. 12-lead EKG Acquisition

a. eTimes.06—Unit Arrived on Scene Date/Time

b. eTimes.07—Arrived at Patient Date/Time

c. EKG Rhythm Group [see Vitals section]

d. Attach 12-lead graphic ePCR (through direct integration linkage with EKG monitor or

attachment of scanned printout as allowed/available in software)

e. 12-lead-EKG Procedure-documented under Procedures Performed Group

6. Trauma/Injury

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The exam fields have many useful values for documenting trauma (deformity, bleeding,

burns, etc.). Use of targeted documentation of injured areas can be helpful, particularly in

cases of more serious trauma. Because of the endless possible variations where this could

be used, specific fields will not be defined here. Note, however that the exam fields use a

specific and useful Pertinent Negative called “Exam Finding Not Present.” This can be used

to document that the clinician actually performed the assessment but did not find any

injury/abnormality.

Vitals

1. Vitals Date/Time Group

a. eVitals.01—Date/Time Vital Signs Taken

b. eVitals.02—Obtained Prior to this Unit's EMS Care

2. Glasgow Coma Score (GCS) Group

a. Vitals Date/Time Group

b. eVitals.19—Glasgow Coma Score-Eye

c. eVitals.20—Glasgow Coma Score-Verbal

d. eVitals.21—Glasgow Coma Score-Motor

e. eVitals.22—Glasgow Coma Score-Qualifier

f. eVitals.23—Total Glasgow Coma Score

3. EKG Rhythm Group

a. Vitals Date/Time Group

b. eVitals.03—Cardiac Rhythm/Electrocardiography (EKG)

c. eVitals.04—EKG Type

d. eVitals.05—Method of EKG Interpretation

4. Temperature Group

a. Vitals Date/Time Group

b. eVitals.24—Temperature

c. eVitals.25—Temperature Method

5. Pain Scale Group

a. Vitals Date/Time Group

b. eVitals.27—Pain Scale Score

c. eVitals.28—Pain Scale Type

6. Stroke Score Group

a. Vitals Date/Time Group

b. eVitals.29—Stroke Scale Score

c. eVitals.30—Stroke Scale Type

7. Additional Vitals Options

All should have a value in the Vitals Date/Time Group and can be documented individually

or as an add-on to basic, standard, or full vitals

a. eVitals.09—Mean Arterial Pressure

b. eVitals.13—Pulse Rhythm

c. eVitals.15—Respiratory Effort

d. eVitals.16—End Tidal Carbon Dioxide (EtCO

)

e. eVitals.17—Carbon Monoxide (CO)

f. eVitals.18—Blood glucose Level

g. eVitals.26—Level of Responsiveness (AVPU)

h. Vitals.32—APGAR

8. Routine Vitals – Includes the following vital signs:

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a. Vitals Date/Time Group

b. Blood Pressure

c. eVitals.06—SBP (Systolic Blood Pressure)

d. eVitals.07—DBP (Diastolic Blood Pressure)

e. eVitals.10—Heart Rate

f. eVitals.12—Pulse Oximetry

g. eVitals.14—Respiratory Rate

h. eVitals.26—Level of Responsiveness (AVPU)

i. Pain Scale Group

9. Initial Vitals

a. Routine Vitals

b. eVitals.18—Blood glucose Level

c. Glasgow Coma Score (GCS) Group

d. Temperature Group

10. Full Vitals

a. Initial Vitals

b. eVitals.13—Pulse Rhythm

c. eVitals.15—Respiratory Effort

d. eVitals.16—End Tidal Carbon Dioxide (EtCO

) (If available and applicable)

e. EKG Rhythm Group (If available and applicable)

Medications Given

1. eMedications.01—Date/Time Medication Administered

2. eMedications.02—Medication Administered Prior to this Unit's EMS Care

3. eMedications.03—Medication Given

a. Pertinent Negatives (medication qualifiers) allowed

i. Contraindication Noted

ii. Medication Already Taken

iii. Denied By Order

iv. Refused

v. Medication Allergy

vi. Unable to Complete

4. eMedications.04—Medication Administered Route

5. eMedications.05—Medication Dosage

6. eMedications.06—Medication Dosage Units

7. eMedications.07—Response to Medication [see Definitions of Medication Response below]

8. eMedications.08—Medication Complication

9. eMedications.09—Medication Crew (Healthcare Professionals) ID (Name or license #)

10. eMedications.10—Role/Type of Person Administering Medication (License level)

Procedures Performed

1. eProcedures.01—Date/Time Procedure Performed

2. eProcedures.02—Procedure Performed Prior to this Unit's EMS Care

3. eProcedures.03 – Procedure

a. Pertinent Negatives Allowed

i. Contraindication Noted

ii. Refused

iii. Denied By Order

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iv. Unable to Complete

4. eProcedures.04—Size of Procedure Equipment

5. eProcedures.05—Number of Procedure Attempts (This should always be “1” with each

attempt at a procedure documented separately with appropriate date/time stamp)

6. eProcedures.06—Procedure Successful

7. eProcedures.07—Procedure Complication

8. eProcedures.08—Response to Procedure [see Definitions for Response to Procedures

below]

9. eProcedures.09—Procedure Crew Members ID

10. eProcedures.10—Role/Type of Person Performing the Procedure

11. eProcedures.13—Vascular Access Location (If applicable)

Narrative

The use of the narrative is essential to an effective and complete Patient Care Record. It

summarizes the incident history and care in a manner that is easily digested between caregivers

for continuity of care and provides a place for EMS to document facts that do not fit into fixed

data fields [see Narrative Section under Notes/Educational Pearls (below) for more detail]

Notes/Educational Pearls

Documenting Signs and Symptoms Versus Clinician Impressions

1. Signs and Symptoms

a. Signs and Symptoms should support the clinician impressions, treatment guidelines and

overall care given. A symptom is something the patient experiences and tells the clinician; it

is subjective. A sign is something the clinician sees; it is objective.

b. Symptoms should not be confused with clinician impressions. The clinician impressions

are the EMS working field diagnosis of the patient’s actual medical condition.

2. Clinician Impressions

a. There is often a great deal of confusion on the part of EMS clinicians about the

difference between symptoms and clinician impressions. Clinician impressions should be

supported by symptoms but not be the symptoms except on rare occasions where they

may be the same (i.e., weakness when no etiology for the weakness can be determined

by the EMS clinician).

b. Correctly documenting impressions is essential to many aspects of EMS data use, such

as EMS reimbursement, reports of incident types, specialty registries (e.g., CARES) and

CPI reviews. EMS agencies could literally lose money or equipment and staffing

resources if the clinicians are incorrectly entering clinician impressions. Addressing this

issue should be an essential part of the record Quality Assurance and CPI process and

documentation training.

c. Example of documenting symptoms versus impressions:

i. An opiate overdose patient who received naloxone and had a positive response.

This patient would have possible Symptoms of altered mental status, unconscious,

respiratory distress, and respiratory failure/apnea. All 4 of these symptoms are

available as clinician impressions, however the correct impression for this patient

would be whatever variation of “Drug Overdose Opiates or Heroin” impression(s)

are setup in the local ePCR system being used. This impression will specifically

define the call as an overdose with opiates, rather than a case where one of the

symptoms was also used as an impression when the use of naloxone and other

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assessments and diagnostic tools could not determine an etiology for the

symptom(s).

Narrative

The various data fields within the ePCR are important as they provide a means of uniformly

entering incident data that can be used for importing into billing software or hospital records,

transmitting between EMS systems or creating descriptive reports, or conducting research. In

most cases, at a local, state, or national level, if something wasn’t documented in the

appropriate data field, it didn’t happen or exist. However, the Narrative plays several essential

roles in the PCR.

1. Role of the Narrative

a. Provides an efficient and effective means to share patient information for continuity of

care between EMS services and EMS and hospital staff. The narrative summarizes the

incident history and care in a manner that is easily digested between caregivers.

b. Provides a place for EMS to document facts that do not fit into fixed data fields.

Specifically, this would include the detailed history of the scene, what the patient may

have done or said or other aspects of thecal that only the clinician saw, heard, or did.

The Narrative is the place for the EMS clinician to “paint the picture” for all others to

more fully understand the incident.

c. Provides a standard means to add essential details about medical history, exams,

treatments, patient response, and changes in patient condition that can’t otherwise be

effectively or clearly communicated.

2. Narrative Formats

Documentation by EMS clinicians demonstrates a wide variation of training and practice

reinforcement. Most training programs provide limited instruction on how to properly

document operational and clinical processes, and almost no practice. Most clinicians learn

this skill on the job, and often proficient mentors are sparse. Therefore, it is essential that

the EMS clinician uses a standard format to ensure they are consistent and complete in their

documentation. There are three standard formats for EMS documentation. EMS clinicians

should choose the best match for them, master the format, and be consistent in its use.

a. Medical Narrative: This format is the one most new EMS clinicians use as it is intuitive

and easy to learn. Some more experienced clinicians use it as they find telling the story

from start to finish works best to organize their thoughts. A drawback to this method is

that it is easy to forget to include facts because of the lack of structure.

b. SOAP: This format stands for Subjective, Objective, Assessment, Plan. This is a format

that is very common in the medical field.

c. CHART: This format stands for Complaint, History, Assessment, Rx (Treatment) and

Transport. Each section’s content is clearly defined and consistent in format. It

minimizes the likelihood of forgetting information and ensures documentation is

consistent between records and clinicians. CHART is the format most recommended as

best practice by EMS legal authorities and is considered the standard in many EMS

systems. A variation is DCHART, where the “D” stands for Dispatch (reason).

Medications Given Showing Positive Action Using Pertinent Negatives

For medications that are required by protocol (i.e., aspirin for cardiac chest pain), pertinent

negatives should be used to show that a medication protocol was considered but was satisfied

by other than clinician action.

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Example: EMS is called to a patient for cardiac chest pain. The patient has already taken 324 mg

of aspirin by the time EMS arrives per 911 pre-arrival instructions. EMS clinicians should

document this as a medication given, prior-to-arrival, with the best estimated time, and qualify

the medication as “Medication Already Taken” using the pertinent negative.

Definitions for Response to Medications

1. Improved:

a. The medication had its intended therapeutic effect and the patient's symptoms

decreased or clinical condition improved or resolved (the word "effective" could

generally be substituted for "improved").

b. If a patient had the intended therapeutic response to the medication, but a side effect

that caused a clinical deterioration in another body system, then "Improved" should be

chosen and the side effects documented as a complication (i.e., nitroglycerin improved

chest pain but dropped the blood pressure).

2. Unchanged:

a. The medication was ineffective and had no intended therapeutic effect or had a sub-

therapeutic and unnoticeable effect,

AND

b. The patient condition did not deteriorate.

3. Worse:

a. The patient condition deteriorated or continued to deteriorate because either the

medication:

i. Was ineffective and had no intended therapeutic effect;

ii. Had a sub-therapeutic effect that was unable to stop or reverse the decline in

patient condition;

iii. Was the wrong medication for the clinical situation and the therapeutic effect

caused the condition to worsen (i.e., giving glucose to a patient with

hyperglycemia/diabetic ketoacidosis).

Definitions for Response to Procedures

1. Not Applicable:

The nature of the procedure has no direct expected clinical response (i.e., patient

assessment, 12-lead EKG acquisition).

2. Improved:

a. The procedure performed had the intended effective outcome and/or the patient's

symptoms decreased, or clinical condition improved or resolved (i.e., defibrillation

resolved VF into a perfusing rhythm; intubation controlled the airway and allowed

effective management of breathing).

b. An effective procedure that caused an improvement in the patient condition may also

have resulted in a procedure complication and the complication should be documented

(i.e., intubation caused minor airway trauma, but the intubation successfully secured

the airway).

3. Unchanged:

a. The procedure performed did not have the clinical effect intended, but did not directly

worsen the patient's symptoms or clinical condition (i.e., attempted defibrillation and

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the person remained in VF);

b. Had a sub-therapeutic effect and the symptoms continued (i.e., a bandage applied to a

bleeding wound failed to stop the bleeding);

c. The nature of the procedure has no direct expected clinical response (i.e., patient

assessment).

NOTE: "Not Applicable" would also be appropriate to choose for these cases

4. Worse:

a. The results of the procedure performed lead to a worsening of the patient's symptoms

or condition (e.g., defibrillation converted VF into asystole, application of a splint caused

significant increase in pain or loss of sensation and pulses).

b. In the case of worsening condition, documentation of the procedure complications may

also be appropriate.

c. NOTE: Just because a patient got worse, doesn’t necessarily mean the clinician

performed the procedure incorrectly.

NEMSIS Data Standards and Limitations

1. NEMSIS is a national dataset and standard used by all EMS software systems. (For additional

information, go to www.nemsis.org.) Currently there are three versions of the data standard

available for documentation and in which data is stored:

a. NEMSIS Version 2.2.1 (v2.2.1)

i. Adopted in 2006, there have been no changes since release

ii. Most states or systems have used this standard since its release, and the majority of

most states’ data available since approximately 2016 is in this format.

iii. NEMSIS accepted v2.2.1 data through 12/31/2016, and some states may continue to

collect data in this standard until they transition to NEMSIS v3 standards.

b. NEMSIS Version 3 (v3)

i. NEMSIS v3 was created and finalized in 2011 to replace v2.2.1 in order to allow the

dataset to become more flexible for updates and adopt technical standards making

linkage to other health records possible.

1. NEMSIS v3.3.4 was released in March 2014 and was the first version in

production where live data was collected by services and states and

subsequently submitted to NEMSIS. NEMSIS will continue to accept v3.3.4 data

until 12/31/2017.

2. NEMSIS v3.4, released in March 2015, included both changed elements and

many added values to existing elements. NEMSIS has been accepting data from

this version concurrently with V3.3.4 data. As of August 2021, v3.4 will be the

only standard and V3.3.4 will be phased out. All documentation guidelines

found in this document are based on the NEMSIS v3.4 dataset and standard.

2. Mandatory and Required Elements

b. Mandatory: NEMSIS makes certain elements or fields mandatory so, if not included, the

record cannot be properly stored or moved electronically. These fields require real data

and do not accept Nil (Blank) values, Not Values, or Pertinent Negatives.

c. Required: NEMSIS requires these elements or fields to be completed or the record

cannot be properly stored or moved electronically. However, required fields allow Nil

(blank) values, Not Values, or Pertinent Negatives to be entered and submitted.

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d. State and local systems may have Mandatory or Required fields that are not Mandatory

or Required by NEMSIS. The manager for these systems should be contacted for a list of

these fields.

3. Not Values, Nil, and Pertinent Negatives

b. Not Values (NV), Nil, and Pertinent Negatives (PN) are values that are attributes of

certain NEMSIS elements designed to clarify a null data entry or qualify data entry into

the element with which the NV, Nil, or PN is associated.

c. Not Values available are “Not Applicable” and “Not Recorded”

i. Some NEMSIS rules require one of these values to be entered when data is

imported/exported if there is no other data in a field (e.g., at least one medication

given must have a value, if no medications are given, then the software system must

insert “Not Applicable” in the medications field when exporting)

ii. At times the EMS clinician use of “Not Applicable” is appropriate documentation

(e.g., using “Not Applicable” under eInjury.03—Trauma Center Criteria, per the ACS-

COT 2022 National Guideline for the Field Triage of Injured Patients, when

transporting a patient with a simple sprained ankle)

d. Nil Values are blank values

i. Values can be left blank, which can either be an accidental or purposeful omission of

data.

ii. Value fields can appropriately and purposefully be left blank if there was nothing to

enter (e.g., a procedure field left blank if no patient was encountered).

e. Pertinent Negatives are attributes or qualifiers for both elements and fields. There are

11 possible Pertinent Negative values and the available list for each field varies as

appropriate to the field. Two examples of the use of Pertinent Negatives are:

i. Documenting non-administration of ASA for chest pain by the EMS clinician with the

Pertinent Negative of “Medication Already Taken” to show evidence that this

treatment requirement was met.

ii. Documenting assessment of, and lack of a gunshot wound to the chest with the

qualifier of “Chest --> gunshot wound --> Exam Finding Not Present” in the

examination section (previously you could only document a positive finding of a

gunshot wound with was no way to document that you looked and did not find

one).

4. NEMSIS Element and Value Name Formats

b. NEMSIS Elements/Fields are organized into groups with other related elements/fields

i. There are two parent datasets: Demographic (designated by a “d”) and EMS

(designated by an “e”). The majority of the documentation in any ePCR falls in the

“e” section. The Demographic dataset is intended to be descriptive of the EMS

agencies and system characteristics for correlation at a larger research level, rather

than for use in operational CPI reviews.

ii. The element numbering structure reflects the dataset and the text group name of

the element

5. Example: “eVitals.06—SBP (Systolic Blood Pressure)” where “e” is the EMS dataset and

“Vitals” is the dataset grouping for all elements related to Vitals and the number is the

number assigned to a specific element.

b. “eVitals.06” is used to store the data in the background and “SBP (Systolic Blood

Pressure)” is what clinicians and reviewers see.

c. Values are designated by a code and text name.

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i. The codes are generally derived from various sources such as ICD-10, SNOMED, or

RxNorm and are used to store and move the data in the system’s background.

ii. Codes are not seen by the EMS clinician in the ePCR, but rather the clinician will see

text names.

Some software systems allow the visible text name to be modified or relabeled to

meet local standards or nomenclature; This feature can help improve data quality

by making documentation easier for the clinician.

iii. An example of a value code and name for cardiac chest pain, found under the

element “eProtocols.01—Protocols Used” is “9914117 – Medical-Cardiac Chest

Pain”.

d. All minimum general documentation guideline requirements are identified using the

NEMSIS element, values codes, and names to allow application across a variety of ePCR

software labels for these fields.

6. Custom Elements/Fields and Values

b. The NEMSIS Standard provides a data format for software vendors to create custom

elements or values requested by states or local systems.

c. States or local systems may create new elements or value extensions for existing

NEMSIS elements to meet regional needs (e.g., adding additional protocol name values

not on the NEMSIS list).

Airway Confirmation Fields

Specific use of the NEMSIS airway confirmation fields in documentation will not be detailed at

this time due to current operational and technical challenges all states, local systems, and ePCR

software vendors are experiencing.

The NEMSIS airway confirmation fields were closely modeled on the “Recommended Guidelines

for Uniform Reporting of Data from Out-of-Hospital Airway Management: Position Statement of

the National Association of EMS Physicians” and the fields and values could provide excellent

and appropriately useful data to evaluate airway management. However, the technical structure

of the fields has made their practical use limited as all the data is collected as a separate, self-

contained group, rather than as part of the procedures group. This means EMS clinicians would

need to enter much of the same information twice in the ePCR, in both the procedures area and

airway confirmation section (when, who did it, what device was used, and complications).

Furthermore, the airway group can only be entered once per ePCR, so the fields cannot be used

again if more than one airway was required (e.g., one airway became ineffective and needed to

be replaced with a different type of airway). Many states and ePCR software vendors have been

struggling with how to make these fields functional for use by only using a portion of them or

looking to add mirrored custom values that are directly linked to procedures performed.

However, solutions are currently far from practical, functional, effective, or uniform in how they

are being implemented or used across various systems.

References

1. National Association of EMS Officials, Data Mangers Council. Extended data definitions,

NEMSIS Version 3.4.0.

https://www.nasemso.org/Councils/DataManagers/documents/Extended-Data-

Definitions_v3_Final.pdf. Published May 2016.

2. National EMS Information System Technical Assistance Center. NEMSIS data dictionary,

NHTSA v3.4.0, Build 160713 Critical Patch 2, EMS Data Standard.

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https://nemsis.org/media/nemsis_v3/release-

3.4.0/DataDictionary/PDFHTML/DEMEMS/NEMSISDataDictionary.pdf. Updated July 13,

2016.

3. Wang HE, Domeier RM, Kupas DF, Greenwood MJ, O'Connor RE. Recommended guidelines

for uniform reporting of data from out-of-hospital airway management: position statement

of the national association of EMS physicians. Prehosp Emerg Care 2004;8(1):58-72.

Revision Date

March 11, 2022

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III. Medications

The project team considered the use of Institute for Safe Medication Practices (ISMP) Tall Man Letters

methodology to avoid the miscommunication of lookalike drug names. Upon review of the list and the

limited number of medications carried by EMS, as well as the expected use of this document, it was

elected not to institute this measure into our medication list. We recommend EMS agencies consider

incorporating these measures into practice where appropriate.

Additional information regarding Tall Man Letters can be found on the ISMP website:

http://www.ismp.org/tools/tallmanletters.pdf and the US Food and Drug Administration website:

http://www.fda.gov/Drugs/DrugSafety/MedicationErrors/ucm164587.htm.

Reference: Trade names, class, pharmacologic action and contraindications (relative and absolute)

information from the website http://www.medscape.com, accessed October 23, 2021. Additional

references include the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care, position statements from the American Academy of Clinical

Toxicology and the European Association of Poison Control Centers

(http://clintox.org/documents/positionpapers/Cathartics.pdf), and the article: Rodrigo GJ, Pollack CV,

Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Database of Systematic

Reviews 2006, Issue 4. Art. No.: CD002884.

NOTE: Not all contraindications listed on the http://www.medscape.com website were included for the

purposes of this document. Contraindications which were not pertinent to EMS clinicians were not

included for the purposes of streamlining this document.

Medication List

Acetazolamide

Name — Diamox Sequels®

Class — Carbonic anhydrase inhibitors

Pharmacologic Action—Inhibits hydrogen ion excretion in renal tubule, increasing sodium, potassium,

bicarbonate, and water excretion and producing alkaline diuresis

Indications — Acute mountain sickness

Contraindications — Known hypokalemia/hyponatremia, hypersensitivity to acetazolamide or sulfa,

liver disease, renal disease, cirrhosis, long term administration in patients with chronic, noncongestive

angle-closure glaucoma

Acetaminophen

Name — There are multiple over-the-counter medications, as well as scheduled drugs, that include

acetaminophen (Tylenol®) as an active ingredient

Class — Analgesics, antipyretic, other

Pharmacologic Action—May work peripherally to block pain impulse generation; may also inhibit

prostaglandin synthesis in CNS

Indications—Pain control, fever control

Contraindications—Hypersensitivity, severe acute liver disease

Acetic acid (vinegar)

Name—Vinegar

Class — Other

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Pharmacologic Action — Stabilizes nematocyst discharge in non-United States jellyfish thus decreasing

pain

Indications — Pain control for jellyfish envenomation (outside of the United States (US))

Contraindications — May increase nematocyst discharge for US jellyfish and therefore should be used

outside of the US only

Acetylcysteine

Name—Mucomyst®, Acetadote®

Class — Antidotes, other

Pharmacologic Action—Acts as sulfhydryl group donor to restore liver glutathione; may also scavenge

free radicals to prevent delayed hepatotoxicity as antioxidant; encourages sulfation pathway of

metabolism for acetaminophen

Indications — Antidote for acetaminophen overdose

Contraindications — Acute asthma

WARNING: Nausea and vomiting are common adverse effects following the oral administration of

acetylcysteine

Activated Charcoal

Name — Actidose-Aqua®

Class — Antidotes, other

Pharmacologic Action—Adsorbs a variety of drugs and chemicals (e.g., physical binding of a molecule to

the surface of charcoal particles); desorbtion of bound particles may occur unless the ratio of charcoal to

toxin is extremely high

Indications — Overdose and poisoning

Contraindications — Unprotected airway (beware of aspiration), caustic ingestions, intestinal

obstruction

Adenosine

Name — Adenocard®

Class — Antidysrhythmics

Pharmacologic Action—Slows conduction through AV node and interrupts AV reentry pathways, which

restore normal sinus symptoms

Indications — Conversion of regular, narrow complex tachycardia – stable supraventricular tachycardia

(SVT) or regular, monomorphic wide complex tachycardia

Contraindications — Hypersensitivity, second- or third-degree AV Block (except those on pacemakers),

sick sinus syndrome, atrial flutter or fibrillation, ventricular tachycardia

Albuterol

Name — Proventil®, Ventolin®, Proair®, Accuneb®

Class — Beta-2 agonist

Pharmacologic Action — Beta-2 receptor agonist with some beta-1 activity; relaxes bronchial smooth

muscle with little effect on heart rate

Indications — Bronchospastic lung disease

Contraindications — Hypersensitivity, tachycardia secondary to heart condition

Amiodarone

Name — Pacerone®, Cordarone®, Nexterone®

Class — Class III antidysrhythmics

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Pharmacologic Action — Class III antidysrhythmic agent, which inhibits adrenergic stimulation; affects

sodium, potassium, and calcium channels; markedly prolongs action potential and repolarization;

decreases AV conduction and sinus node function

Indications — Management of regular wide complex tachycardia in stable patients, irregular wide

complex tachycardia in stable patients, and as antidysrhythmic for the management of ventricular

fibrillation (VF) and pulseless ventricular tachycardia (VT)

Contraindications — Hypersensitivity, Severe sinus node dysfunction, second degree or third-degree

heart block or bradycardia causing syncope (except with functioning artificial pacemaker), cardiogenic

shock

WARNING: Avoid during breastfeeding

Amyl Nitrite

Name — component of the Cyanide Antidote Kit®

Class — Cyanide antidote

Pharmacologic Action — Reacts with hemoglobin to form methemoglobin, an oxidized form of

hemoglobin incapable of oxygen transport but with high affinity for cyanide. Cyanide preferentially

binds to methemoglobin over cytochrome a3, forming the nontoxic cyanomethemoglobin

Indications — Acute cyanide toxicity

Contraindications — None in the case of suspected pure cyanide toxicity noted, documented

hypersensitivity, suspected or confirmed smoke inhalation and/or carbon monoxide poisoning

WARNING: There is a risk of worsening hypoxia due to methemoglobin formation

Aspirin

Name — Multiple over-the-counter medications, as well as scheduled drugs, include aspirin as an active

ingredient. These include, but are not limited to, Bayer Buffered Aspirin®, Alka-Seltzer with Aspirin®,

Ascriptin®, Bayer Women’s Low Dose®, Ecotrin®

Class — Antiplatelet agent, non-steroidal anti-inflammatory drug (NSAID)

Pharmacologic Action — Inhibits synthesis of prostaglandin by cyclooxygenase; inhibits platelet

aggregation; has antipyretic and analgesic activity

Indications — Antiplatelet agent for the care of patients suspected of suffering from an acute coronary

syndrome

Contraindications — Hypersensitivity to aspirin or NSAIDs (aspirin-associated hypersensitivity reactions

include aspirin-induced urticarial or aspirin-intolerant asthma), bleeding GI ulcers, hemolytic anemia

from pyruvate kinase (PK) and glucose-6-phosphate dehydrogenase (G6PD) deficiency, hemophilia,

hemorrhagic diathesis, hemorrhoids, lactating mother, nasal polyps associated with asthma, sarcoidosis,

thrombocytopenia, ulcerative colitis

Atropine

Name — Atropen®, a component of Mark I® kits and DuoDote®

Class — Anticholinergic, toxicity antidotes

Pharmacologic Action — Competitively inhibits action of acetylcholinesterase on autonomic effectors

innervated by postganglionic nerves

Indications — Management of nerve agent toxicity, symptomatic bradycardia (primary or related to

toxin ingestion), organophosphate and carbamate insecticide toxicity

NOTE: Ineffective in hypothermic bradycardia

Contraindications — No absolute contraindications for ACLS, documented hypersensitivity in non-

ACLS/nerve agent/organophosphate scenarios

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RELATIVE CONTRAINDICATIONS: Narrow-angle glaucoma, GI obstruction, severe ulcerative colitis, toxic

megacolon, bladder outlet obstruction, myasthenia gravis, hemorrhage w/cardiovascular instability,

thyrotoxicosis

Calcium Chloride

Name — Calcium Chloride

Class — Antidotes, other; calcium salts

Pharmacologic Action — Bone mineral component; cofactor in enzymatic reactions, essential for

neurotransmission, muscle contraction, and many signal transduction pathways

Indications — For use in topical burns (hydrofluoric acid) or for use in calcium channel blocker overdose

Contraindications — Hypercalcemia, documented hypersensitivity, life-threatening cardiac arrhythmias

may occur in known or suspected severe hypokalemia

WARNING: There is a risk for digitalis toxicity. Be cautious of peripheral IV use as significant tissue

necrosis at injection site may occur

Calcium Gluconate

Name — Gluconate®

Class — Antidotes, other; calcium salts

Pharmacologic Action — Bone mineral component; cofactor in enzymatic reactions, essential for

neurotransmission, muscle contraction, and many signal transduction pathways

Indications — For use in topical burns (hydrofluoric acid) or for use in calcium channel blocker overdose

Contraindications — Hypercalcemia, documented hypersensitivity, sarcoidosis, life-threatening cardiac

arrhythmias may occur in known or suspected severe hypokalemia

WARNING: There is a risk for digitalis toxicity

Cimetidine

Name — Tagamet®

Class — Histamine H2 antagonist

Pharmacologic Action — blocks H2-receptors of gastric parietal cells, leading to inhibition of gastric

secretions

Indications — For the management of gastric or duodenal ulcers, gastroesophageal reflux, as an adjunct

in the treatment of urticarial and/or pruritis in patients suffering from allergic reaction

Contraindications — Hypersensitivity to cimetidine or other H2-receptor antagonists

Dexamethasone

Name — Decadron®, Dexasone®

Class — Corticosteroid, anti-inflammatory drugs

Pharmacologic Action — Potent glucocorticoid with minimal to no mineralocorticoid activity

Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and

reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant synthesis,

increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines;

suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down granulocyte

aggregates, and improves pulmonary microcirculation

Indications — Used in the management of croup and bronchospasm, as well as the management of

patients suffering from high altitude cerebral edema (HACE)

Contraindications — Documented hypersensitivity, systemic fungal infection, cerebral malaria

Dextrose

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Name — D50W, DGlucose®, glucose

Class — Glucose-elevating agents; metabolic and endocrine, other

Pharmacologic Action — Parenteral dextrose is oxidized to carbon dioxide and water, and provides 3.4

kilocalories/gram of d-glucose

Indications — Used for the management of hypoglycemia

Contraindications — Hyperglycemia, anuria, diabetic coma, intracranial or intraspinal hemorrhage,

dehydrated patients with delirium, glucose-galactose malabsorption syndrome, and documented

hypersensitivity

Diazepam

Name — Valium®, Diastat®, AcuDial®

Class — Benzodiazepine, anticonvulsants, skeletal muscle relaxants, anxiolytic

Pharmacologic Action — Modulates postsynaptic effects of GABA-A transmission, resulting in an

increase in presynaptic inhibition. Appears to act on part of the limbic system, as well as on the

thalamus and hypothalamus, to induce a calming effect

Indications — For use in agitated or violent patients, as well as for the management of seizures

Contraindications — Documented hypersensitivity, severe respiratory depression

Diltiazem

Name — Includes Cardizem®, Dilacor®, Diltiaz®

Class — Calcium channel blocker, antidysrhythmic type IV

Pharmacologic Action — Inhibits extracellular calcium ion influx across membranes of myocardial cells

and vascular smooth muscle cells, resulting in inhibition of cardiac and vascular smooth muscle

contraction and thereby dilating main coronary and systemic arteries; no effect on serum calcium

concentrations; substantial inhibitory effects on cardiac conduction system, acting principally at AV

node, with some effects at sinus node

Indications — For management of narrow complex tachycardias

Contraindications — Documented hypersensitivity, Wolff-Parkinson-White syndrome, Lown-Ganong-

Levine syndrome, symptomatic severe hypotension (systolic BP less than 90 mmHg), sick sinus syndrome

(if no pacemaker), second- and third-degree heart block (if no pacemaker present), and complete heart

block. Contraindications for IV administration: Use in newborns (because of benzyl alcohol),

concomitant beta-blocker therapy, cardiogenic shock, ventricular tachycardia (must determine whether

origin is supraventricular or ventricular)

Diphenhydramine

Name — Benadryl®

Class — Antihistamine — first generation

Pharmacologic Action — Histamine H1-receptor antagonist of effector cells in respiratory tract, blood

vessels, and GI smooth muscle

Indications — For urticarial and/or pruritis in the management of patients suffering from allergic

reaction as well as for the management of patents suffering from dystonia/akathisia

Contraindications — Documented hypersensitivity, use controversial in lower respiratory tract disease

(such as acute asthma), premature infants and neonates

Dopamine

Name — Intropin®

Class — Inotropic agent; catecholamine; pressor

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Pharmacologic Action — Endogenous catecholamine, acting on both dopaminergic and adrenergic

neurons. Low dose stimulates mainly dopaminergic receptors, producing renal and mesenteric

vasodilation; higher dose stimulates both beta-1-adrenergic and dopaminergic receptors, producing

cardiac stimulation and renal vasodilation; large dose stimulates alpha-adrenergic receptors

Indications — As a pressor agent used in the management of shock

Contraindications — Hypersensitivity to dopamine, pheochromocytoma, ventricular fibrillation,

uncorrected tachyarrhythmias

WARNING: Dopamine is a vesicant and can cause severe tissue damage if extravasation occurs

Droperidol

Name — Inapsine®

Class — Antiemetic agents; antipsychotic

Pharmacologic Action — Antiemesis: dopamine receptor blockade in brain, predominantly dopamine-2

receptor. When reuptake is prevented, a strong antidopaminergic, antiserotonergic response occurs.

Droperidol reduces motor activity, anxiety, and causes sedation; also possesses adrenergic blocking,

antifibrillatory, antihistaminic, and anticonvulsive properties

Indications — For use in the patient with acute delirium or psychosis

Contraindications — Hypersensitivity, known or suspected prolonged QT interval; QTc interval greater

than 450 msec in females or greater than 440 msec in males

WARNING: Use with caution in patients with bradycardia, cardiac disease, concurrent MAO inhibitor

therapy, Class I and Class III dysrhythmics or other drugs that prolong the QT interval and cause

electrolyte disturbances due to its adverse cardiovascular effects, e.g., QT prolongation, hypotension,

tachycardia, and torsades de pointes

Epinephrine

Name — EpiPen®, TwinJect®, Adrenaclick®, Auvi-Q, Adrenalin®, AsthmaNefrin®, Vaponefrin®

Class — Alpha/beta adrenergic agonist

Pharmacologic Action — Strong alpha-adrenergic effects, which cause an increase in cardiac output and

heart rate, a decrease in renal perfusion and peripheral vascular resistance, and a variable effect on BP,

resulting in systemic vasoconstriction and increased vascular permeability. Strong beta-1- and moderate

beta-2-adrenergic effects, resulting in bronchial smooth muscle relaxation

Secondary relaxation effect on smooth muscle of stomach, intestine, uterus, and urinary bladder

Indications — For use in the management of patients suffering anaphylaxis, shock, cardiac arrest,

bradycardia, or in the nebulized form for croup/bronchiolitis and IM form for refractory acute asthma

Contraindications — Hypersensitivity, cardiac dilatation and coronary insufficiency

Famotidine

Name — Pepcid®

Class — Histamine H2 antagonist

Pharmacologic Action — Blocks H2 receptors of gastric parietal cells, leading to inhibition of gastric

secretions

Indications — For the management of gastric or duodenal ulcers, gastroesophageal reflux, as an adjunct

in the treatment of urticarial and/or pruritus in patients suffering from allergic reaction

Contraindications — Hypersensitivity to famotidine or other H2-receptor antagonists

Fentanyl

Name —Currently only available in the generic form (formerly Sublimaze®)

Class — Synthetic opioid, opioid analgesics

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Pharmacologic Action — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain

pathways, thus altering response to pain; increases pain threshold; produces analgesia, respiratory

depression, and sedation

Indications — Management of acute pain

Contraindications — Hypersensitivity

WARNING: Should be used with caution in the elderly and in patients with hypotension, suspected

gastrointestinal obstruction, head injury, and concomitant CNS depressants

Glucagon

Name — GlucaGen®, Glucagon Emergency Kit®, GlucaGen HypoKit®

Class — Hypoglycemia antidotes, glucose-elevating agents, other antidotes (e.g., beta-blocker or calcium

channel blocker overdose)

Pharmacologic Action — Insulin antagonist. Stimulates cAMP synthesis to accelerate hepatic

glycogenolysis and gluconeogenesis. Glucagon also relaxes smooth muscles of GI tract

Indications — For the management of hypoglycemic patients as well as patients suffering symptomatic

bradycardia after beta blocker or calcium channel blocker overdose

Contraindications — Hypersensitivity, pheochromocytoma, insulinoma

WARNING: Nausea and vomiting are common adverse effects following the administration of glucagon

Haloperidol

Name — Haldol®, Haldol Decanoate®, Haloperidol LA®, Peridol®

Class — First generation antipsychotic

Pharmacologic Action — Antagonizes dopamine-1 and dopamine-2 receptors in brain; depresses

reticular activating system and inhibits release of hypothalamic and hypophyseal hormones

Indications — For the management of acute psychosis or agitated/violent behavior refractory to non-

pharmacologic interventions

Contraindications — Documented hypersensitivity, Severe CNS depression (including coma), neuroleptic

malignant syndrome, poorly controlled seizure disorder, Parkinson’s disease

WARNING: Risk of sudden death, torsades de pointes, and prolonged QT interval from off-label IV

administration of higher than recommended dose. Continuous cardiac monitoring is required if

administering IV

Helium Gas Mixture

Name — Heliox

Class — Optional method of oxygen delivery

Pharmacology — Less resistant than atmospheric air which may reduce the patient’s work of breathing

by increasing tendency to laminar flow and reducing resistance to turbulent flow

Indications — Persistent or severe bronchospasm in non-intubated patients with obstructive airway

disease or pediatric patients with croup that is unresponsive to all other evidence-based medical

interventions.

Contraindications — None

Hydralazine

Name — No listed brand name

Class — Vasodilator

Pharmacology — Direct vasodilator at the level of arterioles, with little effect on veins. Decreases

systemic resistance.

Indications — Severe hypertension with pre-eclampsia symptoms

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Contraindications — Hypersensitivity, coronary artery disease, mitral valve rheumatic heart disease. Use

with caution in CVA, known renal disease, hypotension

Hydrocortisone succinate

Name — Cortef®, SoluCortef®

Class — Corticosteroid

Pharmacologic Action — Glucocorticoid; elicits mild mineralocorticoid activity and moderate anti-

inflammatory effects; controls or prevents inflammation by controlling rate of protein synthesis,

suppressing migration of polymorphonuclear leukocytes (PMNs) and fibroblasts, and reversing capillary

permeability

Indications — For the management of adrenal insufficiency

Contraindications — Untreated serious infections (except tuberculous meningitis or septic shock),

idiopathic thrombocytopenic purpura, intrathecal administration (injection), documented

hypersensitivity

Hydromorphone

Name — Dilaudid

Class — Synthetic opiate, opioid analgesic

Pharmacology — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain pathways, thus

altering response to pain; increases pain threshold; produces analgesia, respiratory depression, and

sedation

Indications — Management of acute pain

Contraindications — Hypersensitivity

WARNING: Should be used with caution in the elderly and in patients with hypotension, suspected

gastrointestinal obstruction, head injury, and concomitant CNS depressants

Hydroxocobalamin

Name — Cyanokit®

Class — Cyanide antidote

Pharmacologic Action — Vitamin B12 with hydroxyl group complexed to cobalt which can be displaced

by cyanide resulting in cyanocobalamin that is renally excreted

Indications — For the management of cyanide toxicity

Contraindications — Documented hypersensitivity

WARNING: Will cause discoloration of the skin and urine, can interfere with pulse oximetry. Due to its

interference with certain diagnostic blood tests, the performance of prehospital phlebotomy is

preferable prior to the administration of hydroxocobalamin

Ibuprofen

Name — There are multiple over-the-counter medications that include ibuprofen, such as Advil®,

Motrin®

Class — Non-steroidal anti-inflammatory drug (NSAID)

Pharmacologic Action — Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2

cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2. May inhibit chemotaxis, alter lymphocyte activity,

decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may

contribute to anti-inflammatory activity

Indications — For the acute management of pain or as an antipyretic

Contraindications — Aspirin allergy; perioperative pain in setting of coronary artery bypass graft (CABG)

surgery; preterm infants with untreated proven or suspected infection; bleeding with active intracranial

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hemorrhage or GI bleed; thrombocytopenia, coagulation defects, proven or necrotizing enterocolitis,

significant renal impairment, congenital heart disease where patency or the patent ductus arteriosus

(PDA) is necessary for pulmonary or systemic blood flow

Ipratropium

Name — Atrovent®

Class — Anticholinergics, respiratory

Pharmacologic Action — Anticholinergic (parasympatholytic) agent; inhibits vagally mediated reflexes

by antagonizing acetylcholine action; prevents increase in intracellular calcium concentration that is

caused by interaction of acetylcholine with muscarinic receptors on bronchial smooth muscle

Indications — For the management of asthma and chronic obstructive pulmonary disease (COPD)

Contraindications — Documented hypersensitivity to ipratropium, atropine, or derivatives.

Isopropyl Alcohol

Name — No brand name available

Class — Secondary alcohol

Pharmacology — In addition to traditional role as antiseptic, may be used as antiemetic

Indications — Nausea and vomiting

Contraindications — None

Ketamine

Name — Ketalar®

Class — General anesthetics, systemic

Pharmacologic Action — Produces dissociative anesthesia. Blocks N-methyl D-aspartate (NMDA)

receptor

Indications — For the management of agitated or violent behavior

Contraindications — Hypersensitivity

RELATIVE/CONTROVERSIAL CONTRAINDICATIONS: Head trauma, intracranial mass/hemorrhage,

hypertension, angina, and stroke, underlying psychiatric disorder

WARNING: Overdose may lead to panic attacks and aggressive behavior; rarely seizures, increased ICP,

and cardiac arrest. Very similar in chemical makeup to PCP (phencyclidine), but it is shorter acting and

less toxic

Ketoralac

Name — Toradol®

Class — Non-steroidal anti-inflammatory drug (NSAID)

Pharmacologic Action — Inhibits synthesis of prostaglandins in body tissues by inhibiting at least 2

cyclo-oxygenase (COX) isoenzymes, COX-1 and COX-2. May inhibit chemotaxis, alter lymphocyte activity,

decrease proinflammatory cytokine activity, and inhibit neutrophil aggregation; these effects may

contribute to anti-inflammatory activity

Indications — For the acute management of moderately severe pain

Contraindications — Allergy to aspirin, ketorolac, or other NSAIDS; women who are in active labor or

are breastfeeding, significant renal impairment particularly when associated with volume depletion,

previous or current GI bleeding, intracranial bleeding, coagulation defects, patients with a high-risk of

bleeding

Labetalol

Name — Trandate

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Class — Beta-blockers, alpha activity

Pharmacology — Nonselective beta blocker with intrinsic sympathomimetic activity; also, alpha blocker

Indications — severe hypertension with pre-eclampsia symptoms

Contraindications — Asthma or obstructive airway disease, severe bradycardia, second-degree or third-

degree heart block (without pacemaker), cardiogenic shock, bronchial asthma, uncompensated cardiac

failure, hypersensitivity, sinus bradycardia, sick sinus syndrome without permanent pacemaker;

conditions associated with prolonged and severe hypotension. Use with caution in patients taking

calcium channel blockers. Hypotension with or without syncope may occur, monitor. Consider pre-

existing conditions, such as, sick sinus syndrome before initiating therapy. Use caution in patients with

history of severe anaphylaxis to allergens; patients taking beta-blockers may become more sensitive to

repeated challenges; treatment with epinephrine in patients taking beta-blockers may be ineffective or

promote undesirable effects. Use with caution in patients with myasthenia gravis, psoriasis, or

psychiatric illness (may cause or exacerbate CNS depression)

Lidocaine

Name — Lidocaine CV®, Lidopen®, Xylocaine®

Class — Class Ib antidysrhythmics

Pharmacologic Action — Class 1b antidysrhythmic; combines with fast sodium channels and thereby

inhibits recovery after repolarization, resulting in decreasing myocardial excitability and conduction

velocity

Indications — For the management of refractory or recurrent ventricular fibrillation or pulseless VT

Contraindications — Hypersensitivity to lidocaine or amide-type local anesthetic, Adams-Stokes

syndrome, SA/AV/intraventricular heart block in the absence of artificial pacemaker. nitro (CHF),

cardiogenic shock, second- and third-degree heart block (if no pacemaker is present), Wolff-Parkinson-

White Syndrome

Lorazepam

Name — Ativan®

Class — Anticonvulsants, other; antianxiety agent; anxiolytics; benzodiazepines

Pharmacologic Action — Sedative hypnotic with short onset of effects and relatively long half-life; by

increasing the action of gamma-aminobutyric acid (GABA), which is a major inhibitory neurotransmitter

in the brain, lorazepam may depress all levels of the CNS, including limbic and reticular formation

Indications — For the management of seizures, uncontrolled shivering in hypothermia, and for the

management of agitated or violent patients suffering behavioral emergencies

Contraindications — Documented hypersensitivity, acute narrow angle glaucoma, severe respiratory

depression, sleep apnea

Magnesium sulfate

Name — MgSO4

Class — Class V antidysrhythmic, electrolyte

Pharmacologic Action — Depresses CNS, blocks peripheral neuromuscular transmission, produces

anticonvulsant effects; decreases amount of acetylcholine released at end-plate by motor nerve

impulse. Slows rate of sinoatrial (SA) node impulse formation in myocardium and prolongs conduction

time. Promotes movement of calcium, potassium, and sodium in and out of cells and stabilizes excitable

membranes

Indications — For the management of torsades de pointes or for severe bronchoconstriction with

impending respiratory failure, seizure during the third trimester of pregnancy or in the postpartum

patient

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Contraindications — Hypersensitivity, myocardial damage, diabetic coma, heart block,

hypermagnesemia, hypercalcemia

Methylprednisolone

Name — Medrol®, Medrol Dosepak®, DepoMedrol®, SoluMedrol®

Class — Corticosteroid, anti-inflammatory agent

Pharmacologic Action — Potent glucocorticoid with minimal to no mineralocorticoid activity. Modulates

carbohydrate, protein, and lipid metabolism and maintenance of fluid and electrolyte homeostasis.

Controls or prevents inflammation by controlling rate of protein synthesis, suppressing migration of

polymorphonuclear leukocytes (PMNs) and fibroblasts, reversing capillary permeability, and stabilizing

lysosomes at cellular level

Indications — For the management of acute bronchospastic disease as well as for adrenal insufficiency

Contraindications — Untreated serious infections, documented hypersensitivity, IM route is

contraindicated in idiopathic thrombocytopenic purpura, traumatic brain injury (high doses)

Metoclopramide

Name — Reglan®, Metozolv ODT®

Class — Antiemetic agent, prokinetic agent

Pharmacologic Action — Blocks dopamine receptors (at high dose) and serotonin receptors in

chemoreceptor trigger zone of CNS; and sensitizes tissues to acetylcholine; increases upper GI motility

but not secretions; increases lower esophageal sphincter tone

Indications — For the management of nausea and vomiting

Contraindications — Hypersensitivity to metoclopramide or procainamide, GI hemorrhage, mechanical

obstruction, perforation, history of seizures, pheochromocytoma. Other drugs causing extrapyramidal

symptoms (e.g., phenothiazines, butyrophenones)

Metoprolol

Name — Lopressor®, Toprol XL®

Class — Beta blocker, beta-1 selective

Pharmacologic Action — Blocks response to beta-adrenergic stimulation; cardio selective for beta-1

receptors at low doses, with little or no effect on beta-2 receptors

Indications — For management of narrow complex tachycardias

Contraindications — Hypersensitivity. When administered for hypertension or angina: Sinus

bradycardia, 2nd or 3rd degree AV block, cardiogenic shock, sick sinus syndrome (unless permanent

pacemaker in place), severe peripheral vascular disease, pheochromocytoma. When administered for

myocardial infarction: Severe sinus bradycardia with heart rate less than 45 beats/minute, systolic BP

less than 100 mmHg, significant first-degree heart block (PR interval at least 0.24 seconds), moderate-to-

severe cardiac failure

WARNING: May cause 1st, 2nd, or 3rd degree AV block

Midazolam

Name — Versed®

Class — Anticonvulsants, other; antianxiety agent; anxiolytics; benzodiazepines

Pharmacologic Action — Binds receptors at several sites within the CNS, including the limbic system and

reticular formation; effects may be mediated through gabba-aminobutyric acid (GABA) receptor system;

increase in neuronal membrane permeability to chloride ions enhances the inhibitory effects of GABA;

the shift in chloride ions causes hyperpolarization (less excitability) and stabilization of the neuronal

membrane

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Indications — For the management of seizures, uncontrolled shivering in hypothermia, and for the

management of agitated or violent patients suffering behavioral emergencies

Contraindications — Documented hypersensitivity, severe respiratory depression, sleep apnea

WARNING: May cause respiratory depression, arrest, or apnea

Morphine Sulfate

Name — MS Contin®, Avinza®, Depodur®, Duramorph®, Infumorph®, Astramorph®, Kadian®, MSO4

Class — Opioid analgesic

Pharmacologic Action — Narcotic agonist-analgesic of opiate receptors; inhibits ascending pain

pathways, thus altering response to pain; produces analgesia, respiratory depression, and sedation;

suppresses cough by acting centrally in medulla

Indications — Management of acute pain

Contraindications — Hypersensitivity, paralytic ileus, toxin-mediated diarrhea, respiratory depression,

acute or severe bronchial asthma, upper airway obstruction, GI obstruction (extended release),

hypercarbia (immediate release tablets/solution), upper airway obstruction (epidural/intrathecal), heart

failure due to chronic lung disease, head injuries, brain tumors, deliriums tremens, seizure disorders,

during labor when premature birth anticipated (injectable formulation), cardiac arrhythmia, increased

intracranial or cerebrospinal pressure, acute alcoholism, use after biliary tract surgery, surgical

anastomosis (suppository formulation)

Naloxone

Name — Narcan®

Class — Opioid reversal agent

Pharmacologic Action — Competitive opioid antagonist; synthetic congener of oxymorphone

Indications — Reversal of acute opioid toxicity

Contraindications — Hypersensitivity

WARNING: Administration of naloxone can result in the sudden onset of opiate withdrawal (agitation,

tachycardia, pulmonary edema, nausea, vomiting, and, in neonates, seizures)

Nifedipine

Name — Procardia®, Adalat CC®, Nifedical®

Class — Calcium channel blocker

Pharmacologic Action — Calcium-channel blocker; inhibits transmembrane influx of extracellular

calcium ions across myocardial and vascular smooth muscle cell membranes without changing serum

calcium concentrations; this results in inhibition of cardiac and vascular smooth muscle contraction,

thereby dilating main coronary and systemic arteries. Vasodilation with decreased peripheral resistance

and increased heart rate

Indications — For the management of high-altitude pulmonary edema (HAPE)

Contraindications — Hypersensitivity to nifedipine or other calcium-channel blockers, cardiogenic

shock, concomitant administration with strong CYP3A4 inducers (e.g., rifampin, rifabutin, phenobarbital,

phenytoin, carbamazepine, St. John's wort) significantly reduces nifedipine efficacy, Immediate release

preparation (sublingually or orally) for urgent or emergent hypertension

Nitrous Oxide

Name — N

Class — Weak inhalational anesthetic

Pharmacologic Action — Its analgesic mechanism of action is described as opioid in nature and may

involve a number of spinal neuromodulators. The anxiolytic effect is similar to that of

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benzodiazepine and may involve gamma aminobutyric (GABA) receptors. The anesthesia

mechanism may involve GABA and possibly N-methyl-D-aspartate receptors as well.[6] In general, the

effect of nitrous oxide ceases as soon as the inhalation stops, with no residual effect

Indications — Analgesia in the patient who is capable of self-administration of this medication

Contraindications — Significant respiratory compromise, suspected abnormal air-filled cavities (e.g.,

pneumothorax, bowel obstruction, air embolism)

RELATIVE CONTRAINDICATIONS: History of stroke, hypotension, pregnancy, known cardiac conditions,

known vitamin B12 deficiency

Nitroglycerin

Name — Nitrostat®, Nitrolingual Pumpspray®, NitroQuick®

Class — Nitrates, anti-anginal

Pharmacologic Action — Organic nitrate which causes systemic venodilation, decreasing preload.

Cellular mechanism: nitrate enters vascular smooth muscle and converted to nitric oxide (NO) leading to

activation of cyclic guanosine monophosphate (cGMP) and vasodilation. Relaxes smooth muscle via

dose-dependent dilation of arterial and venous beds to reduce both preload and afterload, and

myocardial O

demand. Also improves coronary collateral circulation. Lower BP, increases heart rate,

occasional paradoxical bradycardia

Indications — As an anti-anginal medication for the management of chest pain as well as a reducer of

preload for patients suffering from acute pulmonary edema

Contraindications — Hypersensitivity, acute myocardial infarction, severe anemia, recent use of erectile

dysfunction medications (sildenafil (Viagra® — within last 24 hours), tadalafil (Cialis® — within last 48

hours), vardenafil (Levitra® — within last 48 hours), or other phopsphodiesterase-5 inhibitors). There is

potential for dangerous hypotension, narrow angle glaucoma (controversial: may not be clinically

significant). Nitrates are contraindicated in the presence of hypotension (SBP less than 90 mmHg or ≥30

mmHg below baseline), extreme bradycardia (less than 50 BPM), tachycardia in the absence of heart

failure (greater than 100 BPM), and right ventricular infarction

Norepinephrine

Name — Levophed®, Levarterenol®

Class — Alpha/beta adrenergic agonist

Pharmacologic Action — Strong beta-1 and alpha-adrenergic effects and moderate beta-2 effects, which

increase cardiac output and heart rate, decrease renal perfusion and peripheral vascular resistance, and

cause variable BP effects

Indications — As a pressor agent used in the management of shock

Contraindications — Hypersensitivity, hypotension due to blood volume deficit, peripheral vascular

thrombosis (except for lifesaving procedures)

RELATIVE CONTRAINDICATIONS: concomitant use with some general anesthetics: chloroform,

trichloroethylene, cyclopropane, halothane

WARNING: Norepinephrine is a vesicant and can cause severe tissue damage if extravasation occurs. Do

not use in the same IV line as alkaline solutions as these may deactivate it

Olanzapine

Name — Zyprexa®

Class — Antipsychotic, second generation, antimanic agents

Pharmacologic Action — May act through combination of dopamine and serotonin type 2 receptor site

antagonism

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Indications — For the management of agitated or violent patients suffering a behavioral emergency

Contraindications — Documented hypersensitivity

WARNING: Patients are at risk for severe sedation (including coma) or delirium after each injection and

must be observed for at least 3 hours in registered facility with ready access to emergency response

services. Patients are at significant risk of severe sedation when olanzapine is administered with

benzodiazepines or to patients who have are taking benzodiazepines

Ondansetron

Name — Zofran®, Zofran ODT®, Zuplenz®

Class — Antiemetic, selective 5-HT3 antagonist

Pharmacologic Action — Mechanism not fully characterized; selective 5-HT3 receptor antagonist; binds

to 5-HT3 receptors both in periphery and in CNS, with primary effects in GI tract. Has no effect on

dopamine receptors and therefore does not cause extrapyramidal symptoms

Indications — For the management of nausea or vomiting

NOTE: EKG monitoring is recommended in patients who have electrolyte abnormalities, CHF, or

bradyarrhythmias or who are also receiving other medications that cause QT prolongation

Contraindications — Hypersensitivity, coadministration with apomorphine; combination reported to

cause profound hypotension and loss of consciousness

WARNING: May cause dose-dependent QT prolongation, avoid in patients with congenital long QT

syndrome

Oxymetazoline

Name — Afrin®, Duramist Plus®, Dristan 12 Hr®, Sinarest 12 Hour®, Vicks Sinus 12 Hour®

Class — Decongestants, intranasal

Pharmacologic Action — Alpha-adrenergic agonist; stimulates alpha-adrenergic receptors and produces

vasoconstriction in the arterioles of the nasal mucosa

Indications — For the management of epistaxis in the patient suffering facial trauma

Contraindications — Hypersensitivity

Potassium iodide

Name — Pima Syrup®, SSKI®, ThyroSafe®, ThyroShield®

Class — Antidotes, other; antithyroid agents

Pharmacologic Action — As a thyroid protective agent: Systemically circulating potassium iodide is

readily taken up by thyroid gland by sodium/iodide transporter in basal membrane; blocking the thyroid

uptake of radioactive isotopes of iodine; concentration gradient of thyroid gland to plasma is 20—50:1

Indications — Indicated during environmental radiation emergency to block uptake of radioactive iodine

isotopes in thyroid and reduce risk of thyroid cancer

Contraindications — Iodine sensitivity (although allergy to radiocontrast media, contact dermatitis from

iodine-containing antibacterials, allergy to seafood should not be considered evidence of potassium

iodide allergy), hyperthyroidism, respiratory failure

Prednisone

Name – Deltasone®, Rayos®, Sterapred®

Class – Corticosteroid

Pharmacologic Action - Glucocorticosteroid which also elicits mild mineralocorticoid activity and dose

dependent moderate-to-significant anti-inflammatory effects

Indications – WILL NEED TO REVIEW EVERY PLACE PREDNISONE IS MENTIONED IN THE PROTOCOLS

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Contraindications – Avoid in untreated severe infections, documented hypersensitivity, or active

varicella and fungal infections

Prednisolone

Name – Pediapred®, FloPred®, Orapred®, Millipred®, Prelone Syrup®, Veripred®

Class – Corticosteroid

Pharmacologic Action - Glucocorticosteroid which also elicits mild mineralocorticoid activity and dose

dependent moderate-to-significant anti-inflammatory effects

Indications – WILL NEED TO REVIEW EVERY PLACE PREDNISONE IS MENTIONED IN THE PROTOCOLS

Contraindications – Avoid in untreated severe infections, documented hypersensitivity, or

active varicella and fungal infections

Pralidoxime chloride (2-PAM)

Name — Protopam®, 2PAM Antidote®, Pralidoxime Auto Injector®, a component of Mark I® kits and

DuoDote®

Class — Cholinergic, toxicity antidote

Pharmacologic Action — Binds to organophosphates and breaks alkyl phosphate-cholinesterase bond to

restore activity of acetylcholinesterase

Indications — For the management of toxicity caused by organophosphate insecticides and related

nerve gases (e.g., tabun, sarin, soman)

Contraindications — Documented hypersensitivity

Procainamide

Name — Pronestyl®, Procanbid®

Class — Class Ia antidysrhythmic

Pharmacologic Action — Class Ia (membrane stabilizing) antidysrhythmic agent; inhibits recovery after

repolarization resulting in decreasing myocardial excitability and conduction velocity. Direct membrane

depressant that decreases conduction velocity, prolongs refractoriness, decreases automaticity and

reduces repolarization abnormalities

Indications — For the management of stable patients with regular, wide complex tachycardia

Contraindications — Hypersensitivity to procainamide or other ingredients, complete heart block,

second- or third-degree AV block, systemic lupus erythematosus (SLE), torsades de pointes

RELATIVE CONTRAINDICATION: Patients with QT prolongation

Prochlorperazine

Name — Compazine®

Class — Antiemetic agent; antipsychotics, phenothiazine

Pharmacologic Action — Antiemetic: antidopaminergic effect, blocking dopamine receptors in the brain,

blocking vagus nerve in GI tract. Antipsychotic: Blocking mesolimbic dopamine receptors, and blocking

alpha-adrenergic receptors (D1 and D2) in brain

Indications — For the management of nausea and vomiting

Contraindications — Documented hypersensitivity to phenothiazines, coma, severe CNS depression,

concurrent use of large amounts of CNS depressants, poorly controlled seizure disorder, subcortical

brain damage, pediatric surgery, children less than 2 years or weighing less than 9 kg

Sildenafil

Name — Revatio®, Viagra®

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Class — Pulmonary artery hypertension therapy, PDE-5 inhibitors; phosphodiesterase-5 enzyme

inhibitor

Pharmacologic Action — Inhibits PDE-5, increasing cyclic guanosine monophosphate (cGMP) to allow

smooth-muscle relaxation

Indications — As an adjunct to descent in the management of high-altitude pulmonary edema (HAPE)

Contraindications — Concomitant use of organic nitrates in any form (e.g., nitroglycerin, isosorbide,

illicit “poppers”) either regularly or intermittently, increases risk of severe or potentially fatal

hypotension, hypersensitivity

WARNING: Hypotension may occur due to vasodilation

Sodium Bicarbonate

Name — Bicarb

Class — Antidote, other

Pharmacologic Action — Increases blood and urinary pH by releasing a bicarbonate ion, which in turn

neutralizes hydrogen ion concentrations

Indications — For the management of cardiac arrest in cases in which either hyperkalemia or tricyclic

antidepressant (TCA) overdose are suspected as contributory, QRS prolongation in known or suspected

TCA overdose

Contraindications — Documented hypersensitivity, severe pulmonary edema, known alkalosis,

hypernatremia, or hypocalcemia

Sodium Nitrite

Name — Nithiodote®

Class — Cyanide antidote

Pharmacologic Action — Nitrites create methemoglobins to bind to cyanide

Indications — For the management of cyanide toxicity

Contraindications — Documented hypersensitivity, suspected or confirmed smoke inhalation and/or

carbon monoxide poisoning

WARNING: There is a risk of worsening hypoxia due to methemoglobin formation. In addition, sodium

nitrite can cause serious adverse reactions and death from hypotension and methemoglobin formation.

Monitor to ensure adequate perfusion and oxygenation during treatment with sodium nitrite

Sodium Thiosulfate

Name— Nithiodote®

Class — Cyanide antidote

Pharmacologic Action — Thiosulfate is sulfur donor utilized by rhodanese to convert cyanide to less

toxic thiocyanate

Indications — For the management of cyanide toxicity

Contraindications — Documented hypersensitivity

Sorbitol

Name — Sorbitol

Class — Laxatives, osmotic

Pharmacologic Action — Polyalcoholic sugar with hyperosmotic effects

Indications — Administered for the management of patients suffering from toxic ingestions

Contraindications — Acute abdominal pain, nausea, vomiting, or other symptoms of appendicitis or

undiagnosed abdominal pain, documented hypersensitivity

WARNING: Sorbitol is no longer recommended to be given with activated charcoal

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Tadalafil

Name — Cialis®, Adcirca®

Class — Pulmonary artery hypertension therapy, PDE—5 inhibitors; phosphodiesterase-5 enzyme

inhibitor

Pharmacologic Action — Pulmonary arterial hypertension (PAH): inhibits PDE-5, increasing cyclic

guanosine monophosphate (cGMP) to allow relaxation of pulmonary vascular smooth-muscle cells and

vasodilation of pulmonary vasculature

Indications — As an adjunct to descent in the management of high-altitude pulmonary edema (HAPE)

Contraindications — Concomitant use of any form of organic nitrates (e.g., nitroglycerin, isosorbide

dinitrate, isosorbide mononitrate, illicit "poppers"), either regularly or intermittently; may potentiate

hypotensive effect of nitrates. Hypersensitivity, including Stevens-Johnson syndrome and exfoliative

dermatitis

WARNING: Hypotension may occur due to vasodilation

Ziprasidone

Name — Geodon®

Class — Second generation antipsychotic

Pharmacologic Action — Acts as antagonist at dopamine-2 and serotonin type 1 and 2 (5HT1D, 5HT2A)

receptors; acts as agonist at serotonin 5HT1A receptor; moderately inhibits reuptake of norepinephrine

and serotonin; has alpha-blocking and antihistaminic activity

Indications — For the management of agitated or violent patients suffering a behavioral emergency

Contraindications — Documented hypersensitivity, any drugs or conditions that prolong QT interval,

recent acute myocardial infarction, uncompensated heart failure

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IV. Approved Abbreviations

The following is the Project’s list of approved medical abbreviations used in this document. The

Drug.com article “Medical Abbreviations on Pharmacy Prescriptions” at

https://www.drugs.com/article/prescription-abbreviations.html is considered the reference of

authority.

Table X: List of Abbreviations

Abbreviation

Description

ACS

acute coronary syndrome

AED

automatic external defibrillator

A-FIB

atrial fibrillation

ALS

advanced life support

AMS

altered mental status

ASA

aspirin

atrioventricular

AVPU

alert, verbal, pain, unresponsive (neurological status measure)

BiPAP

bi-level positive airway pressure

BLS

basic life support

blood pressure

BPM

beats per minute

BSA

body surface area

BSI

body substance isolation

BVM

bag-valve-mask

CABG

coronary artery bypass graft

CAD

coronary artery disease

CARES

Cardiac Arrest Registry to Enhance Survival

chief complaint

CDC

Centers for Disease Control and Prevention

CHF

congestive heart failure

CNS

central nervous system

carbon monoxide

carbon dioxide

COPD

chronic obstructive pulmonary disease

chest pain

CPAP

continuous positive airway pressure

CPI

continuous performance improvement

CPR

cardiopulmonary resuscitation

C-SECTION

caesarean section

C-SPINE

cervical spine

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cat scan, Cardiac Technician

CVA

cerebrovascular accident (stroke)

D5W

5% dextrose in water

DKA

diabetic ketoacidosis

DNI

do not intubate

DNR

do not resuscitate

delirium tremens

diagnosis

ECPR

extracorporeal cardiopulmonary resuscitation

EEG

electroencephalogram

EENT

eye, ear, nose, and throat

EGD

extraglottic device

EKG

electrocardiogram

EMS

emergency medical services

EMT

emergency medical technician

ePCR

electronic patient call/care record/report

endotracheal

ETA

estimated time of arrival

EtCO

end-tidal carbon dioxide; end-tidal capnography

ETOH

ethanol (alcohol)

ETT

endotracheal tube

FBAO

foreign body airway obstruction

FiO

fraction of inspired oxygen

gram(s)

gastrointestinal

gtt

drops

genitourinary

GYN

gynecology (gynecological)

HFNC

high flow nasal cannula

heart rate (hour)

ICU

intensive care unit

intramuscular

intraosseous

IPPB

intermittent positive pressure breathing

intravenous

IVP

intravenous push

joules

JVD

jugular vein distension

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kilogram

KVO

keep vein open

liter

LMA

laryngeal mask airway

LPM

liters per minute

lactated Ringer’s

MAT

multifocal atrial tachycardia

mcg

microgram(s)

MED

medicine

milligram(s)

mg/dL

milligrams per deciliter

myocardial infarction (heart attack)

milliliter

mmHg

millimeters of mercury

mmol

millimole

MOLST

medical orders for life-sustaining treatment

mental status

msec

millisecond

MVC

motor vehicle crash

N/V

nausea/vomiting

nasal cannula

NRB

non-rebreather

normal saline

NSR

normal sinus rhythm

OB/GYN

obstetrics/gynecology

oxygen

pulse

PAC

premature atrial contraction

PCR

Patient call/care record/report

pulmonary embolus

PEA

pulseless electrical activity

orally

POLST

physician orders for life-sustaining treatment

PPE

personal protection equipment

prn

as needed

PVC

premature ventricular contraction

every (e.g., q 3-5 minutes)

respiratory rate

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APPENDICES Rev. March 2022

IV. Approved Abbreviations 397

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RSI

rapid sequence intubation

medicine

sat

saturation

SBP

systolic blood pressure

subcutaneous

SCBA

self-contained breathing apparatus

SCUBA

self-contained underwater breathing apparatus

SGD

supraglottic device

sublingual

SOB

shortness of breath

sinus tachycardia

SVT

supraventricular tachycardia

temperature

TBSA

total body surface area

TCA

tricyclic antidepressants

TIA

transient ischemic attack

TID

three times a day

TKO

to keep open

ventricular fibrillation

vital signs

ventricular tachycardia

y/o

years old (years old)

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 398

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V. Burn and Burn Fluid Charts

Burn Size Chart 1

Source: Used with permission, University of Utah Burn Center

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 399

Version 3.0

Burn Size Chart 2

Source: American Heart Association, Pediatric Advanced Life Support Textbook, 2013

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 400

Version 3.0

Percentage of Total Body Surface Area by Age, Anatomic Structure, and Body Habitus

Adult

Child

Anatomic Structure

Surface

Area

Anatomic Structure

Surface

Area

Anterior head

4.5%

Anterior head

Posterior head

4.5%

Posterior head

Anterior torso

18%

Anterior torso

18%

Posterior torso

18%

Posterior torso

18%

Anterior leg, each

6.75%

Posterior leg, each

6.75%

Anterior arm, each

4.5%

Anterior arm, each

4.5%

Posterior arm, each

4.5%

Posterior arm, each

4.5%

Genitalia, perineum

Genitalia/perineum

Adult – Obese

80 kg

Infant

10 kg

Anatomic Structure

Surface

Area

Anatomic Structure

Surface

Area

Head and neck

20%

Anterior torso

25%

Anterior torso

16%

Posterior torso

25%

Posterior torso

16%

Leg, each

20%

Leg, each

16%

Arm, each

Genitalia/perineum

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 401

Version 3.0

Parkland Formula

For patients who require fluid resuscitation, consider use of the Parkland formula to calculate

the volume of normal saline or lactated Ringer’s solution that should be administered

intravenously to ensure hemodynamic stability.

Volume of Intravenous Fluid required in the first 24 hours (in mL) =

(4 X patient weight in kg) X (Percentage of total body surface area burned)

The first half of the volume of fluid should be administered over the first 8 hours following the

burn with the remaining fluid administered over the following 16 hours.

For pediatric patients, a weight-based assessment tool (length-based tape or other system)

should be used to provide a more accurate estimate of the patient’s weight. Likewise, the total

body surface area (BSA) estimates are different for pediatric patients compared to adults due to

larger head and trunk size. For children, the palmar surface of the hand (not including the

fingers is approximately equal to 1% BSA. The guidelines listed above will provide assistance

during the estimation of the percentage of total body surface area burned for patients of

various ages and body habitus.

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 402

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Burn Injury IV Fluid Rates

Infusion Rate > 30 KG

Patients with traumatic injuries may require additional fluids.

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APPENDICES Rev. March 2022

V. Burn and Burn Fluid Charts 403

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Burn Injury IV Fluid Rates

Fluid Infusion Rate < 30 KG

Source: Used with permission, University of Utah Burn Center (https://crisisstandardsofcare.utah.edu).

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APPENDICES Rev. March 2022

VI. Neurologic Status Assessment 404

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VI. Neurologic Status Assessment

Neurologic status assessment involves establishing a baseline and then trending any change in patient

neurologic status. Glasgow Coma Score (GCS) is frequently used, but there are often errors in applying

and calculating this score. With this in consideration, Glasgow Coma Score may not be more valid than a

simpler field approach. Either AVPU (Alert, Verbal, Painful, Unresponsive) or only the motor component

of the GCS may more effectively serve in this capacity.

Glasgow Coma Score

Table X: AVPU

The patient is alert

The patient responds to verbal stimulus

The patient responds to painful stimulus

The patient is completely unresponsive

Points

Pediatric

Adult

Eyes

No eye opening

Eye opening to pain

Eye opening to verbal

Eyes open spontaneously

Verbal

No vocalization

No verbal response

Inconsolable, agitated

Incomprehensible sounds

Inconsistently consolable, moaning

Inappropriate words

Cries but consolable, inappropriate

interactions

Confused

Smiles, oriented to sounds, follows

objects, interacts

Oriented

Motor

No motor response

Extension to pain

Flexion to pain

Withdraws from pain

Localizes pain

Obeys commands

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VII. Abnormal Vital Signs 405

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VII. Abnormal Vital Signs

Abnormal Vital Signs

Age

Heart Rate

Respiratory

Rate

Systolic BP

Temp (°C)

0 d – 1 mo

>205

>60

<60

<36 or >38

≥ 1 mo – 3 mo

>205

>60

<70

<36 or >38

≥ 3 mo – 1 yr

>190

>60

<70

<36 or >38.5

≥ 1 yr – 2 yr

>190

>40

<70 + (age in yr x 2)

<36 or >38.5

≥ 2 yr – 4 yr

>140

>40

<70 + (age in yr x 2)

<36 or >38.5

≥ 4 yr – 6 yr

>140

>34

<70 + (age in yr x 2)

<36 or >38.5

≥ 6 yr – 10 yr

>140

>30

<70 + (age in yr x 2)

<36 or >38.5

≥ 10 yr – 13 yr

>100

>30

<90

<36 or >38.5

> 13 yr

>100

>16

<90

<36 or >38.5

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VIII. Evidence-Based Guidelines: GRADE Methodology 406

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VIII. Evidence-Based Guidelines: GRADE Methodology

An Overview of GRADE Methodology

Although engagement in quality EMS research has increased significantly, the demand for evidence-

based quality prehospital research continues to exceed its availability. The need for evidence-based

prehospital patient care protocols was clearly recognized by the Institute of Medicine of the

National Academies and clearly stated in 2007 in The Future of Emergency Care: Emergency Medical

Services at the Crossroads.

The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE)

methodology is a transparent process where the available research is reviewed and assessed by a

panel of subject matter experts. Following this thorough review process, the available research is

reviewed and graded for its validity based upon the assessment of the workgroup, and an evidence-

based guideline (EBG) is developed based upon the outcome of the workgroup.

The Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS

Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model

Process for the development, implementation, and evaluation of evidence-based guidelines. This

Model Process recommends the use of the GRADE methodology for the guideline development tool.

The six process steps of the GRADE EBG development tool are:

• Assemble the expert panel and provide GRADE training

• Define the EBG content area and establish the specific clinical questions to address in patient,

intervention, comparison, and outcome (PICO) format

• Prioritize outcomes to facilitate systematic literature searches

• Create GRADE tables (or evidence profiles) for each PICO question

• Vet and endorse GRADE evidence tables and draft recommendations

• Synthesize recommendations into an EMS protocol and visual algorithm

Some evidence-based guidelines cited in this document were created for and released by NHTSA;

however, the GRADE methodology is not proprietary to NHTSA or any other organization. Local,

regional, and state EMS agencies and EMS systems are encouraged to support the ongoing need for

quality prehospital care, improved patient outcome, and the growing demand for EBGs for EMS.

References:

Brown KM. The development of evidence-based prehospital guidelines using a GRADE-based

methodology, Prehospital Emergency Care, 2014, Suppl 1:3-14, 2014

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IX. 2022 National Guideline for the Field Triage of Injured Patients 407

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IX. 2022 National Guideline for the Field Triage of Injured Patients

Note: "Low-level" refers to less than 10 feet including ground level falls

Source: The American College of Surgeons Committee on Trauma (ACS COT), 2022