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Home My WebLink Aboutems-field-manual-2026-edited-081026- 2026 FIELD MANUAL A L A M E D A C O U N T Y E M E R G E N C Y M E D I C A L S E R V I C E S 1 000 SA N L E AN DRO BL VD . | SU I TE 2 00 | SA N L E AN DRO , CA 9 4577 P HONE : 5 10 . 618 . 20 50 | W EB : ems . acgov .o r g | E m a il: a l coems @ acgov . org Field Code Changed Summary of High-Quality CPR Components for BLS Providers Infants Children Adults and Component (Age Less Than 1 Year, Adolescents (Age 1 Year to Puberty) Excluding Newborns) Make sure the environment is safe for rescuers and victim Scene safety Check for responsiveness No breathing or only gasping (i.e., no normal breathing) Recognition of cardiac arrest No deﬁnite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Witnessed collapse If you are alone with no mobile Follow steps for adults and adolescents on the left phone, leave the victim to activate the emergency response system Unwitnessed collapse Activation of and get the AED before beginning Give 2 minutes of CPR emergency CPR Leave the victim to activate the emergency response system and get the response system AED Otherwise, send someone and begin CPR immediately; use the AED as Return to the child or infant and resume CPR; soon as it is available use the AED as soon as it is available 1 rescuer Compression- 30:2 ventilation 1 or 2 rescuers 30:2 ratio without 2 or more rescuers advanced airway 15:2 Compression- ventilation ratio Continuous compressions at a rate of 100-120/min Give 1 breath every 6 seconds (10 breaths/min) with advanced airway 100-120/min Compression rate At least one third AP diameter of At least one third AP diameter of Compression chest chest At least 2 inches (5 cm) * depth About 2 inches (5 cm) About 1½ inches (4 cm) 1 rescuer 2 ﬁngers in the center of the chest, just below the nipple line 2 hands or 1 hand (optional for very 2 hands on the lower half of the small child) on the lower half of the Hand placement 2 or more rescuers breastbone (sternum) breastbone (sternum) 2 thumb–encircling hands in the center of the chest, just below the nipple line Allow full recoil of chest after each compression; do not lean on the chest after each compression Chest recoil Minimizing Limit interruptions in chest compressions to less than 10 seconds interruptions Minimize interruptions in chest Resume CPR beginning with Attach and use AED/ Deﬁbrillator as compressions before and after compressions immediately after Deﬁbrillation soon as available shock each shock *Compression depth should be no more than 2.4 inches (6 cm). Abbreviations: AED, automated external deﬁbrillator; AP, anteroposterior; CPR, cardiopulmonary resuscitation. TABLE OF CONTENTS AMBULANCE REROUTING CRITERIA .............................................................................v EMERGENCY MEDICAL SERVICES - STAFF DIRECTORY ........................................ vi GENERAL POLICIES TAB GENERAL POLICIES TOC .................................................................................................. 1 AN OVERVIEW OF PATIENT CARE POLICIES ............................................................... 2 ACUTE CORONARY SYNDROME (ACS) .................................................................................. 3 ACUTE CORONARY SYNDROME (ACS) STEMI ................................................................... 4 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ...................... 5 BURN PATIENT CARE ......................................................................................................... 9 BURN PATIENT CRITERIA ................................................................................................. 11 CARDIOPULMONARY RESUSCITATION (CPR) ........................................................... 12 ADDITIONAL INFORMATION & MECHANICAL CPR DEVICES ................................... 13 PIT CREW ROLES ......................................................................................................... 14 CRUSH INJURY SYNDROME ............................................................................................. 15 EXTREMITY INJURY ........................................................................................................... 16 HYPERKALEMIA..................................................................................................................... 17 HYPERTHERMIA / HEAT ILLNESS ................................................................................... 18 HYPOTHERMIA ...................................................................................................................... 19 INFECTION CONTROL AND SCREENING CRITERIA .................................................. 21 OB/GYN EMERGENCIES ..................................................................................................... 22 SCOPE OF PRACTICE - LOCAL OPTIONAL ................................................................... 24 SMOKE INHALATION / CO MONITORING ....................................................................... 25 TRANSPORT GUIDELINES ................................................................................................. 27 TRAUMA PATIENT CARE ................................................................................................... 28 TRAUMA PATIENT CRITERIA ............................................................................................. 29 ADULT POLICIES TAB ADULT POLICIES TOC....................................................................................................... 33 AIRWAY OBSTRUCTION....................................................................................................... 34 ALTERED LEVEL OF CONSCIOUSNESS .......................................................................... 35 ANAPHYLAXIS / ALLERGIC REACTION .......................................................................... 36 BRADYCARDIA ...................................................................................................................... 37 CARDIAC ARREST - GENERAL GUIDELINES ................................................................ 38 i Field Code Changed Field Code Changed CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA............................................................ 39 CARDIAC ARREST - MEDICAL - VF/PVT ........................................................................ 40 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT ............................................ 41 CARDIAC ARREST - TRAUMATIC ..................................................................................... 42 DYSTONIC REACTION ........................................................................................................ 43 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE ....................................44 OPIOID WITHDRAWAL ...................................................................................................................... 46 PAIN MANAGEMENT ............................................................................................................ 47 POISONING | INGESTION | OVERDOSE ......................................................................... 48 PULMONARY EDEMA / CHF ............................................................................................. 49 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ........... 50 RESPIRATORY DISTRESS ................................................................................................. 51 RETURN OF SPONTANEOUS CIRCULATION - ROSC ................................................ 52 ROUTINE MEDICAL CARE - ADULT................................................................................. 53 SEIZURE ................................................................................................................................. 55 SEPSIS ................................................................................................................................... 56 SEVERE NAUSEA ................................................................................................................ 57 SHOCK: HYPOVOLEMIC/CARDIOGENIC ............................................................................. 58 SICKLE CELL PAIN EMERGENCY ..................................................................................... 59 STROKE / CVA ..................................................................................................................... 60 SUBMERSION ........................................................................................................................ 61 TACHYCARDIA ....................................................................................................................... 62 VENTRICULAR ASSIST DEVICES -VAD ......................................................................... 63 PEDIATRIC POLICIES TAB PEDIATRIC POLICIES TOC .............................................................................................. 65 AIRWAY OBSTRUCTION ...................................................................................................... 66 ANAPHYLAXIS / ALLERGIC REACTION .......................................................................... 67 ALTERED LEVEL OF CONSCIOUSNESS .......................................................................... 68 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE ..................................................... 69 BRADYCARDIA ....................................................................................................................... 70 CARDIAC ARREST - GENERAL GUIDELINES ................................................................. 71 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA........................................................... 72 CARDIAC ARREST - MEDICAL - VF/PVT ........................................................................ 73 CARDIAC ARREST - TRAUMATIC ..................................................................................... 74 NEONATAL RESUSCITATION.............................................................................................. 75 ii PAIN MANAGEMENT .......................................................................................................... 76 POISONING | INGESTION | OVERDOSE ....................................................................... 78 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ..........79 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY ....................................... 80 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .................................. 81 ROUTINE MEDICAL CARE - PEDIATRIC........................................................................ 82 SEIZURE ............................................................................................................................... 83 SEVERE NAUSEA .............................................................................................................. 84 SHOCK AND HYPOTENSION ............................................................................................ 85 SICKLE CELL PAIN EMERGENCY ....................................................................................86 SUBMERSION ...................................................................................................................... 87 TACHYCARDIA ......................................................................................................................88 OPERATIONAL POLICIES TAB OPERATIONAL POLICIES TOC ....................................................................................... 89 ALS RESPONDER ............................................................................................................... 90 BLS/FIRST RESPONDER .................................................................................................. 91 DETERMINATION OF DEATH IN THE FIELD ................................................................ 92 DEATH IN THE FIELD - GRIEF SUPPORT..................................................................... 94 END OF LIFE CARE ........................................................................................................... 95 EMS AIRCRAFT TRANSPORT .......................................................................................... 96 EMS EVENT REPORTING ................................................................................................. 100 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION ............................ 101 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ............................................. 102 INTERFACILITY TRANSFERS ...........................................................................................108 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 109 MEDICAL PERSONNEL ON THE SCENE ...................................................................... 110 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE .................................112 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS .................... 113 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING ................. 114 RESTRAINTS........................................................................................................................ 115 PROCEDURES TAB PROCEDURE POLICIES TOC ......................................................................................... 117 ADVANCED AIRWAY MANAGEMENT ............................................................................. 118 CONSENT AND REFUSAL GUIDELINES ........................................................................ 120 iii CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP............................................ 124 ECG - 12 LEAD ..................................................................................................................... 126 HEMORRHAGE CONTROL ................................................................................................. 127 INTRANASAL (IN) MEDICATION ADMINISTRATION ....................................................... 129 INTRAOSSEOUS ACCESS PROCEDURE .........................................................................130 PLEURAL DECOMPRESSION ............................................................................................... 131 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES ....................................................... 132 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ........................... 133 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS ...................................................... 134 REPORTING FORMAT ........................................................................................................135 SEDATION .............................................................................................................................. 136 SPINAL INJURY ASSESSMENT .......................................................................................... 137 SPINAL MOTION RESTRICTION (SMR) ......................................................................... 139 STOMA AND TRACHEOSTOMY .......................................................................................... 140 TRANSCUTANEOUS PACING - TCP ............................................................................... 142 TRANSFER OF CARE ......................................................................................................... 143 TRIAGE TO WAITING ROOM ............................................................................................ 144 TXA - TRANEXAMIC ACID.................................................................................................. 145 STROKE ASSESSMENT SCALES (CPSS AND PSS) ................................................... 146 MCI/ DISASTER/ WMD TAB MCI/ DISASTER/ WMD TOC .............................................................................................. 147 ACTIVE SHOOTER RESPONSE ........................................................................................ 148 BIOLOGICAL ATTACK .......................................................................................................... 149 CHEMICAL ATTACK .............................................................................................................. 151 CHEMPACK DEPLOYMENT ................................................................................................ 152 CYANIDE POISONING ......................................................................................................... 153 DECONTAMINATION INCIDENT ........................................................................................ 154 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ........................................ 155 MULTI-CASUALTY INCIDENT - EMS RESPONSE .......................................................... 157 NERVE AGENT AUTOINJECTOR ADMINISTRATION....................................................... 160 NERVE AGENT TREATMENT ............................................................................................. 162 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ........................ 164 SUSPICIOUS POWDER PROCESS .................................................................................. 165 *SEE THE EMS MOBILE FIELD APP FOR A KEYWORD SEARCH OF THIS BOOK* iv AMBULANCE REROUTING CRITERIA Commented \[ZK1\]: Seems redundant. Can we just (Abbreviated version - see Ambulance Rerouting policy on the EMS Agency Websitein the Administration Manual for the complete policy) have the table? REASONS FOR REROUTING OF AMBULANCES – Conditions that may necessitate REROUTING are: ► CT Failure - When the CT scanner is inoperative, patients demonstrating neurological signs/symptoms of stroke, or acute head injury will be diverted ► Trauma Center Overload - When it has been determined that the hospital is unable to meet the criteria for a Level II Trauma Center in Alameda County (O.R. is full) ► STEMI Diversion - STEMI/Cardiac Arrest Receiving Centers may divert due to diagnostic or treatment equipment failure or scheduled maintenance for patients experiencing acute MI or post cardiac arrest ► Stroke Center Diversion - Certified Stroke Centers may divert due to diagnostic or treatment equipment failure or scheduled maintenance for patients exhibiting signs of acute stroke symptoms/stroke alert ► Physical Plant Casualty (Internal Disaster) - An unforeseeable physical or logistical situation/ circumstance - (e.g., fire, bomb threat, power outage, etc.) that curtails routine patient care and renders continued routine ambulance delivery unsafe. A receiving hospital or trauma center may divert any patient, including critical trauma patients (CTP) as deemed necessary by the facility during this type of incident. The hospital must come off Physical Plant diversion immediately upon resolution of the issue Maximum Reasons for Types of patients Appropriate facility for time Condition Rerouting rerouted rerouted patients allowed Computerized ► Acute head injury ► Nearest Trauma Center Tomography Until resolved CT inoperative ► Acute Stroke by CPSS ► Closest Stroke Center (CT) Trauma Center Until resolved Trauma resources depleted Critical Trauma Patients Designated Trauma Center Overload STEMI Diagnostic, Equipment failure or STEMI/ post cardiac Closest STEMI/Cardiac Until resolved (equip. failure) Scheduled Maintenance, no arrest Arrest Center cardiologist or cath lab availability Stroke Center Diagnostic, Equipment failure or Until resolved Stroke patients Closest Stroke Center (equip. failure) Scheduled Maintenance Physical Plant Physical plant breakdown (bomb Until resolved All Closest appropriate facility Casualty threat, fire, etc.) AREA INTENTIONALLY BLANK v - EMERGENCY MEDICAL SERVICES STAFF DRECTORY 510-618-2050 (main number) EMS Office 510-618-2099 (fax #) On-call EMS Staff 925-422-7595 – ACRECC EMS Website - http://ems.acgov.org | EMS Email- alcoems@acgov.org EMS Event Reporting - go to https://ems.acgov.org and select the “EMS Event Report” link to submit a report EMS DIRECTOR lauri.mcfadden@acgov.org Lauri McFadden 510-618-2055 DEPUTY EMS DIRECTOR william.mcclurg@acgov.org William McClurg 510-618-2030 MEDICAL DIRECTOR zita.konik@acgov.org Zita Konik, MD, FAEMS 510-618-2086 DEPUTY MEDICAL DIRECTOR VACANT EMS COORDINATORS Naila Francies naila.francies@acgov.org 510-208-9061 Clinical Quality Improvement | Data | EHR Cynthia Frankel cynthia.frankel@acgov.org 510-618-2031 EMS for Children | ReddiNet | AED/PAD Prog. | EMS System Plan Kreig Harmon kreig.harmon@acgov.org 510-667-7984 Clinical Quality Improvement | Field Protocols & App | CCT-P | Trauma Mike Jacobs michael.jacobs@acgov.org 510-618-2047 Specialty Systems of Care - Cardiac Arrest Care | STEMI | Stroke Elsie Kusel elsie.kusel@acgov.org 510-481-4197 Specialty Programs Jim Morrissey - Supervisor jim.morrissey@acgov.org 510-618-2036 MHOAC | Emergency Preparedness and Response Ryan Preston ryan.preston@acgov.org 510-618-2033 CA OES Region II Regional Disaster Medical Health Specialist (RDMHS) Scott Salter scott.salter@acgov.org 510-618-2022 Professional Standards | Compliance Leslie Simmons leslie.simmons@acgov.org 510-667-7412 Receiving Facility Liaison | Ambulance Ordinance | Compliance Carolina Snypes carolinae.snypes@acgov.org Special Projects | Procurement Management | BLS Clinical Quality 510-618-2011 Improvement Andrew Sulyma andrew.sulyma@acgov.org Dispatch Liaison | Fire Department Liaison | CA OES Region II Regional 510-667-7533 Disaster Medical Health Specialist (RDMHS) Gerald Takahashi gerald.takahashi@acgov.org 510-667-7588 Educational Programs | EMS Orientation | Paramedic Accreditation Yolanda Takahashi yolanda.takahashi@acgov.org CATT Project Manager | 911 EOA Transport Provider Liaison | Unusual 510-618-2003 Occurrences | Compliance vi ADMINISTRATIVE SERVICES AND SUPPORT TEAM michelle.barrientos@acgov.org Michelle Barrientos - EMS Secretary 510-618-2024 ashley.gutierrez@acgov.org Ashley Gutierrez - Financial Services Specialist II 510-618-2337 erica.campos@acgov.org Erica Campos - Administrative Specialist II 510-618-2008 elise.harris@acgov.org Elise Harris - Specialist Clerk I 510-618-2059 sonya.lee@acgov.org Sonya Lee - Specialist Clerk I 510-618-2034 victor.pires@acgov.org Victor Pires - Data Analyst 510-618-3315 maria.ramos@acgov.org Maria Ramos - Specialist Clerk I 510-618-2096 Shante.Williams2@acgov.org Shant’e Williams - Specialist Clerk I 510-618-2050 EMS CORPS michael.gibson@acgov.org Michael Gibson - EMS Corps Program Director 510-618-2099 lucretia.bobo@acgov.org Lucretia Bobo - Community Outreach Worker II 510-667-7413 martha.lemus@acgov.org Martha Lemus - Clerk II 510-667-2135 HEALTHCARE EMERGENCY PREPAREDNESS & RESPONSE (HEPR) ron.seitz@acgov.org Ron Seitz - Supervising Program Specialist 510-268-2139 beverly.chu@acgov.org Bev Chu - CRI Program Specialist 510-567-8216 teelee.garvin@acgov.org Teelee Garvin - Specialist Clerk II 510-268-2385 preston.lam@acgov.org Preston Lam - HPP Program Specialist 510-268-2384 emma.olenberger@acgov.org Emma Olenberger - Program Services Coordinator 925-307-6633 hunter.park2@acgov.org Hunter Park - Supply Clerk II 510-418-0576 todd.stephenson@acgov.org Todd Stephenson - PHEP Program Specialist 510-567-8241 INJURY PREVENTION kathryn.woolbright@acgov.org Kat Woolbright - Program Manager 510-618-1990 - laura.fultz@acgov.org Laura Fultz Program Specialist 510-618-2028 - ysela.jimenez-patino@acgov.org Ysela Jimenez-Patino Community Health Outreach 510-618-2045 carol.powers@acgov.org Carol Powers - Senior Injury Prevention Program Coordinator 510-667-3055 Follow us on our social media channels @alcoems on Facebook, Instagram, and X Download the Alameda County EMS Field Manual App for free in the Apple App Store or the Google Play Store vii THIS PAGE INTENTIONALLY LEFT BLANK viii Patient Care Policy (General) Modified On: January 1, 2026 GENERAL POLICIES TOC GENERAL POLICIES TOC .................................................................................................. 1 AN OVERVIEW OF PATIENT CARE POLICIES ............................................................... 2 ACUTE CORONARY SYNDROME (ACS).................................................................................. 3 ACUTE CORONARY SYNDROME (ACS) STEMI .................................................................. 4 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE ...................... 5 BURN PATIENT CARE ......................................................................................................... 9 BURN PATIENT CRITERIA ................................................................................................. 11 CARDIOPULMONARY RESUSCITATION (CPR) ........................................................... 12 ADDITIONAL INFORMATION & MECHANICAL CPR DEVICES ................................... 13 PIT CREW ROLES ......................................................................................................... 14 CRUSH INJURY SYNDROME ............................................................................................. 15 EXTREMITY INJURY ........................................................................................................... 16 HYPERKALEMIA ..................................................................................................................... 17 HYPERTHERMIA / HEAT ILLNESS ................................................................................... 18 HYPOTHERMIA ...................................................................................................................... 19 INFECTION CONTROL AND SCREENING CRITERIA................................................... 21 OB/GYN EMERGENCIES ..................................................................................................... 22 SCOPE OF PRACTICE - LOCAL OPTIONAL ................................................................... 24 SMOKE INHALATION / CO MONITORING ....................................................................... 25 TRANSPORT GUIDELINES ................................................................................................. 27 TRAUMA PATIENT CARE ...................................................................................................28 TRAUMA PATIENT CRITERIA .............................................................................................29 GENERAL POLICIES TOC 1 Patient Care Policy (General) Modified On: April 10, 2012 AN OVERVIEW OF PATIENT CARE POLICIES 1. Treatment algorithms should be used as a guideline and are not intended as a substitute for sound medical judgment. Unusual patient presentations make it impossible to develop a protocol for every possible patient situation 2. Patient care protocols are to be utilized by field personnel and Base Hospital Physicians. All procedures and/or medications must be within the scope of practice for field personnel and authorized in Alameda County policies 3. Where scope of practice allows, cardiovascular protocols are consistent with current American Heart Association, Emergency Cardiovascular Care guidelines 4. Medications/Procedures contained in may be performed without base contact, or may non-shaded boxes be called in to the base hospital for consultation with the Base Hospital Physician 5. Medications/Procedures contained in shaded boxes require a Base Hospital Physician order 6. Base contact - Paramedics should contact the Base HospitalPhysician for consultation: 6.1 At any point in a policy or treatment algorithm where base hospital contact is required and/or any time consultation would be in the patient’s best medical interest 6.2 For complicated patient presentations or in situations where a deviation from the standard protocol seems indicated 6.3 For any patient attended by a physician at the scene. (See “Medical Personnel on the Scene - page 110) 6.4 For out-of-protocol medication administration. Unusual circumstances may indicate special applications of medications carried by paramedics that are not covered in the treatment algorithms (e.g. glucagon for beta-blocker overdose) (TXA for nosebleed) 6.5 An EMT may make base contact for consultation with a physician for destination decisions, unusual patient presentations, and/or procedures within the EMT scope of practice. An EMT may not make base contact or accept orders for the patient on behalf of a paramedic 7. If direct communication with the Base Physician cannot be made or maintained, consider immediate transport and attempt base contact en route, if applicable 8. If a difference between policies exists, the policy with the most recent date prevails is to be followed. AN OVERVIEW OF PATIENT CARE POLICIES 2 Yes No Yes No STEMI? Patient Care Policy (Adult) Modified On: January 1, 2026 ACUTE CORONARY SYNDROME (ACS)  Routine Medical Care  Indications: anxiety, chest discomfort, diaphoresis, discomfort or tightness radiating to the jaw, fatigue, shoulder or arms, dizziness, dyspnea, epigastric discomfort, general weakness, nausea or vomiting, palpitations, return of spontaneous circulation (ROSC), syncope, or near syncope  Perform a 12-Lead ECG, as soon as possible. See ECG - 12 Lead page 126. Keep the 12-lead ECG continuously attached to the patient throughout care, as the monitor will perform serial ECGs if cardiac changes are detected, following the initial 12-lead recorded by that device. Commented \[ZK2\]: Standardize aspirin to 324mg throughout Aspirin Considerations:  Contraindications: ■ Allergy to Aspirin  Notes: Ensure the patient is alert enough to chew the tablets safely. If the patient took Aspirin immediately prior to EMS arrival, verify the patient took between 162-324mg; if not, administer additional aspirin. It is ok to administer aspirin to patients who take blood thinners or anticoagulants regularly. Nitroglycerin Considerations:  Contraindications: ■ Allergy to Nitroglycerin ■ Systolic Blood Pressure (SBP) <90mmHg ■ >30mmHg drop in SBP after one dose ■ Erectile dysfunction (ED) medication within the last 24 hours (Viagra/Levitra) or 36 hours (Cialis) ACUTE CORONARY SYNDROME (ACS) 3 Patient Care Policy (Adult) Modified On: January 1, 2026 ACUTE CORONARY SYNDROME - STEMI  Routine Medical Care  Indications: A 12-lead ECG reflecting ST segment elevation in two or more contiguous leads indicates an ST elevation myocardial infarction (STEMI). This may be identified by the paramedic or the ECG monitor. When the monitor detects an acute STEMI, the 12-lead ECG interpretation language will be displayed as follows: ➔ Stryker/Lifepak: *** MEETS ST ELEVATION MI CRITERIA *** ➔ Zoll: *** STEMI ***  Do not delay transport to obtain additional 12-lead ECGs after the initial STEMI-positive interpretation Regardless of which ECG monitor first identified the STEMI, prepare the patient for immediate transport  Do not delay transport to obtain a right-sided 12-lead ECG after a STEMI has been identified  Do not delay transport to obtain the initial or second IV on scene. Establish all IVs en route.  If the monitor interpretation identifies STEMI as outlined above, do not override the monitor’s interpretation  Limit on scene time to <15 minutes and initiate rapid transport for ‘STEMI Alerts’ to a designated STEMI Center Aspirin Considerations:  Contraindications: ■ Allergy to Aspirin  Notes: Ensure the patient is alert enough to chew the tablets safely. If the patient took Aspirin immediately prior to EMS arrival, verify the patient took between 162-324mg; if not, administer additional aspirin. It is ok to administer aspirin to patients who take blood thinners or anticoagulants regularly. Nitroglycerin Considerations:  Contraindications: ■ Allergy to Nitroglycerin ■ Systolic Blood Pressure (SBP) <90mmHg ■ >30mmHg drop in SBP after one dose ■ Erectile dysfunction (ED) medication within the last 24 hours (Viagra/Levitra) or 36 hours (Cialis) ACUTE CORONARY SYNDROME - STEMI 4 Patient Care Policy (General) Modified On: June 15, 2023 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE • Routine Medical Care • Level of distress - Is patient a trauma victim? If yes, see trauma protocol • Provide emotional support to the victim and the family • Contact appropriate law enforcement agencies 1. UNIVERSAL CARE PRINCIPALS: In any situation where EMS personnel know or reasonably suspects a person suffering from any wound or other physical injury inflicted upon the person where the injury is the result of assaultive or abusive conduct: 1.1 Immediately notify the appropriate law enforcement agency 1.2 Reasonable efforts will be made to transport the patient to a receiving hospital for evaluation. Immediately inform hospital staff of your findings. 1.3 Document all pertinent observations on the electronic health record. 1.4 Immediately (or as soon as practical) contact the appropriate agency by telephone and give a verbal report 1.5 A written report for child/elder abuse must be filed within 36 hours ➔ TO REPORT CHILD ABUSE: ► Immediate verbal report to: Alameda County Children and Family Services at: 510-259-1800 - 24-hour number, follow the appropriate prompts. Make sure to note the name and title of the individual that you gave your report to. ► Complete the written report found at: http://tinyurl.com/SCAreportform and fax to 510- 780-8620 within 36 hours of the incident ► ALL responding agencies at a scene must complete their own report - no single agency can report in behalf of another agency. ➔ TO REPORT ELDER OR DEPENDENT ADULT ABUSE: ► By staff at a licensed health care facility contact: Ombudsman - 800-231-4024 ► At home, or by a visitor or another resident at a licensed health care facility contact: Alameda County Adult Protective Services - 866-225-5277 - 24 hour number After 5 pm M-F and weekends, an operator answers this line and can page a social worker (if needed.) If the patient was assaulted or has suffered serious neglect contact local law enforcement. ► A written report can be completed online by going to: https://reporttoaps.org/ and then clicking on "Alameda County Intake Form" and completing the displayed form 2. SEXUAL ASSAULT: This involves any form of non-consensual conduct/contact with another person, or the inability of the victim to give consent due to age, cognitive disability, or voluntary/involuntary incapacitation by substances. Substances are involved in the majority of sexual assaults, keep a high index of suspicion on these patients. When EMS responds to a victim of sexual assault: 2.1 Use best judgement when assigning the primary-care provider noting the gender could be triggering to the victim 2.2 Explain in advance each treatment/procedure and offer the patient simple choices (e.g. to sit up or recline on the gurney) empowering them to feel in control. 2.3 Mirror the patient’s language (e.g., do not say “rape” or “sexual assault” if the patient has not used those words) ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 5 Patient Care Policy (General) Modified On: June 15, 2023 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 2.4 Keep the assessment brief and injury-focused: ► Do not interview the patient about the assault ► In the absence of hemorrhage, there is rarely a need to visualize genitalia ► Assess the patient for strangulation injuries, as this is common with sexual assault 2.5 Preserve the physical evidence: ► Transport the patient “as found.” Discourage showering, removing/changing clothes, brushing teeth, using mouthwash, smoking, eating or drinking. Do not allow the patient to wash or clean their hands. ► If clothes have been removed, place clothing in a paper bag. Do not use plastic bags; they collect moisture, which degrades important organic material. If it is necessary to cut off the patient’s clothes, cut around soiled, torn, or damaged areas by 6 inches. ► Do not clean, irrigate, or apply ointment to wounds. If necessary, apply dry sterile gauze to wounds. ► If the patient needs to urinate, or vomit, preserve in a clean container (e.g. urinal, emesis basin). This evidence is especially important with drug-facilitated sexual assaults. ► Chain of custody must be maintained for each item to be valuable in the forensic process. This is best accomplished by having the patient keep all evidence collected at scene in their possession or law enforcement maintaining possession. 2.6 Transport the patient to a facility capable of performing the sexual assault forensic exam regardless of the hospital's diversion status. This exam can be performed up to 21 days post assault. ► Adult patients: Wilma Chan Highland Hospital or Washington Hospital ► Pediatric patients: Children’s Hospital ( y.o.) 3. SUSPECTED HUMAN TRAFFICKING: Human trafficking involves labor or services, by means of force, fraud or coercion for the purposes of subjection into commercial sex acts or other involuntary servitude. If the person is under 18 years of age, no force, fraud or coercion is required. 3.1 Warning signs of human trafficking include: ► Individuals, who are isolated/segregated from contact with responders, are physically or emotionally bullied by others, or who don’t have control of their own ID/documents. ► Manifest signs of physical neglect – malnourished, unreasonable workplace injuries ► Live or work in locations with unsuitable living conditions or unreasonable safety working environments. ► Incidents where responders are approached and asked for protection/asylum from other individuals at a scene 3.2 Reporting requirements: ► EMS personnel should send an EMS Event Report to Alameda County EMS at ems.acgov.org/Events+Reports for any suspected human trafficking cases. The information provided will be relayed directly to the Northern California Regional Intelligence Center for Human Trafficking. ► For suspected human trafficking offer the patient the 24/7 Human Trafficking Resource Center hotline number 888-373-7888 if it does not compromise patient safety. 4. DOMESTIC VIOLENCE and (DV) LETHALITY SCREEN 4.1 DEFINITION: Domestic violence is the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 6 Patient Care Policy (General) Modified On: June 15, 2023 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 4.1.1 Notify Law Enforcement and Receiving Facility staff (as needed) 4.1.2 Perform Domestic Violence Lethality Screen in Section 4.2 4.2 Determine level of distress – is patient injured or complaining of any medical complaints? ► Assess and treat as appropriate ► If patient c/o or presents with medical complaints, assess for signs & symptoms of possible strangulation ► Attempt private audience with patient (maintaining regard for safety) ► If patient is NOT transported - and if safe, appropriate and feasible - perform a DV Lethality Screen (see questions below in Section 4.3) ➔ If patient screens HIGH RISK, refer patient to the Family Violence Law Center (FVLC) by calling the FVLC 24/7 hotline # 800-947-8301 ➔ Briefly describe the DV circumstances to the FVLC advocate without providing any patient identifying information ➔ If patient consents to speaking with FVLC advocate, hand patient the phone ➔ If patient does not consent to speaking with FVLC advocate, give patient discreet FVLC resource information and advise that he/she can call 24/7 ➔ Repeat basic safety planning tips that the FVLC advocate provides ► If patient is transported, be sure to inform receiving facility of lethality risk (determined by tool) and DV advocacy steps taken 4.3 Questions used in the Domestic Violence Lethality Screen for First Responders ➔ A “yes” response to any of Questions 1–3 automatically triggers the protocol referral 1. Has he/she ever used a weapon against you or threatened you with a weapon? 2. Has he/she threatened to kill you or your children? 3. Do you think he/she might try to kill you? ➔ Negative responses to Questions 1–3, but positive responses to at least four of Questions 4–11, trigger the protocol referral 4. Does he/she have a gun or can he/she get one easily? 5. Has he/she ever tried to choke you? 6. Is he/she violently or constantly jealous or does he/she control most of your daily activities? 7. Have you left him/her or separated after living together or being married? 8. Is he/she unemployed? 9. Has he/she tried to kill himself? 10. Do you have a child that he/she knows is not his/hers? 11. Does he/she follow or spy on you or leave threatening messages? If patient consents, any first responder may trigger the protocol referral to FVLC if not already triggered above, as a result of the victim’s response to the question below, or whenever the first responder believes the victim is in a potentially lethal situation ➔ Is there anything else that worries you about your safety? (If “yes”) What worries you? ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 7 Patient Care Policy (General) Modified On: May 10, 2019 ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE Yes No Patient consents Yes No to speaking with a FVLC advocate? Hand phone to patient Repeat basic safety plan from and advocate to patient Provide discreet DV resource and information Provide discreet DV resource information ASSAULT | ABUSE | HUMAN TRAFFICKING | DOMESTIC VIOLENCE 8 Patient Care Policy (Adult) Modified On: January 1, 2026 BURN PATIENT CARE Routine Medical Care • Rescuer safety • Assume airway/respiratory involvement • Stop the burning process - DO NOT USE COLD PACKS • Assess for associated trauma A. BASIC MANAGEMENT 1. Rule out airway damage 1.1 Assess for thermal airway injury and smoke inhalation 1.2 High flow oxygen is critical 1.3 Be prepared for intubation 2. Assess and expose 2.1 Assess ABCs 2.2 Perform a mini neurological exam - level of consciousness 2.3 Expose and examine the patient for other areas of burn 2.4 Remove jewelry, but do not remove stuck clothing 3. Start IVs 3.1 Two large bore IVs (for major burns) 4. Give IV fluids 4.1 Any patient regardless of age with suspected 2nd and 3rd degree burns over 20% TBSA, should be given IV with Normal Saline at the below rate. Boluses are discouraged except in cases of shock. ➔ Adult: 500 cc/hour (80 drops per minute) or (1-2 drops every second) ➔ Pediatric:  ≤ 5 years old: 125 cc/hour (20 drops per minute) or (1 drop every 3 seconds)  6-12 years old: 250 cc/hour (40 drops per minute) or (1 drop every 1-2 seconds)  ≥ 13 years old: 500 cc/hour (80 drops per minute) or (1-2 drops every second) 5. Document severity and treat the pain 5.1 Estimate the severity of the burns using the “Rule of 9s” and “Rule of 1s.” The Rule of 1s uses the patient’s palm, including fingers, representing approximately 1% of total body surface area, to estimate burn size 5.2 Treat pain. Pain management should be considered mandatory for moderate to severe burns. See Pain Management Policies – Adult (page 47) and Pediatric (page 76) 6. Protect against hypothermia and infection - dress burns 6.1 Keep patient warm to prevent hypothermia (use sheets or blankets) 6.2 Burns involving less than10% total body surface area (TBSA): ➔ Pour cool running water on the affected area for 20 minutes, if possible  Use available tap water (e.g., garden hose) for cooling, sterile water is not required. Do not delay transport to complete the full 20 minutes; cooling does not have to continue in transit. ➔ Apply a dry sterile dressing 6.3 Burns involving greater than or equal to 10% TBSA: ➔ Apply a dry sterile dressing BURN PATIENT CARE 9 Patient Care Policy (Adult) Modified On: January 1, 2026 BURN PATIENT CARE 7. Elevate burned body parts - 30° 8. Address psychological needs 8.1 Be honest and compassionate 8.2 Consider anxiolytics – Contact Base Physician for midazolam 9. Maintain body temperature and observe for hypothermia B. ELECTRICAL BURNS 1. Turn off the power source if patient is still attached 2. See first responder defibrillation protocol if patient is unconscious and pulseless C. TAR BURNS 1. Do not attempt to remove the tar 2. Cool with water 3. Maintain body temperature and observe for hypothermia D. CHEMICAL BURNS 1. Remove clothing 2. Liquid chemicals: ➔ Flush immediately with copious amounts of tepid water for 15 - 20 minutes 3. Dry chemicals: ➔ Brush off as much as possible, then flush with copious amount of tepid water for 10 - 15 minutes 4. Identify chemical 5. Assess for associated respiratory burns Rule of 9s Rule of 1s Patient’s palm and fingers are 1% TBSA 9% 18% Back 18% 18% 18% Back 1% 18% 9% 9% 18% 18% 1% 13.5% 13.5% BURN PATIENT CARE 10 Patient Care Policy (General) Modified On: January 1, 2026 BURN PATIENT CRITERIA 1. INTRODUCTION -The intent of this policy is to transport patients with critical burns, who have a manageable airway, directly to a facility that is staffed and equipped to care for the medical needs of the patient, bypassing other receiving facilities. Minor to moderate burn patients will be transported to the closest, most appropriate receiving hospital. 2. BURN PATIENT CRITERIA (from the American Burn Association – Burn Unit Referral Criteria) 2.1 Partial thickness burns greater than 10% total body surface area 2.2 Moderate to severe burns that involve the face, hands, feet, genitalia, perineum, or major joints 2.3 Full thickness burns in any age group 2.4 Electrical burns, including lightning injury 2.5 Chemical burns 2.6 Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect mortality 2.7 Inhalation injury 3. DESTINATION 5.1 Adult and Pediatric patients who meet burn patient criteria 2.1-2.6 may be transported directly to an out-of-county burn center (see #5 below). 3.2 Exceptions: 3.2.1 Potentially unmanageable airway - (e.g. - soot in the mouth and/or nose, inhalation injury, etc.) transport to the closest trauma center. 3.2.2 Unmanageable Airway - The patient requires intubation, and the paramedic is unable to intubate, and an adequate airway cannot be maintained with B.V.M. device, transport to closest basic E.D. 3.2.3 Patient meets Critical Trauma Patient Criteria – “Mental Status & Vital Signs” - transport to the closest most appropriate designated trauma center 4. OUT-OF-COUNTY TRANSPORT 4.1 Transporting medic must first contact out-of-county hospital to confirm bed availability. This can be done through the appropriate dispatch center or via phone or radio from the field 4.2 Contact the Base Physician if medical consultation is needed 4.3 Consider EMS Aircraft transport for land transport times greater than 45 minutes 4.4 Give a brief report to the receiving facility including ETA Out-of-County Burn Centers: FACILITY ADULT PEDIATRIC TRAUMA HELIPAD LOCATION PHONE # Santa Clara Valley Medical 751 S. Bascom YES YES YES YES (408) 885-6666 Center Ave., San Jose 2315 Stockton UC Davis Medical Center YES YES YES YES (916) 734-3636 Blvd., Sacramento St. Francis Memorial Hospital YES NO NO NO 900 Hyde Street, (415) 353-6255 San Francisco BURN PATIENT CRITERIA 11 Patient Care Policy (General) Modified On: July 21, 2017 CARDIOPULMONARY RESUSCITATION (CPR) Summary of High-Quality CPR Components for BLS Providers Infants Children Adults and (Age Less Than 1 Year, Component Adolescents (Age 1 Year to Puberty) Excluding Newborns) Scene safety Make sure the environment is safe for rescuers and victim Check for responsiveness No breathing or only gasping (ie, no normal breathing) Recognition of cardiac arrest No definite pulse felt within 10 seconds (Breathing and pulse check can be performed simultaneously in less than 10 seconds) Formatted Table Witnessed collapse If you are alone with no mobile Follow steps for adults and adolescents on the left phone, leave the victim to activate the emergency Unwitnessed collapse Activation of response system and get the Give 2 minutes of CPR emergency AED before beginning CPR Leave the victim to activate the emergency response system and get the response system AED Otherwise, send someone and begin CPR immediately; use the Return to the child or infant and resume CPR; use AED as soon as it is available the AED as soon as it is available Compression-1 rescuer 30:2 ventilation 1 or 2 rescuers 30:2 ratio without 2 or more rescuers If suspected opioid overdose, advanced airway 15:2 administer opioid antagonist (eg. If suspected opioid overdose, administer opioid antagonist (eg. naloxone) if available naloxone) if available Compression- ventilation ratio Formatted Table Give 1 breath every 6 seconds (10 breaths/min) with advanced airway Compression-Continuous compressions at a rate of Continuous compressions at a rate of 100-120/min 100-120/min ventilation ratio with advanced Give 1 breath every 2-3 seconds (20-30 breaths/min) Give 1 breath every 6 seconds (10 breaths/min) airway Compression rate 100-120/min At least one third AP diameter of chest At least one third AP diameter of Compression chest At least 2 inches (5 cm)* About 2 inches (5 cm) depth About 1½ inches (4 cm) 1 rescuer 2 fingers in the center of the chest, just below the nipple line 2 hands or 1 hand (optional for very small 2 hands on the lower half of the Hand placement child) on the lower half of the breastbone 2 or more rescuers breastbone (sternum) (sternum) 2 thumb–encircling hands in the center of the chest, just below the nipple line Chest recoil Allow full recoil of chest after each compression; do not lean on the chest after each compression Minimizing Limit interruptions in chest compressions to less than 10 seconds interruptions Formatted Table Formatted Table Formatted Table Patient Care Policy (General) Modified On: July 21, 2017 CARDIOPULMONARY RESUSCITATION (CPR) Minimize interruptions in chest Resume CPR beginning with Attach and use AED/ Defibrillator compressions before and after shock compressions immediately after Defibrillation as soon as available each shock *Compression depth should be no more than 2.4 inches (6 cm). Abbreviations: AED, automated external defibrillator; AP, anteroposterior; CPR, cardiopulmonary resuscitation. Formatted Table CARDIOPULMONARY RESUSCITATION (CPR) 12 Patient Care Policy (General) Modified On: May 27, 2021 CARDIOPULMONARY RESUSCITATION (CPR) ADDITIONAL INFORMATION: 1. Minimize interruptions in chest compressions 2. Use a mechanical compression device whenever possiblewhen possible. Confirm proper device placement during rhythm checks. 2.1 Refer to manufacturer’s instructions for specific information regarding mechanical CPR device 2.2 Upon ROSC, you must discontinue mechanical CPR device 3. If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to respond to initial CPR and defibrillation attempts or demonstrates ROSC. (2015 AHA Guidelines) 4. Emphasis is on high quality, uninterrupted CPR -” push hard and fast” – allow for complete recoil 5. FourTwo minutes CPR between drug doses (epinephrine every other cycle CPR) 6. Once an advanced airway is established, give continuous chest compression without pauses for breaths. One breath every 6 seconds, delivering 10 breaths/min. Avoid hyperventilation 7. Check rhythm q 2 minutes and defibrillate as needed (if safe, pre-charge debrillator prior to rhythm check) 8. Defibrillation: Device specific. While both monophasic and biphasic wave form defibrillators are acceptable, biphasic is preferred. Energy level is dependent upon the manufacturer 9. Newborn: Unresponsive, not breathing but has a pulse: 40-60 ventilations/minute. Compression/ventilation ratio: 3:1 (90 compressions: 30 ventilations per minute) 10. Unresolved or persistent arrest, look for and treat: 11. If patient regains ROSC, refer to Return of Spontaneous Circulation - ROSC (see page 52) ➔ H ypovolemia ➔ T ension pneumothorax ➔ H ypoxia ➔ T amponade, cardiac ➔ H ydrogen Ion (acidosis) ➔ T oxins ➔ H ypo-/H yperkalemia ➔ T hrombosis, pulmonary ➔ H ypothermia ➔ T hrombosis, coronary ➔ H ypoglycemia (pediatric only) MECHANICAL CPR DEVICES: 12. PURPOSE: Effective and uninterrupted compressions are important for survival; AHA/ERC Guidelines for CPR (Cardio-Pulmonary Resuscitation) 2005 emphasize the significance of compressions to provide critical blood flow to vital organs and in the end to increase the chances of a successfulresuscitations and survival. Mechanical CPR allows for consistent, quality CPR that enables caregivers to focus on other aspects of resuscitation while maximizing effectiveness of therapeutic interventions 13. Indications: ► Use mechanical CPR devices wherever manual CPR is indicated ► IMPORTANT NOTE: If ROSC is obtained, mechanical CPR device must be discontinued AutoPulse Contraindications LUCAS Contraindications ➔ ≤ 17 years of age ➔ If it is not possible to position LUCAS safely or correctly on the patient’s chest ➔ Patients with traumatic injury (wounds resulting from sudden physical injury or violence) ➔ Too small patient: if the LUCAS device alerts with 3 fast signals when lowering the Suction Cup, and you cannot enter the PAUSE mode or ACTIVE mode ➔ Too large patient: If you cannot lock the Upper Part of LUCAS to the Back Plate without compressing the patient’s chest CARDIOPULMONARY RESUSCITATION (CPR) 13 Patient Care Policy (General) Modified On: December 1, 2011 CARDIOPULMONARY RESUSCITATION (CPR) PIT CREW ROLES: The roles and responsibilities detailed below are guidelines. There may be fewer personnel on hand for these roles. It is important that there is always a Pit Crew Leader (similar to an Incident Commander on a scene of any MCI). This concept is known as ‘The Pit Crew’ concept and is the standard of care for resuscitations in Alameda County. The roles are as follows: Position and Responsibilities Pit Crew Leader: • Overall team leader • Assigns roles • Monitors time intervals (2 min. CPR, drug intervals, etc.) • Assures quality of CPR • Assures use of proper equipment and adjuncts (e.g., EtCO 2) • Serves as scribe (field notes) • Supervises and assigns crowd control • Supervises DNR/POLST issues • Performs NO patient care • Responsible for overall conduct of resuscitation Airway Leader: • Performs appropriate airway techniques, procedures • Supervises airway decisions • Uses confirmatory adjuncts • Completes EHR at hospital (if appropriate) (with med leader) • Communicates with law/family as needed • Defibrillates if medication leader not available • Inserts advanced airway (see page 118) * (NOTE: Do not interrupt chest compressions to place an advanced airway) Medication Leader: • Defibrillates • Initiates IV or IO • Administers (or supervises) medications • Tracks and notifies team of all monitor changes • Completes EHR (with airway leader) • Communicates with family/law as needed • Terminates resuscitative efforts (with team leader) • Sets up mechanical CPR device* (see page 13) • Monitors mechanical CPR device* (see page 13) CPR Chief: • Supervises and performs CPR (with team leader) • Assists with equipment/medication setup • Performs communications Team Assistant: • Assists with CPR • Assists with communications • Assists with setup Team Leader/Airway Assistant (optional) • Serves at assistant to team leader • Assists airway leader * Indicates vital task to be completed CARDIOPULMONARY RESUSCITATION (CPR) 14 Patient Care Policy (General) Modified On: July 21, 2017 CRUSH INJURY SYNDROME • Routine Medical Care • Trauma Patient Care (see page 28) • Note: Hypovolemia and hyperkalemia may occur, particularly with extended entrapment (usually > 4 hours). Once compression is released cellular toxins and potassium may be released into the body. Administering sodium bicarbonate alkalinizes the urine, controls hyperkalemia and acidosis ➔ Crush Injury syndrome Definition: Crush injury syndrome is the name given to the systemic manifestations of muscle crush injury and cell death. Crush injury syndrome should be suspected in patients with certain patterns of injury. Most patients in whom the syndrome develops have an extensive area of involvement such as a lower extremity and/or pelvis. It requires more involvement than just one hand or foot. The syndrome may develop after one hour in a severe crush situation, but usually requires 4 – 6 hours of compression for the processes that cause crush injury syndrome to occur. CRUSH INJURY SYNDROME 15 Formatted: Character scale: 100% Patient Care Policy (General) Modified On: January 1, 2026 EXTREMITY INJURY 1. ASSESMENT: 1.1. Routine Medical Care 1.2. Document mechanism of injury 1.3. Document past medical history including history of previous injuries 1.4. Check for deformity, open wounds, swelling, shortening, and/or rotation 1.5. Document range of motion, pulses, sensation, and color of the extremity 1.6. Assess severity of pain (1-10 scale) 1.7. Assess for other associated injuries 2. GENERAL CARE: (all patients) 2.1. Control any external bleeding with direct pressure 2.2. Elevate and apply cold packs 2.3. Splint injured extremity. Hand injuries should be positioned in the “safe position” 2.4. Cover open wounds with sterile dressings 2.5. Provide Pain control – see “Pain Management” page 47 (Adult) or page 76 (Pediatric) 2.6. Remove rings or other possibly constricting items 3. FRACTURE/DISLOCATION: 3.1. If the extremity is pulseless, attempt to place it in normal anatomic position by gentle in-line traction 3.2. If repositioning does not restore circulation, do not manipulate further, transport immediately. 3.3. Start IV NS in uninjured extremity 4. AMPUTATION: 4.1. Place amputated part in moist, sterile dressing, place in sealed plastic bag, and place on top of ice or cold packs (do not place part directly in ice - prevent frostbite) 4.2. Start IV of NS in uninjured extremity 4.3. If hypotensive (SBP < 90 or signs of poor perfusion), give fluid challenge (500 mL NS, reassess and repeat if indicated) 5. HIGH-PRESSURE INJECTION INJURY: 5.1. Compressed air injuries, although they may initially look innocuous require immediate transport, especially if paint, paint thinner or grease is involved. These wounds must be debrided in the operating room as soon as possible to prevent further damage and/or amputation 6. SNAKE BITE: 6.1. Gently wash the area with cool, wet cloth 6.2. Avoid constricting bands 6.3. Do not elevate EXTREMITY INJURY 16 tachycardia exacerbate Albuterol Patient Care Policy (General) Modified On: July 24, 2018 HYPERKALEMIA Definition: Hyperkalemia is common in patients with severe renal failure (particularly those on dialysis) and should be suspected when these patients have weakness/fatigue, nausea/vomiting, chest pain, palpitations, shortness of breath, or numbness/tingling. Hyperkalemia can lead to ECG changes that can ultimately result in life-threatening dysrhythmias. Treatment in the prehospital setting is based on the severity of the ECG, is temporizing until definitive treatment is achieved in the hospital, and aims to stabilize patients with the potential to arrest or become unstable Signs/symptoms of suspected Hyperkalemia:  Weakness/Fatigue  Nausea/Vomiting  Chest Pain  Palpitations  Shortness of Breath  Numbness/Tingling  Cardiac Monitor  12 Lead ECG ECG Change(s) Associated with Hyperkalemia: 1. Peaked T Waves 2. Flattened-Absent P waves 3. Widened QRS complex 4. Sinusoidal pattern 5. Ventricular Fibrillation Significant ECG No Yes Change(s)? Reassess as  Calcium Chloride 1 gm slow IVP (over 2 needed min.) Note: flush IV tubing after administering CaCl to avoid precipitation  Sodium Bicarbonate 1 mEq/kg IVP over 60 seconds  Albuterol (only) 10-20mg by nebulizer or BVM HYPERKALEMIA 17 Patient Care Policy (General) Modified On: December 1, 2011 HYPERTHERMIA / HEAT ILLNESS • Routine Medical Care • Protect patient from environment. • If the patient is in extremis, begin treatment prior to secondary survey. • Consider: the environment, patient age, and pre-existing conditions 1. SIGNS AND SYMPTOMS OF A HEAT EMERGENCY ➔ Weakness or exhaustion ➔ Dizziness ➔ Headache ➔ Sweating may or may not be present ➔ Fainting or feeling faint ➔ Rapid heart rate ➔ Muscle cramps ➔ Altered mental status (coma, seizures, delirium) 2. PREEXISTING CONDITIONS THAT CAN CONTRIBUTE TO A HEAT EMERGENCY: ► Psychiatric disorder (both because of the ► Fever medications taken and perhaps the patient’s poor ► Fatigue judgement) ► Obesity ► Heart disease ► Dehydration (either decreased fluid intake or ► Diabetes sweating) ► Alcohol ► Medications ► Age >65 3. TREATMENT: 3.1 If the patient is conscious: 3.1.1 Remove patient from hot environment 3.1.2 Loosen or remove clothing 3.1.3 Place in supine position with legs elevated 3.1.4 Administer O 2 3.1.5 Fan the patient 3.1.6 Water may be given if patient is alert, has a gag reflex, and is not nauseated 3.2 If altered mental status is present: (see above) 3.2.1 Place on left side and monitor airway 3.2.2 Wet the skin and fan aggressively 3.2.3 Apply cold packs to the axillae, groin and neck (if available) 3.2.4 Administer IV fluid challenge (250-500 mL NS) 3.2.5 Transport immediately Formatted: Font color: Auto, Not Expanded by / HYPERTHERMIA / HEAT ILLNESS 18 Condensed by Patient Care Policy (General) Modified On: May 6, 2013 HYPOTHERMIA • Routine Medical Care • Protect the patient from the environment • If patient is in extremis, begin treatment prior to secondary survey • Check skin temperature 1. INTRODUCTION: Hypothermia is a reduced core temperature where the cold challenge overwhelms heat production and heat retention factors. The rate of onset can be: 1.1 Acute (minutes to hours) e.g. immersion in cold water 1.2 Sub-acute (hours) 1.3 Chronic (often over several days) Homeless, drug users, alcoholics, and compromised individuals are at high risk. Elderly persons and those taking certain medicines are also at risk. Injured and seriously ill individuals can become hypothermic quickly ➔ Note: a hypothermic critical trauma patient has a very high mortality and morbidity rate! 2. SIGNS AND SYMPTOMS OF HYPOTHERMIA: 2.1 Altered mental status including: confusion, mood changes, and speech difficulties. The patient’s judgment may be affecting causing him/her to exhibit inappropriate behaviors such as removing clothing 2.2 Decreased motor function, poor coordination 2.3 Diminished sense of cold sensation 2.4 Pupils that respond slowly or sluggishly 3. TREATMENT: 3.1 General: 3.1.1 Remove the patient from the cold environment and prevent further heat loss 3.1.2 Remove wet clothing, begin rewarming - cover with blankets, turn up the heat in the ambulance 3.1.3 Do not let the patient walk or exert him/herself 3.1.4 Administer O - titrate to 94-99% SpO (warmed and humidified is preferred) 22 3.1.5 Closely monitor cardiac rhythm 3.1.6 Check blood glucose levels. Administer glucose as needed (see ALOC page 35 – adult or page 68 - pediatric) 3.1.7 Transport immediately 3.2 BLS: 3.2.1 CPR should be initiated if there is any doubt about pulselessness 3.2.2 Severely hypothermic patients may appear dead. If you find an unresponsive, hypothermic patient, take time (30-45 seconds) to try and find a pulse before beginning CPR. Chest compressions should be avoided if any signs of life are present 3.2.3 If VT or VF is present, defibrillation should be attempted. If one shock is unsuccessful, subsequent shocks should be deferred HYPOTHERMIA 19 Patient Care Policy (General) Modified On: December 1, 2011 HYPOTHERMIA 3.3 ALS: 3.3.1 Give fluid challenge with heated N.S. if possible 3.3.2 Do not delay urgent procedures (IV lines and intubation) but perform them “gently.” The severely cold heart is sensitive to a variety of stimuli, and fatal dysrhythmias can be caused by forceful treatment efforts 3.3.3 Defer ACLS medications until rewarming occurs (> 30° C / 86° F) Commented \[ZK3\]: Are people checking temperatures in the rig? This would have to be core temp. Not sure we should have this in here given we don’t check. HYPOTHERMIA 20 Patient Care Policy (General) Modified On: May 27, 2021 INFECTION CONTROL AND SCREENING CRITERIA 1. INTRODUCTION: The following guidelines are general recommendations to help to protect healthcare personnel by reducing the risk of further disease transmission when they are caring for patients with a potentially infectious disease. 2. PRE-INCIDENT 2.1 Ensure familiarity with organizational policies and procedures related to infection control including but not limited to proper particulate respirator fit testing. 2.2 Ensure availability and familiarity with appropriate PPE and proper donning/doffing procedures for all types of PPE. 2.3 Ensure availability of appropriate cleaning supplies and their usage along with organizational policies and procedures surrounding their usage. 3. DURING INCIDENT: 3.1 Upon dispatch to an incident, utilize provided information to make an initial determination about the potential risk associated with the call. (i.e. a respiratory distress incident has a potentially higher risk associated vs an acute injury). 3.2 Follow standard universal precautions for all incidents. 3.3 If dispatch or initial information gathered at the scene indicates a potentially increased risk for disease transmission, minimize personnel having contact with the patient. 3.4 Apply a procedure or surgical mask to the patient to contain droplets if possible. 3.5 Use caution when performing aerosol generating procedures or high-risk procedures (e.g., mechanical ventilation, ETI, nebulized medications, and/or suctioning). 3.5.1 If you are performing an aerosol generating or other high-risk procedure on a patient with a suspected infectious disease, you are required to wear a N95, P-100, or equivalent respirator during the procedure(s) 3.5.2 It is recommended that a BVM with a HEPA filter be utilized for ventilation. 3.6 Optimize environmental ventilation by using the the vehicle’s ventilation to increase the volume of air exchange during transport 3.7 Minimize personnel and/or additional riders during transport. 3.8 Notify the receiving facility early as possible 4. POST INCIDENT 4.1 Follow standard operating procedures for routine cleaning of the emergency vehicle and reusable patient care equipment 4.2 Document all assessment findings and treatments appropriately. INFECTION CONTROL AND SCREENING CRITERIA 21 Patient Care Policy (General) Modified On: January 1, 2026 OB/GYN EMERGENCIES • Routine Medical Care • Level of distress: • Estimate blood loss (if any) • Is the patient in shock? If yes, Go to the Shock: Hypovolemia/Cardiogenic protocol page 58 • Consider immediate transport or prepare for delivery • Determine stage (trimester) of pregnancy • Any patient that is � 20 weeks pregnant who has sign(s)/symptom(s) that may be pregnancy related (e.g. abdominal ABO • pain), should be preferentially triaged to a receiving facility with a Labor and Delivery department. 1. VAGINAL BLEEDING (Abnormal bleeding between menses, during pregnancy, postpartum or post operative) 1.1 If postpartum, gently massage the fundus to decrease bleeding 1.2 Monitor vital signs frequently 2. SPONTANEOUS ABORTION 2.1 If fetus is > 20 weeks or 500 grams, see neonatal resuscitation protocol (page 75). If non-viable, save and transport any tissue or fetal remains 2.2 Have patient place a sanitary napkin or bulky dressing material over vaginal opening - Do not pack the vagina with anything 3. SEVERE PRE-ECLAMPSIA / ECLAMPSIA 3.1 Inclusion Criteria: 3.1.2 More than 20- weeks’ gestation, presenting with hypertension and evidence of end organ dysfunction including renal insufficiency, liver involvement, neurological, or hematological involvement 3.2 May occur up to 6 weeks postpartum but is rare after 48 hours post-delivery 3.3. Often the presenting symptom of postpartum pre-eclampsia is headache or SOB 3.4. Severe Features of pre-eclampsia include: 3.4.1. Severe hypertension (SBP greater than 160, DBP greater than 110) 3.4.2. Headache 3.4.3. Confusion/altered mental status 3.4.4. Vision changes including blurred vision, spots/floaters, loss of vision (these symptoms are often a precursor to seizure) 3.4.5. Right upper quadrant or epigastric pain 3.5. Shortness of breath/pulmonary edema 3.6. Ecchymosis suggestive of low platelets (bruising, petechiae) 3.7. Vaginal bleeding suggestive of placental abruption 3.8. Focal neurologic deficits suggesting hemorrhagic or thromboembolic stroke 3.9. Observe for seizures, hypertension or coma, if seizing, go to the appropriate seizure protocol 4. BREECH DELIVERY 4.1 Allow delivery to proceed passively until the baby’s waist appears. Gently rotate the baby to a face down position and continue with the delivery 4.2 If the head does not readily deliver, insert a gloved hand into the vagina to relieve pressure on the cord and create an air passage for the infant. Transport. Monitor vital signs and infant condition frequently 5. PROLAPSED CORD 5.1 Place the mother supine position with head lower than hips 5.2 Insert a gloved hand into the vagina and gently push the presenting part (e.g.: the neonate’s head or shoulder off the cord. DO NOT TUG ON THE UMBILICAL CORD. Avoid unnecessary handling of the cord. OB/GYN EMERGENCIES 22 Patient Care Policy (General) Modified On: January 1, 2026 OB/GYN EMERGENCIES 5.3 Place fingers on each side of the neonate’s nose and mouth, split fingers into a “V” to create an opening. Do not attempt to re-position the cord. Do not remove your hand. Cover the exposed cord with saline soaked gauze 6. LIMB PRESENTATION 6.1 Defined as the presentation of a single limb - arm or leg 6.2 It is unlikely that the baby will deliver and immediate transport should be initiated 6.3 Place the mother supine position with head lower than hips 7. SHOULDER DYSTOCIA 7.1 Hyperflex mother’s hips by firmly pressing knees to hips (McRoberts Maneuver). 7.2 Second provider applies suprapubic (not fundal) pressure with fist directed downwards to dislodge anterior shoulder 7.3 Third provider providers gentle downward traction on fetal head. Do NOT pull fetal head. 7.3.1 If unsuccessful, initiate immediate transport and communicate issue of concern over ring down “shoulder dystocia”. OB/GYN EMERGENCIES 23 Patient Care Policy (General) Modified On: June 15, 2023 SCOPE OF PRACTICE - LOCAL OPTIONAL 1. Approved for use in Alameda County – all items require additional training 1.1 BLS PERSONNEL: 1.1.1 Aspirin 1.1.2 Blood Glucose Testing 1.1.3 Epinephrine 1.1.4 Narcan 2. Local Optional Scope of Practice – requires authorization from State EMS Authority and additional training 2.1 ALS PERSONNEL: 2.1.1 Buprenorphine (optional) 2.1.2 Hydroxocobalamin (optional) 2.1.3 Ketamine (Ketalar) (optional) 2.1.4 Ketorolac (Toradol) 2.1.5 Olanzapine (Zyprexa) 2.1.6 Sodium Thiosulfate 2.1.7 Tranexamic Acid 2.2 2.2 BLS Personnel 2.1.72.2.1 Buprenorphine 3. Field personnel will not perform any skill that is not a part of his/her scope of practice or has not been authorized by the Alameda County Health Officer and/or EMS Medical Director 4. During an inter-facility transfer or during a mutual aid response into another jurisdiction, a paramedic or EMT may utilize the scope of practice for which he/she is trained and accredited 5. Paramedics will not draw blood unless approved in advance by the EMS Medical Director 6. Field personnel are prohibited from carrying any medical equipment or medications that have not been authorized for prehospital use by the Alameda County EMS Medical Director Formatted: Font color: Auto, Not Expanded by / Condensed by Formatted: Font color: Auto, Not Expanded by / Condensed by Formatted: Font: 7 pt SCOPE OF PRACTICE - LOCAL OPTIONAL 24 Patient Care Policy (General) Modified On: January 1, 2026 SMOKE INHALATION / CO MONITORING  Routine Medical Care  Symptoms of Carbon Monoxide (CO) poisoning: ➔ Initial symptoms are similar to the flu with no fever and can include dizziness, severe headaches, nausea, sleepiness, fatigue/weakness and disorientation/confusion • Note: Carbon Monoxide is a colorless, odorless and tasteless poisonous gas that can be fatal when inhaled. CO inhibits the blood’s capacity to carry oxygen. CO can be produced when burning any fuel. CO is a by- product of incomplete combustion. Suspect CO in the presence of any fire. SpCO = carboxyhemoglobin 1. Pulse oximetry values may be unreliable in smoke inhalation (SI) patients 2. Cyanide and/or the combination of cyanide and carbon monoxide may be responsible for the majority of SI deaths 3. SI should be particularly suspected in patients rescued from closed-space structure fires 4. Sodium thiosulfate should not be given prophylactically 5. Remove patient from the source of exposure 5.1. Completely remove patient’s clothing prior to transport 5.2. Perform Spinal Motion Restriction (SMR) if indicated by mechanism 5.3. Evaluate patient for facial burns, hoarseness, black sputum, and soot in the nose or mouth 5.4. Monitor SpCO (if available) 5.5. Assess and treat for traumatic and/or thermal injuries - see ”Trauma Patient Care” (see page 28) and/or “Burn Patient Care” ( see page 9). 6. Administer 100% oxygen via NRB 6.1. Control airway early. Use BVM with airway adjuncts 6.2. Perform endotracheal intubation / SGA placement if indicated 6.2.1. Endotracheal intubation is preferred 6.3. If bronchospasm present, go to “Respiratory Distress” (see page 51). 7. Provide cardiopulmonary support (go to appropriate “Cardiac Arrest” policy, if indicated) 8. Start IVs. Consider IV fluids if hypotensive or meeting “Burn Patient Criteria” (see “Burn Patient Care” see page 9). 9. ONLY if the patient exhibits serious signs and symptoms of SI with concern for Cyanide Poisoning (especially burning of nitrogen-containing polymers) – see “Cyanide Poisoning” (see page 153). 9.1. Administer sodium thiosulfate or hydroxocobalamin (Cyanokit) 9.1.1. Sodium thiosulfate IV slowly over 10 minutes Adult: 12.5 g/50 ml | Pediatric: use an LBRT to determine pediatric medication dosages, to for patients with any of the following signs of cyanide poisoning: ➔ Unconsciousness, non-responsiveness ➔ Hypotension ➔ Severely altered level of consciousness with soot in the mouth or nose ➔ Cardiac arrest without full body burns incompatible with life 9.1.2. Hydroxocobalamin - Optional (Additional Training Required) Adults: 5g over 15 minutes 10. Treatment of cyanide poisoning must include immediate attention to airway patency, adequacy of oxygenation and hydration, cardiovascular support, and management of any seizure activity 11. If seizures are present, go to Seizure policy (see page 55). 12. If cardiac arrhythmia present, go to appropriate arrhythmia policy – Bradycardia (see page 37), Cardiac Arrest (see page 38), or Tachycardia (see page 62) 13. Ensure rapid transport SMOKE INHALATION / CO MONITORING 25 Patient Care Policy (General) Modified On: January 1, 2026 SMOKE INHALATION / CO MONITORING Remove patient from source of exposure Does patient show serious signs and No Yes *Signs and symptoms of smoke inhalation: symptoms of smoke ✓ Unconsciousness, non-responsiveness inhalation?* ✓ Hypotension ✓ Severely altered level of consciousness with soot in the mouth or nose ✓ Cardiac arrest without full body burns Maintain airway and incompatible with life adequate respirations. Oxygen IV/IO NS Administer: Sodium Thiosulfate 12.5 g/ 50 ml over 10 minutes or Hydroxocobalamin Measure SpCO 5g over 15 min (if available) Use LBRT for Pediatric Dosing SpCO >25% or >15%if pregnant? Loss of No Yes consciousness? Neurologic impairment? ✓ Transport on 100% O2 SpCO 3-25% Yes No ✓ Consider CPAP NOTE: If unexplained shock/hypotension develops, consider concomitant CO and/or cyanide poisoning Sodium Thiosulfate 12.5 grams/50ml Transport on No further CO over 10 minutes 100% O2 for ED measurement evaluation required SMOKE INHALATION / CO MONITORING 26 Patient Care Policy (General) Modified On: July 21, 2017 TRANSPORT GUIDELINES Note: In addition, see “Trauma Patient Criteria” page 29, “Burn Patient Criteria” page 11, and the "Alameda County Approved Receiving Hospitals" matrix located on inside of the back cover for specific transport instructions. 1. GENERAL TRANSPORT GUIDELINES: All patients who wish to be transported by ambulance to the hospital should be transported 1.1 Patient Destination: 1.1.1 Patients should be transported to the closest hospital appropriate for their medical needs within a reasonable transport time or as specified in the patient care protocols 1.1.2 In general, patients should be transported to the hospital choice of the patient and/or family, if allowed by the protocols, and if there is no compelling reason to take them somewhere else 1.1.3 Paramedics (or EMTs when applicable by protocol) should contact the Base Physician for any questions regarding transport destinations. If the Base Hospital is contacted for medical direction, the ultimate responsibility for determining patient destination will rest with the Base Hospital Physician 2. TRANSPORT DECISIONS: Transport decision should be based on paramedic judgment. Paramedics should take the following into consideration before transport: 2.1 Patient condition or ability of field personnel to provide field stabilization and/or emergency intervention. TRANSPORT OF ACUTE PATIENTS: Any patient with an acute, unstable appearance and/or severe symptoms may be transported Code 3 (lights and siren). Code 3 transport (lights and siren) has significant, inherent risks for the public and the patient. If Code 3 transport of an acute patient does NOT significantly decrease transport time to the hospital, the acute patient should be transported Code 2 (no lights and siren). The hospital must be notified of the patient's Code 3 acuity even if transported Code 2 2.2 Scene assessment and/or potential extrication difficulties 2.3 ETA to the destination facility including traffic delays 2.4 Instructions within specific algorithms to “initiate early transport” 2.5 Hospital diversion status - See “Ambulance Rerouting” page v 2.6 Recommendation from a physician familiar with the patient’s current condition, or the patient’s regular source of hospitalization/healthcare. For physician on-scene - see page 110 2.7 Hospitals with specialized services (e.g.: trauma center, burn center, STEMI Center (SRC), etc.) 3. TRANSFER OF CARE: Any paramedic level personnel may transfer care of a BLS patient to any EMT as long as the care required by the patient is within the scope of practice of an EMT, and the patient has no injury or illness that requires or is likely to require monitoring or treatment by an ALS provider 4. RECEIVING HOSPITAL NOTIFICATION: Transport units should contact the receiving hospital prior to arrival with the patient’s chief complaint, a summary of treatment given and the ETA. 5. OUT OF COUNTY TRANSPORTS: 5.1 Patients may be transported to hospitals outside Alameda County if the out-of-county hospital is the closest most appropriate hospital for the medical needs of the patient. Base contact is not required but should be attempted if there are any questions regarding the transport 5.2 Contact the receiving facility by radio or landline. If unable, contact the appropriate dispatch agency to relay information to the receiving facility. This will provide information on bed availability. Do not transport patient to out-of-county hospital without obtaining prior authorization TRANSPORT GUIDELINES 27 Patient Care Policy (General) Modified On: May 27, 2021 TRAUMA PATIENT CARE • Routine Medical Care • Critical Interventions - See below • Transport Decision - Determine need for rapid intervention/transport • Transport • If traumatic arrest is suspected do not use ACLS medications CRITICAL/TIME SENSITIVE INTERVENTIONS: ► Control major external hemorrhage (see page 127) ► Control the Airway - Consider endotracheal intubation or supraglottic airway device if indicated (See below for patients with closed head trauma) ► Keep patient warm ► Determine patient severity (see “Trauma Patient Criteria” - see page 29): Meets Physiologic and/or Anatomic Factors Meets Mechanism of Injury Criteria ➔ Transport to the Trauma Center In accordance with ➔ Transport to the Trauma Center code 2. Transport Guidelines (page 22). ➔ ADULT/PEDIATRIC - Establish one (1) large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). ➔ ADULT - Establish one (1) large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Establish 2nd IV if appropriate. ➔ PEDIATRIC- Establish one (1) appropriate large bore IV/IO with Normal Saline (NS) or Saline Lock (SL). Do NOT delay transport to establish IV/IO access See “Trauma Patient Criteria" (page 29) for additional judgment decisions on code 2 transports ► Consider spinal motion restriction (SMR) for blunt trauma (see page 139) ► Administer Oxygen - Titrate SpO to 94-99% 2 ► IV fluid resuscitation: ➔ SBP < 90 mmHg, NS IV/IO 250 – 500ml bolus ➔ > 90 mmHg, IV/IO TKO or Saline Lock ➔ Reassess BP q 5 minutes ► Consider TXA for patients with signs of shock or uncontrolled bleeding (see page 145) ► Care of the patient with a closed head injury (GCS < 8): ➔ Advanced airway (ETT or SGA) ➔ End-tidal CO should be between 30-35 mmHg 2 ➔ Track respirations or ventilate to a rate of approx. 12 times/minute with 100% O 2 (AVOID HYPERVENTILATION) ➔ IV/IO NS in 500 mL increments to maintain mean arterial pressure (MAP) of at least 80 mmHg. Reassess BP q 5 minutes IMPORTANT CONSIDERATIONS FORMULA FOR ESTIMATING MAP ► Contact the Base Hospital, if appropriate MAP = diastolic + (systolic - diastolic) ► Contact the Trauma Center, as soon as possible 3 ► Consider pain management when appropriate ► Splint fractures and dress wounds ONLY if time permits TRAUMA PATIENT CARE 28 Patient Care Policy (General) Modified On: June 15, 2023 TRAUMA PATIENT CRITERIA 1. INTRODUCTION: The goal of the Alameda County trauma system is to transport confirmed patients meeting the various criteria below to a designated trauma center in a timely manner, bypassing non-trauma centers 2. RED CRITERIA TRAUMA PATIENTS (High Risk for Serious Injury): 2.1 A patient is identified as at high risk for serious injury when any of the following injury patterns or mental status/vitals signs listed below are present. These patients should be transported to a designated Trauma Center rapidly. Injury Patterns Mental Status & Vitals Signs • Penetrating injuries to head, neck, torso, and proximal All Patients • Total Glasgow Coma Scale ≤ 13 or; Motor GCS < 6 (Unable extremities to follow commands) • Skull deformity, suspected skull fracture • RR < 10 or > 29 breaths/min • Respiratory distress or need for respiratory support • Suspected spinal injury with new motor or sensory loss • Room-air pulse oximetry < 90% • Chest wall instability, deformity, or suspected flail chest Age 0–9 years • Suspected pelvic fracture • SBP < 70mm Hg + (2 x age in years) • Suspected fracture of two or more proximal long bones Age 10–64 years • SBP < 90 mmHg or • Crushed, degloved, mangled, or pulseless extremity • HR > SBP • Amputation proximal to wrist or ankle Age ≥ 65 years • Active bleeding requiring a tourniquet or wound packing with • SBP < 110 mmHg or continuous pressure • HR > SBP 3. YELLOW CRITERIA TRAUMA PATIENTS (Moderate Risk for Serious Injury): 3.1 In addition to above criteria, the following mechanisms of injury and EMS provider judgment of risk factors can be utilized to preferentially triage a patient to a trauma center. In general, these patients are transported code 2, however, differing field circumstances and/or patient condition may require a code 3 transport Mechanism of Injury EMS Judgment • High-Risk Auto Crash Consider risk factors, including: – Partial or complete ejection • Low-level falls in young children (age ≤ 5 years) or older adult – Significant intrusion (including roof) (age ≥ 65 years) with significant head impact • >12 inches occupant site OR • Anticoagulant use • >18 inches any site OR • Need for extrication for entrapped patient • Suspicion of child abuse – Death in passenger compartment • Special, high-resource healthcare needs – Child (age 0–9 years) unrestrained or in unsecured child safety seat • Pregnancy > 20 weeks – Vehicle telemetry data consistent with severe injury • Rider separated from transport vehicle with significant • Burns in conjunction with trauma impact (eg, motorcycle, ATV, horse, etc.) • Children should be triaged preferentially to pediatric capable • Pedestrian/bicycle rider thrown, run over, or with centers significant impact • EMS Provider judgment - If concerned, take to a trauma center • Fall from height > 10 feet (all ages) TRAUMA PATIENT CRITERIA 29 Patient Care Policy (General) Modified On: January 1, 2025 TRAUMA PATIENT CRITERIA 4. TRANSPORT: Patients that meet Red or Yellow trauma criteria in the prior sections will be transported to the closest, most appropriate, designated Trauma Center 4.1 Adult trauma patients are defined as being 15 years of age or older 4.2 Pediatric trauma patients are defined as being 14 years of age or younger 5. Exceptions: The patient is identified as meeting Red or Yellow trauma criteria, but presents with one of the following: PATIENT PRESENTATION ACTION UNMANAGEABLE AIRWAY: The patient requires advanced airway management, and the paramedic is Closest Basic E.D. unable to manage the patient's airway through basic or advanced interven- tions. Proceed to Adult Cardiac Arrest - Traumatic protocol or ADULT TRAUMATIC ARREST: Determination of Death in the Field protocol Proceed to Pediatric - Cardiac Arrest - Traumatic protocol or Determination of Death in the Field protocol ETA to the Pediatric Trauma ➔ Pediatric Trauma Center PEDIATRIC TRAUMATIC ARREST Center ≤ 20 minutes ETA to the Pediatric Trauma ➔ Closest Adult Trauma Center Center ≥ 20 minutes 6. PATIENT TURNOVER REPORTING FORMAT: EMS Clinicians should use the following DMIST format when turning over patient care to the Trauma Center medical team: ➔ D emographics ➔ M echanism ➔ I njuries ➔ S igns - Vital signs ➔ T reatments TRAUMA PATIENT CRITERIA 30 Patient Care Policy (General) Modified On: January 1, 2025 TRAUMA PATIENT CRITERIA 7. BASE HOSPITAL CONTACT: Varying field circumstances make rigid application of any set of rules impractical. These criteria should serve as guidelines. Clinical circumstances may dictate that transport be undertaken immediately with Base Hospital contact made during transport 7.1 Contact the Base Hospital Physician if: ► The patient meets the criteria listed in the "Yellow Criteria”, but the provider is requesting transport to a basic ED ► The patient requires medical treatment not covered in the Trauma Patient Care protocol ► The patient would benefit from consultation with the Base Hospital Physician 8. OUT-OF-COUNTY TRANSPORT 8.1 Patients who meet Trauma Patient Criteria may be transported directly to an out of county Trauma Center if it is the closest, most appropriate destination for the patient 8.2 Prior to transporting to an out-of-county Trauma Center, the transporting provider must: ► Contact the out-of-county Trauma Center by land line to determine if they can accept the patient ► Give a brief report including E.T.A. (See Reporting Format Protocol) ► Contact the Alameda County Base Hospital if medical consultation is required (see #5 above) 8.3 Out-of-County Trauma Centers: TRAUMA CENTER PEDIATRIC CAPABLE LOCATION PHONE # X STANFORD UNIVERSITY MEDICAL CENTER PALO ALTO (650) 723-7337 SAN FRANCISCO GENERAL HOSPITAL SAN FRANCISCO (415) 206-8111 X SANTA CLARA VALLEY MEDICAL CENTER SAN JOSE (408) 885-6912 JOHN MUIR MEDICAL CENTER WALNUT CREEK (925) 947-4444 SAN JOAQUIN GENERAL FRENCH CAMP (209) 982-1975 TRAUMA PATIENT CRITERIA 31 THIS PAGE INTENTIONALLY LEFT BLANK 32 Patient Care Policy (Adult) Modified On: January 1, 2026 ADULT POLICIES TOC ADULT POLICIES TOC ....................................................................................................... 33 AIRWAY OBSTRUCTION ...................................................................................................... 34 ALTERED LEVEL OF CONSCIOUSNESS .......................................................................... 35 ANAPHYLAXIS / ALLERGIC REACTION.......................................................................... 36 BRADYCARDIA ...................................................................................................................... 37 CARDIAC ARREST - GENERAL GUIDELINES ................................................................ 38 CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA ........................................................... 39 CARDIAC ARREST - MEDICAL - VF/PVT .........................................................................40 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT ............................................ 41 CARDIAC ARREST - TRAUMATIC ...................................................................................... 42 DYSTONIC REACTION .........................................................................................................43 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE .................................... 44 OPIOID WITHDRAWAL....................................................................................................................... 46 PAIN MANAGEMENT ............................................................................................................ 47 POISONING | INGESTION | OVERDOSE ......................................................................... 48 PULMONARY EDEMA / CHF ............................................................................................. 49 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) ............ 50 RESPIRATORY DISTRESS................................................................................................. 51 RETURN OF SPONTANEOUS CIRCULATION - ROSC ................................................ 52 ROUTINE MEDICAL CARE - ADULT ................................................................................ 53 SEIZURE ................................................................................................................................ 55 SEPSIS ................................................................................................................................... 56 SEVERE NAUSEA ................................................................................................................ 57 SHOCK: HYPOVOLEMIC/CARDIOGENIC ............................................................................. 58 SICKLE CELL PAIN EMERGENCY .................................................................................... 59 STROKE / CVA ..................................................................................................................... 60 SUBMERSION ........................................................................................................................ 61 TACHYCARDIA ....................................................................................................................... 62 VENTRICULAR ASSIST DEVICES -VAD .................................................................. 63 ADULT POLICIES TOC 33 Patient Care Policy (Adult) Modified On: April 10, 2012 AIRWAY OBSTRUCTION • Routine Medical Care • If obstruction due to laryngeal trauma, see page 28 "Trauma Patient Care" • Obstruction due to epiglottitis: ➔ Do not attempt to visualize the throat or insert anything into the mouth ➔ Minimize outside stimulation. Keep the patient calm. Position of comfort. • Do not use a tongue/jaw lift or perform blind finger sweeps • Rapid Transport Apply abdominal thrusts in *Signs of severe obstruction: rapid sequence. If ineffective, or ✓ Poor air exchange the patient is obese or in the ✓ Increased breathing difficulty late stages of pregnancy, ✓ Silent cough consider chest thrusts. ✓ Cyanosis ✓ Inability to speak or breathe ✓ Ask the patient “Are you choking”? If patient nods yes, act *Severe signs Yes No of obstruction? Maintain airway Suspect No Yes epiglottitis? and Oxygen Position of Encourage coughing comfort spO2 monitoring O2 to maintaine saturatio >92% Continue abdominal and Monitor airway chest thrusts. If the patient deteriorates, or If the patient becomes becomes completely obstructed, unresponsive: positive pressure ventilation via Begin CPR bag-valve-mask should be Check mouth for F.B. attempted first. If airway can not be Attempt Intubation maintained with BVM or Consider: Assist Ventilation Intubation with Bag-Valve-Mask (see page 118) Able Maintain to ventilate Transport to the airway Yes adequately? closest ED and Oxygen AIRWAY OBSTRUCTION 34 Formatted: Right: 0.6", Space Before: 4.85 pt, Line spacing: Multiple 1.06 li Formatted: Font: 5 pt Result TIPS – AEIOU Consider NS IV/IO 2 SpO 99%-94 to – 2 O respirations. adequateMaintain airway and glucoseblood Check 10% Dextrose additional Give blood glucose remains < 60 mg/dl patient’s the If administration. D10 after 10 minutes-Recheck blood glucose 5 10% Dextrose neededas Reassess Yes No Response?Appropriate No ?dLmg/ 60 < Patient Care Policy (Adult) Modified On: July 1, 2014 ALTERED LEVEL OF CONSCIOUSNESS • Routine Medical Care • Obtain a complete patient history including current medications • Identify and document neurological deficits • Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 8 breaths per minute) (see page 50) • Note: Glucose paste may be administered if the patient: 1) is able to hold head upright; 2) has a gag reflex; and, 3) can self- administer the medication • Dextrose should not be given with suspected Acute Stroke unless blood sugar reading is < 60 mg/dL • Perform 12-Lead ECG, as appropriate, and transport to a STEMI Receiving Center if STEMI is identified. (See page 126 - ECG 12-Lead) for STEMI Receiving Center information • SMR for trauma or suspicion of trauma (see page 139) • Contact the Base Physician if: ➔ the Blood Glucose reading is > 60 mg/dL but hypoglycemia is suspected Yes ALTERED LEVEL OF CONSCIOUSNESS 35 YES 50mg50mgup to 1 §DIPHENHYDRAMINE (Hives/Itching) Urticaria for Consider obstruction) airway or anaphylaxis signs of withoutsymptoms only (Skin or mucous membrane REACTION *ALLERGIC minutesrepeat q 10 May mg 0.1 dose single Max slowly***IV/IO (0.1mg) 1mL 0.1mg/mLEPINEPHRINE bolus: If VS not improved with epi. IM 10-5 Reassess min. 50May Repeat x 1 in 1 IM - Providers: ALS x1 in 10 minMay repeat IM Providers: BLS 1mg/mlEPINEPHRINE required as BVM ventilations Assist NS liters 2-1 BOLUS FLUID NS IV/IO consult Physician If no response 2 hrs.-in the past 1 diphenhydramine has patient if Consider reduced dosage .phylaxis-not an essential treatment of ana is discomfort from rash/itching but Diphenhydramine may lessen§ signs of profound shock to IM epinephrine and patient has used if symptoms are unresponsive be only should epinephrine *** IM). (0.3mg dose consider CAD, with mild symptoms or history of In elderly, small, or in patients ** 150mg §DIPHENHYDRAMINE (Hives/Itching) Urticaria for Consider BVMor nebulizer, held-hand 5 mg in 6 mL NS via ALBUTEROL distress respiratory or wheezing persistent For algorithm this of arm to go anaphylaxis, If patient develops signs of* NOTES NO SHOCK? OF SIGNS Patient Care Policy (Adult) Modified On: May 10, 2019 ANAPHYLAXIS / ALLERGIC REACTION • Epinephrine IM is the cornerstone of treatment of anaphylaxis and should be given as early as possible. It is best absorbed from an injection in the lateral thigh • If the patient is in severe distress, administer Epinephrine IM and consider immediate transport • SIGNS OF ANAPHYLAXIS (Systemic Reaction) – wheezing, repetitive cough, tightness in chest, stridor, difficulty swallowing or tightness in throat, change in voice, dizziness or feeling faint, abdominal complaints (pain, repeated vomiting, diarrhea or incontinence), anxiety, lethargy • SIGNS OF ANAPHYLACTIC SHOCK – pallor, hypotension, cool, clammy mottled skin, altered sensorium • Facial/oral swelling (Angioedema) can accompany anaphylaxis, but is not always present ANAPHYLAXIS OXYGEN (Systemic Reaction) If Any Distress ANAPHYLAXIS / ALLERGIC REACTION 36 Routine HyperkalemiaConsider transport rapid consider not pacing and symptomatic patient If )136 page (see patient hypotensive the in caution with sedation Use )142 page (see tolerance patient and capture mechanical verify (TCP), Pacing Transcutaneous utilizing If Note:• symptoms: signs Serious block degree 3rd block, degree 2nd beats/minute, 50 < Bradycardia: Care Medical Patient Care Policy (Adult) Modified On: May 27, 2021 BRADYCARDIA ➔ Acute altered mental status ➔ Hypotension ➔ On-going chest pain ➔ Other signs of shock **if patient is symptomatic, do not delay pacing to start an IV or wait for Atropine to take effect Push Dose Epinephrine mixing instructions: ›› Take Epinephrine 1 mg of 0.1 mg/ml preparation (Cardiac Epinephrine) and waste 9 ml of Epinephrine ›› In that syringe, draw 9 ml of normal saline from the patient’s IV bag and shake well ›› Mixture now provides 10 ml of Epinephrine at a 0.01 mg/ ml (10 mcg/ml) concentration BRADYCARDIA 37 Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - GENERAL GUIDELINES Medical Trauma Formatted: Character scale: 100% CARDIAC ARREST - GENERAL GUIDELINES 38 Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA • Routine Medical Care • Consider and treat other possible causes – See CPR page 12 • If patient presents with signs of obvious death or a valid DNR is presented - See Determination of Death in the Field Procedure Proceed to Cardiac 2 minutes or Arrest – Medical – VF/ Shockable 5 cycles of CPR Yes pVT protocol rhythm? Check rhythm No Proceed to: Consider: Return of Spontaneous Determination of Death Criteria – Circulation protocol Medical Arrest Resuscitation or Organized rhythm Yes No or Bradycardia protocol and pulse present? Continue CPR or Transport Tachycardia protocol Important Considerations: ■ Do not interrupt CPR to administer medications or perform airway management ■ Use of a mechanical CPR device is required whenever it is available and appropriate ■ Once mCPR device is in place check for proper placement during rhythm check and adjust accordingly ■ Consider and treat reversible causes as appropriate: • Hypovolemia • Hypoxia • Hydrogen ion (acidosis) • Hypo-/hyperkalemia • Hypothermia • Tension pneumothorax • Tamponade, cardiac • Toxins • Thrombosis, pulmonary / coronary ■ If renal failure or hyperkalemia suspected, you may consider administering the following: Calcium Chloride 1 gm slow IVP (over 2 min.) Note: flush IV tubing after administering CaCl to avoid precipitation Sodium Bicarbonate 1 mEq/kg IVP Note: make sure to have a second IV line as other medications may not be compatible CARDIAC ARREST - MEDICAL - ASYSTOLE / PEA 39 Formatted: Font: Arial, 5.5 pt, Character scale: 100%, Not Expanded by / Condensed by Formatted: Font: 5.5 pt, Font color: Custom Color(RGB(35,31,32)) Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - VF/PVT • Routine Medical Care • Note: Use of a mechanical CPR device is required whenever available and appropriate. Check proper placement with every rhythm check *Manual chest compressions Place defibrillator pads in the anterior / posterior configuration Anterior/Posterior pad Apply mechanical CPR (mCPR) device if available placement illustration: Shockable No rhythm? Yes **Defibrillate (see note)  Resume CPR immediately  BLS Airway (OPA) with BVM (30:2 with BLS airway)  BVM Vventilation at rate of 10-12 with 10-15 lpm O2 with Advanced Airway during continuous chest compressions  ETCO2 Monitoring  IV/IO NS  2 minutes or 5 cycles of CPR VF/Pulseless VT notes: Proceed to Cardiac  Check Rhythm Arrest – Medical – *Chest compressions: Asystole/PEA protocol No Shockable or Return of CPR/mCPR must be minimally Spontaneous Circulation Rhythm? interrupted (<10 secs) and should protocol not be paused for airway placement. mCPR does not need to be paused for defibrillation(s). Manual chest compressors must  CPR while defibrillator charging be rotated at every rhythm check.  **Defibrillate (see note)  Resume CPR **Defibrillation:  ***Epinephrine 0.1mg/mL 1 mg IV/IO Refer to manufacturer’s  2 minutes or 5 cycles of CPR documentation for energy dose recommendations  Check Rhythm ***Epinephrine May be repeated q 5mins to a max of 3 doses Shockable No Rhythm? Yes Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - VF/PV 40 Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT • Routine Medical Care • Note: Use of a mechanical CPR device is required whenever available and appropriate. Check for proper placement with every rhythm check. • Indications: VF/Pulseless VT is considered refractory if 3 defibrillations have been delivered and additional defibrillation(s) are required at any point in a resuscitation. If patient meets the above indications, prepare a second defibrillator and place the second defibrillator’s pads in the anterior/lateral position as pictured Shockable No rhythm? Double-sequential defibrillation steps: Yes 1. Charge both defibrillators to ✓ CPR while defibrillators are charging recommended energy level ✓ Double-sequential Defibrillation (see note) ✓ Resume CPR 2. Deliver shock using ✓ Prepare for patient transport to STEMI defibrillator placed in A/P Center position first ✓ Notify receiving STEMI center of pt inbound with refractory VF/VT as early as possible 3. Deliver shock with A/L ✓ ***Epinephrine 0.1mg/mL 1mg IV/IO placed defibrillator 1 second ✓ 2 minutes or 5 cycles of CPR after the first defibrillation ✓ Check Rhythm DO NOT DELIVER SHOCKS Go to Policy: SIMULTANEOUSLY ✓ Asystole/PEA page 39 Shockable ✓ Return of No Spontaneous rhythm? Circulation page 52 VF/Pulseless VT notes: Yes *Chest compressions: CPR/mCPR must be minimally ✓ CPR while defibrillators are charging interrupted (<10 secs) and should ✓ Double-sequential Defibrillation (see note) not be paused for airway ✓ Resume CPR placement. mCPR does not need to be paused for defibrillation(s). ✓ Amiodarone 150mg IV/IO st Manual chest compressors must 3-5 minutes after 1 dose be rotated at every rhythm check. ✓ 2 minutes or 5 cycles of CPR ✓ Check Rhythm **Defibrillation: Refer to manufacturer’s documentation for energy dose Shockable recommendations No rhythm? ***Epinephrine May be repeated q 5mins to a Yes max of 3 doses CARDIAC ARREST - MEDICAL - REFRACTORY VF/PVT 41 Do 8. Trauma is not a contraindication for the use of mechanical CPR device as longa s it does not delay transport suspected head or spinal injury outwithSubmersion or Mechanical Asphyxiation (drowning, hanging, strangulation) - :closest hospitalPatient to suspected head or spinal injury with(drowning, hanging, strangulation) Asphyxiation Submersion or Mechanical- Penetrating or Blunt trauma with significant hypovolemia from exsanguination- :Trauma CenterPatient to Destination choice: minimal signs of external chest trauma but VP/VT rhythm)likely –cordis Do administer for arrests caused by hanging, strangulation, submersion/drowning, or blunt cardiac trauma (commotio- administer if arrest was caused by hypovolemia from exsanguination not Do- incidents, or if staging, extrication (without resuscitation) and/or transport exceeds 20 minutes.protocol, mass casualty in the Field Determination of Deathsuscitate in the setting of obvious death as outlined in re not Patient Care Policy (Adult) Modified On: January 1, 2025 CARDIAC ARREST - TRAUMATIC CARDIAC ARREST - TRAUMATIC 42 IV NSairway Maintain 2 SpO 99%-94 to titrate – 2 O signs/symptoms.continuing for minutes 15 May repeat dose inIV/IO: given dose initial If needed asReassess up to 50 mgIM or IO IV, mg/kg 1Diphenhydramine No present?symptoms and/or Signs Yes Patient Care Policy (Adult) Modified On: December 1, 2011 DYSTONIC REACTION • Routine Medical Care • History includes ingestion of phenothiazines: ➔ Levomepromazine (Nozinan) ➔ Chlorpromazine (Thorazine, Largactil) ➔ Piperidines (Haloperidol, Risperidone) ➔ Promazine (Compazine) ➔ Promethazine (Phenergan) ➔ Triflupromazine (Vesprin) • Signs and Symptoms (often mistaken for a seizure disorder or tetany): ➔ Agitated/frightened appearance ➔ Jaw muscle spasm ➔ Small pupils ➔ Oculogyric crisis (circular movement of the eyeballs) ➔ Hypotension ➔ Torticollis (twisting of the neck) ➔ Facial grimaces ➔ Spasms of the back muscles, causing the head and legs to bend backward and the trunk to arch up ➔ Protruding tongue DYSTONIC REACTION 43 Operations Modified On: January 5, 2026 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE Acetaminophen 1000 mg IV infused over 10 min Adenosine 1st dose: 6 mg; 2nd dose: 12 mg (rapid IV/IO push) Albuterol 5 mg in 6 ml normal saline Amiodarone Wide complex Tachycardia: 150 mg IV/IO over 10 mins VF/VT: 1st dose: 300 mg IV/IO; 2nd dose: 150 mg IV/IO Follow each dose with 20mL NS flush. (two doses only) Aspirin 162 mg chewable or 324 mg (5gr.) tablet – not enteric coated) Atropine Sulfate Bradycardia: 1 mg IV/IO - (max total 3 mg) Buprenophrine 16mg Sublingual (SL) Calcium Chloride 10% 1 gm over 2 minutes IV/IO Charcoal 1 gm/kg (Max 50 gms) PO Dextrose 10% 10 gms IV/IO Diphenhydramine Allergic Reaction: 1 mg/kg IV/IO/IM up to 50 mg (Benadryl) Epinephrine 1mg/mL Anaphylaxis: 0.3 mg-0.5 mg IM Bronchospasm: 0.01 mg/kg IM (max dose 0.5mg) Commented \[ZK4\]: Match policy with set dose Epinephrine 0.1mg/mL Anaphylactic shock: 1mL (0.1mg) IV/IO slowly Cardiac arrest: 10mL (1 mg) IV/IO Cardiogenic/Distributive Shock: Diluted to 0.01mg/ml (10mcg/ml), 0.5ml (5mcg) slow IV/IO Fentanyl Pain Management: 5025-100 mcg IV/IO/IM/IN (max single dose 100 mcg) Glucagon 1 mg IM Oral Glucose 30 gms PO Ipratropium (Atrovent) 500 mcg (2.5 ml unit dose) Via nebulizer/CPAP/BVM Lidocaine 2% 40 mg IO (2 mL) slowly (1 ml over 30 seconds) Ketamine (Ketalar) 0.3 mg/kg IV/IO/IM/IN - IV/IO dose to be mixed in 100ml NS/D5W and infused over 10 min (max single dose 30mg) Ketorolac (Toradol) 15 mg IM/IV/IO Sedation: IV/IO (slowly) 1-2 mg, IM/IN: 2-5 mg Midazolam (Versed) Seizure: IM/IN: 10 mg, IV/IO: 5 mg Initial dose: Titrated up to 2 mg IV/IM/IN BLS Providers may only use IN Naloxone (Narcan) Route. Max. initial dose is 2mg. MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE 44 Operations Modified On: January 5, 2026 MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE Nitroglycerin Spray 0.4 mg metered spray or tablet Normal Saline 250 - 500 ml IV/IO fluid bolus Olanzapine (Zyprexa) 10 mg PO orally dissolving tablet 4 mg IV †Slowly over 30 seconds or 4 mg IM/PO (oral dissolving Ondansetron (Zofran) tablets) (†rapid IV administration <30 seconds can cause syncope) Oxygen 2 - 6 L/nasal cannula | 15 L/non-rebreather mask (titrate to 94%-99% SpO2) Sodium Bicarbonate 1 mEq/kg IV/IO Sodium Thiosulfate 12.5 grams IV/IO over 10 minutes Tranexamic Acid- TXA 21 gram in 100ml NS or D5W IV/IO over 10 minutes, or 2gram slow IVP Hydroxocobalamin Smoke Inhalation/Cyanide Poisoning: 5g IV/IO over 15 minutes Atropine Sulfate Nerve agent exposure: ➔ Patient: 2 mg IV/IM (for use only by Paramedics or specially-trained EMTs) ➔ Autoinjector antidote kit: 2 mg in 0.7mL 1 - 3 kits depending on exposure (given with Pralidoxime chloride) ► Additional atropine may be needed until a positive response is achieved Pralidoxime Chloride Nerve agent exposure: (2-PAM) ➔ Patient: 1 - 2 grams IV/IM (for use only by Paramedics or specially-trained EMTs) ➔ Autoinjector antidote kit: 600 mg in 2 ml’s 1 - 3 kits depending on exposure (given with atropine) MEDICATIONS - AUTHORIZED | STANDARD INITIAL DOSE 45 Routine Disorder Use Opioid treating for (www.cabridge.org) Program Bridge CA a into entry Patient and; suffering patient Reduce Goals: (COWS) Scale Withdrawal Opiate Clinical the on score positive any with consistent signs/symptoms with presenting Patient (OUD) Disorder Use Opioid for assistance seeking or withdrawals opioid of complaint stated Patient withdrawals opiate of signs/symptoms with Administration Post Indications: Care Medical Patient Care Policy (Adult) Modified On: January 1, 2026 OPIOID WITHDRAWAL Signs/Symptoms of Opioid Withdrawals:  Tachycardia  Sweating/diaphoresis  Restlessness and/or agitation  Dilated pupils  Chills/body or joint aches  Rhinorrhea/lacrimation  Yawning  Tremors  Nausea/Vomiting/Diarrhea/ABD pain  Piloerection Alameda County - CA Bridge Facilities:  Alta Bates  Summit  Highland  St. Rose  Kaiser Fremont  Kaiser Oakland  Kaiser San Leandro  San Leandro Hospital  Eden Medical Center  Washington Hospital *Precipitated Withdrawal: Withdrawal symptoms that start after Naloxone administration after opioid overdose. 46 Patient Care Policy (Adult) Modified On: February 3, 2026 PAIN MANAGEMENT  Routine Medical Care  Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures  Document the level of pain prior to and after any interventions BLS Interventions: Positioning, Cold Pack(s), Splinting, and/or Coaching Minor-Moderate Pain: Ketorolac - 15 mg IM/IV/IO x 1 - (No repeat dose) and/or Acetaminophen – 1gm IV slowly over 10 min – (No repeat dose) Ketorolac is the preferred first-line medication for minor-moderate pain and for patients with suspected kidney stones or chronic pain conditions. Moderate-Severe Pain: Fentanyl IV/IO: 1 mcg/kg (50-100 mcg) Slow push. Repeat q 5min PRN to a max. cumulative dosage of 200 mcg IM/IN: 1 mcg/kg (50-100 mcg) Repeat q 10min PRN to a max. cumulative dosage of 200 mcg Base contact required if contraindications are present or >200 mcg is needed OR Ketamine IV/IO: 0.3 mg/kg in 100ml of NS/D5W Slow IV Infusion over 10 minutes. (max. dose is 30 mg, no repeat) IM/IN 0.3 mg/kg (max. dose is 30 mg, no repeat) Ketorolac Considerations:  Contraindications:  Patients who meet Trauma Criteria, NSAID Allergy (e.g. Ibuprofen, Naproxen, Aspirin), Pregnancy, History of: GI Bleed, Ulcers, Renal disease, or Current anticoagulant use  Note:  Standard doses of Fentanyl OR Ketamine may be administered if Ketorolac is ineffective Acetaminophen Considerations: Contraindications: Allergy to Acetaminophen (Tylenol), ingested >4gms acetaminophen in past 24 hours Fentanyl & Ketamine Considerations:  DO NOT CO-ADMINISTER FENTANYL AND KETAMINE  Patient Monitoring  Continuous monitoring of the patient’s LOC and respiratory status via direct observation/ ETCO2/SpO2, etc is required.  Contraindications:  Decreased respiratory rate, Altered mental status/LOC, or Suspected Traumatic Brain Injury  Notes:  Consider lower doses of Fentanyl for older adults  Have Naloxone readily available when administering Fentanyl  Acetaminophen and/or Ketorolac may be used with either Fentanyl or Ketamine for moderate-severe pain. Do not co- administer Fentanyl and Ketamine. PAIN MANAGEMENT 47 Patient Care Policy (Adult) Modified On: January 1, 2026 POISONING | INGESTION | OVERDOSE  Routine Medical Care  Protect Yourself - See “Hazardous Materials Incidents - EMS Response” page 155  Identify substance - Bring any containers, labels or a sample (if safe) into the hospital with the patient. Determine type, amount and time of the exposure.  For treatment options for specific exposures, contacting Poison Control (1-800-222-1222) in conjunction with consulting Base Physician for assistance with identification and management of unknown toxins/medications  Remove the patient from the hazardous environment (including removing pill bottles, pill packs, toxic substances) ➔ Remove contaminated clothing. Decontaminate to remove continued absorption, ingestion, inhalation or injection. See “Decontamination Incident” page 154. Brush off powders, wash off liquids with copious amounts water  Evaluate intention of ingestion, consider law enforcement, see “Psychiatric Evaluation - 5150 Transports” page 134 Monitor Assess ABC’s O2 – titrate to 94-99% Alert and ventilating Yes No adequately with a gag reflex? Assist respirations with bag-valve-mask If ingestion within one hour, of non-acid, non-caustic, non-petroleum substance consider: If narcotic/opioid overdose is suspected see Respiratory Depression or Apnea Charcoal 1g/kg PO, max dose of 50g (Suspected Narcotic OD) page 50 Patient must have a gag reflex and be able If altered mental status, check the blood to self-administer glucose level and treat per Altered Level Determine which of Consciousness protocol on page 35 ingestion is suspected Consider an advanced airway IV/IO Tricyclic Anti-Organophosphate Dystonic Calcium Channel Beta Blocker Ingestion Reaction OD depressant OD Blocker OD Involuntary muscle Salivation, Hypotension SBP Wide QRS > Hypotension SBP contractions, lacrimation, < 90 mmHg: 0.10 seconds, < 90 mmHg: urination, diarrhea, abnormal postures hypotension SBP gastric upset, or twisting < 90 mmHg Administer IV fluids Zofran 4mg movements emesis, and/or unresponsive to see Shock page 58 IV/IM/PO prior to secondary to miosis: fluids, and/or Glucagon. May suspected ingestion seizures: Calcium Chloride 1g repeat x1 q of phenothiazine Atropine 2mg IV/IO, IV/IO over 2 minutes, 15minutes medications: repeat every 5 Sodium max dose of 1g minutes until Bicarbonate Contraindications: Glucagon 1mg IM, Diphenhydramine asymptomatic 1mEq/kg IV/IO over Digoxin repeat x1 if 50mg IV/IM 60 seconds hypotension persists Consider Nerve Zofran 4mg IV/IM/PO Agent Autoinjector prior to Glucagon. May If symptoms persist Administration see repeat x1 q 15minutes administer a single page 160 dose of 50 mEq IV/IO Glucagon 1mg IM, may repeat x1 POISONING | INGESTION | OVERDOSE 48 Patient Care Policy (Adult) Modified On: May 27, 2021 PULMONARY EDEMA / CHF • Routine Medical Care • Consider ASA, 162 – 324 mg po, for acute coronary syndrome patients • Perform 12-Lead ECG, and transport to a STEMI Receiving Center if STEMI is identified. (See page 126 - ECG 12-Lead) for STEMI Receiving Center information • Rapid transport if on scene stabilization is unlikely O – titrate to 94-99% SpO 22 *Note #1: Commented \[ZK5\]: Trying to minimize base calls: IV NS remove, make contraindication if bp<90 Consult the base physician if the B/P drops below 90/ systolic at any point, before continuing NTG, or for any questions regarding dosage *B/P > 90 No Yes systolic? Go to: Cardiogenic Shock Commented \[ZK6\]: Consider x3 max dose page 58 ^ Note #2: ✓ Repeat vital signs between doses. Commented \[ZK7\]: Remove 0.8mg dose of nitro. Hold nitro if bp<90 ✓ Only increase NTG dose to 0.8 mg while the B/P is > 150/systolic. ✓ If B/P drops below 150/systolic resume 0.4 mg dose. PULMONARY EDEMA / CHF 49 Patient Care Policy (Adult) Modified On: May 10, 2019 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) • Routine Medical Care • Naloxone can cause acute withdrawal symptoms (agitation, vomiting, etc.) in patients who are chronic utilizers of Narcotics Consider administration of Buprenoprhine and move to Opioid Withdrawal protocol. • Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%) • Older patients are at higher risk for cardiovascular complications • Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management Commented \[ZK8\]: Should we put COWS eval in the flowchart? Yes Patient Care Policy (Adult) Modified On: May 10, 2019 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) 50 Routine for severe distress needed as Intubate anxiety patient reduce exertion, physical Limit Care Medical Patient Care Policy (Adult) Modified On: May 27, 2021 RESPIRATORY DISTRESS-Bronchospasm ➔ Asthma ➔ Anaphylaxis (see page xxx) ➔ COPD ➔ Bronchospasm ➔ Pulmonary edema (see page 49) Formatted: Font color: Auto, Not Expanded by / Condensed by NOTE: For patients with COPD, oxygen supplementation should be given to achieve an oxygen saturation of 88%-92%. Higher oxygen saturations in COPD patients have been shown to be harmful. RESPIRATORY DISTRESS 51 rate by 10 bpm, to a maximum of 100 bpm the increasing consider symptomatic remains patient but maintained capture If 10% by level output the increase obtained then• capture until mA 10 of increments in increase mA; 0 bpm, 80 at Begin ):142 page( Pacing Note: Transcutaneous• Hospitalappropriate, transport pediatric patients to Children's If• patients) trauma critical (except Center STEMI to time any at ROSC with patients Transport• rhythm arrest of reoccurrence for Monitor• Care Medical Routine• Patient Care Policy (Adult) Modified On: May 27, 2021 RETURN OF SPONTANEOUS CIRCULATION - ROSC ✓ Monitor and support ABCs ✓ Confirm Palpable pulse and auscultated BP ✓ Monitor EtCO2 (maintain 35-40 mmHg with PPV) ✓ O2 titrate to 94-99% ✓ Perform 12-LEAD ✓ Check blood glucose B/P < 90 systolic B/P ≥ 90 systolic Pulse Pulse Monitor < 60 BPM ≥ 60 BPM Atropine 1 mg IV/IO Repeat q 5 min as needed Max. dose is 3 mg Transcutaneous Pacing if indicated (see note above) Push Dose Epinephrine Mixing Instructions: → Take Epinephrine 1 mg of 0.1 mg/ml preparation B/P < 90 Systolic (Cardiac Epinephrine) and waste 9ml of Epinephrine and HR ≤ 60 bpm? → In that syringe, draw 9 ml of normal saline from the No Yes patient’s IV bag and shake well → Mixture now provides 10 ml of Epinephrine at a 0.01 mg/ml (10 mcg/ml) concentration Consider: Go to appropriate arm Epinephrine of this algorithm 0.5ml (5 mcg) SIVP every 3 minutes, titrate to a SBP of ≥ 90 RETURN OF SPONTANEOUS CIRCULATION - ROSC 52 Patient Care Policy (Adult) Modified On: June 10, 2013 ROUTINE MEDICAL CARE - ADULT 1. DEFINITIONS: Commented \[ZK9\]: Do we need this whole policy? Baseline vital signs: SAMPLE History: ➔ Pulse rate S = Signs & symptoms ➔ Blood pressure A = Allergies ➔ Respiratory rate M = Medications ➔ Pulse Oximetry P = Pertinent past history ➔ Consider temperature L = Last oral intake E = Events leading to the injury/illness Adapted from Emergency Care and Transportation of the Sick and Injured, 8th Edition 2. SCENE SIZE-UP: ➔ Substance isolation ➔ Scene safety ➔ Determine mechanism of injury | nature of illness ➔ Determine number of patients ➔ Request additional assistance 3. INITIAL ASSESSMENT: ➔ Form general impression of the patient ➔ Assess mental status ➔ Assess the airway ➔ Assess breathing ➔ Assess circulation ➔ Identify priority patients 4. TRAUMA PATIENTS: Focused History and Physical Exam - Reconsider mechanism of injury Significant Mechanism of Injury: No Significant Mechanism of Injury: ➔ Rapid trauma assessment ➔ Focused assessment based on chief complaint ➔ Baseline vital ➔ Baseline vital signs ➔ SAMPLE History ➔ SAMPLE History ➔ Transport ➔ Transport ➔ Detailed physical exam ➔ Detailed physical exam 5. MEDICAL PATIENTS - Focused History and Physical Exam - Evaluate responsiveness Responsive: Unresponsive: ➔ History of illness ➔ Rapid medical assessment ➔ SAMPLE history ➔ Baseline vital signs ➔ Focused physical exam based on ➔ SAMPLE history ➔ Chief complaint ➔ Re-evaluate transport decision ➔ Baseline vital signs ➔ Detailed physical exam ➔ Re-evaluate transport decision ➔ Detailed physical exam 6. ONGOING ASSESSMENT ➔ Repeat initial vital signs ➔ Reassess vital signs ➔ Repeat focused assessment ➔ Reassess interventions ROUTINE MEDICAL CARE - ADULT 53 Patient Care Policy (Adult) Modified On: May 10, 2019 ROUTINE MEDICAL CARE - ADULT 7. TREAT AS APPROPRIATE, WITHIN SCOPE OF PRACTICE (See specific treatment protocols) 7.1 Airway: ► Open airway – suction, as needed ► Head tilt / Chin lift or jaw thrust without head extension if C-spine injury suspected ► Oropharyngeal | Nasopharyngeal airway 7.2 Breathing: 7.2.1 Oxygen Administration: ► Administer O 2 – titrate to 94-99% SpO 2 appropriate to patient condition ► If there is a history of COPD, observe for respiratory depression and support respirations as needed. Do not withhold oxygen from a patient in distress because of a history of COPD ► The patient presents with signs and symptoms of pulmonary edema or severe respiratory distress, O 2 should be initiated at 15L/minute by non-rebreather mask 7.2.2 Assist ventilation. 7.2.3 CPAP (see page 124) 7.2.4 ETI or SGA (see Advanced Airway Management see page 118) 7.3 Circulation: ► Initiate CPR, as needed. (see page 12) 7.4 Fluid Administration: ► Start an intravenous/intraosseous line as needed ► When IV access is needed, most of the time a saline lock is sufficient. Consider an IV line with Normal Saline when the patient may need to receive volume or when frequent IV meds are being given (e.g. - cardiac arrest) ► When starting an IV/IO/saline lock, use chlorhexidine as a skin prep. Label insertion site with “PREHOSPITAL IV – DATE AND TIME" 8. PATIENT POSITION 8.1 Conscious, no trauma, good gag reflex: Position of comfort 8.2 Depressed Level of Consciousness, no trauma, decreased gag reflex: Left lateral position 8.3 Trauma: Spinal Motion Restriction (SMR), as needed. (see Spinal Motion Restriction (SMR) Procedure page 139). Make sure the patient can be rolled to the side in the event of vomiting 8.4 Pregnancy: Do not lay the patient flat if more than 20 weeks pregnant. Transport either in semi-fowlers position or left lateral decubitus position. If patient requires SMR, secure to a backboard first then tilt the board 20 – 30 degrees to the left 8.5 Respiratory distress: Fowler’s position or position of comfort 9. PATIENT MEDICATIONS 9.1 Field personnel must either bring all medication bottles with the patient to the hospital (preferred), or make a list of the medications, including the drug name, dose and frequency. 9.2 Field personnel may assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices ROUTINE MEDICAL CARE - ADULT 54 Patient Care Policy (Adult) Modified On: June 21, 2023 SEIZURE Commented \[ZK10\]: Consider checking BGL after • Routine Medical Care seizure stopped • Midazolam should not be given unless the patient is actively seizing - 3 or more seizures in ≤ 5 minutes or any seizure lasting > 5 minutes. • Protect the patient from further injury by padding or moving objects as necessary; do not forcibly restrain the patient Maintain airway and adequate respirations Oxygen Midazolam: IM: 10 mg (preferred route) OR Actively IN: 10 mg (5 mg in each nare) Reassess as No Yes seizing? OR needed IV/IO 5 mg, may repeat x 1 in 10 minutes Maximum dosage of 10 mg per patient regardless of route If ALOC considered, Go to page 35 Check Blood Glucose Result Yes No ≤ 60 mg/ dL? I If patient continues Go to ALOC to seize consider: page 35 - Additional Midazolam SEIZURE 55 Patient Care Policy (Adult) Modified On: August 18, 2017 SEPSIS Sepsis is the body's overwhelming and life-threatening response to infection. In Sepsis, when an infection occurs at any potential site in the body, the immune system's inflammatory response can be overwhelmed leading to SIRS (Systemic Inflammatory Re- sponse Syndrome) which causes tissue damage that can lead to organ dysfunction, failure and death. The symptoms of SIRS can include fever, tachypnea, tachycardia or hypotension. 1. Risk Factors ► Age (Elderly, Newborn) ► Diabetes ► Compromised immune system including: • Cancer • Renal Disease • Alcoholism / IV Drug Abuse • Malnutrition • Hypothermia • Recent surgery or invasive procedure • Patients on immunosuppressant therapies which can include those with autoimmune disease, transplants, etc. 2. Although sepsis patients can be any age, the Prehospital Sepsis Screening Tool triages for sepsis patients aged 15 years and older. For these patients, notify the receiving hospital of a SEPSIS ALERT as early as possible via radio or phone. Does patient have suspected or NO documented infection? *Consider: Sepsis Alert patients present with various signs and symptoms. Additionally, patients with ≥ 2 SIRS criteria, an EtCO 2 of ≤ 25 YES mmHg are strongly correlated with lactate levels > 4 mM/L and increased mortality Does patient meet TWO or more of the following SIRS Observe and NO criteria? YES monitor -Temp > 100.4 or < 96 Formatted: Font color: Auto, Not Expanded by / -HR > 90 Push Dose Epinephrine mixing instructions: EtCO 2 * Call a SEPSIS ALERT to »Take Epinephrine 1 mg of 0.1 mg/ml preparation Condensed by the receiving hospital (Cardiac Epinephrine) and waste 9 ml of Epinephrine »In that syringe, draw 9 ml of normal saline from the patient's IV bag and shake well Initiate Fluids IV/IO »Mixture now provides 10 ml of Epinephrine at a 0.01mg/ml (10 mcg/ml) concentration SEPSIS 56 If patient continues to have signs If patient also has signs and and symptoms of shock after symptoms of shock, administer IV/IO 30ml/kg total fluid dose, consider NS in 500-1000ml boluses. Reassess. Epinephrine diluted to 0.01mg/ml Titrate fluid boluses to SBP > 90 or (10mcg/ml), 0.5ml (5mcg) slow IV/IO, to 30 ml/kg total fluid dose titrate to SBP > 90 IV NSairway Maintain minutes15x1repeat May symptomsIf no improvement of neededasReassess IV given if )sec30 (over Slowly POIM/IV/mg (ondansetron) ZofranNoand/ or vomiting?severely nauseated Is the patient Yes Patient Care Policy (Adult) Modified On: May 13, 2015 SEVERE NAUSEA • Routine Medical Care • Indications: Intractable vomiting or severe nausea • Contraindications: Hypersensitivity to 5-HT3 receptor antagonists (i.e. – dolasetron (Anzemet), granisetron (Kytril) • Relative Contraindications: Zofran administration during first trimester of pregnancy is not recommended • Note #1: Consider other treatable causes • Note #2: Administering Zofran rapidly can cause syncope • Note #3: If patient has s/s of anaphylaxis/allergic reaction, follow Anaphylaxis/Allergic Reaction policy (Anaphylaxis policy 35) Formatted: Font: Not Bold SEVERE NAUSEA 57 0.01mg/ml (10 mcg/ml) concentrationatEpinephrineofml10providesnowMixture» patient's IV bag and shake wellIn that syringe, draw 9 ml of normal saline from the» Epinephrine of ml waste and Epinephrine) (Cardiacpreparationmg/ml 0.1ofmgEpinephrineTake» instructions:mixingEpinephrineDosePush 56page see suspected sepsis If• 28page see ,suspectedtrauma If• 36page see ,suspectedanaphylaxis If•sounds. lung clear with shock cardiogenic in patient adult an to given be may Saline Normal ml 500 to up of bolus fluid NOTE:•appropriate. if route, en treat and transport early Initiate•following: the of more or - Shock CareMedicalRoutine Patient Care Policy (Adult) Modified On: August 18, 2017 SHOCK: HYPOVOLEMIC/CARDIOGENIC-OVERHAUL Commented \[ZK11\]: Should we separate out cardiogenic and hypovolemic policies? Blood admin will be available for trauma/medical bleeding causes. ➔ Pulse > 120/minute ➔ Altered Mental Status ➔ BP < 90/systolic ➔ Pale, cool and/or diaphoretic skin signs SHOCK: HYPOVOLEMIC/CARDIOGENIC 58 sleep of stress/lack dehydration, changes, temperature infection, be emergencies cell sickle Triggers Patient Care Policy (Adult) Modified On: January 1, 2025 SICKLE CELL PAIN EMERGENCY • Early and aggressive pain management is key to stopping the progression of ischemic processes associated with Sickle Cell emergencies. • Patients with Sickle Cell Disease (SCD) are at higher risk for other serious conditions including ACS, CVA, pulmonary embolism, and sepsis. A high index of suspicion should be maintained for other serious etiologies to symptoms especially in the setting of patient reporting abnormal pain or S/S patterns. Assess for other serious conditions such as ACS, CVA, pulmonary embolus and No utilize appropriate protocol(s) for patient presentation Yes Pain Management BLS Interventions (Do not delay ALS interventions while waiting for BLS interventions to improve patient pain) → Heat packs/blankets/warming measures → Distraction (Screen/phone use) ALS Interventions Fentanyl IV: 1 mcg/kg (50-100 mcg) Slow push. Repeat q 5min PRN to a max. cumulative dosage of 200 mcg IM/IN: 1 mcg/kg (50-100 mcg) Repeat q 10min PRN to a max. cumulative dosage of 200 mcg OR Ketamine IV: 0.3 mg/kg in 100ml of NS/D5W Slow IV Infusion over 10 minutes. (max. dose is 30 mg, no repeat) IM/IN 0.3 mg/kg (max. dose is 30 mg, no repeat) Additional Interventions/Adjuncts PRN: → IV fluids only if hypovolemic/dehydrated → Oxygen if SpO2 is ≤ 95% → Ondansetron PRN for N/V → Diphenhydramine for allergic reaction S/S → Consider Ketorolac if the above interventions are contraindicated, declined, or ineffective (see pain management protocol) Transport per Transport Guidelines Protocol SICKLE CELL PAIN EMERGENCY 59 Patient Care Policy (Adult) Modified On: January 1, 2025 STROKE / CVA • Routine Medical Care • Rapidly identify signs of a stroke using the Cincinnati Prehospital Stroke Scale (CPSS) and Posterior Stroke Scale (PSS) • For detailed information on obtaining a CPSS / PSS - See the Procedures Section - Stroke Assessment Scales • Last Known Well Time (LKWT) must be obtained from a reliable patient or bystander. See note • Limit on scene time to <15 minutes and initiate rapid transport for ‘Stroke Alerts’ to a designated Stroke Receiving Center Negative Patient Care Policy (Adult) Modified On: January 1, 2025 STROKE / CVA 60 Yes Keep warmclothing wet Remove ImmobilizationSpinal Consider: 2 SpO 99%-94 to titrate – 2 O note abovesee suspectedhypothermia If neededas Reassess page 28Care PatientTrauma Go to No Trauma?Critical Suspect Yes protocolarrest cardiacappropriate Go to No breathing?-nonPulseless Patient Care Policy (Adult) Modified On: December 1, 2011 SUBMERSION • Routine Medical Care • Consider spinal precautions prior to extrication if possibility of neck trauma • Rapid extrication from water • If hypothermia suspected and the patient is in Ventricular Fibrillation, rapid transport to the closest receiving hospital is essential for rewarming. Patients who are hypothermic rarely respond to treatment. (see Hypothermia page 19) • Consider CPAP - see CPAP procedure (page 124) for indications SUBMERSION 61 page See Sedation patient. hypotensive the in caution use however, possible, whenever patient awake the in sedation Precardioversion• beats/min 150 < heart for needed seldom is cardioversion Immediate• RhythmSinus to rhythm converts if • Cardioversion:Synchronized • Shock Chest Symptoms: Signs Serious• Care Medical Routine• No Yes Patient Care Policy (Adult) Modified On: June 10, 2013 TACHYCARDIA ➔ Acute MI ➔ BP < 90/systolic ➔ Shortness of Breath ➔ CHF ➔ Decreased LOC ➔ Pulmonary Congestion ✓ IV/ IO NS O– titrate to 94-99% SpO✓ Consider: precardioversion 2 2 sedation with Midazolam Monitor ✓ Consider Pain Management titrate to effect (see page 47) ✓ Immediate Synchronized Cardioversion **If patient is unstable, do not delay ** Is patient No 100 J, 200 J, 300 J, 360 J stable? cardioversion to start an IV monophasic energy dose (or clinically equivalent biphasic Yes energy dose ++) If any delay in synchronized cardioversion, and the patient is critical, go to defibrillation. IV/ IO NS 12-lead EKG or ++Both monphasic and rhythm strip biphasic waveforms Narrow Wide are acceptable QRS QRS > 0.12 sec Regular Regular Yes rhythm? rhythm? No Yes No If V-tach or uncertain: ✓ Vagal maneuver ✓ Monitor Base Amiodarone Drip: ✓ If no conversion: ✓If patient becomes Physician 150 mg in 100 ml ^Adenosine unstable go to consult D5W give over 10 appropriate arm of mins.(= 100 gtts/min this algorithm with10 gtts/ml tubing) Regular ^Adenosine dose: converts? ✓ 6 mg rapid IV If no response in 2 minutes: ✓ 12 mg rapid IV Monitor for recurrence. Look for and treat Treat with underlying cause ^Adenosine 62 TACHYCARDIA Patient Care Policy (Adult) Modified On: July 17, 2014 VENTRICULAR ASSIST DEVICES -VAD OVERVIEW: 1. The VAD assists the native ventricle pumping action and provides the cardiac output needed to survive. 2. These devices are either pulsatile or continuous flow (non-pulsatile/pulseless). They are further divided into: ➔ Left Ventricular Assist Devices (LVAD), The more common continuous flow pump located in the patient’s thorax attached to the patients’ left ventricle and aorta ➔ Right Ventricular Assist Devices (RVAD), ➔ Biventricular Assist Devices (BiVAD). ASSESSMENT: 3. Assess for presence of a DNR, POLST or Advance Directive. 4. First ASSESS THE PATIENT, not the device. ➔ The reason for the call may or may not be a problem with the VAD. VAD patients can and frequently do have other medical conditions. ➔ Patients with a continuous flow VAD may have no discernible pulse or blood pressure. ► Because there may be no palpable pulse, utilize other parameters for patient assessment (level of consciousness, skin signs, capillary refill, etc.) ► Pulse oximetry may be unreliable. ➔ Utilize the American Heart Association’s C-A-B recommendations, with one addition: ► C = Circulation / Connections and Function (device) ► A = Airway ► B = Breathing ➔ ETCO2 will read accurately and be useful in assessment. 5. Assess the device to see if it is working. ➔ Information regarding the type of device, the implantation hospital, and/or the VAD Coordinator contact telephone number may be available by a tag on the device, on the refrigerator, or on a medical alert bracelet. ➔ If a caregiver is present, utilize his/her knowledge. The patient and their caregiver are the experts on scene for all issues related to the VAD. Listen to their directions regarding VAD device management until you are able to contact the VAD Coordinator (24-hour VAD center contacts pg 64). ➔ The VAD Coordinator can help you decide the best course of action regarding assessment of the equipment. NOTE: Only the base hospital is legally allowed to give orders regarding patient care. ➔ If the patient has a continuous flow VAD (non-pulsatile / pulseless or artificial pulse (hearteMate 3)), auscultate the left upper quadrant of the patient’s abdomen for the “hum” of the VAD, which can help direct the appropriate actions. ► A pulsatile VAD will make an audible sound without auscultation. ► Pulsatile VADs are usually older devices which pump blood via pulsatile mechanism, generating a peripheral pulse. ➔ Determine if the device has power. ► If the device has power it does not necessarily mean that it is working, so the previous step is very important. ► If the device has power, you will see a green light on the HeartMate 2 and 3II, the most commonly implanted device ► On the HeartWare device, the display will clearly tell you the Liters per Minute (LPM) of blood flow. ➔ Check the VAD for secure connections and that the batteries are charged and functional. 6. Remain patient-centric. Check the VAD device as directed, but remain aware of how your patient is doing clinically. Deliver routine medical care as required. VENTRICULAR ASSIST DEVICES -VAD 63 Patient Care Policy (Adult) Modified On: May 10, 2019 VENTRICULAR ASSIST DEVICES -VAD ➔ If the pump is pumping then the problem is usually with the patient, not the device. ➔ Do ABCs in conjunction with your VAD assessment. TREATMENT/TRANSPORT: 7. If the patient's condition is related to their VAD, and it is safe and reasonable, it is preferred to transport the patient to their Bay Area VAD centers (Kaiser Santa Clara, Stanford, UCSF, and CPMC) unless the patient has any of the following conditions: 7.1 MINOR medical or trauma patients with adequate perfusion: Follow appropriate protocol and transport to ANY basic ED or hospital of record. 7.2 Suspected STROKE (STROKE ALERT) patient: Follow Acute Stroke policy and transport to closest Stroke Center. 7.3 Suspected STEMI (STEMI ALERT) patient: Follow CP Suspect Cardiac/STEMI policy and transport to closest STEMI Center. 7.4 Trauma patient (activation): Follow Trauma Care Policy and transport to closest Adult Trauma Center. 7.5 Cardiac Arrest or critical / unstable patients (poor perfusion): Follow Shock or appropriate resuscitation policy and transport to closest STEMI / Cardiac Arrest Center. 7.6 “Ring down” the receiving hospital early to help the facility prepare for this highly specialized patient. VAD CENTER 24-HOUR HOTLINE 650-723-6661 Stanford Hospital and Clinics (ask operator to page Lucille Packard Children’s Hospital at the VAD Coordinator- Stanford* pager code #12502) California Pacific Medical Center 415-600-1051 415-443-5823 UC San Francisco (pager number) Kaiser Santa Clara 408-851-3750 *Stanford Hospital and Clinics & Lucille Packard Children’s Hospital at Stanford share the same VAD Coordinators VENTRICULAR ASSIST DEVICES -VAD 64 Patient Care Policy (Pediatric) Modified On: January 1, 2026 PEDIATRIC POLICIES TOC PEDIATRIC POLICIES TOC .............................................................................................. 65 AIRWAY OBSTRUCTION ...................................................................................................... 66 ANAPHYLAXIS / ALLERGIC REACTION .......................................................................... 67 ALTERED LEVEL OF CONSCIOUSNESS .......................................................................... 68 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE ..................................................... 69 BRADYCARDIA ....................................................................................................................... 70 CARDIAC ARREST - GENERAL GUIDELINES................................................................. 71 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA .......................................................... 72 CARDIAC ARREST - MEDICAL - VF/PVT ........................................................................ 73 CARDIAC ARREST - TRAUMATIC ..................................................................................... 74 NEONATAL RESUSCITATION ............................................................................................. 75 PAIN MANAGEMENT ............................................................................................................ 76 POISONING | INGESTION | OVERDOSE ......................................................................... 78 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) .......... 79 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY ........................................ 80 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY .................................... 81 ROUTINE MEDICAL CARE - PEDIATRIC ......................................................................... 82 SEIZURE ................................................................................................................................. 83 SEVERE NAUSEA ................................................................................................................ 84 SHOCK AND HYPOTENSION .............................................................................................. 85 SICKLE CELL PAIN EMERGENCY ..................................................................................... 86 SUBMERSION ........................................................................................................................ 87 TACHYCARDIA ....................................................................................................................... 88 PEDIATRIC POLICIES TOC 65 Patient Care Policy (Pediatric) Modified On: May 10, 2019 AIRWAY OBSTRUCTION • Pediatric Routine Medical Care • If airway obstruction is caused by laryngeal trauma, see page 28 "Trauma Patient Care" • Do not use a tongue/jaw lift or perform blind finger sweep • s • Obstruction due to suspected epiglottitis: ➔ Do not attempt to visualize the throat or insert anything into the mouth ➔ Minimize outside stimulation. Keep the patient calm. Position of comfort. • Rapid Transport • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as Formatted: Font color: Auto, Not Expanded by / necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate. Condensed by *Severe signs No Yes of obstruction? ✓ If the patient is < 1 year old: Observe - Deliver 5 back blows followed by 5 chest thrusts. *Signs of severe obstruction ✓ If the patient is > 1 year old: ✓ Poor air exchange - Apply abdominal thrusts ✓ Increased breathing difficulty in rapid sequence. ✓ Silent cough - If ineffective, consider ✓ Cyanosis chest thrusts. ✓ Inability to speak or breathe ✓ Ask the patient “Are you choking”? If patient nods yes, act Formatted: Font color: Red AIRWAY OBSTRUCTION 66 Patient Care Policy (Pediatric) Modified On: June 29, 2023 ANAPHYLAXIS / ALLERGIC REACTION • Epinephrine IM is the cornerstone of treatment of anaphylaxis and should be given as early as possible. It is best absorbed from an injection in the lateral thigh • If the patient is in severe distress, administer Epinephrine IM and consider immediate transport • SIGNS OF ANAPHYLAXIS (Systemic Reaction) – wheezing, repetitive cough, tightness in chest, stridor, difficulty swallowing or tightness in throat, change in voice, dizziness or feeling faint, abdominal complaints (pain, repeated vomiting, diarrhea or incontinence), anxiety, lethargy • SIGNS OF ANAPHYLACTIC SHOCK – pallor, hypotension, cool, clammy mottled skin, altered sensorium • FACIAL/ORAL SWELLING (Angioedema) can accompany anaphylaxis, but is not always present • Use a length-based resuscitation tape (LBRT) to determine pediatric medication dosages and fluid bolus *ALLERGIC REACTION ANAPHYLAXIS OXYGEN (Skin or mucous membrane (Systemic Reaction) symptoms only without signs of If Any Distress anaphylaxis or airway obstruction) EPINEPHRINE 1mg/ml IM BLS Providers: 0.15mg IM Consider for Urticaria (Hives/ Itching) May repeat 0.15mg IM x 1 in 5 min § DIPHENHYDRAMINE ALS Providers: See LRBT for IM dose- may repeat LBRT dose x 1 in 5 min See LBRT for IV/IM/IO dose BLS Providers: 0.15mg IM Max. dose: 50mg YES ** SIGNS OF NOTES NO SHOCK? * If patient develops signs of IV/IO Access anaphylaxis, go to other arm of this FLUID BOLUS NS algorithm See LRBT for dose - may repeat x 1 **Shock in children may be subtle For persistent wheezing or Assist ventilations with BVM and hard to recognize. BP readings respiratory distress as required may be difficult to determine or ALBUTEROL inaccurate and may be a late sign 5 mg in 6 ml NS via hand- of shock. held nebulizer, mask, or Reassess 5-10 mins. after IM BVM Epi. If V/S not improved with ***IV/IO epinephrine should only be fluid bolus: Consider for Urticaria (Hives/ used if symptoms are unresponsive Itching) EPINEPHRINE 0.1mg/mL to IM epinephrine and patient has IV/IO slow push*** § DIPHENHYDRAMINE signs of profound shock See LBRT for IV/IO dose See LBRT for IV/IM/IO dose • Max single dose 0.1 mg § Diphenhydramine may lessen dis- Max. dose: 50mg • May repeat q 5 minutes comfort from rash/itching but is not an essential treatment of anaphy- laxis. Consider reduced dosage if If no response patient has taken diphenhydramine Base Physician consult in the past 1-2 hrs. Patient Care Policy (Pediatric) Modified On: June 29, 2023 ANAPHYLAXIS / ALLERGIC REACTION 67 Patient Care Policy (Pediatric) Modified On: June 29, 2023 ALTERED LEVEL OF CONSCIOUSNESS • Pediatric Routine Medical Care • Naloxone should not be given as treatment for altered level of consciousness in the absence of respiratory depression (respiratory depression = rate of less than 12 breaths per minute) (see page 79) • Consult with the Base Physician if the Blood Glucose reading is ≥ 60 mg/dL% but hypoglycemia is suspected • Use an LBRT to determine pediatric drug doses (Shown underlined on the algorithm) • Note: Oral Glucose may be administered if the patient: 1) is able to hold head upright; 2) has a gag reflex; and, 3) can self- administer the medication • Note: A newborn newly born in this protocol is considered such for the first 30 minutes after being born. Results < 60 mg mg/dL? Yes No (<40 mg/dL for newly born) Yes No IV/ IO Access? Dextrose 10% IV / IO Oral Glucose (see note above) See LBRT for dose See LBRT for dose Or May repeat LBRT dose until FSBS is Glucagon >60 mg/dL or >40 mg/dL in See LRBT for dose newborns Yes Adequate No response? Reassess Consider AEIOU – TIPS As needed ALTERED LEVEL OF CONSCIOUSNESS 68 Patient Care Policy (Pediatric) Modified On: September 5, 2017 BRIEF RESOLVED UNEXPLAINED EVENT - BRUE • Pediatric Routine Medical Care 1. DEFINITION: 1.1 An Brief Resolved Unexplained Event (BRUE) was formally known as a Apparent Life Threatening Event- ALTE 1.2 A BRUE is an episode that is frightening to the observer (may think the infant has died) and involves some combination of: ► Apnea (central or obstructive) ► Color change (cyanosis, pallor, erythema, plethora) ► Marked change in muscle tone (limpness) ► Choking or gagging 1.3 Usually occurs in infants < 12 months old, however, any child less than 2 years old who exhibits the symptoms in 1.2 may be considered a BRUE 1.4 Most have a normal physical exam when assessed by responding field personnel 1.5 50–60% have no known etiology 1.6 40–50% have an identifiable etiology (e.g. Child abuse, SIDS, swallowing dysfunction, infection, bronchiolitis, seizures, CNS anomalies, tumors, cardiac disease, chronic respiratory disease, upper airway obstruction, metabolic disorders, or anemia) 2. MANAGEMENT 2.1 Assume the history given is accurate 2.2 Determine the severity, nature and duration of the episode ► was the patient awake or asleep at the time of the episode ► details of the resuscitation required 2.3 Obtain a medical history ► known chronic diseasess ► evidence of seizure activity ► current or recent infections ► gastroesophageal reflux ► inappropriate mixture of formula ► recent trauma ► medication history (current and recent) 2.4 Do a comprehensive physical exam that includes the general appearance of the child, skin color, extent of interaction with environment, and evidence of trauma 2.5 Perform glucose analysis if hypoglycemia suspected (see ALOC page 68 if B.S. < 60mg/ dL) 2.6 Treat any identifiable causes 2.7 Transport 2.8 Note: Contact the Base Physician for consultation if the parent/guardian is refusing medical care and/or transport, prior to completing a Refusal of Care form BRIEF RESOLVED UNEXPLAINED EVENT - BRUE 69 kg 15 < child if electrodes pediatric Use interventions. ALS and BLS to refractory bradycardia symptomatic with children for reserved TCP algorithm) the on underlined - dosages medication pediatric determine to LBRT an Use causes: possible and Consider Care Medical Routine Pediatric symptomatic of Signs/Symptoms Steps Abbreviated IV/IO 0.1mg/mL Atropine proceed develops, asystole/PEA If protocol Management Pain and procedure Sedation Consider Patient Care Policy (Pediatric) Modified On: January 1, 2025 BRADYCARDIA ➔ Hypoxia (most common) ➔ Hypothermia ➔ Head Injury ➔ Heart Block ➔ Toxins/ drugs ➔ Beta Blockers or calcium channel blockers No BRADYCARDIA 70 Patient Care Policy (Pediatric) Modified On: January 1, 2025 CARDIAC ARREST - GENERAL GUIDELINES Assess cause of Medical Trauma arrest (medical vs. trauma For Cardiac Arrests of all causes:  Initiate and maintain manual chest compressions until a mCPR device is available and appropriate to place  Minimize interruptions to chest compressions at all times  Immediately initiate timekeeping  Consider SGA placement if persistent hypoxia/hypercarbia is present with BLS airway (OPA with BVM)  Do not interrupt chest compressions for airway management Patient Disposition Go to appropriate cardiac arrest protocol for guidance on patient dispositions CARDIAC ARREST - GENERAL GUIDELINES 71 Patient Care Policy (Pediatric) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA • Pediatric Routine Medical Care • In PEA, identify other causes and treat (See CPR page 12) • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate. 2 minutes CPR Shockable 30:2 5 cycles 1 rescuer Yes rhythm? Commented \[ZK12\]: Move lower 15:2 10 cycles 2 rescuers Check rhythm No Resume CPR REVERSIBLE CAUSES IV / IO NS • Hypovolemia • Hypoxia Do not interrupt Epinephrine 0.1mg/mL IV/IO • Hydrogen ion (acidosis) CPR to administer See LBRT for dose • Hypoglycemia medications • Hypo-/hyperkalemia (1st dose ASAP – preferably within 5 • Hypothermia min from start of CPR) • Tension pneumothorax q 5 minutes, up to 3 doses • Tamponade, cardiac • Toxins • Thrombosis, pulmonary • 2 Proceed to: minu Cardiac Arrest – Shockable tes Medical – VF/pVT Yes No rhythm? CPR protocol • 30:2 5 cycle s 1 rescu Non-shockable er rhythm • 15:2 10 continues? cycle s 2 Yes No rescu ers • Chec k Proceed to rhyth Consider Continue CPR Bradycardia m Determination of and medication protocol or If pulse present - post Death Criteria – administration • Thrombosis, coronary Tachycardia resuscitation care Medical Arrest protocol Transport Resuscitation CARDIAC ARREST - MEDICAL - ASYSTOLE/PEA 72 Patient Care Policy (Pediatric) Modified On: January 1, 2025 CARDIAC ARREST - MEDICAL - VF/PVT • Pediatric Routine Medical Care • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate CARDIAC ARREST - MEDICAL - VF/PVT 73 incidents, or if staging, extrication (without resuscitation) and/or transport exceeds 20 minutes. protocol, mass casualtyDetermination of Death in the Field Do not resuscitate in the setting of obvious death as outlined in Patient Care Policy (Pediatric) Modified On: January 1, 2025 CARDIAC ARREST - TRAUMATIC Yes No CARDIAC ARREST - TRAUMATIC 74 Patient Care Policy (Pediatric) Modified On: June 29, 2023 NEONATAL RESUSCITATION • Pediatric Routine Medical Care • Resuscitation should be initiated on all premature infants who meet the following criteria: Weight: > 500 gms or 1 pound and Gestational Age: ≥ 20-24 weeks • If naloxone considered for persistent respiratory depression, HR and color must first be restored • Avoid naloxone for neonates whose mothers are suspected of long-term exposure to opioids • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate. Term Gestation? Amniotic fluid clear? No Yes Breathing or crying? Good muscle tone? ✓ Provide warmth ✓ Provide warmth ✓ Position - Clear airway if ✓ Clear airway if needed needed ✓ Dry off ✓ Dry, stimulate, reposition ✓ Assess color Pink? Monitor Breathing & Yes Pink? HR > 100? No Cyanotic? Supplemental O 2 Apneic or HR < 100 Persistent Cyanosis? Effective Positive pressure ventilation ventilation, HR > 100 & 40-60 breaths/minute color pink NOTE: Routine suctioning of vigorous, full term newborns at birth is not indicated. Post HR Wiping the face, nose, mouth is preferred No Yes Resuscitation < 60? Note: Delayed cord clamping of at least 60 care seconds is recommended Note: encourage skin to skin contact with parent if baby is term, good tone and crying ✓ Continue ventilation and otherwise stable. Continue to monitor. ✓ Administer chest compressions compression: ventilation ratio 3:1 (90:30 for a total of 120 combined events/minute) ✓ ✓ Epinephrine 0.1mg/mL See LRBT for dose ✓ Fluid bolus See LBRT for dose - may repeat LBRT dose x 1 as needed No Yes HR < 60? NEONATAL RESUSCITATION 75 Patient Care Policy (Pediatric) Modified On: May 10, 2019 PAIN MANAGEMENT •Pediatric Routine Medical Care. If oxygen is administered, titrate to 94-99% SpO2 •Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures •The preferred route of administration is intranasal (IN) ASSESSMENT: Document level of pain (as a fraction - e.g.: 2/10 or 6/10) prior to and after any interventions are performed: ► < 3 years old – Behavioral tool or FACES Scale: ► 3–7 years old – FACES scale or visual analog scale ► 8–14 years old – visual analog scale 0 1 2 Face No particular expression Occasional grimace or Frequent to constant frown or smile Frown, withdrawn, disinterested Clenched jaw, quivering chin 0 1 2 Legs Normal or relaxed position Uneasy, restless, tense Kicking, or legs drawn up 0 1 2 Activity Lying quietly, normal Squirming, tense, shifting Arched, rigid or jerking position, moves easily Back and forth 0 1 2 Cry No cry (awake or asleep) Moans or whimpers; Cries steadily, screams, occasional complaint sobs, frequent complaints 0 1 2 Consolability Content, relaxed Reassured by “talking to, Difficult to console hugging; distractible or comfort From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pe- diatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission. Instructions: Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Ask the person to choose the face that best describes how he/she is feeling ➔ Face 0 is very happy because he doesn't hurt at all ➔ Face 2 hurts just a little bit ➔ Face 4 hurts a little more ➔ Face 6 hurts even more ➔ Face 8 hurts a whole lot ➔ Face 10 hurts as much as you can imagine, although you don't have to be crying to feel this bad VISUAL ANALOG SCALE 0 1 2 3 4 5 6 7 8 9 10 No Worst Pain Pain Ever PAIN MANAGEMENT 76 ALS available readily Naloxone Have doses require may patients Burn recommended Capnography monitoring is Notes: Suspected Traumatic Brain Altered rate respiratory Decreased hypotension adjusted-Age Contraindications: Considerations: Fentanyl CoachingSplinting Cold Pack(s)Positioning Interventions: BLS Monitor/Reassess contraindication(s) are presentif or mcg 200 > requires patient if consult Physician Base 3 total doses via all routesof max. a to min, 5 q LBRT on dose May dose for LBRT See (preferred)/IM/IV/IO IN Fentanyl Intervention: Patient Care Policy (Pediatric) Modified On: June 29, 2023 PAIN MANAGEMENT • Pediatric Routine Medical Care. If oxygen is administered, titrate to 94-99% SpO2 • Pain management should be initiated as early as possible and before transport in the stable patient. Consider pain management prior to the manipulation of suspected fractures • The preferred route of administration is intranasal (IN) • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) PAIN MANAGEMENT 77 Yes to: go suspected: order See LBRT for dose Activated Charcoal PO caustic, -non -non If BVM with 79 No reflex?gag good a with Ventilating Patient Care Policy (Pediatric) Modified On: June 29, 2023 POISONING | INGESTION | OVERDOSE- possible OVERHAUL • Pediatric Routine Medical Care • Protect Yourself! - See page 155 "Hazardous Materials Incidents - EMS Response" • Identify substance – contact the Base Physician regarding other treatment options. Bring any containers, labels or a sample (if safe) into the hospital with the patient • Determine type, amount, and time of the exposure • Base Physician consult for treatment options if suspecting: organophosphate poisoning, or calcium channel or beta blocker OD. Consider contacting Poison Control for other substances 800-222-1222 • Remove contaminated clothing. Brush powders off, wash off liquids with large amount of water • Withhold charcoal if rapidly decreasing level of consciousness a possibility (e.g., tricyclic OD) • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate. 78 POISONING | INGESTION | OVERDOSE 78 Patient Care Policy (Pediatric) Modified On: June 29, 2023 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) Commented \[ZK13\]: Same comment as adult. Do we • Routine Medical Care want to incorporate COWS into workflow? • Naloxone can cause acute withdrawal symptoms (agitation, vomiting, etc.) in patients who are chronic utilizers of Narcotics. If patient is at least 16 years told, consider Buprenorphine and move to Opioid Withdrawal protocol. • Naloxone can cause cardiovascular side effects (chest pain, pulmonary edema) or seizures in a small number of patients (1-2%) • Patients who are maintaining adequate respirations with decreased level of consciousness do not generally require Naloxone for management • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Maintain airway patency and adequate respirations with BLS airway adjuncts and BVM as needed Oxygen- titrate to SpO2 of 94-99% Consider vascular access Respiratory No Yes rate ≤ 12 Monitor/Reassess Patient Care Policy (Pediatric) Modified On: June 29, 2023 RESPIRATORY DEPRESSION OR APNEA (SUSPECTED NARCOTIC OD) 79 Suspect Patient Care Policy (Pediatric) Modified On: May 10, 2019 RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY Commented \[ZK14\]: Add in cool mist and/or nebulized • Pediatric Routine Medical Care epi • CROUP/EPIGLOTTITIS: ➔ If the patient deteriorates, or becomes completely obstructed, positive pressure ventilation via bag-valve-mask should be attempted ➔ Do not attempt to visualize the throat or insert anything into the mouth if epiglottitis suspected ➔ Allow a parent to hold the child or the O2 mask if the presence of the parent calms the child ➔ Minimize outside stimulation. Keep the patient calm ➔ Position of comfort • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate. RESPIRATORY DISTRESS (STRIDOR) – UPPER AIRWAY 80 Patient Care Policy (Pediatric) Modified On: June 29, 2023 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY • Pediatric Routine Medical Care • Position of comfort • Use an LBRT to determine pediatric medication doses - (Shown underlined on the algorithm) • Note: Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary. Consider Advanced Airway Management (page 118) if BVM ventilation is not adequate Consider use of ETCO2 monitor to assess respiratory effort Patient Care Policy (Pediatric) Modified On: June 29, 2023 RESPIRATORY DISTRESS (WHEEZING) – LOWER AIRWAY 81 Patient Care Policy (Pediatric) Modified On: January 1, 2025 ROUTINE MEDICAL CARE - PEDIATRIC Commented \[ZK15\]: Consider standardizing The defined age of a pediatric patient is 14 years old or less, and unless specified otherwise, pediatric protocols should be used terminology: pediatric treatment if on the tape. For to treat these patients. Note: An infant is considered to be < 1 year old. A child is considered to be ≥ 1 year old. Specified ages for transport or treatment other than 14 years old include: transport, consider 14 and up. TRANSPORT TREATMENT Advanced Airway Management (page 118): 5150 Psych Evaluation (page 134): ➔ Children ( ≤ 11 y.o.) – Children’s Hospital ➔ <40kg- authorized airway is OPA/NPA, BVM, or SGA CPAP (page 124): ➔ Adolescents ( ≥ 12 y.o. & ≤ 17 y.o.) – ALCO Youth CSU Trauma Destination (page 30): ➔ < 8 y.o. – Absolute Contraindication ➔ ≤ 14 y.o. – Children’s Hospital IO Access (page 130): ➔ ≥ 15 y.o. – Closest Adult Trauma Center Sexual Assault (page 5): Refusal of Care (page 120): ➔ Children ( ≤ 13 y.o.) – Children’s Hospital ➔ ≤ 17 y.o. may not refuse transport or ➔ All Others ( ≥ 14 y.o.) – Highland or Washington treatment unless legally emancipated An approved Alameda County-specific, pediatric LBRT shall be used to determine appropriate medication dosages, fluid volumes, defibrillation settings and equipment sizes. The tape is designed to estimate a child’s weight based on length (head to heel). When the child's height exceeds the length of the tape, refer to the adult dose. PRIMARY SURVEY SPECIAL CONSIDERATIONS Establish level of ► AVPU: Alert, Verbal, Painful, Unresponsive responsiveness ► Identify signs of airway obstruction and respiratory distress, including: ➔ cyanosis ➔ intercostal retractions ➔ choking Evaluate airway and protective ➔ stridor ➔ absent breath sounds ➔ grunting airway reflexes ➔ drooling ➔ apnea or bradypnea ➔ nasal flaring ➔ tachypnea ► Open airway using jaw-thrust and chin-lift (and/or head tilt if no suspected spinal trauma). Suction as needed. Consider placement of an oral or nasal airway adjunct if the child is Secure airway unconscious ► If cervical spine trauma is suspected, see page 137 Consider Spinal Motion ► Use chest rise as an indicator of ventilation Restriction (SMR) ► Use pulse oximetry ► CPR as needed (see CPR page 12) ► Assess perfusion using the following indicators: Assess need for ventilatory assistance ➔ heart rate ➔ mental status ➔ skin signs Formatted: Font: Bold ➔ quality of pulse ➔ capillary refill ➔ blood pressure ► Perform a head-to-toe assessment, including temperature Evaluate and support ► Obtain a patient history circulation. Stop Hemorrhage ► Do environmental assessment, consider possibility of intentional injury ► Perform a head-to-toe assessment, including temperature Formatted: Font: Bold Continue with secondary survey ► Obtain a patient history ► Do environmental assessment, consider possibility of intentional injury ► Provide family psychosocial support ► An approved Alameda County-specific, pediatric LBRT shall be used to determine appropriate medication dosages, fluid volumes, defibrillation settings and equipment sizes. ► When starting an IV/IO/saline lock, use chlorhexidine as a skin prep ► Label insertion site with “PREHOSPITAL IV – DATE and TIME” Determine appropriate treatment ► Pediatric patients are subject to rapid changes in body temperature. Steps should be taken to protocols prevent loss of or increase in body temperature ► Compared to the adult patient, a small amount of fluid, lost from or administered to, a pediatric patient can result in shock or pulmonary edema ► Scene time for treatment of pediatric patients should be kept at a minimum. Most treatment should be done en route ROUTINE MEDICAL CARE - PEDIATRIC 82 Midazolam Additional - consider: seize to continues patient If needed as Reassess measures Cooling febrile: If Glucose Blood Check seize? to Continues page ALOC to Go No mg/dL? 60 < Results No seizing? Actively 1 in 10 minutes if still actively seizing x dose LBRT repeat - routes dose LBRT IV/IO: dose LBRT dose (half of dose in each nare) LBRT – route Preferred Midazolam No Patient Care Policy (Pediatric) Modified On: June 29, 2023 SEIZURE • Pediatric Routine Medical Care • Midazolam should not be given unless the patient is actively seizing - 3 or more seizures in ≤ 5 minutes or any seizure lasting > 5 minutesAdminister midazolam for an actively convulsing patient with a seizure lasting >5 min or for recurrent seizures without return to baseline between seizures • Cooling Measures: Loosen clothing and/or remove outer clothing/blankets • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Base Physician order Commented \[ZK16\]: Check LBRT for max dose versed SEIZURE 83 40kg?> patient Is given sec.) (over Slowly (Zofran) Ondansetron Patient Care Policy (Pediatric) Modified On: June 29, 2023 SEVERE NAUSEA • Routine Medical Care • Indications: Intractable vomiting or severe nausea in patients aged 4 years and older • Contraindications: Hypersensitivity to 5-HT3 receptor antagonists (i.e. – dolasetron (Anzemet), granisetron (Kytril) • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • Note #1: Consider other treatable causes • Note #2: Administering Zofran rapidly can cause syncope • Note #3: If patient has s/s of anaphylaxis/allergic reaction, follow Anaphylaxis/Allergic Reaction policy (see pg xxx) Formatted: Font: Not Bold SEVERE NAUSEA 84 Bolus needed No Continuing Yes Spinal ShockSeptic Shock physician Patient Care Policy (Pediatric) Modified On: June 29, 2023 SHOCK AND HYPOTENSION • Pediatric Routine Medical Care • IMPORTANT SIGNS OF SHOCK: ➔ Cool, clammy, mottled skin ➔ Pallor - due to decreased skin perfusion ➔ Altered level of consciousness - due to decreased perfusion to the brain ➔ BP < 70 systolic • Initiate early transport and treat en route, if appropriate ➔ Go to Trauma Patient Care (page 28) if trauma suspected ➔ Go to Allergic Reaction (page 67) if anaphylaxis suspected • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) • NOTE: Shock in children may be subtle and hard to recognize. Determining BP may be difficult and readings may be inaccurate Base physician consult SHOCK AND HYPOTENSION 85 Pediatric sleep of stress/lack dehydration, changes, temperature infection, be can emergencies cell sickle for Triggers Considerations: Special PRN: Interventions/Adjuncts Additional S/S reaction allergic for Diphenhydramine → Protocol Guidelines per Tylenol) (Ketorolac, medications opioid-Non use) (Screen/phone Distraction → measures packs/blankets/warming Heat → patterns S/S or pain abnormal reporting patient high index of suspicion should be maintained for other serious etiologies to symptoms especially in the setting of A embolism, pulmonary CVA, ACS, including conditions serious other for risk higher at are (SCD) Disease Cell Sickle with Patients Cell Sickle with associated processes ischemic of the stopping to key is management pain aggressive and Early Care Medical Routine Patient Care Policy (Pediatric) Modified On: January 1, 2025 SICKLE CELL PAIN EMERGENCY SICKLE CELL PAIN EMERGENCY 86 Patient Care Policy (Pediatric) Modified On: April 10, 2012 SUBMERSION • Pediatric Routine Medical Care • Contact the Base Hopsital Physician if patient is also showing signs of pulmonary edema before moving to the appropriate policy • Consider CPAP (see CPAP page 124 for indications) • Consider spinal precautions prior to extrication if possibility of neck trauma. Otherwise place the patient on his/her side to protect the airway and prevent aspiration; be prepared to suction • Rapid extrication from water • Initiate rapid transport to the closest most appropriate receiving hospital • Note: If hypothermia is suspected and the patient is in ventricular fibrillation, rewarming is essential. Remove wet clothing, wrap in warm blankets and place in warm ambulance SUBMERSION 87 0.08sec < QRS Narrow sec >0.08 QRS Wide monitor Attach✓ 2 SpO 99%-94 to titrate – 2 O✓ needed if ABCs Support✓ duration QRS Evaluate Patient Care Policy (Pediatric) Modified On: June 29, 2023 TACHYCARDIA • Pediatric Routine Medical Care • Use an LBRT to determine pediatric medication dosages - (Shown underlined on the algorithm) Possible/probable Evaluate rhythm V-tach Consider causes: compensatory vs. non- compensatory If unstable If stable (with pulses but (with pulses and poor perfusion) good perfusion) Sinus Tachycardia Supraventricular Tachycardia < 220/min - infant (SVT) < 180/min - child > 220/min - infant ✓ P wave present/normal Consult with Base Physician for > 180/min - child ✓ R to R - variable Amiodarone IV/IO infusion ✓ P waves - absent/abnormal ✓ PR - constant (over 20-60 mins) ✓ Heart rate - constant See LBRT for dose Treat underlying cause(s) If stable If unstable Consider: Fluid bolus – See (with pulses and (with pulse but LBRT for dose good perfusion) poor perfusion) May repeat LBRT dose x 1 Consider: Synchronized Cardioversion Vagal See LBRT for dose Maneuver If not effective, increase to the next dose listed on LBRT Consider Sedation but do not delay cardioversion See Adenosine Rapid IVP Sedation page 136 ✓ See LBRT initial dose (max. 1st dose 6 mg) ✓ See LBRT repeat dose (max. 2nd dose 12 mg) TACHYCARDIA 88 Operations Modified On: May 27, 2021 OPERATIONAL POLICIES TOC OPERATIONAL POLICIES TOC ....................................................................................... 89 ALS RESPONDER ............................................................................................................... 90 BLS/FIRST RESPONDER ................................................................................................... 91 DETERMINATION OF DEATH IN THE FIELD ................................................................ 92 DEATH IN THE FIELD - GRIEF SUPPORT ..................................................................... 94 END OF LIFE CARE ........................................................................................................... 95 EMS AIRCRAFT TRANSPORT .......................................................................................... 96 EMS EVENT REPORTING ................................................................................................. 100 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION ............................ 101 EQUIPMENT AND SUPPLY SPECIFICATIONS - ALS/BLS ............................................. 102 INTERFACILITY TRANSFERS .......................................................................................... 108 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 109 MEDICAL PERSONNEL ON THE SCENE ...................................................................... 110 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE ................................ 112 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS..................... 113 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING.................. 114 RESTRAINTS ........................................................................................................................ 115 OPERATIONAL POLICIES TOC 89 Operations Modified On: September 10, 2017 ALS RESPONDER 1. ALS PERSONNEL - In Alameda County, an "ALS responder" is defined as: An individual who is licensed as a paramedic in the state of California and accredited to practice in Alameda County. 2. MEDICAL MANAGEMENT 2.1 An ALS responder is responsible for the care of the patient after accepting responsibility from the first responder personnel until the care of the patient is turned over to the staff at the receiving hospital (if transported), or until the patient leaves the scene 2.2 Consider a second accredited paramedic to accompany the transporting paramedic for critical patients (e.g. - arrest, complicated airway, ROSC, severe trauma, STEMI, etc.) 2.3 Initiate "START" triage if appropriate. (See page 157 "Multi-Casualty Incident - EMS Response (MCI)") 2.4 If it is determined that helicopter transport of the patient might be necessary, activate the air ambulance and secure an appropriate landing zone. (see page 96 "EMS Aircraft") 2.5 A verbal and Electronic Health Record (EHR) must be completed for every patient, describing the care rendered and given to the staff at the receiving hospital. 2.5.1 First Responder and transport personnel providing patient care are responsible for accurately documenting all available and relevant patient information on the electronic health record 2.5.2 Exception: ➔ Multi-Casualty Incident – EMS Response (MCI) page 157 ➔ Consent and Refusal Guidelines page 120 2.6 The EHR should include a chief complaint, a general assessment, a physical assessment and emergency care rendered by the ALS responder. 3. PATIENT CARE 3.1 The following should be performed for each patient during an emergency response: 3.1.1 A physical assessment and initiation of emergency first aid, basic life support, and/or advanced life support, as necessary 3.1.2 A EHR must be completed for every patient (exception: Multi-Casualty Incident and Refusal of Service) 3.2 ALS responders are held to the following standards during patient care: 3.2.1 CPR & Basic Life Support for Healthcare Providers course (AHA or approved equivalent) that includes in-person skills testing of the following: ➔ Single and multiple responder CPR for adult, child, and infant; ➔ AED utilization; ➔ Relief of foreign-body airway obstruction (choking) and ventilation techniques for adult, child, and infant 3.2.2 Advanced Cardiac Life Support 3.2.3 PEPP (Pediatric Education for Prehospital Personnel), or Pediatric Advanced Life Support (PALS), or Emergency Pediatric Care (EPC), or an approved equivalent 3.2.4 "START" or "JumpSTART" Triage for MCI. 3.2.5 OSHA and CAL-OSHA for infection control 3.2.6 International Trauma Life Support (ITLS), PreHospital Trauma Life Support (PHTLS), Assessment and Treatment of Trauma (ATT) or an approved equivalent 3.2.7 Alameda County EMS policies for patient care not covered by, or in addition to the above ALS RESPONDER 90 Operations Modified On: July 24, 2018 BLS/FIRST RESPONDER 1. FIRST RESPONDER PERSONNEL - In Alameda County, First Responder personnel are: 1.1 Public Safety personnel (lifeguard, firefighter or peace officer) trained in "First Aid and CPR Standards for Public Safety Personnel", according to the standards defined in Title 22, Chapter 1.5 1.2 Individuals who are certified as an EMT by a California local EMS agency, the California State Fire Marshall's Office, or another certifying authority 1.3 California Licensed, Alameda County Accredited Paramedics 2. MEDICAL MANAGEMENT 2.1 The First Responder is responsible for the care of the patient, once contact with the patient has occurred and continues that responsibility until care of the patient is turned over to the arriving ambulance personnel 2.2 If it is determined that the incident does not involve illness or injury, the First Responder shall cancel the ambulance response (see page 114 "Responding Units - Canceling/Upgrading/Downgrading ") 2.3 If it is determined that helicopter transport of the patient might be necessary, activate the air ambulance and secure an appropriate landing zone (see page 96 "EMS Aircraft") 2.4 A verbal report must be given to the arriving ambulance personnel before the care of the patient may be turned over. The First Responder form should include a chief complaint, physical assessment and Commented \[ZK17\]: Does everyone have access to emergency care rendered by the First Responder this? 2.5 The First Responder must remain on scene until an approved ambulance provider arrives and patient care is transferred or if the patient is in the care of a higher level of care (RN, MD) and deemed stable and care is transferred back. The First Responder may return to service once patient care is transferred, or remain on scene and assist as necessary 2.6 Initiate "START" or "JumpSTART" triage as necessary (see page 157 "Multi-Casualty Incident - EMS Response") 3. PATIENT CARE 3.1 The following should be performed for each patient during an emergency response: 3.1.1 A physical assessment and initiation of emergency first aid or basic life support as necessary (see page 53 "Routine Medical Care"). 3.1.2 A First Responder form must be completed for every patient (exception: see page 157 “Multi- Casualty Incident - EMS Response” and page 120 “Refusal of Service”). 3.2 BLS/First Responders are held to the following standards during patient care: 3.2.1 CPR & BLS for Healthcare Provider Course (AHA or approved equivalent) that includes in- person skills testing of the following: ➔ Single and multiple responder CPR for adult, child, and infant; ➔ AED utilization; ➔ Relief of foreign-body airway obstruction (choking) and ventilation techniques for adult, child, and infant 3.2.2 Approved training program curriculum for emergency first aid. 3.2.3 "START" or "JumpSTART" Triage for MCI. 3.2.4 Alameda County Policy “Multi-Casualty Incident - EMS Response” page 157 for medical management at a MCI. 3.2.5 OSHA and CAL-OSHA for infection control. 3.2.6 Alameda County EMS policies for protocols not covered by, or in addition to the above BLS/FIRST RESPONDER 91 Operations Modified On: January 1, 2025 DETERMINATION OF DEATH IN THE FIELD 1. INTRODUCTION 1.1 BLS and ALS prehospital personnel are not required to initiate resuscitative measures in any of the following circumstances: ► Signs of obvious death are present: ➔ Total decapitation ➔ Total incineration ➔ Total separation or destruction of the heart or brain ➔ Decomposition of body tissues ➔ In cases of traumatic arrest, if the staging and extrication time (without resuscitation) exceeds 20 minutes ALS clinicians only: For the signs below, an ECG reading of asystole in two or more leads must be observed for one minute in conjunction with these signs ➔ Dependent pooling of blood resulting in skin discoloration indicating lividity ➔ Rigidity throughout the entire body, including the limbs, indicating rigor mortis ● Isolated tightness in the jaw is not sufficient for determining rigor mortis ► During multi-casualty incidents (MCIs); follow MCI triage principles ► Presence of a signed Do Not Resuscitate (DNR) order, or Physician Order for Life- Sustaining Treatment (POLST), an approved medical medallion inscribed with the words, “Do Not Resuscitate- EMS", or family discretion criteria ➔ Family discretion criteria: • In the absence of a valid DNR/POLST directive, if an identifiable immediate family member or spouse requests no resuscitation, with the unanimous agreement of others present, resuscitation efforts may be withheld or ceased if already initiated ➔ Copies or original forms of the signed DNR/POLST directives are acceptable • All forms require the patient's signature (or signature of appropriate surrogate) and the signature of the patient's physician to be valid ➔ For additional DNR/POLST special considerations see Section 4 of this policy 1.2 If any doubt exists, begin CPR immediately, and continue resuscitation efforts until it is determined the patient has signs of obvious death, meets determination of death criteria as outlined in this policy, a valid DNR/POLST is presented, or family discretion criteria 1.3 Contacting base should be reserved for cases of determining death in situations not addressed by this policy 2. Determination of Death Criteria – Medical Arrest Resuscitation 2.1 In the absence of obvious death, an MCI, a valid DNR/POLST, or family discretion criteria, adult and pediatric medical arrest resuscitation efforts may be terminated by ALS prehospital personnel after resuscitation efforts have continued for at least 20 minutes, and all of the following are present: ➔ Apnea ➔ No palpable carotid or femoral pulse for 10 seconds ➔ ECG reading of Asystole or PEA < 40 bpm ➔ ETC02 < 20 mmHg; advanced airway preferred ➔ ROSC never achieved (ROSC defined as consecutive 5 minutes of palpable pulses at any point) ➔ Patient has received ≤ 2 defibrillations ➔ Hypothermia is not suspected as the cause of arrest DETERMINATION OF DEATH IN THE FIELD 92 Operations Modified On: January 1, 2025 DETERMINATION OF DEATH IN THE FIELD 2.2 If any of the Determination of Death Criteria for Medical Arrest Resuscitation are not met, continue resuscitation and contact base hospital 3. Procedure After Determination of Death in the Field 3.1 Reference the Death in the Field – Grief Support guidelines 3.2 Request the coroner and local public safety agency and remain with the deceased until either agency arrives 3.3 The public safety agency with local jurisdiction is responsible for the deceased. The deceased’s body may not be moved or disturbed until a disposition is determined by the Alameda County Coroner’s Bureau 3.4 Complete an EHR and attach a one-minute ECG rhythm strip of the final cardiac rhythm in two leads 4. DNR/POLST Special Considerations 4.1 If the patient is in cardiac arrest, the DNR/POLST directive should be honored, and resuscitation withheld ➔ While family can reverse a DNR/POLST encouragement should be given to honor patient wishes 4.2 Correct identification of the patient is essential. After a good faith effort to identify the patient, the presumption should be that the identity is correct if proper documentation is present, and the circumstances are consistent. When available, a reliable witness may be used to identify the patient 4.3 If the patient is transported, a copy of the DNR/POLST directive should stay with the patient ➔ If the patient arrests while in transit, do not start resuscitation. Continue transporting to the original destination 4.4 A copy of the DNR directive should be attached to the EHR. If a copy is unavailable, document the type of DNR directive, date the order was issued, and the name of the physician 4.5 If the patient’s physician issued the DNR order verbally while on scene, document the name of the physician and have the physician sign the EHR 4.6 There are other valid forms of directives including Advanced Health Care Directive (AHCD), the California Natural Death Act, and living wills ➔ The AHCD contains a “Health Care Instructions” section with the patient’s resuscitation preferences 4.7 When a patient is not in cardiac arrest, has a DNR/POLST, and requests treatment, up to and including resuscitation, the request should be honored DETERMINATION OF DEATH IN THE FIELD 93 Operations Modified On: May 27, 2021 DEATH IN THE FIELD - GRIEF SUPPORT 1. PHILOSOPHY 1.1 The intent of this policy is to provide grief support to the families of deceased individuals who are not transported from the field. Grief Support will be available to assist families in dealing with the death of a family member. 1.2 Field personnel should identify the need for grief support as soon as possible, especially for an unexpected death or if considering discontinuation of CPR in the field. 1.3 Field personnel should follow their agency/department procedure for initiating grief support Commented \[ZK18\]: Do departments have specific 2. RESPONSIBILITIES policies? 2.1 Assist the family in dealing with the death, or anticipated death, of the patient. 2.2 If resuscitation is in progress determine if the family wants the patient transported to the hospital. 2.3 Once death has been determined: ► remain on scene with the family to provide support and assist with decisions ► contact all appropriate agencies (e.g. Police, Coroner) if not already done ► remove all medical equipment used during the resuscitation if cleared by the Coroner's bureau (see "Determination of Death in the Field" page 92). ► assist with the notification of clergy, if requested ► provide information regarding the disposition of the remains 3. GRIEF SUPPORT GUIDELINES: Breaking the News. . . Coroner's Case • Physically join the family. • Cause of death must be investigated. • Introduce yourself. • Investigator can explain more. • Go over with the family what has been done, what • Police must stay if a coroner's case. (may choose to stay Commented \[ZK19\]: Need to investigate process interventions have been tried. until mortuary arrives if not a coroner's case) • "The paramedics (we) found your \[husband, wife, • Mortuary will pick up at coroner's office. daughter, etc.\] not breathing. We began CPR. I am very • Explain scene preservation nothing may be moved or sorry to tell you but your \[husband, wife, daughter, etc.\] disturbed. has died." Mortuary Case • Give the family time to react don't leave. • Family should choose and call a mortuary. Grief Support Skills • Ask family/friends/church for suggestion. • Ask the family if there is someone they would like you to • Mortuary will come to the scene. call. Find a neighbor. • Remove and dispose of all medical equipment. • Things to say: • Body may be left with family if they are OK and not a ► "Mrs. Smith, tell me what happened today" coroner's case. Ask how they feel. ► "I am sorry Joe has died.” Knowing when to Leave ► “This is a difficult time, it is OK to cry” ► "You may not remember all I have said right • Tell them it is time for you to go "is there anything else I can do?" now and that's OK.” • Go through the grief support brochure, point out referral ► “I will be available later to talk to you” numbers. Give them your card or how they can reach you. ► "I don't know but I will find out" • Offer your condolences shake hands or touch if • Remember: You cannot fix grief. Just give it an honest and appropriate. safe place to exist. • Leave • Give the family the grief support brochure. Tell the family what happens next • The coroner must be notified (Paramedics and/or police to do this) • Ask if the family has selected a mortuary. • Get the private doctorsdoctor’s name and as much patient history as possible (including medications that indicate specific medical conditions) DEATH IN THE FIELD - GRIEF SUPPORT 94 Operations Modified On: May 27, 2021 END OF LIFE CARE • Routine Medical Care • Indications: ➔ Patient has a life limiting or terminal illness, prefers comfort-focused treatment, and has one of the following: • POLST form specifying DNAR and comfort-focused treatment and/or: • Patient is enrolled in hospice care • Goals: ➔ Reduce patient symptom distress and; ➔ Maintain patient dignity by aligning care with stated end-of-life preferences All interventions should be minimally invasive with the goal to maintain patient comfort ⮚ Airway – Position/Suction PRN ⮚ Breathing – Oxygen PRN ⮚ Circulation – Control hemorrhage ⮚ Position of comfort ⮚ Review and verify POLST/DNAR Documentation END OF LIFE CARE 95 Operations Modified On: December 1, 2011 EMS AIRCRAFT TRANSPORT-OVERHAUL NOTE: EMS Aircraft utilized in Alameda County for prehospital emergency care will meet the qualifica- tions specified in Title 22, Chapter 8. 1. INITIATING EMS AIRCRAFT RESPONSE 1.1 The decision to request an EMS Aircraft is based on medical and scene management considerations 1.2 Prior to arrival at the scene - An EMS Aircraft may be activated by any responding agency if there may be a potential need for air transport based on the incident type or location of the victim(s) 1.3 All responding agencies shall be notified when an EMS Aircraft has been requested via main radio channel, TAC channel and CAD 1.4 When on-scene, the decision to activate an EMS Aircraft shall be made by the IC (Incident Commander or his/her designee). upon: ► the advice of on-scene medical personnel and/or ► the suitability of the scene for helicopter operations 2. CONSIDERATIONS FOR REQUESTING EMS AIRCRAFT: (one or more of the following conditions exists) 2.1 Long response times to scene (>20 minutes) 2.2 Inaccessibility to the scene by ground personnel or equipment 2.3 Extended extrication 2.4 Extended transport to an appropriate facility > 20 minutes (e.g. remote area, peak traffic, closest most appropriate facility closed) 2.5 Patients meeting Critical Trauma Patient Criteria (see page 28) with extended transport time to an approved Trauma Center 2.6 Patients requiring advanced skills not in the Alameda County Paramedic scope of practice. (e.g. RSI, Surgically places thoracostomy tubes) 2.7 Patient conditions where a decrease in transport time to an appropriate medical facility may be a significant factor 2.8 Patientsincardiacarrestfromdrowningor penetratingtraumawithashort down time. Ingeneral, all Patients in cardiac arrest from drowning or penetrating trauma with a short down time. In general, all otherpatientswithcardiacarrestshouldnotbetransportedinanairambulance other patients with cardiac arrest should not be transported in an air ambulance or rescue or rescue aircraft aircraft. 2.9 A multi-casualty incident exists with a need for increased resources 3. EMS AIRCRAFT DISPATCH 3.1 All EMS Aircraft activations shall be made through the dispatch channel or TAC channel. ALCO-CMED. ALCO should be given the following information if available: ► Number of Patients and acuity of each ► Type and extent of injuries ► Location of Landing Site (use Thomas Brothers Map coordinates or Longitude and Latitude, if ► possible) ► Nearest landmarks (e.g., highways, railroad tracks, water towers) ► Weather conditions, especially high winds, fog or visibility problems. 4. COMMUNICATION 4.1 ALCO-CMED shall request activation of the EMS Aircraft that has the shortest total response time to the scene/rendezvous site 4.2 The responding EMS Aircraft may contact ALCO on VHF TAC 4 (154.070) while en route to the scene to confirm radio frequency and ground contact/incident identifier ► The preferred frequency for helicopter to ground unit communications is: CALCORD (156.075) ►Alternate frequencies are VHF TAC 4 (154.070) and VHF TAC 5 (154.235), but should be EMS AIRCRAFT TRANSPORT 96 Modified On: December 1, 2011 Operations EMS AIRCRAFT TRANSPORT coordinated through ALCO-CMED ► Fire White (154.280) is not authorized for cross patch to an ambulance or helicopter 4.3 The responding EMS Aircraft will advise ALCO of ETA in minutes and clock hours. ALCO shall advise the requesting agencies of the EMS Aircraft's ETA 4.4 ALCO shall keep responding/on scene ground personnel updated as to aircraft status (cancellation, delays, inability to respond, etc.) 4.5 If multiple aircraft are responding to the scene or in the area of the incident, ALCO shall attempt to notify each aircraft of multiple aircraft response 4.6 The EMS Aircraft shall contact the receiving hospital prior to arrival. A patient care report and an ETA should be given 5. UTILIZATION OF RESCUE AIRCRAFT 5.1 A number of public agencies, including East Bay Regional Park District, California Highway Patrol, Coast Guard and various military units, operate aircraft which are classified as ALS Rescue Aircraft, BLS Rescue Aircraft or Auxiliary Aircraft 5.2 The decision to transport in a rescue aircraft should be made by on-scene medical personnel and is based on patient condition and availability of other resources 5.3 Considerations for utilizing rescue aircraft: ► the patient is in an area that is inaccessible to ground transport vehicle, ► the ETA of a ground ambulance and/or Air Ambulance exceeds the loading and lift-off time by the rescue aircraft ► an air ambulance is unavailable ► the patient clearly does not require the level of service provided by an air ambulance ► a rescue requiring the use of a hoist device is indicated 5.4 When an EMT-P accompanies a patient in a BLS rescue aircraft, the EMT-P must: ► have available all appropriate medical equipment needed to care for the patient; ► receive orientation to the aircraft and to medical air transport procedures according to Title 22, Chapter 8, Section 100302 6. SAFETY/LANDING - Safety rules at the scene include: 6.1 Landing Zone considerations (L-Z): ► 75' x 75' during daylight, 100' x 100' during night hours, ► clear of cross wires, debris, or other obstacles, relatively flat ► Consult CHP/Law Enforcement when landing on roadways 6.2 Ground personnel should coordinate with public safety agency for road closures, if necessary 6.3 The fire department should determine the landing zone and assure scene safety during landing 6.4 Before clearing EMS aircraft to land the IC must ensure that the helicopter will not block the transport of patients out of the scene by ground. If ground transport will be blocked then the IC must make sure that ground units with critical patients have departed before clearing aircraft to land 6.5 The pilot in command shall have the final authority as to the safe operation of the air transport. If, in the pilot's judgment, patient transport by an EMS aircraft would be unsafe, regardless of the patient's condition, the patient should be transported by ground ambulance 6.6 Ground personnel shall not approach the aircraft unless directed to do so and accompanied by the aircraft crew 6.7 Regardless of how the request was initiated, only the IC shall authorize the landing of a helicopter at EMS AIRCRAFT TRANSPORT 97 Modified On: December 1, 2011 Operations EMS AIRCRAFT TRANSPORT the scene. Coordination between medical personnel and the IC is essential 7. CANCELING EMS AIRCRAFT RESPONSE 7.1 Ground transport should be utilized if: ► the overall prehospital time will not be decreased by the use of air transport and/or ► the patient does not meet criteria identified in Section 3 for Requesting EMS Aircraft. 7.2 Regardless of how an EMS Aircraft activation was initiated, only the IC shall cancel the response. The IC will cancel the EMS Aircraft response if so advised by on-scene medical personnel (see 9.1 below) . Coordination among all medical personnel and the IC is essential 7.3 The IC should only cancel an EMS Aircraft response if on scene and aware of the patient’s condition 7.4 EMS Aircraft response can be canceled by: ► notifying ALCO, who will then notify all responding agencies ► the IC if in contact with the responding Aircraft 7.5 The IC shall be immediately advised of the decision to transport by ground 7.6 If the EMS Aircraft arrive on scene prior to the ground ambulance, the responding ground ambulance shall not be canceled until: ► the EMS Aircraft has left the scene with the patient aboard; and, ► it is determined by the IC or his/her designee that there are no additional patients to be transported 8. TRANSPORT 8.1 The transporting ALS provider shall have authority and responsibility to determine mode of patient transport (air vs. ground) and patient destination. The transporting ALS provider must consult with first responder personnel and EMS Aircraft crew, if applicable, prior to making this decision 8.2 Alameda County transport policies shall be followed for all patients requiring air transport. Patients shall be transported to the closest hospital most appropriate for the medical needs of the patient with an approved Helipad or EMS Landing Site 8.3 Trauma Centers with approved helipads or emergency landing sites are: ► Eden Hospital (Castro Valley) ► Children's Hospital (Oakland) ► John Muir Hospital (Walnut Creek) ► Highland General Hospital (Coast Guard Island) ► Regional Medical Center (San Jose) ► Valley Medical Center (San Jose) ► Stanford University Hospital (Palo Alto) 8.4 Alameda County Receiving Hospitals with approved helipads or emergency landing sites are: ► Eden Hospital ► Washington Hospital ► Valley Care Medical Center ► Children's Hospital 9. PATIENT CARE RESPONSIBILITIES 9.1 Transfer of care shall occur: ► upon arrival/landing of the responding personnel at the scene when patient contact is made ► after a verbal patient care report is given to the transporting agency in accordance with page 143, "Transfer of Care" 9.2 The EMS Aircraft crew may release the patient to an ALS ground transport unit if ground transport is EMS AIRCRAFT TRANSPORT 98 Modified On: December 1, 2011 Operations EMS AIRCRAFT TRANSPORT determined appropriate 9.3 The EMS Aircraft or ALS ground ambulance crew may release a patient to BLS rescue aircraft if the patient does not require ALS care but air transport is determined to be appropriate. 10. DOCUMENTATION - Appropriate documentation must be completed on all patients transported by the EMS Aircraft crew and faxed immediately to ALCO EMS at (510) 618 – 2099 11. REQUEST FOR MILITARY AIRCRAFT 11.1 Military assistance may be used when non-disaster inland search and rescue operations may exceed local and state capabilities. Examples: water rescue, rescue in inclement weather. hoist rescue 11.2 One hour response time minimum time should be expected. An ETA can only be given after the request is made and an assessment of available resources has been completed 11.3 If hoist rescue requested do not place the patient on a stretcher or stokes basket, although the patient may be placed on a backboard. The hoist equipment requires specialized equipment 11.4 The incident commander determines the need for military aircraft and contact ALCO with the following information: ► Incident location and longitude and latitude if known ► Incident description including the number of injured, types of injuries and topography ► If a hoist is requested, an estimate of the distance the patient will need to lifted from the ground to the aircraft ► Altitude of incident if known ► Air to ground contact frequencies 11.5 Notification Procedure - ALCO: ► For maritime rescue: call Coast Guard Dispatch directly at (415) 556-2105 or (415) 556-2103 ► For land (non-maritime) rescue or assistance call: ➔ State OES Law Division at (800) 852-7550 for approval ➔ Coast Guard dispatch (415) 556-2103 to give the Coast Guard helicopter flight crew an advanced notification. Since the Coast Guard’s primary responsibility is maritime search and rescue, they can notify ALCO of their availability 11.6 If additional information is needed, ALCO will direct the questions to the requesting IC's dispatch center for direct contact. EMS AIRCRAFT TRANSPORT 99 Operations Modified On: January 1, 2025 EMS EVENT REPORTING 1. EMS EVENT REPORTING CRITERIA: 1.1 Events shall be reported to the Alameda County EMS Agency within twenty-four (24) hours from time of discovery if the event resulted in harm, had the potential to result in harm, or was deemed to be a potential threat to public health and safety within any of the following areas: 1.1.1 Deviations from Alameda County EMS Administrative Policies or the Field Manual 1.1.2 Medication, or clinical treatment errors 1.1.3 Deviation from authorized list of supplies or equipment 1.1.4 Equipment failures 1.1.5 Unintentional patient harm or injury during care 1.1.6 Communication failures, e.g., radios, phones, technological challenges 1.1.7 Base hospital communication and/or guidance 1.1.8 Specialty systems of care destination errors, e.g., Stroke, STEMI, Cardiac Arrest, Trauma, Sexual Assault, Psychiatric receiving 1.1.9 Collision of any EMS vehicle that resulted in injury 1.2 Any EMS clinician act or omission pursuant to Division 2.5, Chapter 7, Section 1798.200, of the Health and Safety Code, including but not limited to the following: 1.2.1 Diversion of controlled substances 1.2.2 Substance-related impairment while on duty 1.2.3 Gross negligence 1.2.4 Mistreatment or physical/sexual abuse of a patient 1.3 Events where exceptional EMS care was provided are strongly encouraged to be submitted for commendation and recognition 1.3.1 A nomination for the Alameda County EMS Award can be submitted in addition to the EMS Event Report 1.3.11.4 Any suspected human trafficking - - 2. EMS EVENT REPORTING HOWTO: ► All EMS Event Reports must by submitted digitally. To submit a EMS Event Report: ► Scan the QR code on this page with any mobile device ► Go to https://tinyurl.com/alcoems-eventreport Link to EMS Event Reporting Form EMS EVENT REPORTING 100 Formatted: Font color: Auto, Not Expanded by / Condensed by Operations Modified On: January 1, 2025 EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION 1. EQUIPMENT AND SUPPLIES: The provider agency is responsible for providing a full inventory of equipment and supplies to its units 2. All ALS and BLS patient care response vehicles (transporting and non-transporting) shall have at a minimum, all equipment and supplies specified in Alameda County EMS Agency's "Minimum Equipment and Supply Specifications Policy. This policy does not supersede the California Vehicle Code or California Code of Regulations, Title 13 requirements for ambulance equipment. In addition, each patient care response vehicle shall have: 2.1 Adequate space in the patient care compartment to accommodate one stretcher, a patient(s) and two providers. There must be sufficient space to allow for patient care activities during transport 2.2 County approved communications equipment capable of contact with receiving hospitals, base hospitals, and other provider agencies during an MCI or mutual aid situation 2.3 Personal protective equipment in accordance with Cal/OSHA standards and/or California EMSA Guideline #216 3. Each ALS provider (transport and non-transport) shall have an approved controlled substance/medication restock procedure on file with the EMS Agency 4. INSPECTION: Alameda County EMS Agency personnel may inspect any BLS, CCT and/or ALS mobile unit at any time for compliance with the identified standards for equipment and personnel. ► Deficiencies may result in the unit's removal from service until the deficiencies are remedied ► The Alameda County EMS Agency will notify the service provider agency's designated management representative immediately of the infraction 5. EQUIPMENT AND SUPPLIES LIST: See the EMS Agency's website for the latest copy of the Equipment and Supplies List at: https://ems.acgov.org or by scanning the QR code below Link to Equipment and Supplies List EQUIPMENT AND SUPPLY REQUIREMENTS AND INSPECTION 101 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport AIRWAY EQUIPMENT ► Airways: 1 each 1 each 2 each  Oropharyngeal (Sizes 0 - 6)…………………………………… Commented \[ZK20\]: Consider removing and putting  Nasopharyngeal (soft rubber) 1 each 1 each 1 each » 14 Fr., 18 Fr., 22 Fr., 26Fr. ………………………….. on the website so can be updated easily. 1 1 1 » 30 Fr……………………………………………………. 1 1 2 » 32 Fr. …………………………………………………... 1 1 1 » 34 Fr. …………………………………………………... ► Atomizer for intranasal medication administration 2 1 3 ► County approved Continuous Positive Airway Pressure 1 1 (CPAP) Device Intubation Equipment:  County approved video laryngoscopy device……………….. 1 (optional) 1 (optional)  Laryngoscope (handle)………………………………………… 1 1  Batteries (extra)………………………………………………… 1 set 1 set  Adult Blades (Curved McIntosh) » # 4………………………………………………………. 1 1 » # 3………………………………………………………. 1 1  Pediatric Blades (Curved McIntosh) » # 2………………………………………………………. 1 1 » # 1………………………………………………………. 1 1  Adult Blades (Straight Miller) » # 4………………………………………………………. 1 1 » # 3………………………………………………………. 1 1  Pediatric Blades (Straight Miller) » # 2………………………………………………………. 1 1 » # 1………………………………………………………. 1 1  Magill Forceps » Adult……………………………………………………. 1 1 » Pediatric……………………………………………….. 1 1  Adult Endotracheal Intubation (ET) Tubes (cuffed with adaptor) 1 2 » Size 6.0………………………………………………… 1 2 » Size 6.5………………………………………………… » Size 7.0………………………………………………… 1 2 ®  i-gelSupraglottic Airway 1 (optional) 1 (optional) » Size 1.0………………………………………………… 1 1 » Size 1.5………………………………………………… 1 1 » Size 2.0………………………………………………… 1 1 » Size 2.5………………………………………………… 1 1 » Size 3.0………………………………………………… » Size 4.0………………………………………………… 1 1 » Size 5.0………………………………………………… 1 1  Tracheal tube introducer (bougie)…………………………….. 1 2  ET Tube Holder 2 3 » Adult……………………………………………………. 2 (optional) 2 5  Disposable Waveform Capnography………………………….  Nebulizer  Patient activated………………………………………………... 1 2  Hand-held for inhalation……………………………………….. 1 2  In-Line nebulizer equipment with 22 & 24 mm “T-piece”…… 1 2 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 102 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport ► Oxygen equipment and supplies:  OTank (portable)……………………………………………… 2 1 1 1  Non-rebreather masks (transparent) 2 1 2 » Adult……………………………………………………. 1 1 1 » Pediatric/Infant………………………………………… » Nasal cannula for Oadministration......................... 2 1 2 2 1 1 1 » Portable Pulse-Oximetry.......................................... » Adult end-tital COsampling nasal cannula……….. 1 1 2 » Pediatric end-tital COsampling nasal cannula…… 2 1 1 ► County-approved pleural decompression kit 1 2  BVM with Oreservoir and facemask 2  Adult……………………………………………………………… 1 1 1  Pediatric…………………………………………………………. 1 1 1  Infant…………………………………………………………….. 1 1 1  Suction and equipment supplies  Rigid Suction Catheter…………………………………………. 1 1 2  Suction apparatus (portable)………………………………….. 1 1 1  Suction catheters, pediatric: 6 Fr……………………………………………………... » 1 1 1 » 10 Fr……………………………………………………. 1 1 1 » 18 Fr……………………………………………………. 1 1 1  Suction Canisters………………………………………………. 1 1 1 DRESSING MATERIALS ► County Approved Chest Seals……………………………………. 2 2 ► Adhesive bandages (Assorted)…………………………………… 1 container 1 container 1 container ► Cold Pack…………………………………………………………… 2 2 2  Dressing Materials  4” x 4” gauze……………………………………………………. 6 12 12  10 x 30” or larger universal dressings………………………... 2 2 3  ABD pad (9 x 5”)………………………………………………... 2 2 2  Roller bandages » 2”……………………………………………………….. 1 2 2 » 3”……………………………………………………….. 1 2 2 » 4”……………………………………………………….. 2 2 2 ® TM  QuickClotCombat Gauze …………………………………. 1 (Optional) 1 (Optional) ► Elastic Bandage 3” (ACE Style Bandage)………………………. 1 1 1 ► Scissors (heavy duty)……………………………………………… 1 1 1  Splints – cardboard splint with a soft or cushioned surface,flexible, form-fitting splint (e.g., SAM or vacuum splint):  Adult Arm………………………………………………………... 1 1 2  Adult Leg………………………………………………………… 1 1 2 1 1  Traction Splint…………………………………………………...  Tape  1”…………………………………………………………………. 1 roll 1 roll 1 roll  2”…………………………………………………………………. 1 roll 1 roll 1 roll ► Triangular Bandage………………………………………………... 1 1 2 ► County Approved Tourniquet (for hemorrhage control) …… 1 1 1 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 103 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport EQUIPMENT AND SUPPLIES  Automated External Defibrillator (AED) equipment  Automated External Defibrillator – pediatric ready…………. 1  “Hands-off” defib pads » Adult……………………………………………………. 1 set » Pediatric……………………………………………….. 1 set ► Blanket Disposable…………………………………………………. 1 1 1  Blood pressure cuff (portable): ↓  Adult……………………………………………………………… 1 1 1  Large Adult...……………………………………………………. 1 1  Pediatric…………………………………………………………. 1 1 1  Infant……………………………………………………………... 1 1 ► Bulb Syringe (optional if supplied in Delivery Kit) 1 1 1 ► Burn Sheets (sterile) 1 1 1 ► CO Monitor 1 (Optional) 1 (Optional)  Delivery Kit Sterile, prepackaged to include: ↓  a minimum of two (2) umbilical cord clamps  scissors (may be packaged separately) 1 1 1  aspirating bulb syringe  gloves drapes  antiseptic solution ► EMS Field Manual (maybe print or digital copy) 1 1 1 ► Gloves, disposable 1 box 1 box 2 boxes ► Glucometer 1 1 1  Irrigation Equipment: ↓  Sterile Saline or Sterile Water for irrigation………………….. 2 1 (Optional) 2  Tubing for irrigation…………………………………………….. 1 ► EMS Approved Length Based Resuscitation Tape – (LBRT) 1 1 ► Lubricant, water soluble 2 packs 2 packs 2 packs ► County Approved Mechanical CPR Device 1 (Optional) 1 (Optional)  ↓ Monitor/defibrillator equipment:  Defibrillator………………………………………………………. Must have strip recorder, synchronized cardioversion and transcutaneous pacing capability, and be portable and operational. Both 1 1 monophasic and biphasic waveform defibrillators are acceptable; however, biphasic is preferred. Energy level dependent upon manufacturer.  Batteries, extra (if available) …………………………………... 1 set 1 set  “Hands-off” defib pads » Adult……………………………………………………. 1 set 1 set » Pediatric……………………………………………….. 1 set 1 set  EKG electrodes…………………………………………………. 3 packs 6 packs  12-lead EKG capability………………………………………… 1 1 ► Pen Light 1 1 1 ► Point of Wounding (POW) Kit (Items location in this kit may be 1 1 1 counted towards minimums of other items in this table) EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 104 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport ► Radio unit(s) (Must be able to function with all facets of the 1 1 1 current EBRCS radio system) ► Thermometer – patient safe 1 1 (Optional) 1 ► Triage Tags 20 20 20 ► Triage Tape 1 roll ea. - red, yellow, green, black 1 (optional for ► Scoop Stretcher or equivalent 1 IFT) ► Flexible multi-positional patient carrying device 1 (Optional) 1 (Optional) 1 (Optional) ► Stethoscope 1 1 1 ► Stretcher 1 1 IMMOBILIZATION EQUIPMENT ► Cervical collars – Stiff: 1 each 1 each 2 each size Sizes to fit all patients over one year old ► Head immobilizer: 1 1 2 that provides lateral and built-in occipital support…………………. ↓ Spine boards (rigid) ↓  Long board (72” x 14”) …………………………………………. 1 1 1 With removable 5-strap adjustable immobilization device 1 (Optional for  Pediatric Velcro straps and head harness…………………… 1 1 IFT) ► Vacuum Mattress 1 (Optional) 1 1 ► Athletic helmet face mask removal tool (optional) 1 1 1 IV EQUIPMENT/SYRINGES/NEEDLES  Armboards ↓  Short……………………………………………………………... 1  Pediatric…………………………………………………………. 1 1 ↓ Catheters  16 gauge………………………………………………………… 1 (optional) 2  18 gauge………………………………………………………… 2 2  20 gauge………………………………………………………… 2 2  22 gauge………………………………………………………… 2 2  24 gauge………………………………………………………… 2 2 ► Chlorhexidine………………………………………………………… 6 12 Handheld↓ Battery Powered Intraosseous Equipment ®  EZ-IODriver…………………………………………………… 1 1  15 mm Needle Set (pink hub, 3kg-39kg).…………………...... 1 (Optional) 2 (Optional)  25 mm Needle Set (blue hub, >3kg)…………………………... 1 2  45 mm Needle Set (yellow hub, >40kg with excessive tissue) 1 2  Vascular access pack………………………………………….. 1 2  Needles ↓  22 g x 1.5”……………………………………………………….. 1 4  23 g x 1”…………………………………………………………. 1 2  18g x 1 1/2” 5 micron filter needle (optional)………………… 1 2 ► Pressure Infusion Bags 1 1 ► Saline Lock 2 2  Syringes - Luer-Lock type ↓ EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 105 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport  1 mL……………………………………………………………… 1 1 2  3 mL……………………………………………………………… 1 2  10 mL…………………………………………………………….. 2 2  30 mL…………………………………………………………….. 2 2 ► T-connector 1 2 ► Tourniquet (for IV start) 1 1 ► Tubing – Adjustable flow 3-way or 2-way administration set 1 2 MEDICATIONS AND SOLUTIONS – preloads preferred ► Acetaminophen 1000 mg (optional) 1 2 ► Adenosine 6 mg / 2 mL NS 1 2 ► Adenosine 12 mg / 4 mL NS 1 2 ► Albuterol 2.5 mg in 3 mL NS 2 4 ► Amiodarone 150 mg in 3 mL or 150 mg in 100ml 2 3 premixed bag ► Aspirin 81 mg chewable tablet or 325 mg/5 gr. tablet 1 bottle 1 bottle 1 bottle ► Atropine Sulfate 1 mg / 10 mL 3 3 ► Autoinjector antidote kit (optional) 3 per person 3 per person 3 per person (atropine 2mg in 0.7mL’s & pralidoxime chloride 600mg in 2 mL’s) ► Calcium Chloride 1 gm / 10 1 1 ► Charcoal, 25 grams 1 bottle 2 bottles ► Dextrose 10% in 250mL bags 1 2 ► Diphenhydramine 50 mg / 1 mL 1 2 2 2 ► Epinephrine 1mg / mL 1 mg / 1 mL ► Epinephrine 0.1mg/mL 1 mg / 10 mL 3 3 1 of each ► Epinephrine Auto-Injectors Adult 0.3mg, Pediatric 0.15mg Auto-injector ► Epinephrine 1mg / mL 1 mg / 1 mL or 1 vial ► Fentanyl 100 mcg / 2 mL 2 2 ► Glucagon 1 mg Kit 1 1 ► Glucose (Oral) - 31 grams 2 2 2 ► Hydroxocobalamin 5g / 250ml Optional ► Ipratropium (Atrovent) 500 mcg (2.5 mL) 1 2 ► Ketamine (Ketalar) 500 mg / 10 ml (50 mg / ml) Min. 30 mg Min. 30 mg OR 10 mg / ml concentration (optional) ► Ketorolac (Toradol) 15mg / 1ml 1 1 ► Lidocaine 2% 40 mg / 2 mL 1 1 ► Midazolam 10 mg / 2 mL 2 2 2 2 2 ► Naloxone 2 mg / 2 mL ► Nitroglycerine 1 bottle 1 bottle ► Olanzapine (Zyprexa) 10mg oral dissolving tablets 2 2 ► Ondansetron (Zofran) 4mg / 2 mL for IV/IM injection 1 2 ► Ondansetron (Zofran) 4mg oral dissolving tablets 2 4 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 106 Operations Modified On: January 1, 2026 EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS ALS ALS BLS MINIMUM SUPPLY SPECIFICATIONS Non-Transport Transport ► Saline, sterile (for injection) 10 mL 2 2 ► Sodium bicarbonate 50 mEq / 50 mL 1 2 1 ► Sodium Thiosulfate 12.5 gms with 10 gtt/mL vented tubing (Supervisor or Battalion Chief) 1 1 ► Tranexamic Acid 1 gram in 100ml NS or D5W  Bags for infusion ↓  DW or Normal Saline 100mL 5 1 2  Normal Saline (NS) – May use 500mL or 1000 mL bags 1,000mL 2,000mL EQUIPMENT AND SUPPLY SPECIFICATIONS – ALS/BLS 107 Operations Modified On: July 24, 2018 INTERFACILITY TRANSFERS Note: This policy pertains to emergency transfers to a higher level of care that come through the 9-1-1 system. See “Scheduled Interfacility Transfers Using Paramedic Personnel” (policy #4605 Administration Policy Manual) for more information. 1. All patient care rendered by prehospital care personnel must be within the defined scope of practice according to Title 22 and Alameda County EMS protocols 2. A paramedic may only take orders from a base hospital physician. (See 5.2 below) There are no provisions for an EMT to take orders from a physician 3.2. EMT-Bs may only transfer a patient without an emergency medical condition; or, with an emergency medical condition that has been stabilized and has no potential (within reasonable probability) to deteriorate en route 4.3. Paramedics (in addition to 3) may only transport a patient who has not been stabilized to a facility that provides a higher level of care. The transferring physician must determine if the care that may be required during transport is within the scope of practice of a paramedic. If not, appropriate hospital staff and/or equipment should be sent with the patient 5. Base Contact by Paramedics 5.1 Base Contact is required prior to transport if the transferring physician orders any ALS treatment and/or the patient has not been stabilized 5.2 Paramedics may follow transferring physician's written orders ONLY when 1) the transferring physician speaks to the Base Physician, and they mutually agree on the course of treatment; 2) the proposed treatment plan is within the paramedic's scope of practice 5.3 Base Physician contact shall be made: ► When there is a request to transfer a patient to a higher level of care facility that is not the "closest, most appropriate" higher level of care facility. 5.4 Base Contact is not required if the patient is stable and no ALS treatment has been ordered by the transferring physician. If the patient's condition changes during transport see the appropriate patient care policy and treat accordingly 6.4. Base Contact may be made anytime a paramedic has a question regarding patient condition, destination and/ or the appropriateness of the transfer 7. An Alameda County Unusual Occurrence (U.O.) form should be completed for any problem-oriented interfacility transfers. The U.O. form should be sent to the EMS office for review. \[See Administration Manual UNUSUAL OCCURRENCES (#2300)\] 8.5. Refer to “Interfacility Transfer Guidelines” \[see Administration Manual INTERFACILITY TRANSFER GUIDELINES (# 5600)\] for transfer approval process INTERFACILITY TRANSFERS 108 Operations Modified On: December 1, 2011 IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 1. PURPOSE: To define the scope of practice of the EMT and paramedic with respect to the management of patients during emergency or routine transport from the field or during an interfacility transfer 2. Certified EMT or a supervised EMT student may: ► Assist patients with the administration of physician prescribed devices, including but not limited to, patient operated medication pumps, sublingual nitroglycerin, and self-administered emergency medications, including epinephrine devices ► Monitor intravenous lines delivering glucose solutions or isotonic balanced salt solutions including Ringer’s lactate for volume replacement; ► May monitor, maintain, and adjust if necessary in order to maintain, a preset rate of flow and turn off the flow of intravenous fluid; ► May transfer a patient, who is deemed appropriate for transfer by the transferring physician, and who has nasogastric (NG) tubes, gastrostomy tubes, heparin locks, foley catheters, tracheostomy tubes and/or indwelling vascular access lines, excluding arterial lines ► May Monitor preexisting vascular access devices and intravenous lines delivering fluids with additional medications pre-approved by the Director of the EMS Authority 3. Licensed Paramedics, in addition to the above may: ► Monitor and administer medications through pre-existing vascular access ► Monitor and adjust IV solutions containing potassium equal to, or less than, 20 mEq/L ► Transport and monitor a patient that has fluid and/or medication running through a central line, central venous access device, or heparin lock as long as the medications are within the paramedic scope of practice. Medications not included in the paramedic scope of practice may not be administered during transport. (12/21/05) 4. Infusion Devices - An EMT or Paramedic may transport a patient with an infusion device under the following conditions: ► The transport is authorized, in writing, by the patient's physician or is approved by the Base Hospital physician ► For BLS transport - the patient must be stable, non-critical and the purpose of the transport must be of a routine nature, such as a pre-scheduled appointment to a medical facility for examination or treatment (e.g. dialysis, chemotherapy, doctor's office visit) ► Paramedics should transport the patient if the reason for the transport is a change in condition or a new medical complaint ► The patient or trained family member must be present to monitor and regulate the device during the transfer, without any assistance from the EMT or paramedic ► If any doubt exists as to the ability of the patient or family member to manage the device or the device is not functioning properly, the patient should be assessed by ALS personnel and if appropriate, consultation with the Base Physician should be obtained 5. Ventilators: ► If during a response to a 911 or scheduled interfacility transport, an EMT – I discovers a patient on a ventilator that requires transport, a CCT – Paramedic or CCT – RN response shall be initiated ► Paramedics may disconnect the patient from the ventilator and assist ventilation using a bag-valve device. If it is in the best interest of the patient to remain on a ventilator during transport and a delay in transport will not compromise patient care or comfort, a CCT – Paramedic or CCT – RN response shall be initiated. If any doubt exists regarding the condition of the patient, the Base Physician should be consulted 6. Thoracostomy tubes: Only CCT - Paramedics may monitor thoracostomy tubes IV LINES & DEVICES, VENTILATORS & OTHER PATIENT CARE EQUIPMENT 109 Modified On: December 1, 2011 Operations MEDICAL PERSONNEL ON THE SCENE 1. MEDICAL PERSONNEL ON THE SCENE (non-physician) - If a bystander at the scene of an emergency identifies him/herself as a medical person, other than a physician, the First Responder or paramedic should: 1.1 Inform the individual that they may assist the emergency response team and/or offer suggestions, but may not assume medical management for the patient 1.2 Maintain overall scene management 2. PHYSICIAN ON THE SCENE - If a bystander at an emergency scene identifies him/herself as a physician: 2.1 BLS responder will work in conjunction with the physician until the arrival of ALS. 2.2 Paramedics should: ► give the physician a "Note to Physicians on Involvement with EMTs and Paramedics" card. (available at the EMS Office or on the EMS website.) The document below is a representation of the actual card) ► determine the alternative the physician has chosen (1, 2, or 3 on the card below) ENDORSED ALTERNATIVES FOR PHYSICIAN INVOLVEMENT STATE OF CALIFORNIA cma After identifying yourself by name as a physician licensed in the CALIFORNIA Sate of California, and, if requested, showing proof of identity, MEDICAL ASSOCIATION you may choose one of the following: NOTE TO PHYSICIANS ON INVOLVEMENT WITH 1. Offer your assistance with another pair of eyes, hands or EMTs AND PARAMEDICS suggestions, but let the life support team remain under A life support team (EMT or Paramedic) operates under stan- base hospital control; or, dard policies and procedures developed by the local EMS 2. Request to talk to the base station physician and directly agency and approved by their Medical Director under Authority offer your medical advice and assistance; or, of Division 2.5 of the California Health and Safety Code. The drugs they carry and procedures they can do are restricted by 3. Take total responsibility for the care given by the life law and local policy. support team and physically accompany the patient If you want to assist, this can only be done through one of the until the patient arrives at a hospital and responsibility alternatives listed on the back of this card. These alternatives is assumed by the receiving physician. In addition, you have been endorsed by CMA, State EMS Authority, CCLHO and must sign for all instructions given in accordance with BMQA. local policy and procedures. (Whenever possible, remain Assistance rendered in the endorsed fashion, without com- in contact with the base station physician) pensation, is covered by the protection of the Good Samaritan Code@ (see Business and Professional Code, Sections 2144, (REV. 1/12) 88 49638 Provided by the EMS Authority 2395-2298 and Health and Safety Code, Section 1799.104). (over) ► ALTERNATIVE #1 - If the physician on scene chooses alternative #1, the physician should assist the paramedic team or offer suggestions but allow the paramedics to provide medical treatment according to County protocol ► ALTERNATIVE #2 or ALTERNATIVE #3 - If the physician on scene chooses alternative #2 or #3 the paramedics should ask to see the physician's medical license, unless the physician is known to the paramedics. Contact the Base Physician and have the physician on scene speak directly with the Base Physician 3. BASE HOSPITAL PHYSICIAN RESPONSIBILITY - After speaking to the physician on scene, the Base Physician should evaluate the situation and decide which of the available alternatives is in the best interests of the patient. These alternatives include: 3.1 retain medical control and request the physician on scene to assist the paramedics and/or offer suggestions only (alternative #1); or, 3.2 retain medical control but consider suggestions offered by the physician on scene (alternative #2); or, 3.3 delegate medical control to the physician on scene (alternative #3) MEDICAL PERSONNEL ON THE SCENE 110 Modified On: December 1, 2011 Operations MEDICAL PERSONNEL ON THE SCENE 4. PARAMEDIC RESPONSIBILITY 4.1 Alternative #1 or #2: ► Maintain medical control of the patient and provide medical treatment according to County Protocol 4.2 Alternative #3: ► ALS equipment and supplies should be made available to the physician. Offer assistance as needed ► The physician must go with the patient in the ambulance to the receiving hospital ► Document all care rendered to the patient on the EHR and ensure that the physician signs for all instructions and medical care given ► If appropriate, maintain communication with the Base Hospital or recontact if any problems arise 5. An EMS Unusual Occurrence Event Form shall be completed: 5.1 On any Physician or Medical Personnel on-scene calls if there was a problem associated with care rendered 5.2 For physician on-scene call if Alternative #3 was chosen (paramedics only) MEDICAL PERSONNEL ON THE SCENE 111 Operations Modified On: December 1, 2011 ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE 1. INTRODUCTION: Ambulance response to the scene of a motor vehicle accident shall only be dispatched through County Dispatch (ALCO-CMED 925-422-7595). If a non-contract ambulance company is called to respond to an accident, the dispatcher should immediately call County Dispatch to initiate the appropriate public safety and ambulance response. 2. Ambulance First on Scene 2.1 If an ambulance unit witnesses an accident, the accident should be reported to their dispatch for initiation of appropriate public safety and/or emergency ALS ambulance personnel 2.2 If there are no first responders on scene and the crew is not en route to a medical emergency or transporting a patient code 3, they should stop to ascertain if there are injuries. If there are injuries, they are to render appropriate care within their scope of practice 2.3 If an emergency ALS ambulance has already been dispatched, the ambulance should not transport unless the delay might jeopardize the patient. The decision to transport should be made based upon the patient’s condition and the estimated time of arrival (ETA) of the emergency ALS ambulance 2.4 If an emergency ALS ambulance has not been dispatched but the patient’s condition is such that immediate transport is not required, the crew should request County Dispatch to dispatch an emergency ALS ambulance 3. Public Safety on Scene (police, CHP, fire) but no Ambulance Personnel 3.1 Stop to ascertain if assistance is required. The crew should notify the officer on-scene that they have not been dispatched to this call 3.2 If an emergency ALS ambulance is not on the scene, medical authority rests with the most medically qualified responder. The decision to wait for an emergency ALS ambulance or to authorize transport by the ambulance is the responsibility of the most medically qualified responder, who should consider the condition of the patient, whether an ambulance has been requested through County Dispatch and the ETA of the emergency ALS ambulance 3.3 If the emergency ALS ambulance arrives on scene, medical authority rests with the personnel of the emergency ALS ambulance. This individual(s) should determine if assistance from the on-viewing ambulance is required 4. Responsibility of an Ambulance Transporting from Scene 4.1 If the ambulance transports a patient(s) from an accident scene in accordance with this policy, and no other patients remain at the scene, County Dispatch should be immediately informed so that any additional responding units may be cancelled 4.2 The transporting ambulance should notify the receiving hospital emergency department by radio, cellular phone, or through their dispatch of their imminent arrival (see page 135) 4.3 A patient care report on the patient’s condition and treatment should be left at the emergency department. A copy of the report and an unusual occurrenceEMS event form explaining the circumstances of the transport shall be submitted to the county within ten (10) days ON VIEWING AN ACCIDENT - NON-CONTRACT AMBULANCE 112 Operations Modified On: December 1, 2011 PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS 1. PURPOSE: To allow Paramedic Field Supervisors to utilize ALS skills, within their scope of practice, while functioning in the role of Field Supervisor 2. Paramedic Field Supervisors must carry all of the ALS equipment authorized in Alameda County as per policy 3. Paramedic Field Supervisors must be able to perform all ALS procedures authorized in Alameda County as per policy 4. Each ALS provider agency planning to use Paramedic Field Supervisors in the role of care- giver must develop policies and procedures to assure that appropriate equipment and supplies are stocked and checked 5. In all instances, if a Paramedic Field Supervisor initiates any ALS procedure or administers any medications, prior to the arrival of an ALS unit, he/she must assist with documentation on the EHR and sign the EHR as a team member 6. The paramedic Field Supervisor may transfer the care of the patient to the arriving ALS unit after giving a report 7. The paramedic Field Supervisor will not be required to accompany the patient to the hospital unless requested by the arriving ALS unit PARAMEDIC FIELD SUPERVISORS - UTILIZATION OF ALS SKILLS 113 Operations Modified On: July 24, 2018 RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING 1. GENERAL PRINCIPLES: In general, it is better to respond with more personnel and equipment than is needed and cancel excess assigned resources, than fail to dispatch appropriate personnel and equipment. First Responder and transport units should be dispatched in accordance with MPDS-based guidelines as approved by County EMS when there is a report of people who are ill or injured 2. CANCELING RESPONDING UNITS: Medical personnel first on the scene of an incident: 2.1 shall cancel a responding ambulance unit upon determination that, in the best judgment of the first responder, the incident does not involve an injury or illness. The ambulance should not be canceled if the patient is requesting care and transport, even if there is no apparent illness or injury 2.2 shall cancel the ambulance response if the patient meets the "Determination of Death" criteria or the patient has a valid Alameda County or California Medical Association (CMA) "Do Not Attempt Resuscitation" form (see "Determination of Death in the Field" page 92) 2.3 Ambulance personnel arriving first on the scene of a medical emergency shall cancel the First Responder/Law enforcement response only if assistance is not needed and a potential public safety risk does not exist at the emergency scene 3. UPGRADING RESPONDING UNITS: Medical personnel first on the scene of an incident should upgrade a responding unit to a "non-divertible" response status: 3.1 If it is determined by first on-scene medical personnel that the patient’s illness/injury meets any of the time-sensitive conditions requiring expedited transport criteria below: 3.1.1 Patients found to be experiencing a STEMI by 12-lead ECG 3.1.2 Patients shown to have findings of an active CVA within the current time treatment window 3.1.3 Patients who meet “Trauma Patient Criteria” as defined on page 25 of this book 3.1.4 Patients who have significant compromise to their airway, breathing, circulation and/or vital signs 3.1.43.1.5 Patients whose situation as deemed by clinical assessment to need more immediate care 3.2 If a life-threatening scene safety issue(s) exists Commented \[ZK21\]: Too vague? How to define clinical judgement 4. DOWNGRADING RESPONDING UNITS: Medical personnel first on the scene of an incident: 4.1 shall reduce the responding resource(s) from Code 3 to Code 2 upon determination that, in the best judgment of the first medical personnel on-scene, the illness or injury is not immediately life threatening or that the difference in Code 3 and Code 2 response time would not likely have an impact on patient outcome. Formatted: Font color: Auto, Not Expanded by / Condensed by RESPONDING UNITS - CANCELING / UPGRADING / DOWNGRADING 114 Operations Modified On: January 1, 2025 RESTRAINTS 1. Patient restraints are to be utilized only when necessary and, in those situations, where the patient is exhibiting behavior deemed to present danger to him/herself or to the field personnel. When restraints are used: 1.1 The minimum restraint necessary, to accomplish necessary patient care and safe transportation, should be utilized 1.2 Circulation to the extremities (distal to the restraints) will be evaluated q 5 minutes 1.3 Leather or soft restraints, designed specifically for patient restraint, are the only authorized method of restraining patients. 1.4 The restraints must not be placed in such a way as to preclude evaluation of the patient's medical status (e.g. airway, breathing, circulation) necessary patient care activities, or in any way jeopardize the patient medically 2. If the patient is under arrest and handcuffs are applied by law enforcement officers: 2.1 The patient will not be cuffed to the stretcher, and a law enforcement officer shall accompany the patient in the ambulance, if the handcuffs are to remain applied 2.2 A law enforcement officer may elect to follow the ambulance in a patrol car to the receiving facility if the patient has been restrained on the gurney using leather or soft restraints RESTRAINTS 115 THIS PAGE INTENTIONALLY LEFT BLANK 116 Procedures Modified On: December 1, 2011 PROCEDURE POLICIES TOC PROCEDURE POLICIES TOC .......................................................................................... 117 ADVANCED AIRWAY MANAGEMENT............................................................................... 118 CONSENT AND REFUSAL GUIDELINES ......................................................................... 120 CONTINUOUS POSITIVE AIRWAY PRESSURE – CPAP ............................................ 124 ECG - 12 LEAD...................................................................................................................... 126 HEMORRHAGE CONTROL ................................................................................................. 127 INTRANASAL (IN) MEDICATION ADMINISTRATION ....................................................... 129 INTRAOSSEOUS ACCESS PROCEDURE ........................................................................ 130 PLEURAL DECOMPRESSION .............................................................................................. 131 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES ....................................................... 132 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES- OLANZAPINE ........................... 133 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS ..................................................... 134 REPORTING FORMAT ........................................................................................................ 135 SEDATION ............................................................................................................................. 136 SPINAL INJURY ASSESSMENT ......................................................................................... 137 SPINAL MOTION RESTRICTION (SMR) ......................................................................... 139 STOMA AND TRACHEOSTOMY ........................................................................................... 140 TRANSCUTANEOUS PACING - TCP ............................................................................... 142 TRANSFER OF CARE.......................................................................................................... 143 TRIAGE TO WAITING ROOM ............................................................................................. 144 TXA - TRANEXAMIC ACID .................................................................................................. 145 STROKE ASSESSMENT SCALES (CPSS AND PSS) .................................................... 146 PROCEDURE POLICIES TOC 117 Procedures Modified On: June 21, 2023 ADVANCED AIRWAY MANAGEMENT 1. INTRODUCTION: The approved airway management procedure consists of endotracheal intubation (ETI) or insertion of a supraglottic airway (SGA) device. ***Nasotracheal intubation is NOT an approved skill in Alameda County*** 1.1 Manage the patient's airway with proper airway positioning, simple airway adjuncts, suctioning, and BVM ventilation as necessary with all patients. 1.2 For patients ≥ 40kg, personnel are authorized to perform the skill of endotracheal intubation or placement of an SGA. 1.3 For patients < 40kg, BVM ventilation is the preferred method of ventilatory management. If BVM ventilation is unsuccessful or impossible, a SGA device may be placed. 1.4 If advanced airway placement will interrupt chest compressions, providers may consider deferring insertion of the airway until the patient fails to responds to initial CPR and defibrillation or demonstrates ROSC (2015 AHA Guidelines) 1.5 Personnel must confirm tube placement (ETI or SGA) with capnography / capnometry, auscultation and physical assessment (auscultation, observation of chest rise, visualization of the tube passing through the cords, etc.). See Section #4. 2. INDICATIONS: 2.1 Non-traumatic cardiac and/or respiratory arrest. 2.2 Traumatic cardiac and/or respiratory arrest or severe ventilatory compromise where the airway cannot be adequately maintained by BLS techniques. 3. APPROVED ADVANCED AIRWAY MANAGEMENT PROCEDURE: 3.1 Endotracheal intubation 3.1.1 Definition: An intubation attempt is defined as the insertion of the laryngoscope blade into the patient's mouth. 3.1.2 All ETI attempts should be performed with two providers. 3.1.3 All ETI attempts must utilize a gum elastic bougie device when direct laryngoscopy (DL) or non- channeled video laryngoscopy (VL) is utilized. Channeled VL does not require bougie utilization. 3.1.4 The maximum ETT size that can be utilized for ETI is 7.0mm. 3.1.5 Make no more than 2 total intubation attempts per patient. Each attempt should not last longer than 30 seconds. Ventilate with 100% oxygen for one minute prior to each attempt. 3.1.6 If patient has a Cormack-Lehane* grade of 3 or 4 (epiglottis is not or is barely visible), consider primary use of a supraglottic airway. ADVANCED AIRWAY MANAGEMENT 118 Procedures Modified On: May 10, 2019 ADVANCED AIRWAY MANAGEMENT ® 3.2 Supraglottic Airway Device (i-gel) 3.2.1 Definition: A supraglottic airway attempt is defined as the insertion of the supraglottic airway device into the patient's mouth. ® 3.2.2 For patients ≥ 40kg, a supraglottic airway (i-gel) device may be placed as a primary airway (if Cormack- Lehane grade is 3 or 4) or after unsuccessful attempt(s) at endotracheal intubation. 3.2.3 For patients < 40kg, BVM ventilation is the preferred method of ventilatory management. If BVM ventilation is unsuccessful or impossible, an SGA device may be placed ® 3.2.4 The i-gelSGA device comes in seven sizes determined by the patient's weight: Size 5 4 3 2.5 2.0 1.5 1.0 Weight (kg) >90kg 50-90kg 30-60kg 25-35kg 10-25kg 5-12kg 2-5kg 3.2.5 The patient should be in the sniffing position. The chin should be gently pressed down/inferior before proceeding to insert the i-gel device. 3.2.6 Introduce the leading soft tip into the mouth of the patient in a direction toward the hard palate. 3.2.7 Glide the i-gel device downwards and backwards along the hard palate with a continuous, but gentle push until definitive resistance is felt. 3.2.8 Do not apply excessive force during insertion. 3.2.9 If unexpected resistance is met during insertion, apply jaw-thrust and slightly rotate the device. ® 4. CONFIRM TUBE PLACEMENT: To be used on an endotracheal tube or the i-geldevice in the order listed below 4.1 Visualize the ETT passing through the vocal cords and look for chest rise with ventilation (for ETT only). 4.2 Auscultate both lung fields for breath sounds. Listen over left upper quadrant of the abdomen for air in the stomach 4.3 Waveform capnography/capnometry must be continuously monitored. 4.4 Document. All devices used to confirm ETT/SGA placement should be electronically uploaded into and documented on the patient's EHR. 4.4.1 Describe waveform (e.g. box, shark fin, straight line, bumpy line, etc.) 4.4.24.4.1 Capnometry number in mmHg (e.g.15 mmHg) should be, at a minimum, documented at the initiation of monitoring, after every patient movement, and at transfer of patient care. 4.5 If there is any doubt as to proper placement of the endotracheal tube, visualize the pharynx and vocal cords with laryngoscope and use capnographic waveform to make a decision. If still in doubt, suction the patient, deflate the cuff, remove the endotracheal tube and replace with a supraglottic airway. (Be prepared - removal of an ET tube may induce vomiting). Ventilate between attempts with 100% oxygen 5. If the patient regains consciousness while intubated, do not extubate. Use restraints as necessary to prevent uncontrolled extubation. Consider Sedation (see Sedation page 136) 6. If the patient has a suspected spinal injury: ► Open the airway using a jaw-thrust without head extension ► If airway cannot be maintained with jaw thrust use a head-tilt/chin-lift maneuver ► Manually stabilize the head & neck rather than using an immobilization device during CPR ADVANCED AIRWAY MANAGEMENT 119 Procedures Modified On: January 1, 2025 CONSENT AND REFUSAL GUIDELINES 1. PATIENT DEFINITION: 1.1 A 'patient' is an individual meeting anyone one of the following criteria: ► Requests evaluation for potential illness or injury ► Medical assistance has been requested for the individual by another person ► Has obvious evidence of illness or injury ► Has experienced an acute event that could reasonably lead to illness or injury ► Is in a circumstance or situation that could reasonably lead to illness or injury ► A person who is deceased ► A person who demonstrates impaired psychiatric function or suicidal intent ► An assessment was performed (V/S, history, diagnostic, physical exam) 2. DOCUMENTATION OF NON-PATIENT / PATIENT CONTACTS 2.1 If a person does not meet the definition of a patient in Section 1, detailed patient information is not required to be entered into the EHR. 2.2 If a person meets the definition of a patient in Section 1, they shall be offered a treatment and/or transport after a complete assessment which shall include a full set of vital signs. Patients/Designated Decision Makers (DDM) with mental capacity have the right to refuse any or all treatment(s) and/or transport as long as EMS personnel have explained the care and the patient/DDM demonstrates capacity as defined below. 3. PATIENTS WHO MAY LEGALLY GIVE CONSENT OR REFUSE MEDICAL TREATMENT ARE AS FOLLOWS: 3.1 Is an adult (18 years old or older) with mental capacity 3.2 A minor who is: 3.2.1 Legally emancipated 3.2.2 Lawfully married 3.2.3 On Active Duty with the Armed Forces 3.2.4 >12 years old seeking prevention or treatment of pregnancy or sexual assault 3.2.5 >12 years old seeking treatment of rape, contagious diseases, alcohol, or drug abuse 3.3 A patient who has a Designated Decisions Maker (DDM) 3.3.1 A Designated Decision Maker (DDM) is defined as: An individual to whom the patient or a court has given legal authority to make medical decisions concerning the patient’s healthcare (a parent or Durable Power of Attorney DPOA) 4. ASSESS AND RELEASE (AAR) FROM EMS CARE DEFINITION: 4.1 A patient who, after assessment by EMS personnel, does not desire treatment and/or transport to an emergency department 5. ASSESS AND RELEASE (AAR) FROM EMS CARE CRITERIA: 5.1 EMS clinician and the patient or DDM agree that the illness/injury does not require immediate treatment/ transport via emergency/911 services 5.2 In order to release care, a patient, parent, or guardian must have legal and mental decision-making capacity by meeting all of the following criteria: 5.2.1 Understands the nature of the medical condition, and the risks and consequences of not seeking treatment now 5.2.2 Exhibits evidence of decision-making capacity sufficient to understand the nature of the medical condition as well as the risks and potential consequences of not seeking additional medical care/ transport 5.2.3 Exhibits no evidence of: ► Altered level of consciousness ► Alcohol or drug ingestion that impairs decision-making capacity CONSENT AND REFUSAL GUIDELINES 120 Procedures Modified On: January 1, 2025 CONSENT AND REFUSAL GUIDELINES 5.3 EMS personnel should advise the patient/DDM of alternative care and transport options, which may include directing them to other services: 5.3.1 Private transport to a clinic, physician’s office, or an Emergency Department 5.3.2 Telephone consultation with a physician 6. ASSESS AND RELEASE (AAR) FROM EMS CARE DOCUMENTATION ESSENTIALS: 6.1 What the patient is refusing (i.e. medical care, transport) 6.2 Why the patient is refusing care and their plan for follow up care 6.3 The apparent capacity of the patient to refuse care 6.4 The presence or absence of impairment (i.e. drugs, alcohol, or significant head trauma) 6.5 Risk and consequence of refusing care as explained to the patient or legal representative 6.6 Statement that the patient understands the risks and consequences of refusing care 6.7 The patient understanding that they may re-access 911 if needed 6.8 Signature of patient or legal representative refusing care 6.9 Documentation that interpreter was used, when appropriate 6.10 Under “Reason for Refusal or Release” choose "Patient/Guardian states intent to transport by other means" or "Released following protocol guidelines” as disposition category in EHR 7. AGAINST MEDICAL ADVICE (AMA) DEFINITION: 7.1 A patient who after assessment by ALS personnel is recommended to accept treatment and/or transport, but refuses 8. AGAINST MEDICAL ADVICE (AMA) CRITERIA: 8.1 EMS clinician advises the patient or DDM to receive treatment and transport. The patient or DDM refuse medical care against the advice of the EMS clinician 8.2 In order to refuse care, a patient, parent, guardian, or DDM must have legal and mental decision-making capacity by meeting ALL of the following criteria: 8.2.1 Understands the nature of the medical condition, and the risks and consequences of refusing care 8.2.2 Exhibits evidence of decision-making capacity sufficient to understand the nature of the medical condition as well as the risks and potential consequences of not seeking additional medical care/ transport 8.2.3 Exhibits no evidence of: ► Altered level of consciousness; ► Alcohol or drug ingestion that impairs decision-making capacity; ► Danger to self or others 9. AGAINST MEDICAL ADVICE (AMA) DOCUMENTATION ESSENTIALS: 9.1 What the patient is refusing (i.e. medical care, transport) 9.2 Why the patient is refusing care and their plan for follow up care 9.3 The apparent capacity of the patient to refuse care 9.4 The presence or absence of impairment (i.e. drugs or alcohol) 9.5 Risk and consequence of refusing care as explained to the patient or legal representative 9.6 Statement that the patient understands the risks and consequences of refusing care 9.7 The patient understanding that they may re-access 911 if needed 9.8 Signature of patient or legal representative refusing care 9.9 Documentation that interpreter was used, when appropriate 9.10 Under “Reason for Refusal or Release” choose AMA as disposition category in EHR CONSENT AND REFUSAL GUIDELINES 121 Procedures Modified On: January 1, 2025 CONSENT AND REFUSAL GUIDELINES 10. BASE CONTACT: Can be made to help convince the patient to receive treatment and/or transport when the refusal would cause potential harm or death to the patient 11. PEDIATRIC CONSIDERATIONS: Parents or guardians who refuse treatment and/or transport for pediatric patients whom the clinician feels should receive treatment and/or transport deserve special consideration 11.1 Base contact should be made, as well as considering law enforcement involvement to encourage treatment and/or transport. 11.2 Consider potential abuse or neglect of the child in the parent or guardian’s refusal. 12. SPECIAL CONSIDERATIONS: 12.1 Consider early involvement of law enforcement if there is any threat to self, others or grave disability. 12.2 If the patient cannot legally refuse care or is mentally incapable of refusing care, document on the PCR that the patient required immediate treatment and/or transport, and lacked the mental capacity to understand the risks/ consequences of the refusal (implied consent) 12.3 At no time are field personnel to put themselves in danger by attempting to transport or treat a patient who refuses. At all times, good judgment should be used, appropriate assistance obtained, and supporting documentation completed 12.4 An individual under arrest or incarcerated, or on a 5150 is legally capable of consenting or refusing medical care but cannot refuse transport. 12.5 If you cannot complete the refusal of service log due to scene safety issues or upon the insistence of another agency, complete an EMS Event form and send it to the EMS Agency CONSENT AND REFUSAL GUIDELINES 122 No Procedures Modified On: January 1, 2025 CONSENT AND REFUSAL GUIDELINES 13. CONSENT AND REFUSAL GUIDELINES WORKFLOW: Is this person a patient? A patient is defined as any one of the following:  Requests evaluation for potential illness or injury  Medical assistance has been requested for the individual by another person  Has obvious evidence of illness of injury  Has experienced an acute event that could reasonably lead to illness or injury  Is in a circumstance or situation that could reasonably lead to illness or injury  A person who is deceased  A person who demonstrates impaired psychiatric function or suicidal intent  An assessment was performed (v/s, history, diagnostic, physical exam) Yes Assessment Does the Transport Does the patient patient No Does the to need emergent Transport Yes Yes request Yes patient agree receiving treatment or to transport? to transport? center transport? receiving center No Who can consent or refuse Involve Can the person Can the person Involve treatment and transport? DPOA for consent to refusal No consent to refusal DPOA or No ▪ Patients who are ≥ 18 years of Assess and of care or of care or LE age with mental capacity transport? transport? Release ▪ A minor who is either: Yes o Legally emancipated, or Yes o Lawfully married, or o On Active Duty with the Assess and AMA Armed Forces Release Against Medical Advice Definition (AMA): Assess and Release (AAR) From EMS Care Definition: A patient or who, after assessment by A patient who, after assessment and EMS clinicians, does not desire treatment and/or recommendation from Advanced Life Support EMS transport to an emergency department and does not clinicians for treatment and/or transport, the patient meet protocol criteria for an emergency medical who has decision-making capacity or the legal condition for treatment and/or transport to an representative, declines treatment and/or transport. emergency department. Against Medical Advice Criteria: Assess and Release from EMS Care Criteria: EMS clinician advises the patient or designated EMS clinician and the patient or designated decision maker (DDM) agree that the illness/injury does not decision maker (DDM) to receive treatment and require immediate treatment /transport via transport. The patient or DDM refuse medical care against the advice of the EMS clinician. emergency /911 services and the patient and/or DDM does not want to be transported. Base Contact Considerations: Pediatric Consideration ▪ See Consent and Refusal Guidelines Section 11.0 Special Consideration ▪ See Consent and Refusal Guidelines Section 12.1 -12.5 CONSENT AND REFUSAL GUIDLINES 123 Procedures Modified On: December 1, 2011 CONTINUOUS POSITIVE AIRWAY PRESSURE - CPAP 1. PURPOSE: To improve ventilation and oxygenation and avoid intubation. CPAP is required for all ALS providers. 2. INDICATIONS: Patients age 8 or older in severe respiratory distress and: ► CHF with pulmonary edema ► Near-drowning ► Other causes of severe respiratory distress 3. CONTRAINDICATIONS - Bag-valve-mask ventilation or endotracheal intubation should be considered for any patient who exhibits one or more of the following contraindications 3.1 Absolute Contraindications (DO NOT USE): ► Age < 8 ► Respiratory or cardiac arrest ► Agonal respirations ► Severely depressed level of consciousness ► Systolic blood pressure < 90 ► Signs and symptoms of pneumothorax ► Inability to maintain airway patency ► Major trauma, especially head injury with increased ICP or significant chest trauma ► Facial anomalies or trauma (e.g., burns, fractures) ► Vomiting 3.2 Relative Contraindications (USE CAUTIOUSLY): ► History of Pulmonary Fibrosis ► Decreased LOC ► Claustrophobia or unable to tolerate mask (after first 1-2 minutes trial) 4. COMPLICATIONS: ► Hypotension ► Pneumothorax ► Corneal Drying 5. GOALS OF CPAP: ► Elimination of dyspnea ► Decreased respiratory rate ► Decreased heart rate ► Increased Sp0 2 ► Stabilized blood pressure Bag-valve-mask ventilation or endotracheal intubation should be considered if the patient fails to show improvement based on the above goals. CONTINUOUS POSITIVE AIRWAY PRESSURE - CPAP 124 Procedures Modified On: December 1, 2011 CONTINUOUS POSITIVE AIRWAY PRESSURE - CPAP For all CPAP patients: 6. FAILURE TO IMPROVE: Should the patient fail to show improvement with CPAP (as evidenced by any of the following) remove the CPAP device and assist ventilations with BVM, as needed 6.1 Sustained or increased heart rate, 6.2 Sustained or increased respiratory rate, 6.3 Sustained or increased blood pressure, 6.4 Sustained or decreasing pulse oximetry readings, and/or 6.5 Decrease in level of consciousness 7. DOCUMENTATION: 7.1 The use of CPAP must be documented on the EHR 7.2 Vital signs (BP, HR, RR, Sp0 2) must be documented every 5 minutes. 7.3 Narrative documentation should include a description of the patient's response to CPAP. Refer to "Goals of CPAP" for descriptive terms that may be useful 7.4 Additional narrative documentation should include if the patient does not respond to CPAP and endotracheal intubation is required CONTINUOUS POSITIVE AIRWAY PRESSURE - CPAP 125 above by the assigned color association. lead ECG represent the same heart region, as indicatedContiguous leads in a 12 LeadsLimb LeadsPrecordial (Chest)LLRL LARA Procedures Modified On: January 1, 2026 ECG – 12 Lead 1. INDICATIONS: Patients should receive a 12-lead electrocardiogram (ECG) when they present with one or more of the following acute coronary syndrome (ACS) signs or symptoms: ► Anxiety ► Fatigue ► Chest discomfort ► General weakness ► Diaphoresis ► Nausea or vomiting ► Palpitations ► Discomfort or tightness radiating to the jaw, shoulder or arms ► Return of spontaneous circulation (ROSC) ► Dizziness following a cardiac arrest ► Dyspnea ► Syncope, near syncope ► Epigastric discomfort 2. PROCEDURE: Place limb lead electrodes on the wrists and ankles, rather than the torso, whenever possible. When applying the limb leads avoid positioning the electrodes over bony areas. Attach the six precordial (chest) leads directly to the chest wall as described: th ► V1 4intercostal space to the right of the sternum th ► V2 4intercostal space to the left of the sternum ► V3 Directly between leads V2 & V4 th ► V4 5intercostal space at the midclavicular line ► V5 Level with V4 at the left anterior axillary line ► V6 Level with V5 at the left midaxillary line 3. INTERPRETATION: ST segment elevation in two or more contiguous leads meets the criteria for a ST elevation myocardial infarction (STEMI). This may be identified by the paramedic or the ECG monitor. When the monitor detects an acute STEMI, the 12-lead ECG interpretation language will be displayed as follows: ► Stryker/Lifepak Monitor: *** MEETS ST ELEVATION MI CRITERIA *** ► Zoll Monitor: *** STEMI *** 4. ECG TRANSMISSION: The first positive STEMI 12-lead should be immediately transmitted to the STEMI Receiving Center, followed by an early pre-arrival notification. Attach all 12-lead ECG tracings to the electronic health record (EHR). 5. SPECIAL CONSIDERATIONS: ► STEMIs can evolve during prehospital care. The 12-lead ECG should not be detached after a 12-lead is negative for STEMI. The monitor will perform serial ECGs if it detects cardiac changes, following the initial 12-lead recorded by that device. ► For patients with breast tissue, do not place precordial (chest) leads directly over the breast, as the tissue may reduce electrical signal detection, potentially leading to ECG misinterpretation. Ensure electrodes are positioned directly on the chest wall for accurate readings. ► Do not perform a Right-Sided 12-lead after a STEMI has been identified, as the patient’s treatment plan will remain unchanged regardless of the findings. ECG - 12 Lead 126 Procedures Modified On: May 10, 2019 HEMORRHAGE CONTROL 1. INTRODUCTION: Controlling severe bleeding from an extremity injury can be challenging (especially in the lower limbs). Use of a County-approved tourniquet can assist in the care of patients with uncontrollable bleeding in the extremities safely and effectively when the appropriate precautions are taken. Approved for both ALS and BLS. 2. INDICATIONS: ► Amputation ► Mass casualty event ► Failure to stop bleeding with pressure dressing(s) ► Significant extremity hemorrhage in the face of any or all of: ► Injury does not allow control of bleeding with pressure dressing(s) • Need for airway management ► Impaled foreign body with ongoing extremity bleeding • Need for breathing support • Circulatory shock ► Under difficult or dangerous situation for responding • Need for other emergent interventions or caregivers assessment • Significant bleeding from multiple locations 3. TOURNIQUET: Place County-approved tourniquet according to manufacturer's instructions 4. WOUND PACKING: Significant uncontrolled bleeding from extremity and junctional (shoulder or groin) wounds may be packed with standard or hemostatic gauze. Wounds to the chest, abdomen, or pelvis should not be packed. 5. HEMOSTATIC AGENT: After tourniquet placement, and to aid in severe arterial bleeding; or to control severe bleeding where tourniquets are not indicated (trunk, head, neck, etc), use of a hemostatic gauze is indicated. Use of hemostatic gauze is optional. 6. PROCEDURE: Any standard gauze or County-approved hemostatic gauze may be utilized HEMORRHAGE CONTROL 127 Yes §AlgorithmTourniquet Removal transport and on transport and tourniquet Retighten (leave it in place) tourniquet loosen dressing, applying pressureAfter tourniquet. loosening before dressing pressure needed as Reassess No from Bleeding Significant Yes No extremity? Amputated Yes transport and on algorithm removal Go to tourniquet No resources? or personnel Limited Yes No situation? clinical Unstable Yes No shock? circulatory in Patient Procedures Modified On: May 6, 2013 HEMORRHAGE CONTROL Significant Extremity Bleeding Yes No with need for other interventions?* Go to Before applying a * Apply tourniquet to appropriate tourniquet, and if time bleeding limb(s) on permits, attempt to control protocol proximal segment bleeding via direct pressure Transport time Yes > 30 minutes No expected? Go to tourniquet Leave on and transport reassessment algorithm § NOTE: Do not go to the Tourniquet Removal Algorithm unless transport time is greater than 30 minutes AND criteria have been met in the Tourniquet Reassessment Tourniquet Reassessment Algorithm Algorithm for removal HEMORRHAGE CONTROL 128 Procedures Modified On: May 13, 2015 INTRANASAL (IN) MEDICATION ADMINISTRATION 1. INDICATIONS: ► Fentanyl for pain management ► Naloxone for suspected opiate overdose on patients who are apneic or near-apneic with a pulse -or- ► Midazolam for seizures or sedation 2. PROCEDURE: 2.1 Assess ABC’s (Airway, Breathing, Circulation) 2.2 For pulseless patient, go to appropriate cardiac arrest protocol 2.3 Establish airway and begin bag-valve-mask ventilation with 100% O 2 if appropriate 2.4 Load syringe with the appropriate dose.. See specific treatment algorithms: ► Pain Management – Adult page 47 | Pediatric page 76 ► Respiratory Depression or Apnea – Adult page 50 | Pediatric page 79 ► Sedation – page 136 ► Seizure – Adult page 55 | Pediatric page 83 2.5 Attach MAD nasal atomizer 2.6 Place atomizer 1.5 cm into the nostril 2.7 Briskly compress the syringe to administer 1/2 of the medication 2.8 Remove and repeat into the other nostril until all the medication has been administered. ► Continue ventilating the patient as needed ► If no appropriate response within 3 minutes, go to appropriate policy INTRANASAL (IN) MEDICATION ADMINISTRATION 129 Proximal y/o) (≤10 Femur Distal Humerus Proximal Tibia Procedures Modified On: May 27, 2021 INTRAOSSEOUS ACCESS PROCEDURE 1. PURPOSE: To obtain rapid circulatory access to provide necessary intravenous fluids or medications 2. INDICATIONS: ► Consider for use in any unconscious or seriously ill or injured patient in whom IV access cannot be established in a very timely fashion ► Any medications or fluids that can be given in a peripheral vein can be given intraosseous 3. CONTRAINDICATIONS: ► Fracture in target bone ► Previous, significant orthopedic procedure at the site, prosthetic limb or joint ► IO catheter use in past 48 hours of the target bone ► Infection at the area of insertion ► Excessive tissue (severe obesity) and/or absence of adequate anatomical landmarks 4. APPROVED IO ACCESS SITES (see additional references below): 4.1 Proximal Tibial Tuberosity 4.2 Proximal Humerus 4.3 Distal Femur ( y/o) 5. NEEDLE SIZING REFERENCE ► 15 mm Needle Set (pink hub, 3kg-39kg) ► 25 mm Needle Set (blue hub, >3kg) ► 45 mm Needle Set (yellow hub, >40kg with excessive tissue) 6. IO ACCESS SITE PAIN MANAGEMENT 6.1 If the patient is responsive to pain, consider Pain Management Adult page 47, Pediatric page 76. Also, consider use of 2% Lidocaine for anesthetic effect. Prime EZ-Connect extension set with lidocaine Note that the priming volume of the EZ-Connect is approximately 1.0mL ► ADULT - 40mg (2 mL) 2% Lidocaine slowly over 120 seconds. Let Lidocaine dwell for 60 seconds. Flush with 5 to 10ml NS. Slowly administer an additional 20mg of lidocaine IO over 60 seconds. Repeat PRN ► PEDIATRIC - 0.5mg/kg (not to exceed 40mg) 2% Lidocaine slowly over 120 seconds. Let Lidocaine dwell for 60 seconds. Flush with 2 to 5ml NS. Slowly administer subsequent lidocaine (half the initial dose) IO over 60 seconds. Repeat PRN INTRAOSSEOUS ACCESS PROCEDURE 130 Procedures Modified On: May 10, 2019 PLEURAL DECOMPRESSION 1. INDICATIONS: When clinical findings reveal a tension pneumothorax (severe respiratory distress, diminished breath sounds on the affected side, tracheal deviation) with rapidly deteriorating vital signs, or in the setting of a traumatic cardiac arrest and tension pneumothorax is suspected to be a contributing factor of the arrest. 2. EQUIPMENT: 2.1 County-approved decompression needle/kit 3. PROCEDURE: 3.1 Preferred Site: ► 2nd or 3rd intercostal space, mid-clavicular line th ► Anterior mid-axillary 5 intercostal space 3.2 Prep site with chlorhexidine 3.3 Firmly but carefully insert the needle at a 90-degree angle just over the superior aspect (superior border) of the rib, through the skin and pleura until air escapes or a distinct "give" is felt. The undersurface of the rib should be avoided to limit injury to the neurovascular bundle. Air should be freely aspirated (if not, you are not in the pleural space) 3.4 Remove the needle 3.5 Attach a one-way valve (if necessary). 3.6 Recheck breath sounds and continuously monitor cardio-respiratory status. 4. COMPLICATIONS: Formatted: Font color: Auto, Not Expanded by / 4.1 Lung laceration 4.2 Pneumothorax 4.3 Hemorrhage secondary to damage to the intercostal artery or vein Condensed by Formatted: Superscript PLEURAL DECOMPRESSION 131 Procedures Modified On: January 1, 2025 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES Commented \[ZK22\]: Should we add something about dementia not a reason to consider 5150? Or is that more of an education point? PSYCHIATRIC AND BEHAVIORAL EMERGENCIES 132 Procedures Modified On: May 10, 2019 PSYCHIATRIC AND BEHAVIORAL EMERGENCIES - OLANZAPINE 1. INTRODUCTION: Olanzapine (Zyprexa) 10 mg sublingual is an atypical antipsychotic with minimal side effects. The major side effect would be minimal sedation that can be worsened by alcohol or other sedatives. Orally disintegrating Olanzapine sublingual allows for rapid absorption, with effects occurring within 10-15 minutes of administration. 2. INDICATIONS: 2.1 Olanzapine is indicated for the cooperative, anxious adult patient with a primarily behavioral health presentation and a history of psychiatric disorder. These patients will commonly be hearing voices or having paranoid thoughts after not taking their usual psychiatric medications. 2.2 In accordance with Restraint Policy (page 115), restraints may be utilized after patient self- administers Olanzapine. 3. CONTRAINDICATIONS: ➔ Age less than 18 or over 65 ➔ Clinical intoxication with other substances ➔ Pregnant patients 4. POSSIBLE ADVERSE EFFECTS: ► Dystonic Reaction ► Anticholinergic Effects ► CNS Depression 5. ADMINISTRATION: Olanzapine (Zyprexa) 10mg, should be handed to the patient for sublingual self-administration. No water is needed for the orally disintegrating tablet. PSYCHIATRIC AND BEHAVIORAL EMERGENCIES - OLANZAPINE 133 Procedures Modified On: December 5, 2012 PSYCHIATRIC EVALUATION - 5150 TRANSPORTS 1. GENERAL INFORMATION: Any patient who has been, or will be (e.g. - self-committal) placed on a 5150 hold for psychiatric evaluation shall be assessed and transported according to this policy. For minors (age below 18) the hold is called a 5585 hold and is similar to 5150 hold 2. MEDICAL CLEARANCE CRITERIA: 2.1 Age 65 and Above: Patients with or without acute medical issues, should be transported to the closest most appropriate receiving hospital for evaluation 2.2 Age 12 to 64: 2.2.1 Transport patients to a closest most appropriate receiving hospital* if there is a suspected acute medical or traumatic condition requiring emergent or urgent attention in an Emergency Department. Patients with these conditions include: ➔ Patients “in extremis” (those with a potential life-threatening illness or injury) ➔ Patients who are unconscious, unresponsive, have chest or abdominal pain, significant bleeding, or suspected shock ➔ Patients who shows signs of potential significant toxicity from illicit drugs or alcohol, which may include the following findings: ► depressed mental status ► inability to ambulate ► diaphoresis, agitation ➔ Patients with combative behavior who require field sedation with Midazolam or whose combativeness prevents assessment (vital signs or examination) ➔ Patients with abnormal vital signs or findings: ► Systolic blood pressure over 190 mmHg or diastolic blood pressure over 110 mm/Hg ► Pulse rate sustained over 120 ► Blood glucose under 60 mg/dL or over 250 mg/dL ➔ Patients with a suspected overdose of medication 2.2.2 Adult patients on 5150 who do not meet medical clearance criteria (see 2.1 and 2.2) should be transported to John George Pavilion, San Leandro. These include: ➔ Patients with history of use of drugs or alcohol who do not show signs of significant toxicity ➔ Patients with abnormalities in vital signs, but without other significant physical findings or history suggesting an acute medical problem (systolic BP up to 190, diastolic BP up to 110 and pulse up to 120) ➔ Patients with minor abrasions or contusions (not needing laceration repair or other complex care or evaluation) ➔ Patients who otherwise appear healthy but have communication barriers due to language or developmental disability, or are unwilling to answer questions 2.3 Adolescents Age 12 to 17 2.3.1 Criteria for transport to the closest most appropriate receiving hospital for medical clearance listed above (2.2.1) for adults also apply to adolescent patients on 5585 (5150) holds 2.3.2 Additionally, adolescent patients with the following findings should also be transported to receiving hospitals: ➔ Patients who have been outside of adult supervision/control for more than 24 hours ➔ Patients with recent vomiting over a prolonged period or who report no food or fluid intake for 16 hours or more ➔ Patients with known severe chronic medical conditions 2.3.3 Adolescent patients who do not meet medical clearance criteria (see 2.2) should be transported to ALCO Youth CSU, San Leandro. Notify ALCO Youth CSU en route (510) 483-3030 2.4 Children Age 11 and Under ➔ All children age 11 and under on a 5585 (5150) hold should be transported to Children's Hospital Oakland unless there is a need to divert to another hospital because of medical instability NOTE: Additional considerations for most appropriate facility are listed in the Transport Guidelines and Abuse/Assault Policies PSYCHIATRIC EVALUATION - 5150 TRANSPORTS 134 Procedures Modified On: July 1 2014 REPORTING FORMAT RECEIVING FACILITY NOTIFICATION 1. INTRODUCTION: Early notification of receiving facilities with information about your patient(s) is important to ensure the appropriate resources are prepared, especially for patients that may need specialty care services. Notifications should be brief and to the point. Utilize the templates below to guide the content of notifications.  Receiving facility notification should not be performed by the EMS Clinician that is driving the transporting unit.  Detailed Vital Signs should include: RR, HR, B/P, SpO2, GCS (the number of each category E/V/M)  Trauma Activations: for trauma center staff to activate the most appropriate resources for the patient, a detailed GCS and vitals signs (including any episodes of hypotension) must be communicated. 2. ALL PATIENTS: Agency Pertinent negatives/positives Unit Number V/S “stable” or detailed V/S if abnormal ETA Pertinent Treatment(s) Age & Gender Repeat ETA Chief Complaint Check for questions 1. Additional Information for Specialty Care Patients: Provide the information above plus the information below if your patient is being transported for specialty care Trauma Patients 1. Mechanism of Injury 3. Detailed GCS – each category E/V/M + Total GCS 2. Injuries 4. Detailed Vital Signs – including lowest SBP Cardiac Arrest / ROSC 1. Airway – patent, non-patent, airway 4. Total estimated down time device placed / not placed 5. Summary of treatment(s) given 2. Breathing – absent/spontaneous 3. Circulation – pulses present / not present Stroke Alert 1. Last seen normal time 3. Blood glucose 2. Stroke Assessment/Scale findings STEMI 1. Estimated onset of S/S 3. Detailed Vital Signs 2. Was 12-lead ECG transmitted? Sepsis Procedures Modified On: July 1 2014 1. Temperature 3. Detailed Vital Signs 2. Suspected source of infection (if known) Pediatric Patients 1. Patient’s weight-based color code 3. Status of parent/guardian (at pt’s side, POV, etc.) 1. INTRODUCTION: Patient reports to a Base Hospital, Trauma Center or Receiving Hospital should be brief and to the point. Only pertinent information should be presented initially; however the Base Physician may need to request additional information in order to make sound treatment or triage decisions. Occasionally pause briefly to confirm reception and allow for questions or orders 2. MEDICAL PATIENTS: 2.1 Receiving Hospital Report ► ETA ► General patient information - For emergent patients, include medical record number (if available without compromising patient safety and care) ► Physical assessment ✓ Vital signs / Glasgow Coma Scale ✓ Pertinent positives and pertinent negatives, as needed ✓ For STEMI patients see "ECG 12-Lead" policy (page 126) for reporting information ► Interventions made and patient response, if applicable ► Problems encountered, if applicable (e.g. unable to intubate) 2.2 Base Contact ► General patient information ► Chief complaint and general assessment ► Patient destination and ETA ► Physical assessment ✓ Vital signs / Glasgow Coma Scale ✓ Pertinent positives and pertinent negatives to support the general assessment. ► Treatment rendered prior to contact and patient response, if applicable ► Specific requests for medications/procedures 3. TRAUMA PATIENTS: 3.1 Receiving Hospital Report ► ETA ► General patient information ► Triage criteria met, including mechanism of injury ► Physical assessment ✓ Vital signs/Glasgow Coma Scale ✓ Pertinent positives and pertinent negatives, as needed ► Interventions made and patient response, if applicable ► Problems encountered, if applicable (e.g. unable to intubate) 3.2 Trauma Destination (60 seconds) ► ETA to the closest appropriate ED vs. TC ► General patient information Procedures Modified On: July 1 2014 ► Triage criteria met ► Mechanism of injury ► Physical assessment ✓ Vital signs, if available / Glasgow Coma Scale ✓ Pertinent positives and pertinent negatives REPORTING FORMAT Procedures Modified On: July 1 2014 Procedures Modified On: July 1 2014 135 Procedures Modified On: May 27, 2023 SEDATION 1. GENERAL INDICATIONS: 1.1 To reduce combative behavior that endangers patient or caregivers (See Psychiatric and Behavioral Emergencies Protocol) 1.2 As an adjunct to pain relief for ALS procedures such as cardioversion and/or transcutaneous pacing (TCP) in the conscious patientcardiac pacing 1.3 Use CAUTION with: ► Concomitant use of an opiate and midazolam can cause significant respiratory depression, hypotension and decreased level of consciousness. Administer concomitantly only when absolutely indicated. Administer lower doses of one or both agents ► Elderly patients are especially sensitive to the effects of midazolam. They should receive a lower dose and especially close monitoring ► A very small proportion of patients may have a paradoxical effect (i.e. - increased agitation) 2. CONTRAINDICATIONS: 2.1 Absolute: ► Sensitivity to Midazolam ► Systolic BP < 90 mmHg (adult) - except for patients who need TCP or cardioversion 2.2 Relative: ► Nausea/vomiting ►Depressed mentation ► Suspected drug/alcohol intoxication ►Multiple systems trauma ► Head injury ► Concomitant narcotic administration - (this is a RELATIVE contraindication and is not intended to prevent the use of necessary narcotic analgesia, when indicated) (These MAY be the most likely cause for the condition that requires proposed sedation. The best judgment of the paramedic is necessary to evaluate the need for sedation) 3. PROCEDURE: 3.1 Give supplemental oxygen (titrate to 94-99% SpO 2) 3.2 Institute continuous cardiac monitoring 3.33.2 Continuously monitor the patient which includes visual assessment, ETCO2, SpO2, and ECG monitoringusing the Airway Checklist, including ETCO2 3.43.3 Establish IV access if possible 3.53.4 Be prepared to provide airway/ventilation management 3.5 Ensure that receiving hospital personnel are aware that patient has been sedated 3.6 Do not place the patient in a prone position. INDICATIONS: MEDICATION – DOSE/ROUTE: SEDATION INDICATIONS MIDAZOLAM: ✓ To reduce combative behavior that endangers patient Adult: or caregivers ✓ IV/IO (slowly): 1-2 mg increments- titrated to desired ✓ Anticipated: degree of sedation. May repeat, everyq 5 min, to a total max • Cardioversion in the conscious patient dose of 10 mg • • ✓ IM/IN: 2-5 mg increments- titrated to desired degree • Transcutaneous Pacing (TCP) in the conscious patien of sedation. May repeat everyq 5 min, to a total max dose of 10 mg • Cardiac pacing in the conscious patient Pediatric (> 5kg or <40kg) ✓ IN / IM: See LBRT for dosage - May repeat LBRT dosage x 1 - 15 minutes after the initial dose if needed Formatted: Font color: Auto, Not Expanded by / Condensed by Procedures Modified On: May 27, 2023 SEDATION 136 Procedures Modified On: June 6, 2012 SPINAL INJURY ASSESSMENT ► Alameda County EMS is supporting efforts to decrease unnecessary immobilizations in the field and reduce the risks and complications associated with this procedure ► If the immobilization process is initiated prior to assessment, STOP and perform spine injury assessment to determine best course of action ► Studies show that immobilizing trauma victims may cause more harm than good to the patient. Penetrating trauma victims benefit most from rapid assessment and transport to a trauma center without spinal motion restriction (SMR) 1. INTRODUCTION: 1.1 Omit SMR if all assessment criteria are safely assessed and normal 1.2 Consider SMR for a patient who is suspected of having a traumatic unstable spinal column injury. Have high index of suspicion for pediatrics and patients with degenerative skeletal/connective tissue disorders (i.e. osteoporosis, elderly, previous spinal fractures, etc.) 1.3 Victims of penetrating trauma (stabbings, gunshot wounds) to the head, neck, and/or torso SHOULD NOT receive SMR unless there is one or more of the following: ► Obvious neurologic deficit to the extremities ► Significant secondary blunt mechanism of injury (e.g.- fell down stairs after getting shot) ► Priapism ► Neurogenic shock ► Anatomic deformity to the spine secondary to injury 2. Pediatric Patients and Car Seats: 2.1 Infants restrained in a rear-facing car seat may be immobilized and extricated in the car seat. The child may remain in the car seat if the immobilization is secure and his/her condition allows (no signs of respiratory distress or shock) 2.2 Children restrained in a car seat (with a high back) may be immobilized and extricated in the car seat; however, once removed from the vehicle, the child should be placed in SMR 2.3 Children restrained in a booster seat (without a back) need to be extricated and immobilized following standard SMR procedures 3. Helmet removal: Safe and proper removal of the helmet should be done by two people following steps outlined in an approved trauma curriculum SPINAL INJURY ASSESSMENT 137 A Reliable Patient is cooperative, sober and INJURY? SPINAL UNSTABLE FOR POTENTIAL SMR OMIT SMR APPLY INJURYPOSSIBLE SPINE safe omission of SMR allow above factors risk-low The tenderness spine cervical midline of •Absence scene at pain neck •No sceneon time any at •Ambulatory MVC end-rear •Simple Factors:Risk -Low parathesias)extremities(e.g. to sensations abnormal for Check extremities all in sensation gross Check➔ NO feet) (both Dorsiflexion feet) (both Plantarflexion hands) (both extension finger or Wrist EXAM: MOTOR/SENSORY thoroughly column vertebral Palpate PAiN/TENDERNESS SPiNAl MOTOR/SENSORY? NORMAL EXAM?SPINE NORMAL PATIENT? RELIABLE YES Barrier Language Injuries Distracting Significant without: alert Procedures Modified On: June 6, 2012 SPINAL INJURY ASSESSMENT High-Risk Factors: Age ≥ 65 •Meets Trauma Patient Criteria for •Mechanism of Injury (Section 3) •Axial load to the head (e.g. - diving injury) •Numbness or tingling in extremities If any one of the high-risk factors above are present, strongly consider SMR YES SPINAL INJURY ASSESSMENT 138 Procedures Modified On: June 6, 2012 SPINAL MOTION RESTRICTION (SMR) 1. INTRODUCTION: The term Sspinal Mmotion Rrestriction (SMR) better describesis the procedure used to care for patients with possible unstable spinal injuries. SMR includes: ► Reduction of gross movement by patient ► Prevention of duplicating the damaging mechanism to spine ► Regular reassessment of motor/sensory function 2. PURPOSE: To decrease the risk of negative effects caused by traditional spinal immobilization while still providing appropriate care to patients with possible spinal injury by implementing alternative methods to achieve SMR 3. INDICATIONS: Any patient identified usingby Alameda County’s Spinal Injury Assessment protocolto warrant spinal motion restriction. The spinal injury assessment should be performed prior to application of SMR. 4. PROCEDURE: If patient experiences negative effects of SMR methods used, alternative measures should be implemented. 4.1 Methods/tools to achieve SMR that are allowable: (less invasive to more invasive) lateral, semi- fowler’s or fowler’s position with cervical collar only, soft collars, pillows, vacuum splint or mattress, children’s car seats, KED, backboards with adequate padding, head immobilizers and straps 4.2 Provide manual stabilization restricting gross motion. Alert and cooperative patients may be allowed to self-limit motion if appropriate with or without cervical collar 4.3 Apply cervical collar 4.4 If extrication is needed, extricate patient limiting flexion, extension, rotation and distraction of spine 4.5 Considerations for patient movement when decision to SMR has been made: ► Keeping with the goals of restricting gross movement of spine and preventing increased pain and discomfort, self-extrication by patient is allowable ► Pull sheets, other flexible devices, scoops and scoop-like devices can be employed if necessary. RigidHard backboards should only have limited utilization 4.6 Apply adequate padding or vacuum mattress to prevent tissue ischemia and increase comfort 4.7 Place patient and SMR materials in position best suited to protect airway 4.8 Regularly reassess motor/sensory function (include finger abduction, wrist/finger extension, plantar/dorsal flexion and sharp/dull exam if possible) 4.9 Consider the use of SpO and EtCO to monitor respiratory function 22 5. SPECIAL CONSIDERATIONS 5.1 Patients with acute or chronic difficulty breathing: SMR has been found to limit respiratory function an average of 17% with the greatest effect experienced byespecially in geriatric and pediatric subjects restricted to a hard backboard. Patients placed on a rigid backboard. ► Use SMR with caution with patients presenting with dyspnea and position appropriately 5.2 Pediatric patients: 5.2.1 Consider use of padded pediatric motion restricting board 5.2.2 Avoid methods that provoke increased spinal movement 5.2.3 If choosing to apply SMR to patient in car seat, ensure that proper assessment of patient posterior is performed 5.3 Combative patients: Avoid methods that provoke increased spinal movement and/or combativeness SPINAL MOTION RESTRICTION (SMR) 139 Procedures Modified On: December 1, 2011 STOMA AND TRACHEOSTOMY 1. INTRODUCTION: 1.1 Temporary or permanent placement of a tracheostomy tube is often necessary to maintain an open airway. Patients with tracheostomy tubes or stomas should not be intubated orally. Suctioning of surgical airways is often required to attempt to clear and maintain an open airway. Administration of inhaled medications will need to be given via the stomas or tracheostomy tubes 1.2 Tracheostomy tube replacement: A dislodged tracheostomy tube should not be replaced unless the paramedic has the skill and training to do so. Training should be consistent with the material contained in “Pediatric Education for Prehospital Personnel – 2000” pages 300-302. (See #4 below for stoma intubation technique.) 2. SUCTIONING: 2.1 Equipment: 2.1.1 Appropriate sized suction catheter (Pediatrics use 8-10F) 2.1.2 Suction unit with adjustable suction capacity 2.1.3 Bag-valve-mask with oxygen supply 2.1.4 5 mL syringe filled with sterile saline 2.2 Contraindication: Use of demand valve 2.3 Procedure: 2.3.1 Adjust suction to 120 - 150 mmHg for adults; decrease suction to 80 - 100 mmHg for pediatrics 2.3.2 Apply sterile gloves 2.3.3 Flush suction catheter with saline to lubricate tip and establish patency of suction catheter 2.3.4 Remove the T tube if a tracheostomy patient is on humidified oxygen 2.3.5 Ventilate the patient with 100% oxygen several times 2.3.6 Insert the suction catheter into the stoma or tracheostomy opening with the suction off (the thumb hole open). The short length of the tracheostomy tube facilitates suctioning. The catheter may be directed through the right or left bronchus by having the patient turn his/her head to the opposite side 2.3.7 Apply suction by occluding the thumb hole while slowly withdrawing the catheter in a twisting motion. Suction of a tracheostomy tube should take no longer than 10 seconds for the adult patient and 3-4 seconds for the pediatric patient 2.3.8 If mucus plugs or thick secretions are present, the instillation of 3 - 5 mL of sterile saline may be helpful 2.3.9 Pre-oxygenate with 100% O 2 2.3.10 Check breath sounds 2.3.11 Suctioning can stimulate a cough reflex. Allow the patient to cough. Be prepared to suction or catch secretions from the tracheal opening. Recheck breath sounds 3. ALBUTEROL MEDICATION ADMINISTRATION: 3.1 Equipment 3.1.1 Albuterol 3.1.2 Sterile Normal Saline 3.1.3 Handheld Nebulizer 3.1.4 Oxygen tubing and supply 3.1.5 Additional reservoir tubing (optional) 3.2 Procedure: 3.2.1 Assure clear airway. Suction if necessary 3.2.2 Assemble handheld nebulizer as for patient with intact upper respiratory track 3.2.3 Attach trach collar to reservoir tubing 3.2.4 Connect oxygen delivery tubing to oxygen source at sufficient flow rate to produce misting STOMA AND TRACHEOSTOMY 140 Procedures Modified On: December 1, 2011 STOMA AND TRACHEOSTOMY 3.2.5 Fit trach collar over stoma or tracheostomy tube 3.2.6 Instruct patient to breathe slowly and deeply 3.2.7 Optional: Mouthpiece may be replaced by additional reservoir tubing. 4. STOMA INTUBATION: 4.1 Equipment: 4.1.1 appropriate sized cuffed and uncuffed ET tubes 4.1.2 bag-valve-mask 4.1.3 appropriate sized suction catheters 4.1.4 oxygen supply 4.1.5 suction equipment with adjustable suction capacity 4.2 Contraindication: Use of demand valve 4.3 Procedure: 4.3.1 Select the largest endotracheal tube that will fit through the stoma without force. Check the cuff, unless an uncuffed tube is being used on a pediatric patient 4.3.2 Pre-oxygenate with 100% oxygen using a bag valve mask device with the face mask fitted over the stoma. Do not use demand valve 4.3.3 Wear sterile gloves. Do not use a stylet. It is not necessary to lubricate the tube 4.3.4 Suction, if necessary 4.3.5 Pass the endotracheal tube and inflate the cuff. The pharynx has been bypassed, so the tube will protrude from the neck several inches 4.3.6 Hold the tube in place, watch for chest rise with ventilation 4.3.7 Secure the tube and ventilate with 100% O 2 4.3.8 Auscultate the lung fields. Check the neck for subcutaneous emphysema, indicating false passage 4.3.9 Allow no longer than 30 seconds for the procedure STOMA AND TRACHEOSTOMY 141 Procedures Modified On: January 1, 2025 TRANSCUTANEOUS PACING - TCP 1. INDICATIONS: This procedure should be used on patients experiencing symptomatic bradycardia (see Adult Bradycardia or Pediatric Bradycardia protocols. This includes patients with “failed” pacemakers. Note: Bradycardia in children is usually due to respiratory causes Consider alternate causes of the dysrhythmia and treat appropriately prior to initiation of TCP: ► Hypoxia ► Trauma ► Drug overdose ► Electrolyte imbalance (not treatable in the field setting) ► Hypothermia 2. CONTRAINDICATIONS: 2.1 Asystole 2.2 Bradyasystolic arrest 2.3 Hypothermia Example of ECG with electrical capture 3. PROCEDURE: 3.1 Consider sedation with midazolam (See Sedation procedure) and/or appropriate Pain Management protocol for all conscious patients undergoing pacing. Hypotension is not an absolute contraindication in this setting. If unable to start IV, consider administering IM or IN 3.2 Place pads on the patient in anterior/posterior (A/P) position. If unable to place posterior pad, the pads can be placed in the anterior/lateral (A/L) position. Do not place pads over pre-existing implanted devices such as pacemakers or AICDs 3.3 Set pacing rate to: 3.3.1 Adults ( y/o): 60-80 bpm (goal of >30 bpm above patient's initial rate) 3.3.2 Pediatrics ( y/o) set pacing rate at 100 bpm 3.4 Start pacer current output at 0 milliamps (mA). Increase milliamps until electrical captured is obtained on the ECG (Max 120mA) 3.5 Confirm mechanical pacer capture by palpation of a femoral pulse. A pulse should be associated with at least every paced QRS complex. (Note: assessment of carotid pulse is not recommended as pacing can cause muscle contractions that are difficult to distinguish from pulse) 3.6 If electrical/mechanical capture cannot be achieved at 120mA, change vector of pads and repeat above steps. 3.7 Pediatric patients: Continue CPR until able to achieve electrical/mechanical capture 3.8 Once both electrical and mechanical capture obtained, increase the pacer current by 5-10mA 3.9 Once electrical and mechanical capture is obtained, the pacing rate may be increased slowly to relieve patient's symptoms (acute ALOC, hypotension, weak pulses, or central cyanosis) from bradycardia 4. SPECIAL CONSIDERATIONS: 4.1 TCP should not be delayed for IV access, 12-lead ECG, or while waiting for atropine to take effect in an unstable patient 4.2 CPR is safe during TCP and should be performed in pediatric population 4.3 Electrical capture can occur without mechanical capture. Electrical capture can be assessed on the monitor with identification of QRS complexes after every pacer spike. Mechanical capture is evaluated with palpation of a femoral pulse with every QRS complex 4.4 TCP is safe to perform in pregnant patients TRANSCUTANEOUS PACING - TCP 142 Procedures Modified On: December 1, 2011 TRANSFER OF CARE AUTHORITY: Division 2.5 of the California Health and Safety Code, Section 1798.6 "Authority for patient health care management in an emergency shall be vested in that licensed or certified health care profes- sional, which may include any paramedic or other prehospital emergency personnel at the scene of the emergency, who is most medically qualified specific to the provision of rendering emergency medical care. If no licensed or certified health care professional is available, the authority shall be vested in the most appropriate medically qualified representative of public safety agencies who may have responded to the scene of an emergency." "Notwithstanding ... authority for the management of the scene of an emergency shall be vested in the appropriate public safety agency having primary investigative authority. The scene of an emergency shall be managed in a manner designed to minimize the risk of death or health impairment to the patient and to other persons who may be exposed to the risks as a result of the emergency condition, and priority shall be placed upon the interests of those persons exposed to the more serious and immediate risks to life and health. Public safety officials shall consult emergency medical services personnel or other authoritative health care professionals at the scene in the determination of relevant risks." 1. Medical personnel will not enter an unsafe emergency/crime scene, or continue to render care until released by the incident commander. Public safety personnel shall secure the scene to make entry reasonably safe 2. Components of the transfer of care at the scene of an emergency include: 2.1 Evaluation of the scene 2.2 Medical aspects of extrication and all movement of the patient(s) 2.3 Assessment 2.4 Treatment rendered 2.5 Destination 3. If a disagreement occurs between medical personnel at the scene on any aspects of the transfer of care: 3.1 If time permits, contact the Base Physician to determine the appropriate treatment/destination. Otherwise, the more conservative patient-based decision will prevail (e.g. if field personnel disagree on transport vs. non- transport, the patient will be transported) 3.2 If necessary, involved personnel will immediately notify the EMS on-call representative through ALCO-CMED. The EMS on-call representative will notify the EMS Medical Director 3.3 If appropriate, the EMS Medical Director will organize a meeting with the personnel involved to resolve the issues within two (2) business days Commented \[ZK23\]: I would propose we suggest EMS event reporting or bring to their leadership to discuss TRANSFER OF CARE 143 Procedures Modified On: May 27, 2023 TRIAGE TO WAITING ROOM 1. PURPOSE: To provide guidelines for field providers to identify which patients are appropriate to bring directly to ER waiting rooms. 2. NOTES: ➔ All decisions on where the patient is brought to must be patient centered; ➔ Work with ER staff to ensure that they are informed of the patient's eligibility for placement in the waiting room; ➔ Document pt's final disposition (ER Bed, waiting room, etc.) Yes No Yes No TRIAGE TO WAITING ROOM 144 Procedures Modified On: June 21, 2023 TXA - TRANEXAMIC ACID 1. DESCRIPTION - Tranexamic Acid (TXA) is a Lysine analogue that works to inhibit the formation of plasmin, which is a molecule responsible for clot degradation. It has had multiple medical applications in the past including pre-operative use, menorrhagia, hemophilia and hereditary angioedema. It has recently been shown in multiple studiesa medicine that helps stop bleeding to reduce mortality in trauma patients who meeting specific physiologic criteria or who have obvious signs of massive hemorrhage. 2. INCLUSION CRITERIA EXCLUSION CRITERIA ► Any patient <15 years of age Within three hours of onset of injury or illnessbleeding, prehospital administration of TXA should be ► Any patient more than three hours post-injurywho has considered for all patients with blunt or penetrating had bleeding for more than 3 hours trauma or other massive uncontrolled bleeding (Vaginal hemorrhage, dialysis shunt rupture etc.) that ► Isolated penetrating cranial injury have signs and symptoms of hemorrhagic shock and ► Traumatic brain injury with brain matter exposed meet any one of the following inclusion criteria: ► Suspected cervical cord injury with motor deficits ► SBP < 90 mmHg ► Significant hemorrhage with a HR > 110120 ► Bleeding not controlled by direct pressure or tourniquet ► Major amputation of any extremity above the wrists or ankles 3. ADMINISTRATION 3.1 Administer TXA 21 grams slow IV/IO push over two minutes or in 100ml NS or D 5 W IV/IO over 210 minutes Do NOT administer IV push. This will cause hypotension. 3.2 Place an approved wristband on the patient. 3.33.2 Ensure that RN/MD at receiving facility is notified that TXA was administered. 3.43.3 Follow IV fluid resuscitation guidelines on page 26, “in the Trauma Patient Care Protocol and consider the Prehospital Blood Product Transfusion Protocol” TXA - TRANEXAMIC ACID 145 Procedures Modified On: January 1, 2025 STROKE ASSESSMENT SCALES (CPSS AND PSS) 1. PURPOSE: To be used in conjunction with the STROKE / CVA Protocol for the assessment of suspected stroke / CVA Cincinnati Prehospital Stroke Scale (CPSS) Sign/Symptom Testing Procedure Normal Abnormal One side of the face does Have the patient show their Both sides of the face move F acial Droop not move as well as the teeth or smile equally other One arm either does not The patient closes their Both arms move the same, move, or one arm drifts A rm Drift eyes and extends both arms downward compared to the or both do not move at all straight out for 10 seconds other The patient says correct The patient slurs words, The patient repeats “The S peech words with no slurring of says the wrong words, or is sky is blue in Cincinnati." words unable to speak Posterior Stroke Scale (PSS) Sign/Symptom Testing Procedure Normal Abnormal Face the patient, ask them to look straight at your nose, move your fingers in each of the four visual quadrants Vision intact in all of the four Missing vision in any of the Visual Fields (upper right/left, lower right/ quadrants four quadrants left), and ask the patient to state the side they see the fingers moving Patient holds arms at their shoulder to 90 degrees with elbows flexed to 90 degrees, place your index finger at various locations in front of the patient at a dis- Weakness, wobbling, or tance that requires patient to shaking in either arm while extend their elbow to reach attempting to make contact No weakness, wobbling, or your finger, ask patient to with your finger shaking in either arm while use their index finger on one ***When both arms are Finger-to-Nose attempting to make contact hand to touch their index equally shaking or weak, with your finger finger to your finger, then this is not considered an touch their index finger to abnormal finding*** their own nose, then to your finger. Repeat several times moving their target finger each time. Patient repeats the process using the oppo- site hand's index finger STROKE ASSESSMENT SCALES (CPSS AND PSS) 146 MCI/ Disaster/ WMD Modified On: January 1, 2026 MCI/ DISASTER/ WMD TOC MCI/ DISASTER/ WMD TOC ...............................................................................................147 ACTIVE SHOOTER RESPONSE ........................................................................................ 148 BIOLOGICAL ATTACK .......................................................................................................... 149 CHEMICAL ATTACK ............................................................................................................. 151 CHEMPACK DEPLOYMENT ................................................................................................. 152 CYANIDE POISONING .......................................................................................................... 153 DECONTAMINATION INCIDENT ........................................................................................ 154 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE ......................................... 155 MULTI-CASUALTY INCIDENT - EMS RESPONSE .......................................................... 157 NERVE AGENT AUTOINJECTOR ADMINISTRATION ...................................................... 160 NERVE AGENT TREATMENT .............................................................................................. 162 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” ....................... 164 SUSPICIOUS POWDER PROCESS .................................................................................. 165 MCI/ DISASTER/ WMD TOC 147 MCI/ Disaster/ WMD Modified On: April 10, 2012 -OVERHAULViolent Threat ResponseACTIVE SHOOTER RESPONSE 1. INTRODUCTION 1.1 ACTIVE SHOOTER RESPONSE- The EMS response to Active Shooter Incidents needs to be coordinated with on scene law enforcement. 1.2 EMS providers need to be ready to enter a secured scene quickly and aggressively 1.3 EMS providers should be “forward leaning” and have trauma focused medical gear and triage tools available 1.4 Working closely with law enforcement is critical in getting life saving medical assets to the injured as soon as the threat has been mitigated or neutralized. The UNIFIED COMMAND model is best for these types of incidents 1.5 Make sure law enforcement command knows that an EMS team is ready, staged and awaiting direction. Most SWAT teams have an imbedded tactical medic that would be the logical liaison to EMS assets on scene 1.6 Concepts applied are based on the Tactical Combat Casualty Care (TCCC) and the International School of Tactical Medicine (ISTM) 2. Consider the following items during an EMS response to an Active Shooter Incident: ► Communication must be maintained throughout the incident with respective dispatch centers and on scene medical, fire and law enforcement ► Law enforcement is in charge of the event. While in a warm zone environment, EMS should follow the direction of law enforcement ► Law enforcement may provide a protective envelope (force protection model) around EMS providers and escort them into “warm zone” areas to treat or evacuate victims. (No active threat in the area) ► Make sure to have emergency egress routes and casualty collection points (CCP), as well as evacuation rally points identified ► If EMS team is brought in to extricate patient, only minimal equipment should be carried. Roll up evacuation stretchers should be considered ► EMS teams need to be prepared to split up if law enforcement requires it ► EMS providers should use individual medical packs with lifesaving bleeding and airway tools so they can work “independently” on trauma victims ► Spinal motion restriction is not indicated for patients suffering only from penetrating trauma ► Once the threat is eliminated, law enforcement may be available to help evacuate the injured ACTIVE SHOOTER RESPONSE 148 MCI/ Disaster/ TREATMENT PROPHYLAXIS DISEASE/ (Adult dosage) TRANSMISSION & AGENT SYMPTOMS SIGNS PRECAUTIONS Note: these are for reference only, and are not in Incubation ALCO EMS protocol Inhalation: fever, followed ANTHRAX Inhalation: Flu-like Aerosol inhalation Mechanical ventilation Ciprofloxacin 500 WMD by ✓abrupt onset of 2-6 days symptoms, nausea, No person-to-person Antibiotic therapy mg or vomiting, abdominal pain , respiratory failure, confusion transmission (inhalation) Doxycycline Range: 1 day to 8 fever, respiratory distress widened mediastinum on Standard precautions Ciprofloxacin 400 100 mg po q 12 hr ~ weeks (Bacillus anthracis) Cutaneous: initial itching chest X-ray (adenopathy), mg IV q 8-12 hr OR 8 weeks papule; fever bloody pleural effusions, Amoxicillin in bacteria Doxycycline 200 mg IV atypical pneumonia initial, then 100 mg IV q pregnancy and children Cutaneous: initial itching 8-12 hr PLUS (if susceptible) papule, 1-3 cm painless Rifampin 10 mg/kg/d po Vaccine if available ulcer, then necrotic center; (up to 600 mg day) OR lymphadenopathy Clindamycin 1200-2400 mg/day IM or IV BOTULISM Difficulty swallowing or Dilated or un-reactive pupils Aerosol inhalation Mechanical ventilation Experimental vaccine BIOLOGICAL BIOLOGICAL 12-72 hours speaking (symmetrical Drooping eyelids (ptosis) Food ingestion Parenteral nutrition has been used in Range: cranial neuropathies) Double vision (diplopia) No person-to-person laboratory workers 2 hrs – 8 days Symmetric descending Slurred speech (dysarthria) transmission Trivalent botulinum toxin caused by weakness Descending flaccid paralysis Standard precautions antitoxin available the bacterium Respiratory dysfunction Intact mental state from State Health (Clostridium No sensory dysfunction Departments and CDC botulinum) No fever Pneumonic: Hemoptysis; PLAGUE Sudden onset of fever, Person-to-person Streptomycin 30 mg/kg/ Asymptomatic contacts ATTACK ATTACK ✓ radiographic pneumonia -- 1-3 days by chills, headache, myalgia transmission in day in two divided doses or potentially exposed inhalation Pneumonic: cough, chest ✓ patchy, cavities, confluent pneumonic forms x 14 days patients (Yersinia pestis) pain, dyspnea, fever consolidation, hemoptysis, Droplet precautions until Gentamicin 3-5 mg/ Doxycycline bacteria Bubonic: painful lymph cyanosis patient treated for at kg/day IV/IM in q 8 hr 100 mg po q 12 h nodes Bubonic: typically painful, least three days dosage Ciprofloxacin enlarged lymph nodes in Tetracycline 2-4 g per 500 mg po q 12 h groin, axilla, and neck day Tetracycline Ciprofloxacin 400 mg IV 250 mg po q 6 hr q 12 hr Vaccine: not available RICIN Fever, SOB, nausea, chest Sweating, pulmonary edema, No person to person Supportive care Vaccine under If inhaled, S/Sx tightness cyanosis, hypotension, transmission GI decontamination if development within 4-8 hour pulmonary and circulatory Airborne precautions ingested Modified On: Protein toxin collapse Standard precautions produced from castor beans (Ricinus communis) April 10, 149 2012 150 MCI/ Disaster/ TREATMENT PROPHYLAXIS DISEASE/ (Adult dosage) TRANSMISSION & AGENT SYMPTOMS SIGNS PRECAUTIONS Note: these are for reference only, and are not in Incubation ALCO EMS protocol TULAREMIA Fever, cough, chest Community-acquired, Inhalation of agents Streptomycin 30 mg/kg/ Ciprofloxacin WMD 2-5 days tightness, pleuritic pain atypical pneumonia No person-to-person day IM divided bid for 500 mg po q 12 hr Hemoptysis rare Radiographic: bilateral transmission but 14 days Range: 1-21 Doxycycline patchy pneumonia with laboratory personnel Gentamicin 3-5 mg/kg/ 100 mg po q 12 hr days “pneumonic” hilar adenopathy (pleural at risk day IV in three equal Tetracycline (Francisella effusions like TB) Standard precautions divided doses x 10-14 250 mg po q 6 hr tularensis) Diffuse, varied skin rash days Experimental live bacteria May be rapidly fatal Ciprofloxacin possibly vaccine effective 400 mg IV q 12 hr (change to po after clinical improvement) x 10-14 day SMALLPOX High fever and myalgia; Maculopapular then vesicular Person-to-person Supportive care Vaccination (vaccine BIOlLOGICAL BIOlLOGICAL 12-14 days itching; abdominal pain; rash -- first on extremities transmission Vaccinate care givers available from CDC) Range:7-17 days delirium (face, arms, palms, soles, Airborne precautions (Variola virus) oral mucosa) Negative pressure Experimental: cidofovir Rash on face, extremities, Rash with hard, firm pustules Clothing and surface (useful in animal studies) hands, feet; confused with (“intradermal blisters”) decontamination Rash is synchronous on chickenpox which has less various segments of the uniform rash body ATTACK ATTACK Modified On: December 1, 2011 MCI/ Disaster/ TREATMENT SYMPTOMS CHEMICAL PROPERTIES IMMEDIATE ACTIONS Note: these are for reference only, and are not in ALCO EMS protocol ► If you are exposed, ► Remove clothing, flush WMD ► Pupils shrink to pinpoints the effects will appear eyes/skin with plenty of and victim begins sweating Can be liquid or gas fairly rapidly water and twitching Enters the body through: NERVE AGENTS ► People around you may ► Get medical attention ► Runny nose, watery • VX ► Skin and eyes begin fainting, vomiting or immediately; there are eyes, drooling, increased • Sarin have difficulty breathing antidotes for specific ► Inhalation respiratory secretions, • Tabun chemical agents excessive sweating, ► Birds and insects ► Ingested difficult breathing, dimness may die quickly and ► Atropine is an effective of vision, nausea, vomiting antidote fall from the sky Generally thick liquid, yellow ► Blistering agent, burning ► IMMEDIATELY ► Remove clothing and flush or brown in color, with a slight exposed eyes and skin; leave the area eyes/skin with plenty of garlic or mustard odor. Enters and lungs, mouth and water CHEMICAlL ► Avoid puddles of liquid the body through: CHEMICAlL throat if it is breathed in SULFUR MUSTARDS ► Get medical attention ► Skin and eyes (inhaled). ► If the attack was outside, immediately, there are you should get into ► Inhalation antidotes for specific Not usually noticed until 1-6 a building or car chemical agents hours after exposure ► Ingested ► If the attack was inside, Extremely flammable, colorless Get fresh air immediately ► Burning and redness of get to the outside gas or liquid Flush skin/eyes with plenty ATTACK the skin and eyes ATTACK Enters the body through: ► If you were directly of water ► Inhalation causes exposed, remove HYDROGEN CYANIDE Get medical attention ► Skin and eyes confusion, drowsiness, clothing (place in plastic immediately; there are ► Inhalation shortness of breath, bags, if possible) antidotes for specific chemical leading to collapse agents ► Ingested ► Removing contaminated clothing is more important than modesty ► Do not remove contaminated clothing over your head; cut or tear Greenish-yellow gas with Modified Get fresh air immediately it off to avoid contact with stinging odor. Heavier than air, Flush skin/eyes with plenty the eyes, nose, and mouth so it will settle in low spots Very harmful to the eyes and of water Enters the body through: skin and can cause tearing, ► Thoroughly flush all Seek medical attention CHLORINE On: blurred vision, difficulty ► Skin and eyes areas where agent immediately; there are breathing, and burns contacted your skin, using December antidotes for specific chemical ► Inhalation nearest water available agents ► Ingested ► Hazmat/fire crews are trained for immediate 1, response and medical 151 2011 treatment is available at most hospitals staging, medical)appropriate destination (i.e. to the scene and reports to EMS Unit transports Chempack request to housing facility. Fire/ automatically(closest) Chempack and Dispatch (CAD) determines best DISPATCH LLNL location (staging, medical, etc.)and transports unit to site opens (break seals), loads up Fire/EMS Chempack site STORAGE SITEFIRE/EMS CHEMPACK Chempack assetssite -hospital with onTreatment continues in HOSPITAL hospitalsroute to -scene and en-Chempack assets onMedical unit utilizes MEDICAL SCENE-ON MCI/ Disaster/ WMD Modified On: December 1, 2011 CHEMPACK DEPLOYMENT-OVERHAUL Commented \[ZK24\]: Needs new flowchart ON-SCENE Incident Commander (IC) has authority to request Chempack(s) based on medical personnel (Fire/EMS) assessment of presenting symptoms of patients and other field specific information (detectors, intelligence) R EQUEST MADE TO D ISPATCH CHEMPACK DEPLOYMENT 152 (if availableO2 flow High exposurecyanide of symptomsand/or Signs Zone Hot Zone Warm IV NSMonitor grams) 12.5 dose (max Child: grams 12.5 Adult: minutes 10 over IV Thiosulfate Sodium apneic if MCI/ Disaster/ WMD Modified On: December 1, 2011 CYANIDE POISONING • This policy is to be used in conjunction with Smoke Inhalation page 23 and HazMat page 155 • Medications are only given if the patient is showing signs and symptoms of cyanide poisoning. THEY ARE NOT TO BE GIVEN PROPHYLACTICALLY Symptoms: ► Anxiety ► Exposure to a vapor or liquid that may smell like “bitter ► Agitation almonds” ► Vertigo ► Upper airway and/or eye irritation ► Weakness ► Flushing ► Nausea ► Headache ► Muscular trembling Signs: ► Normal pupils ► Transient hyperpnea, followed by seizures, apnea and cardiac collapse ► Diaphoresis ► Tremor ► Cyanosis Commented \[ZK25\]: Pediatric dosing Commented \[ZK26\]: Should we add cyanokit here? CYANIDE POISONING 153 MCI/ Disaster/ WMD Modified On: December 1, 2011 DECONTAMINATION INCIDENT ► This policy is for instances where a patient presents to EMS personnel without forewarning of a possible hazardous materials incident ► All patients exposed or contaminated by suspected hazardous materials should be decontaminated prior to transportation to the emergency department e.g. - Industrial Response Team, Fire Hazardous Materials Response 1. Paramedics will advise the base hospital of the following: 1.1 Nature of the emergency (i.e., describe the incident) 1.2 Total number of suspected patients exposed or contaminated 1.3 Number of patients exposed and exhibiting symptoms 1.4 Chemical identification, if known 1.5 Patient status 1.6 Treatment prior to transport 1.7 Describe decontamination provided on scene 1.8 ALS, BLS 2. Base will acknowledge report and advise on further treatment as necessary. If, while enroute to the hospital, the crew inadvertently discovers a potentially contaminated individual, the following instructions will be followed: 2.1 Crew should ensure that receiving hospital has clear understanding of the potential for a hazardous materials incident 2.2 Stage the ambulance away from the receiving hospital ED until notified where the decontamination area will be located 2.3 Keep the patient and ambulance personnel in or near the ambulance until the decontamination area is ready to receive the patient(s) 2.4 Ambulance personnel should remain in or near their vehicle until the decontamination team is ready to decontaminate EMS personnel, if necessary 3.53.4 If facilities are available, remove clothes and place them in a sealed plastic bag 3.63.5 Save contaminated clothing to allow for testing for radiation exposure 3.73.6 Take a shower to wash off dust and dirt, or to reduce radiation exposure, if the explosive device is radioactive 3.83.7 If radiation was released, local news will advise people where to report for: ► Radiation monitoring ► Blood tests ► Other tests 3.93.8 Test to determine if in fact exposed and what steps to take to protect health. 4. Risk of Cancer 4.1 Short time or small doses of radioactive dust does not mean a person will get cancer 4.2 The additional risk will likely be very small 4.3 Potassium Iodide (KI) will not be protective except in the unlikely event that the dirty bomb contained radioactive iodine isotopes 4.4 The iodine isotopes would have to be in large quantities 4.5 Radioactive iodine isotopes are not particularly attractive for use in an RDD 4.6 KI only protects the thyroid from radioactive iodine 4.7 KI offers no protection to other parts of the body or against other radioactive isotopes Commented \[ZK27\]: Do we need this here? DECONTAMINATION INCIDENT 154 MCI/ Disaster/ WMD Modified On: December 1, 2011 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE The information contained in this policy is based on guidelines contained in EMSA #231 - Hazardous Materials Medical Management Protocol 1. INTRODUCTION: Individuals who respond to and function within the Exclusion Zone (Hot Zone) or Contamination Reduction Zone (Warm Zone) must be members of specially trained HazMat teams, trained in the use of self-contained breathing apparatus, selection of appropriate chemical protective suits and how to function in them. Other rescuers should be trained in accordance with Federal OSHA standards identified in OSHA 29 CFR 1910.120 and California OSHA as defined in the California Code of Regulations, Title 8, Section 5192 2. EMS interface with HazMat teams 2.1 The Incident Command System (ICS) shall be used for on scene management 2.2 The Medical Branch Supervisor shall make contact with the Incident Commander, face-to-face or by radio, who will direct the Medical Branch Supervisor to the Hazardous Materials Group Supervisor 2.3 Pertinent information will be relayed to the Medical Branch Supervisor including patient information (number requiring transport and injuries) and the type of exposure (chemical name and information about the chemical \[SPELL CHEMICAL NAME\]) 2.4 The Medical Branch Supervisor shall make Base contact in order to obtain recommendations regarding decontamination and patient treatment 2.5 Once cleared by the Site Access Leader, EMS personnel may proceed to the end of the "Contamination Reduction Corridor" to receive patients. Any secondary treatment by EMS personnel should be done in the "Support Area" 3. Definitions 3.1 Exclusion Zone (Hot Zone) - Area that encompasses all known or suspected hazardous materials 3.2 Contamination Reduction Zone (Warm Zone) - Area between the "Exclusion Zone" and the "Support Area". "Safe Refuge Area" and "Contamination Reduction Corridor" are set up within this area 3.3 Contamination Reduction Corridor - An area within the "Contamination Reduction Zone" where the actual decontamination takes place. EMS personnel, once cleared, receive patients at the end of the "Contamination Reduction Corridor" and move them to the "Support Area" for secondary treatment 3.4 Support Zone (Cold Zone) - Clean area outside "Contamination Reduction Zone" where equipment and rescue personnel are staged to receive and treat decontaminated patients. Secondary exposure to hazardous materials is not expected in this area and special clothing is not required HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE 155 MCI/ Disaster/ WMD Modified On: December 1, 2011 HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE 4. Patient Management 4.1 Follow the Multi-casualty Incident (MCI) Plan – page 157, if appropriate 4.2 For nerve gas/cyanide exposure: ► Patient exposure: Cyanide Poisoning – page 153 Nerve Agent Treatment - page 162, (HazMat trained paramedics only) ► Rescuer exposure: Nerve Agent Autoinjector Administration – page 160 4.3 Paramedics should contact the Base Hospital Physician early in the incident regarding treatment for other specific exposures 4.4 EMTs and paramedics may only render care within their scope of practice 5. Scene Management Responsibilities Specific to HazMat Incidents 5.1 Police Responsibilities 5.1.1 Evacuations ahead of hazard area. Evacuation plans developed under unified command 5.1.2 Traffic control in and around effected area(s) 5.1.3 Incidents on State/Federal Highways joint command is with CHP 5.2 Fire Department Responsibilities 5.2.1 Incident Stabilization 5.2.2 Rescue and medical treatment (all paramedics may provide treatment in Cold Zone) 5.2.3 Assistance to responsible party or agency with development of appropriate cleanup/disposal plan. May include the assistance of other agencies, (i.e. environmental health, etc.) HAZARDOUS MATERIALS INCIDENTS - EMS RESPONSE 156 MCI/ Disaster/ WMD Modified On: May 29, 2019 MULTI-CASUALTY INCIDENT - EMS RESPONSE 1. INTRODUCTION: A Multi-Casualty Incident (MCI) is any incident where the number of injured persons exceeds the day-to-day operating capabilities; requiring additional resources and/or the distribution of patients to multiple hospitals. This may be different for each incident based on time of day, location, resources available, etc. 2. NOTIFICATIONS: Incident CommandersAny First Responder shall make notifications through ACRECC. Organizations should have internal notification procedures 3. MCI RESOURCE ORDERING, INITIATION AND TERMINATION: 3.1 The first arriving unit should initiate an MCI through ACRECC 3.2 Inform ACRECC of the Incident Type (Medical, Trauma, MVC, Haz-Mat etc.) 3.3 Responders should order MCI Resource Response (MCI Response) as soon as possible in order to get resources responding. This resource ordering can occur before an exact patient count is obtained. 3.4 Patient count approximations should be used as guidelines for initiating a specific MCI LEVEL and are not intended as a substitute for sound scene judgment 3.5 As soon as there is an approximate number of patients determined, the MCI Level should be declared 3.6 Immediately cancel assigned resource(s) when no longer required 3.7 Terminate the MCI through ACRECC when the MCI has been mitigated 4. RESOURCE ORDERING PRIORITY LIST 4.1 ALCO 911 Ambulances 4.2 ALCO BLS Permitted Ambulances MCI RESOURCE ORDERING MCI RESOURCE RESPONSE MCI RESPONSE MCI NOTIFICATIONS PACKAGE ➔ 5 Closest 911 Ambulances ➔ Jurisdictional Fire Battalion Chief ➔ 1 EMS Supervisor ➔ County EOA Provider ➔ EMS TAC channel assigned MCI Response 1 Operations Supervisor Note: Immediately cancel assigned ➔ LEMSA Duty Officer resource(s) when no longer required ➔ 5 Closest Ambulances ➔ 1 EMS Supervisor ➔ 1 DMSU ➔ All County Fire Duty Chiefs MCI Response 2 ➔ Consider Air Assets-IC to request Note: Immediately cancel assigned resource(s) when no longer required Resources in MCI Response 2 are in addition to resources assigned in MCI Response 1 ➔ 5 Closest Ambulances ➔ 1 EMS Supervisor MCI Response 3 ➔ Consider Air Assets-IC to request Note: Immediately cancel assigned resource(s) when no longer required Resources in MCI Response 3 are in addition to resources assigned in MCI Response 2 For Each Additional level: ➔ 5 Closest Ambulances Additional Levels ➔ 1 EMS Supervisor MULTI-CASUALTY INCIDENT - EMS RESPONSE 157 Formatted: Font color: Auto, Not Expanded by / Condensed by MCI/ Disaster/ WMD Modified On: May 29, 2019 MULTI-CASUALTY INCIDENT - EMS RESPONSE MCI LEVELS MCI Level Approximate Patient Count I 5-14 Patients II 15-50 Patients III > 50 Patients 4.3 Mutual Aid from contiguous county(ies) 5. MANAGEMENT OF MCI INCIDENTS AND PATIENT DISTRIBUTION 5.1 Once an MCI alert is determined by prehospital personnel, ACRECC will be notified and will “Initiate an MCI” under the Reddinet MCI module. ACRECC will immediately send an “ED Capacity poll and general notification” to the hospitals in Alameda County 5.2 For all MCI Levels II & III, ACRECC will notify the EMS Duty Officer of the incident 5.25.3 If the DMSU is needed, the highest level of authority on scene to request deployment of the asset through dispatch 5.35.4 Emergency responders shall perform triage using one of the following triage methods: ► The Simple Triage and Rapid Treatment (START) algorithm for adults and JumpSTART for pediatrics ► The Sort, Assess, Lifesaving Interventions, Treatment / Transport (SALT) algorithm for patients in all age groups 5.3.15.4.1 Acuity based Triage colors for both Triage Tape and Triage Tags are universally accepted as Black (expectant / deceased), Red (immediate / life threatening,), Yellow (delayed / serious not life threatening), and Green (minor / walking wounded). Only Black, Red, Yellow, and green are acceptable triage colors 5.3.25.4.2 The use of colored “Triage Tape” upon initial contact with victims at the crisis site is preferred over Triage Tags to identify initial acuity. Triage tags should be used at the external Casualty Collection Point (CCP) outside the crisis site or applied to patients during transport. Acuity-guided transport of all patients shall occur in a coordinated and expedient manner 5.45.5 Hospital Poll: For MCI incidents involving 15+ patients, ACRECC the Alameda County Duty Officer will send a “bed capacity” poll to all hospitals in Alameda County to confirm bed availability 5.55.6 For the duration of the MCI, the Transportation Unit Leader under ICS will determine transportation methods and destinations 5.65.7 Whenever possible, patients should be transported to the most appropriate hospital without overloading one particular facility. Every effort will be made to transport trauma patients to a designated trauma hospital. In a Formatted: Font color: Auto, Not Expanded by / Level II or III MCI, transport to a designated trauma center may not always be possible 5.75.8 First Round Destination Procedure may be implemented without prior authorization. All Alameda County receiving hospitals should prepare to receive patients, especially those in close proximity to the incident Condensed by First Round Destination Procedure Non-Trauma patients** to each Alameda County Trauma patients to each Alameda County Trauma receiving hospital (for a total of 6): Center (for a total of 7): ✓ Two (2) “Immediate” ✓ Three “Immediate” ✓ Four (4) “Delayed” and/or “Minor” ✓ Four (4) “Delayed” and/or “Minor” ** e.g.: Medical incident, HazMat MCI/ Disaster/ WMD Modified On: May 29, 2019 MULTI-CASUALTY INCIDENT - EMS RESPONSE MULTI-CASUALTY INCIDENT - EMS RESPONSE 158 MCI/ Disaster/ WMD Modified On: May 29, 2019 MULTI-CASUALTY INCIDENT - EMS RESPONSE 5.85.9 ACRECC in conjunction with the incident command structure will track patient numbers, acuity and destinations in ReddiNet in as close to real-time as possible. ReddiNet will serve as the primary mechanism notifying receiving facilities of the number and acuity of incoming patients. Receiving hospitals will enter patient names and other relevant information into ReddiNet. This will facilitate patient accountability and reunification. On scene EMS Supervisors may also have the ability to enter information into ReddiNet 5.95.10 Verbal notification to hospitals: In a Level I MCI, transporting units should contact the receiving hospital enroute to give an abbreviated report on the patient(s) status and ETA. In a Level II or III MCI, if ReddiNet is unavailable or non-functional, a medical communications coordinator should be designated to notify receiving facilities of the number and acuity of incoming patients. 5.105.11 Incident Log - The Transportation Unit Leader should maintain an incident log 5.115.12 The on-scene Incident Commander or designee (i.e.. Medical Group Supervisor or Transportation Unit Leader) should contact ACRECC during and at the conclusion of the MCI to provide and reconcile patient tracking information to ensure accountability 6. RESOURCE MANAGEMENT - The Incident Commander has the overall responsibility for developing objectives and requesting the necessary resources required to mitigate the incident. There will be no self-dispatching. Clear communications between all involved agencies is imperative 6.1 The following items are MCI Management points to consider ► The three “T’s” ensure that Triage, Treatment and Transport have been addressed ► Request resources through the Incident Commander in the early stages of the incident. Ensure adequate personnel and equipment ► Establish staging areas. Transport Units and/or other units that do not immediately have an assignment should report to the designated staging area and wait for instructions ► Use a one-way traffic pattern. Transport units should be staged to assure good access and egress from Loading Area ► All incoming units drop off required EMS equipment at a designated location ► County Disaster Trailers shall be requested through ACRECC 6.2 Use ICS identification vests. At a minimum the IC, Medical Group Supervisor, Triage and Treatment, and Transportation Unit Leader should be clearly identified with vests MUl TI-CASUAl TY INCIDENT - EMS RESPONSE 159 Modified On: December 1, 2011 MCI/ Disaster/ WMD NERVE AGENT AUTOINJECTOR ADMINISTRATION 1. INTRODUCTION: Nerve agent auto-injectors are to be used when EMS personnel are exposed to nerve agents (Sarin, Soman, Tabun, VX) and have signs and symptoms of nerve agent exposure, or when ALS/ specially trained BLS personnel treat victims in an MCI situation in the hot zone 2. EQUIPMENT: 2.1 Mark I autoinjector antidote kit containing: ► Atropine autoinjector (2 mg in 0.7 mL) ► Pralidoxime chloride autoinjector - 2-PAM (600 mg in 2 mL) 2.2 Additional atropine (2 mg) autoinjectors 3. PROCEDURE: If you experience any or all of the nerve agent poisoning symptoms, you must IMMEDIATELY self- administer the nerve agent antidote and symptoms) (see “Nerve Agent Treatment” - page 162 for signs MARK I antidote kit 3.1 Injection Site Selection: ► The injection site for administration is normally in the outer thigh muscle (Figure 1). It is important that the injections be given into a large muscle area ► If the individual is thinly-built, then the injections should be administered into the upper outer quadrant of the buttocks (Figure 2) Figure 1 - Thigh injection site Figure 2 - Buttocks injection site 3.2 Arming The Autoinjector: ► Immediately put on your protective mask ► Remove the antidote kit ► With your non-dominant hand, hold the autoinjectors by the plastic clip so that the larger autoinjector is on top and both are positioned in front of you at eye level ► With your dominant hand grasp the atropine autoinjector (the smaller of the two) with the thumb and first two fingers. DO NOT cover or hold the needle end with your hand, thumb, or fingers-you might accidentally inject yourself. An accidental injection into the hand WILL NOT deliver an effective dose of the antidote, especially if the needle goes through the hand ► Pull the injector out of the clip with a smooth motion. The autoinjector is now armed 3.3 Administering the antidote to yourself: ► Hold the autoinjector with your thumb and two fingers (pencil writing position). Be careful not to inject yourself in the hand! ► Position the green (needle) end of the injector against the injection site (thigh or buttock). DO NOT inject into areas close to the hip, knee, or thigh bone ► Apply firm, even pressure (not jabbing motion) to the injector until it pushes the needle into your thigh (or buttocks). Using a jabbing motion may result in an improper injection or injury to the thigh or buttocks ► Hold the injector firmly in place for at least 10 seconds. Firm pressure automatically triggers the coiled spring mechanism. This plunges the needle through the clothing into the muscle and at the same time injects the antidote into the muscle tissue ► Carefully remove the autoinjector from your injection site ► Next, pull the 2 PAM injector (the larger of the two) out of the clip ► Inject yourself in the same manner as the steps above, holding the black (needle) end against your outer thigh (or buttocks) ► Massage the injection sites, if time permits NERVE AGENT AUTOINJECTOR ADMINISTRATION 160 Modified On: December 1, 2011 MCI/ Disaster/ WMD NERVE AGENT AUTOINJECTOR ADMINISTRATION ► After administering the first set of injections, wait 5 to 10 minutes ► After administering one set of injections, you should initiate decontamination procedures, as necessary, and put on any additional protective clothing ► Atropine only may be repeated every 10 - 15 minutes as needed. (Note: multiple doses of atropine may be needed.) 3.4 Administering the antidote to another in the Hot Zone: ► Squat, DO NOT kneel, when masking the casualty or administering the nerve agent antidotes to the casualty. Kneeling may force the chemical agent into or through your protective clothing ► Mask the casualty ► Position the casualty on his or her side (swimmer’s position) ► Position yourself near the casualty's thigh ► The procedure for site selection and medication administration is the same as 3.1 – 3.3 ► Atropine only should be repeated as needed- multiple doses may be needed 4. DOSAGE SCHEME FOR MARK I ADMINISTRATION - via autoinjector Additional atropine may be needed until a positive response is achieved (decrease in bronchospasm and/or respiratory secretions) Signs & Symptoms Onset # of autoinjectors to use: Vapor: small exposure Seconds MARK I autoinjector antidote kit – 1 dose initially ✓ Pinpoint pupils (containing atropine and 2-PAM) ✓ Runny nose May repeat x1 in 10 minutes ✓ Mild SOB Liquid: small exposure Minutes to Hours MARK I autoinjector antidote kit – 1 dose initially ✓ Sweating (containing atropine and 2-PAM) ✓ Twitching May repeat x1 in 10 minutes ADULT ✓ Vomiting ✓ Feeling weak Both: large exposure Seconds to Hours MARK I autoinjector antidote kit – 3 doses initially ✓ Convulsions (containing atropine and 2-PAM) ✓ Apnea May repeat x1 in 10 minutes ✓ Copious secretions Age Weight Autoinjectors (#) Atropine 2-PAM (approx.) (approx.) (each type) dose range (mg/kg) dose range (mg/kg) 3-7 13-25 kg 1 0.08-0.13 24-46 Commented \[ZK28\]: Why is this included? We should 8-14 26-50 kg 2 0.08-0.13 24-46 make clearer. Instead of mg/kg, just put the mg for the PEDIATRIC >14 > 51 kg 3 0.11 or less 35 or less kg range. Or leave out entirely. NOTE: While not approved for pediatric use, autoinjectors should be used as initial treatment in children with severe, life-threatening nerve agent toxicity where IV treatment is not possible or available, or a more precise IM dosing would be logistically impossible. NERVE AGENT AUTOINJECTOR ADMINISTRATION 161 MCI/ Disaster/ WMD Modified On: July 24, 2018 NERVE AGENT TREATMENT ► ALS and specially trained BLS personnel may administer nerve agent antidote medications to patients. (See page 160 for auto-injector procedure) ► Nerve agent antidote medications are only given if the patient is showing signs and symptoms of nerve agent poisoning. THEY ARE NOT TO BE GIVEN PROPHYLACTICALLY ► This policy is to be used in conjunction with page 155 (HazMat) ► Note: A decrease in bronchospasm and respiratory secretions are the best indicators of a positive response to atropine and 2-PAM therapy Signs and Symptoms of Nerve Agent Exposure (from mild to severe) Exposure Signs & Symptoms ► Unexplained runny nose ► Tightness in the chest ► Difficulty breathing MILD ► Bronchospasm ► Pinpoint pupils resulting in blurred vision ► Drooling ► Excessive sweating ► Nausea and/or vomiting ► Abdominal cramps MODERATE ► Involuntary urination and/or defecation ► Jerking, twitching and staggering ► Headache ► Drowsiness ► Coma SEVERE ► Convulsions ► Apnea MNEMONIC FOR NERVE AGENT EXPOSURE Muscarinic Effects: Nicotinic Effects: D iarrhea M ydriasis U rination T achycardia M iosis W eakness B radycaria, bronchorrhea H ypertension E mesis F asciculations L acrimation S alivation NERVE AGENT TREATMENT 162 Warm Zone if needed0.1 mg/kg in 10 minutes -at 0.05 repeat –0.3 mg/kg -0.1 Child: as needed-5 Adult: Diazepam with seizures Treat exposures severe in repeat May gram 1 maximum mg/kg 40-20Child: grams 2-1 Adult: IM or IO IV/ PAM)-(2 area affected Cover water of amounts large with area Flush agent the off Blot clothing Strip off exposed: patient If ExposuresSevere to Mild MCI/ Disaster/ WMD Modified On: December 1, 2011 NERVE AGENT TREATMENT-OVERHAUL Hot Zone Severe Exposures Only *See page 160 for autoinjector use in the hot zone. Document the number of autoinjectors *Atropine IM only: administered to the victim IV/ IO NS Adult/Adolescent - 2 mg Child: < 2 years 0.5 mg ^Administer 2-PAM as soon 2-10 years 1 mg as possible, especially for (see note) agents that ‘age’ quickly Atropine IV/ IO or IM: Adult: 2mg Note: In a moderate Child: 0.02 mg/kg - *^Pralidoxime (2-PAM) IM only: to severe exposure – minimum dose 0.1 mg Adult/Adolescent: 1-2 grams repeat as needed (see note) Child: 20 mg/kg until a positive maximum 1 gram response is achieved May repeat in severe exposures Treat seizures with Commented \[ZK29\]: Maybe we separate out adult and Midazolam IM only pediatric charts Adult/Adolescent: 105 mg Child: 0.1 mg/kg (maximum 5 mg) Note: MMRS providers may use Diazepam Autoinjector 10 mg IM - ADULTS ONLY NERVE AGENT TREATMENT 163 MCI/ Disaster/ WMD Modified On: December 1, 2011 RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB”-either OVERHAUL OR GET RID OF “POLICY” Adapted from: Nuclear Regulatory Commission http://www.nrc.gov 1. Background: 1.1 Principal type of “dirty bomb” combines a conventional explosive such as Dynamite/Explosives with radioactive material 1.2 A conventional explosive itself would have more immediate lethality than dirty bombs 1.3 Most probably, not enough radiation would be present in a dirty bomb to: ► Kill people ► Cause severe illness 1.4 Most radioactive material employed in hospitals is sufficiently benign 1.5 About 100,000 patients a day are released with this material in their bodies 1.6 Certain other radioactive materials could contaminate up to several city blocks 1.7 It could create fear and possibly panic and requiring potentially costly cleanup 1.8 A second type of RDD might involve a powerful radioactive source hidden in a public place 1.9 Hiding places may include such places as: ► Trash receptacles ► Latrines ► Delivery vehicles ► Vending machines ► Parked vehicles 1.10 A dirty bomb is in no way similar to a nuclear weapon 1.11 The presumed purpose of its use would be as a Weapon of Mass Disruption 1.12 Not as a Weapon of Mass Destruction 2. Impact of a Dirty Bomb: 2.1 The extent of local contamination would depend on a number of factors 2.2 Factors includes: ► The size of the explosive ► The amount and type of radioactive material used ► The weather conditions 2.3 Prompt detection of the kind of radioactive material employed would greatly assist local authorities 2.4 It would assist in advising the community on protective measures, such as: ► Quickly leaving the immediate area or ► Going inside until being further advised 2.5 Subsequent decontamination of the affected area could involve considerable: ► Time ► Expense 3. What Should You Do Following an Explosion 3.1 Move away from the immediate area--at least several blocks from the explosion 3.2 Head inside and establish shelter-in-place 3.3 This to reduce exposure to radioactive dust 3.4 Turn to radio/TV channels for advisories from: ► Emergency response ► Health authorities RADIOLOGICAL DISPERSION DEVICE (RDD), AKA “DIRTY BOMB” 164 MCI/ Disaster/ WMD Modified On: December 1, 2011 SUSPICIOUS POWDER PROCESS Commented \[ZK30\]: Do we know how to contact FBI from the field? Dispatch center to contact DO Formatted: Font: 8 pt DO to notify appropriate agencies (public health, environmental health as needed) See applicable Table of Contents to locate protocols or utilize the EMS Mobile App for keyword searches SUSPICIOUS POWDER PROCESS 165 Formatted: Font: 8 pt Formatted: Font: 8 pt THIS PAGE INTENTIONALLY LEFT BLANK 166 ALAMEDA COUNTY APPROVED RECEIVING HOSPITALS (510) area code unless otherwise specified (Rev. 07/2024) 5150 5150 CA Medical Eval. Sexual Hospital Main Number ED Number Helipad L&D Stroke Trauma STEMI Psych Eval. Bridge Adults / Assault Adolescen ts x 522-3700 814-4095 x Alameda Adolescents 483-3030 ALCO Youth CSU ----- Age 12-17 204-4444 204-2500 x x Alta Bates x 428-3000 428-3240 Age < 11 Age < 11 x x Age < 14 Children’s Age < 13 537-1234 727-3015 x x x x Age > 15 Eden x 437-4559 x 437-4800 x x Age > 14 Age > 15 Highland (ACMC) x x (base MD) 535-6000 346-1300 346-1421 Age > 18 John George (925) 813-6500 (925) 813-6099 x x Kaiser - Antioch x 248-3000 248-7208 x Kaiser - Fremont x x x 752-1000 752-7667 x x Kaiser - Oakland x x x 454-1000 454-4348 x x Kaiser – San Leandro x (925) 295-4000 (925) 939-1788 x x x Kaiser – Walnut Creek x 357-6500 667-4545 x San Leandro (925) 275-9200 (925) 275-8280 x San Ramon x x 264-4000 264-4026 x x St. Rose x x x 655-4000 869-8700 x Summit (925) 847-3000 (925) 416-6525 x x x Valley Care x x 797-1111 818-8531 x x Age > 14 Age > 15 Washington x x x OUT-OF-COUNTY RESOURCES Hospital ED Number Base Number Helipad L & D STEMI Stroke Trauma Burn (925) 939-5804 or (925) 941-3379 x x x x John Muir Medical Center x 5805 (ALS/Trauma) (BLS ringdowns) Regional Medical Center (408) 729-2854 x x San Francisco General (628) 206-8111 (628) 647-4747 x x x x San Joaquin General (209) 468-6301 (209) 982-1975 x x x x (Adult & Ped) Santa Clara Valley (VMC) (408) 885-3228 (408) 885-6937 x x x x (408) 885-6666 Stanford (650) 723-7337 x x x x x St. Francis Memorial (415) 353-6300 ext. 5 x (415) 353-6255 x x x x UC Davis Medical Center x (916) 734-3636 Base Physician Contact Template Highland Hospital Base Physician – 510-535-6000 ■ Identify yourself/unit number S ituation ■ State purpose of call: (e.g. AMA consult, destination decision, etc.) ■ Provide basic patient demographics (e.g. age/gender) ■ Reason for patient contact/EMS activation ■ Provide history of present illness/injury B ackground ■ Medical history ■ Vital signs A ssessment ■ Physical findings ■ Treatment provided ■ State your recommendation/request R ecommendation/Request ■ Confirm Base Physician’s recommendation/orders Hospital Notification Template Basic Notifications 1. Unit Number 6. Pertinent negatives/positives 2. Transport code 7. Treatment(s) 3. Age & Gender 8. Repeat ETA 4. Chief Complaint 9. Check for questions 5. V/S stable or detailed V/S if abnormal Specialty care patient notifications For each category below, include info from the basic notification template plus the appropriate category below Trauma 1. Mechanism of Injury 3. GCS – each category of E/V/M + total 2. Injuries 4. Detailed Vital Signs Cardiac Arrest / ROSC 4. Total estimated down time 1. Airway – non-patent, patent, airway 5. Summary of treatment(s) given placed/not-placed 2. Breathing – absent/spontaneous 3. Circulation – pulses present/absent Stroke Alert 1. Last seen normal time 3. Blood glucose 2. Stroke Assessment/Scale findings Sepsis 1. Temperature 3. Detailed Vital Signs 2. Suspected source of infection (if known) STEMI 1. Estimated onset of S/S 3. Detailed Vital Signs 2. Was 12-lead ECG Transmitted Pediatric Patients 1. Patient’s weight-based color code 2. Status of parent/guardian Note: Detailed Vital Signs should include: RR, HR, B/P, SpO2, GCS (number of each category E/V/M)