Header:
CODE OF RHODE ISLAND RULES
AGENCY 96. COMMISSIONS AND OTHER AGENCIES - OTHER
SUB-AGENCY 010. AMBULANCE SERVICE COORDINATING BOARD
Date:
08/31/2009
Document:
96 010 001 PROTOCOLS AND STANDING ORDERS
These protocols and standing orders are established by the RHODE ISLAND AMBULANCE SERVICE COORDINATING BOARD pursuant to the authority conferred under Sections 23-4.1-4and 23-17.6-4 of the General Laws of Rhode Island 1956, as amended.
These protocols and standing orders shall supercede all protocols and standing orders previously established and promulgated by the Rhode Island Department of Health Division of Emergency Medical Services.
....
Glenn W. Mitchell, MD
Chairman, Rhode Island
Ambulance Service
Coordinating Board
TABLE OF CONTENTS
BURNS
CARDIAC PATIENT (SUSPECTED)
CARDIAC ARREST
EXPOSURE
IMPAIRED CONSCIOUSNESS
RESPIRATORY DISTRESS
SHOCK
TRAUMA
APPENDIX
BURN SEVERITY CHART
ESOPHAGEAL OBTURATOR AIRWAY
PNEUMATIC ANTI-SHOCK GARMENT
TRIAGE PLAN
BURNS
TREATMENT
1. Stop burning process (but ensure your own safety).
2. Assess the airway and follow Respiratory Distress protocol, if necessary. Check for ventilation and pulse. If not present, start CPR.
3. Remove clothing and rings (BUT do not pull off skin or tissue).
4. Suspect an inhalation injury if the following are present on Secondary Assessment: closed space burn; burns of face; singed nasal hairs, beard or mustache; sooty or bloody sputum; difficulty breathing or brassy cough.
a. Assist ventilation with high-flow oxygen, if necessary, or administer 4-6 1/min. by nasal cannula if respirations are normal.
b. Do not use an esophageal airway.
5. Assess for additional trauma not originally suspected.
6. Assess degree of burn and Body Surface Area affected (See Rule of Nines chart).
7. Wrap exposed areas with sterile sheets. Cold packs may be applied to 1st and 2nd degree burn areas over the sterile sheets for pain relief if the burn is less than 10% of the Body Surface Area. (3 deg. burns are not usually painful).
8. Wash chemical burns with copious amounts of water or normal saline.
9. Do not allow any food or liquids to be consumed by the patient.
10. EMT-Cardiacs and higher should start an IV with lactated Ringer solution at 300 cc/hour in patients with 2nd or 3rd degree burns that are greater than 20% of the Body Surface Area.
11. Contact Medical Control for any serious burn of the body and for all inhalation injuries.
12. Transport the patient to a Hospital Emergency Facility.
CARDIAC PATIENT (SUSPECTED)
TREATMENT
1) Loosen tight clothing and allow the patient to sit in a comfortable position unless hypotensive.
2) Administer oxygen by nasal cannula at 4-6 liters/min.
3) Perform a routine medical secondary assessment.
4) For Advanced Life Support units:
a) Attach the patient to EKG monitor, observe rhythm, and be prepared to transmit EKG.
b) If the patient's status indicates significant cardio-pulmonary distress, or if it is likely that the patient will become unstable en route to the hospital, then start an IV with D5W at keep vein open rate using a 20 gauge catheter.
5) Contact Medical Control.
6) Transport the patient to a Hospital Emergency Facility.
CARDIAC ARREST (GENERAL TREATMENT)
1. Quickly check for unresponsiveness, airway patency, spontaneous respirations, and carotid pulses.
2. If there is a cardio-pulmonary arrest, immediately begin the Basic Life Support (CPR) sequence of the American Heart Association or the American Red Cross.
DO NOT CEASE CPR FOR MORE THAN 5 SECONDS except a maximum of 10 seconds to obtain an EKG strip during advanced life support or a maximum of 30 seconds to intubate or move the patient UNTIL THE PATIENT HAS BEEN STABILIZED, OR UNTIL AUTHORIZED BY MEDICAL CONTROL TO DO SO.
3. For ventilatory support:
a) Follow the Respiratory Distress Protocol if there are airway difficulties.
b) Intubation with an esophageal obturator airway (EOA) may be performed according to training guidelines by a licensed EMT-Intermediate or higher, and respirations assisted with high-flow oxygen. A bag-valve-mask and/or other airway adjuncts may be used if E.O.A. intubation is unavailable.
4. a) Basic Life Support units should transport the patient to the nearest hospital emergency facility as soon as possible giving CPR en route and notifying Medical Control of the situation.
b) Advanced Life Support units may give further treatment as outlined below for the specific cardiac rhythm observed by:
(1) using the quick-look EKG via paddles on the defibrillator with the recorder "on" (interrupt CPR) to obtain a 6 to 10 SECOND STRIP for inclusion with the runsheet submitted to the Division of Emergency Medical Services (EKG strips should be marked for time taken);
OR
(2) attaching EKG monitoring leads after initial CPR measures above are begun and using the monitor cable mode. A 6 to 10 SECOND STRIP (interrupt CPR) must be obtained for inclusion with the runsheet submitted to the Division of Emergency Medical Services (EKG strips should be marked for time taken). Additional strips should be taken for each change in cardiac rhythm, marked for time, and attached to the EMS runsheet.
Transmitted EKG telemetry should also be in the form of 6 to 10 second strips and should be sent at the request of either the EMT-Cardiac on-scene or Medical Control. Transport should always occur as soon as possible after identification of cardiac rhythm and on-scene therapy.
ADVANCED LIFE SUPPORT MEASURES FOR CARDIAC ARREST
A. ASYSTOLE
[See graphic or tabular material in printed version]
TREATMENT
1) Check monitor to see if it is properly functioning by observing EKG complexes when touching both paddles (or monitor leads) yourself.
2) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) for cardiac arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, continue CPR and transport the patient to a hospital emergency facility immediately.
3) Contact Medical Control for further orders; if communications with Medical Control fail to be established, the following are STANDING ORDERS:
a) Administer 1 1/2 amps of Sodium Bicarbonate followed by 1 amp (1.0 mg) Epinephrine (1:10,000) IV push.
b) If still asystolic, administer 1 amp (1.0 mg) Atropine Sulphate IV push.
c) If ventricular fibrillation results, defibrillate at 200 watt-seconds (adults). If VF continues, reshock immediately at 200 watt-seconds (adults).
d) Administer 1 amp of Sodium Bicarbonate IV push every 10 minutes after the initial dose while en route if this does not interfere with rapid transport.
e) Transport the patient to a Hospital Emergency Facility while maintaining CPR if pulses have not returned.
B. VENTRICULAR FIBRILLATION (VF)
[See graphic or tabular material in printed version]
TREATMENT
1) Immediately defibrillate at 200 watt-seconds (adults). If VF continues reshock immediatley [immediately] at 200 watt-seconds (adults).
2) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) catheter for cardiac arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, continue CPR and transport the patient to a Hospital Emergency Facility.
3) Contact Medical Control for further orders: if communications with Medical Control fail to be established, the following are STANDING ORDERS:
a) If VF persists, administer 1 1/2 amps of Sodium Bicarbonate followed by 1 amp (1.0 mg) Epinephrine (1:10,000) IV push.
b) If VF still persists, repeat defibrillation at full charge (adults).
c) Transport the patient to a Hospital Emergency Facility while maintaining CPR if pulses have not returned.
d) Administer 1 amp of Sodium Bicarbonate IV push every 10 minutes during CPR after the initial dose while en route if this does not interfere with rapid transport.
C. VENTRICULAR TACHYCARDIA (VT) Patient Unconscious and Pulseless
[See graphic or tabular material in printed version]
TREATMENT
1) Administer a precordial thump.
2) If ventricular tachycardia persists, immediately countershock at 200 watt-seconds (adults) or, if EKG monitoring leads are in place, cardiovert (Synch Mode) at 200 watt-seconds (adults).
3) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) catheter for arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, continue CPR and transport the patient to a Hospital Emergency Facility.
4) Contact Medical Control for further orders; if communications with Medical Control fails to be established, the following are STANDING ORDERS:
a) If ventricular fibrillation occurs, go to the Ventricular Fibrillation Standing Orders on the previous page.
b) Give Lidocaine 75 mg IV push.
c) Administer 1 amp of Sodium Bicarbonate IV push every 10 minutes during CPR after the initial dose while en route if this does not interfere with rapid transport.
d) Transport patient to a Hospital Emergency Facility while continuing CPR if pulses have not returned.
D. VENTRICULAR TACHYCARDIA (VT) Patient Unconscious with a pulse
[See graphic or tabular material in printed version]
TREATMENT
1) Administer a precordial thump.
2) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) catheter for arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, transport the patient to a Hospital Emergency Facility.
3) Contact Medical Control for further orders; if communications with Medical Control fail to be established, the following are Standing Orders:
a) If ventricular fibrillation occurs, go to the Ventricular Fibrillation Standing Orders on the previous page.
b) Give Lidocaine 75 mg IV slow push.
c) Transport patient to a Hospital Emergency Facility
E. VENTRICULAR TACHYCARDIA (VT) Patient Conscious
[See graphic or tabular material in printed version]
TREATMENT
1) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) catheter for arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, transport patient to a Hospital Emergency Facility.
2) Contact Medical Control for further orders; if communications with Medical Control fail to be established, the following are Standing Orders:
a) Give Lidocaine 75 mg IV slow push.
b) Transport patient to a Hospital Emergency Facility
F. ELECTROMECHANICAL DISSOCIATION (EMD) - Patient Unconscious and Pulseless
[See graphic or tabular material in printed version]
TREATMENT
1) Start an IV:
a) D5W at keep vein open rate for routine cardiac arrest.
b) 1 or 2 IV lifelines with lactated Ringer solution infusing "wide open" (up to 2,000cc) through a large bore (18g or larger) catheter for cardiac arrest accompanying trauma with external or internal blood loss.
If unable to establish IV within 2 tries, continue CPR and transport the patient to a Hospital Emergency Facility.
2) Contact Medical Control for further orders; if communications with Medical Control fail to be established, the following are Standing Orders:
a) Administer 1 1/2 amps Sodium Bicarbonate IV push followed by 1 amp (1.0 mg) Epinephrine (1:10,000) IV push.
b) If ventricular fibrillation results, defibrillate at 200 watt-seconds (adults). If VF continues, reshock immediately at 200 watt-seconds (adults).
c) Administer 1 amp of Sodium Bicarbonate IV push every 10 minutes during CPR after the initial dose while en route if this does not interfere with rapid transport.
d) Transport the patient to a Hospital Emergency Facility while continuing CPR (if pulses have not resumed).
EXPOSURE COLD - HEAT - RADIATION
I. COLD
A. HYPOTHERMIA
TREATMENT
1. Primary Assessment:
a. Secure the airway - suction if necessary.
b. Support respirations as needed with high-flow oxygen by face mask or bag-mask.
c. Chest compressions if systolic blood pressure is < 40 mm.
2. Check for other injuries - fractures, head, etc.
3. Handle victim gently -- jarring movements can cause cardiac arrest!
4. Remove from cold environment.
5. Remove wet clothing (by cutting).
6. Rewarm using blankets (or sleeping bag, etc.).
7. EMT-Cardiacs and higher should monitor the EKG.
8. Call Medical Control for further instructions.
9. Transport the patient to a Hospital Emergency Facility.
B. FROST BITE
TREATMENT
1. Avoid trauma to the injured area -- do not rub and do not break blisters.
2. Place dry padding over part and splint -- No pressure constriction; do not allow the patient to use injured parts.
3. Do not apply snow or ice but do not thaw the part if there is a chance that it may refreeze before reaching the hospital.
4. Keep the frozen part away from your heater but keep the patient warm.
5. Contact Medical Control.
6. Transport the patient to a Hospital Emergency Facility.
II. HEAT
A. HEAT CRAMPS AND HEAT EXHAUSTION
RECOGNITION
1. Profuse sweating with or without adequate replacement or water but with inadequate replacement of salt.
2. Severe painful muscular cramping of leg and abdominal muscles.
3. Patient is agitated -- the mental state is clear in heat cramps, but may be confused in heat exhaustion.
4. Skin wet and warm with normal color progressing to moist, cool and pale in heat exhaustion.
5. Temperature normal or slightly elevated.
6. Generalized weakness, headache, and nausea/vomiting may be present with exhaustion,
TREATMENT
1. Move to cool area.
2. Loosen or remove non-essential clothing.
3. Assess vital signs and mental status.
4. Elevate the patient's legs, if hypotensive.
5. P.O. fluids with salt (1/3 tsp salt in 8 oz of water or Gatorade), if patient is alert enough to swallow easily.
6. Contact Medical Control for further orders.
7. Transport the patient to a Hospital Emergency Facility, if hypotensive or the patient requests.
C. HEAT STROKE
RECOGNITION
1. Air temperature usually 90 deg. F or above with high humidity.
2. Usually in elderly people or those with medical problems.
3. Core temperature 103 deg. F to 106 deg. F.
4. Absence of sweating.
5. Skin warm, red and dry.
6. Blood pressure low in 50% of patients.
7. Impaired consciousness or comatose.
8. Rapid breathing.
TREATMENT
1. Rapid cooling as soon as possible.
2. Remove to cool place -- open windows -- fans if available.
3. Wrap patient in sheets soaked in cold water.
4. Assess and continue to monitor vital signs.
5. High-flow oxygen by mask.
6. EMT-Cardiacs and higher should start an IV with Normal Saline at 200 cc/hr.
7. Contact Medical Control for further orders and to notify them of your transport of a seriously ill patient.
7. Transport the patient to a Hospital Emergency Facility.
III. RADIATION
ACTION AND TREATMENT
1. Immediately notify Rhode Island State Police (401) 647-3311 of any radiation accident (they will then notify other proper authorities).
2. Use common sense. The time you are exposed and the distance you are away from the source are the exposure factors for contaminants. Once away from the source, an exposed (not contaminated) person is not a risk to you.
3. If accident is at a plant, a supervisor or co-worker can usually inform rescue personnel of type and amount of radiation exposure or contamination.
4. Responsibility for Patient:
a. Give lifesaving emergency assistance, as needed.
b. Secure pertient information from appropriate bystanders.
c. If patient has a wound, cover it with clean dressings using gauze tape or elastic bandage -- not adhesive tape.
d. Cover stretcher, including pillow, with an open blanket, then wrap the patient in the blanket to limit spread of contamination.
e. Notify Rhode Island Hospital (the State Radiation Receiving Center) by radio (or telephone) of the available information and estimated time of arrival of your unit and get further instructions for decontamination of the patient, your vehicle and yourself.
IMPAIRED CONSCIOUSNESS
TREATMENT
1. Secure the airway, following the Respiratory Distress Protocol, if needed. Administer oxygen at 4-6 1/min. by nasal cannula if patient is breathing adequately; otherwise assist ventilation with a bag-mask and high-flow oxygen.
2. Initiate chest compressions if no cardiac activity is present; EMT-Cardiacs and higher should utilize the quick-look paddles or monitor leads for an EKG strip to assess the cardiac rhythm. If CPR is indicated, proceed to Cardiac Arrest Protocols.
3. Rapidly assess the patient for:
a. Signs of shock (see Shock Protocol).
b. Signs of trauma (see Trauma Protocol).
c. Level of consciousness (Glascow Coma Scale):
1) Eye opening spontaneously, to voice or to pain;
2) Speech oriented, confused, inappropriate, or none;
3) Movement on command, to pain spot, flexes arms to pain, extends arms to pain, or no movement at all.
d. Loss of movement of any extremities (may require painful stimuli to each limb to stimulate movement).
e. Pupillary response and size.
f. Breath odors (alcohol or acetone).
4. EMT-Cardiacs and higher should perform the following:
a. Rapidly draw (1) red top tube blood sample (which may be done while starting the IV).
b. Start IV with D5W at KVO (use normal saline if acetone odor is on breath or patient seems dehydrated).
c. Give 50 cc D5OW IV push.
5. Check vital signs every five minutes.
6. Obtain available information from family/witnesses including medical history, recent mental state and possible drugs.
7. Contact Medical Control.
8. Transport the patient to Hospital Emergency Facility.
RESPIRATORY DISTRESS ---- UPPER AIRWAY OBSTRUCTION
TREATMENT
A. Conscious Patient:
1) Look for the International Sign of Choking, labored breathing, wheezing, crowing sounds, and/or cyanosis.
2) If the victim can speak or can breathe and cough at all, standby to assist.
3) If a foreign body is suspected and the victim cannot speak or brethe, use back blows followed by abdominal (or chest) thrusts executed quickly four times each.
4) If still unsuccessful, continue to give series of four back blows and four abdominal (or chest) thrusts followed by mouth sweeps.
5) Administer supplemental oxygen at 4 to 6 liters per minute if breathing can be resumed or transport the patient immediately to a Hospital Emergency Facility while continuing the series of blows and thrusts.
B. Impaired Consciousness
1) Hyperextend neck and establish airway via chin lift or triple airway maneuver. (Disregard hyperextension if head/neck injury is suspected).
2) If the initial effort at inflation of the lungs is unsuccessful, clear any debris from oral cavity (well-fitting dentures excluded). Reposition the airway and again try to inflate the lungs.
3) If patient still cannot be ventilated, use four back blows and four abdominal (or chest) thrusts followed by mouth sweeps. Recheck ventilation after each sequence for up to four total cycles.
4) If ventilation is still impossible, apply positive pressure via bag-valve-mask.
5) Contact Medical Control for further orders. If communications fail, the following is a standing order:
If the measures above are unsuccessful, transport the patient to a Hospital Emergency Facility immediately for intubation or cricothyrotomy.
6) Medical Control may authorize transportation to a non-hospital medical facility for temporary stabilization.
SHOCK
1. Consider the diagnosis of shock in any patient with:
a. Altered consciousness, restlessness, coma.
b. Pale, cool, clammy skin.
c. Tachycardia with a weak, thready pulse > 110/minute.
d. Tachypnea (rapid shallow respirations).
e. Hypotension
1) Adult Systolic BP < 90 mm
2) Child (4 to 12 yrs.) Systolic BP < 80 mm
3) Infant (to 4 yrs.) Systolic BP < 70 mm
2. Stop external bleeding by direct pressure or pressure points.
3. Secure the airway using the Respiratory Distress Protocol, if necessary. Administer high-flow oxygen by mask and assist ventilation as needed. If systolic BP is < 40 mm, begin chest compressions and transport the patient to a hospital emergency facility.
4. Rapidly examine for causes of shock. (Blood / volume loss; Cardiogenic; Neurogenic; Anaphylactic; Septic)
5. Elevate the patient's legs, and monitor vital signs at least every five minutes.
6. For EMT-Intermediates and higher:
If shock is due to blood or volume loss or neurogenic shock, apply the pneumatic anti-shock garment. Inflate it according to training guidelines. If, after the pneumatic anti-shock garment is inflated, signs of pulmonary edema appear, deflate the suit immediately.
7. For EMT-Cardiacs and higher:
a) If shock is due to blood or volume loss or neurogenic shock, start IV of 1000cc Ringer lactate using a large (18 ga or larger) catheter and run it "wide open". Start a second IV at a different site if transport will be longer than 15 minutes.
b) If shock is due to other causes, start IV of Normal Saline and run it at keep vein open rate.
c) Apply EKG leads and evaluate cardiac activity.
If unable to establish IV within 2 tries, transport the patient to a Hospital Emergency Facility.
9. Contact Medical Control for further orders and to notify them of your transport of a critical patient to a Hospital Emergency Facility.
TRAUMA
TREATMENT
1. Rapid initial assessment is essential. Access to the patient for the Primary Assessment and initial treatment should take precedence over complete extrication.
2. Ensure adequacy of the airway and ventilation:
a. Use the chin lift or triple airway maneuver only due to the possibility of cervical spine injury.
b. Clear upper airway manually or by suction, as necessary. Follow the Respiratory Distress Protocol, if needed.
d. Administer oxygen at 4-6 liters/minute by nasal cannula, if breathing is adequate, or assist with a bag valve mask as needed.
3. Control hemorrhage by direct pressure. Do not remove penetrating objects.
4. If no pulse is present, start chest compressions.
5. For EMT-Intermediates and higher, pneumatic anti-shock garments may be used as per protocol.
6. For EMT-Cardiacs and higher:
If shock is due to blood or volume loss or neurogenic shock, start IV of 1000cc Ringer lactate using a large (18 ga or larger) catheter and run it "wide open". Start a second IV at a different site if transport will be longer than 15 minutes.
If unable to establish IV within 2 tries, transport the patient to a Hospital Emergency Facility.
7. Continue further therapy as indicated:
a. Chest Trauma
1) Flail chest (paradoxical movement of a portion of the chest wall):
a. Injured side down;
b. Manual or sand-bag stabilization, if needed;
c. High-flow oxygen, with bag-mask assistance if significant respiratory distress is present.
2) Open pneumothorax (sucking wound)
Close by any appropriate means available: gauze pad with Vaseline, Saran wrap, etc.
3) Tension pneumothorax (increasing ventilatory impairment; distended neck veins).
If present following closure of a sucking chest wound, remove the dressing to convert it to a simple open pneumothorax again.
4) Assess for cardiac rhythm disturbances; use EKG monitor, if available; otherwise monitor pulse.
b. Abdominal Trauma:
1) Closed (Blunt)
a. Place patient supine with legs elevated.
b. For EMT-Intermediates and higher, place pneumatic anti-shock garment on the patient if not already done and inflate using training criteria.
c. For EMT-Cardiacs and higher, if shock exists, start large bore (18 ga.) catheter with lactated Ringer solution wide open (up to 2000cc).
2) Open (Penetrating)
a. Place patient supine with legs elevated;
b. Cover wound with sterile dressing (stabilize any impaled object);
c. Moisten sterile pad, with sterile saline, if evisceration is present;
d. For EMT-Intermediates and higher, place pneumatic anti-shock garment on the patient if not already done and inflate using training criteria. Impaled object(s) in the abdominal wall do not allow inflation of the abdominal compartment of the garment.
e. For EMT-Cardiacs and higher, start a large bore (18 ga.) catheter with lactated Ringer solution wide open (up to 2000cc);
c. Suspected Head/Spinal Injuries:
1) Immobilize neck and spine with stiff collar and spine board as soon as possible.
2) Control scalp bleeding by direct pressure.
3) Do a careful neurologic check recording ability to respond with eye opening to voice or pain, ability to speak coherently, ability to move extremities to voice or pain, pupillary reaction, any drainage from nose/ears, and presence of sensation in extremities.
d. Eye Trauma
1) Check for pain, loss of vision, and eye muscle function (left-to-right and up-and-down motions of the eyes).
2) Record the type of injury - contusion, laceration, chemical, foreign body.
3) Manage eye trauma by:
a. Irrigation of chemical or small foreign body injuries using at least 500cc of normal saline or water.
b. Protecting traumatized eye by applying a protective eye shield and covering both eyes. Do not apply pressure or dressings to the eyeball (globe) directly.
e. Extremity Trauma (amputation, fracture):
1) Immobilize an apparent fracture or amputation in the position found, unless there are no pulses distal to fracture site or unless the position is extreme and interferes with transport.
2) Cover open (compound) fractures or amputation stumps with sterile dressings and then immobilize the limb. Elevation of an extremity is often helpful in controlling bleeding.
3) Amputated parts should be placed in a sterile dressing, and, if an ice pack is available, the part(s) should be wrapped in a towel or put in a plastic bag and placed on the ice pack. DO NOT place the amputated parts directly on ice or in any liquids.
4) For EMT-Cardiacs and higher, in long bone fractures or multiple fractures, start an IV with lactated Ringer solution at KVO in the uninvolved extremity or proximal to fracture sites in cases of multiple fractures. If shock symptoms develop, run the IV wide open.
5) Carefully apply a traction splint for femoral shaft fractures above the knee, or use another appropriate splint for other fractures.
6) Contact Medical Control if fracture is open, an amputation is present, or for any other serious injuries.
f. Record any unusual circumstances involving the injury e.g.; gross contamination; a movement from the original position prior to your arrival, etc.
8. Contact Medical Control to notify them of your transport of any severely injured patient.
APPENDIX
[See graphic or tabular material in printed version]
ESOPHAGEAL OBTURATOR AIRWAY
A. Only individuals certified in an approved EMT-Intermediate or higher level training course and licensed as such may insert an esophageal obturator airway during prehospital care.
B. Use the esophageal obturator airway (EOA) only in deeply unconscious patients without a gag reflex. This usually means cardiac arrest.
C. Do NOT use the EOA without direct authorization from Medical Control in:
a. conscious or semi-conscious patients;
b. children under 16 years old; or
c. patients known to have swallowed corrosive materials, to have diseases of the esophagus, or with inhalation burn injuries.
D. Do not interrupt ventilation for more than 30 seconds to insert the EOA.
E. Whenever possible, ventilate the patient with oxygen prior to EOA insertion.
F. Never use force to insert the EOA.
G. Always check to see that the chest rises with ventilation efforts after insertion of the EOA and periodically thereafter.
H. Do not remove the EOA in the field unless the patient is breathing spontaneously.
I. If you do remove the EOA, be prepared for regurgitation with suction immediately available.
J. Proper procedure for use of the EOA is included in the texts for EMT-Intermediate and higher levels and in the RIEMS Continuing Education Manual (Chapter 3 - Demonstration 2).
PNEUMATIC ANTI-SHOCK GARMENT
A. Only individuals certified in an approved EMT-Intermediate or higher level training course and licensed as such may inflate pneumatic shock garments during prehospital care.
B. Inflation of these garments should follow the sequence of both legs first, then the abdominal compartment. Each should be inflated in steps of approximately 30 mm (to maximum) with reassessment of the patient's blood pressure after each step.
C. The presence of pulmonary edema contraindicates the use of these garments without medical authorization directly. The presence of open abdominal wounds, impaled objects, uncontrolled bleeding above the garment, massive obesity, and pregnancy require radio consultation prior to inflation of the garment.
D. The garment may be installed on any patient in shock or in danger of rapid development of shock when authorized in the protocols or when the transportation time to a hospital emergency facility is longer than five (5) minutes and no untoward delays would be caused by its placement.
E. Every case in which these garments are inflated MUST be documented on the runsheet.
F. The garment should be inflated to produce a systolic blood pressure of 100-110 mm in patients over 12 years old with a systolic blood pressure < 70 mm. Other patients, or situations in which there is any cause for doubt, should have contact with Medical Control prior to inflation of the garment.
G. The garment may be used during CPR in the following cases:
a. at least 4 persons are present so that effective CPR is not jeopardized;
b. there is longer than a five (5) minute transport time to the nearest hospital emergency facility; and,
c. the leg compartments only are inflated (without Medical Control authorization directly) due to possible adverse effects of the abdominal compartment during compressions.
H. If signs of pulmonary edema develop after inflation, deflate the garment immediately (this is the only time it can be deflated quickly).
I. Proper procedure for use of the garment is included in the texts for EMT-Intermediate and higher courses and in the RIEMS Continuing Education Manual (Chapter 4 - Demonstration 2).
TRIAGE PLAN
OVERVIEW
1. Triage, or sorting of victims in a mass casualty incident, is performed several times by different people at different places. Each time victims are sorted, more sophisticated decisions can be made.
2. The major triage points are as follows:
Primary Triage - at position victim is found.
Secondary Triage - at treatment area on-site.
Tertiary Triage - at hospital door.
3. The treatment priorities of victims are:
First priority - RED
severe injuries with shock needing stabilization and treatment as soon as possible.
Second priority - YELLOW
severe to moderate injuries requiring treatment soon but shock not present.
Third priority - GREEN
injuries require minor treatment; this person could ride to the hospital in a bus!
Zero priority - BLACK
obviously dead (dismembered, decomposed, etc).
4. Each disaster scene presents its own unique hazards and difficulties. This plan is a general guide to the handling of mass casualty incidents. It should be understood that modifications will need to be made by command personnel on scene as such changes are needed.
DETAIL
1. PRIMARY TRIAGE
This first step in sorting of victims is begun by the least senior EMT(s) arriving in the first rescue unit(s). The actual number of EMTs assigned to this task will depend on the size of the incident; selection of the individuals to do this will be done by the senior EMT acting as Secondary Triage (see below). The purpose of this level of triage is two-fold:
1. To prevent victims from dying of problems such as airway obstruction and/or hemorrhage.
2. To assign priorities for evacuation of victims from the positions found to the treatment area.
The EMT brings a supply of bandages (preferably battle dressings with ties, but pads and Kling are acceptable) and triage tags (METTAGS) with him/her from the vehicle to the disaster scene. Victims are approached with the concept firmly in mind that ONLY INITIAL CARE is to be provided. The process should take about one minute for each victim.
An easy way to remember what to do is the word BASIC which stands for:
Bleeding - only severe hemorrhage is to be dressed with a pressure tie.
Airway is to be secured by repositioning the victim.
Shock is treated by elevation of lower extremities and covering, if possible.
Immobilization of flailing limb by kling or of wandering victims by authoritative verbal command.
Classification is performed by ripping off the proper color levels on the METTAG as above and placing the tag on the right ankle.
2. SECONDARY TRIAGE
Victims are evacuated from the actual positions found in priority order by firefighters and others available to assist with this task, and are brought to the Secondary Triage EMT. This person is the Senior EMT who arrives first on the scene, although this EMT may relinquish his post to a more experienced Senior EMT. He does NOT leave his position between the disaster area and the treatment area (see below), and he always wears his marked vest to mark his authority. He is the person who assigns the additional EMS personnel to various roles as below:
Primary Triage - EMTs (need dressings & tags); given orange arm bands for right arm, if available.
Evacuation - firefighters and others not needed for other duties. Backboards and supplies for removal of victims from the site to the treatment area may be obtained from assembled rescue vehicles.
Secondary Triage - himself - marked vest.
Treatment Crew - Senior EMTs (need full supplies)
Transport Triage - EMT with radio expertise (secondary triage officer may do this himself with portable unit if disaster is small scale).
Transporters - EMTs finished with primary role and others (not necessarily EMTs) as available to drive.
This Secondary Triage EMT alerts his dispatcher of the disaster scene with an estimate of the scope of the problem and asks for mutual aid.
He is also responsible for staking out the treatment areas prior to evacuation of victims from the primary site. They should be set up by placing color-coded flags on areas selected according to road access, level ground, upwind location from fire/smoke/spread and relative size. The area selected as a temporary site for dead victims should be somewhat removed from the remainder of the treatment areas. Also the area for walking wounded should not be near the seriously wounded, if possible.
Victims should be evacuated from the primary site and be brought to the Secondary Triage position at the head of the treatment areas. Here, the Secondary Triage EMT reevaluates BRIEFLY the victims and assigns each to a treatment area; this triage may not agree with the tag color. One upper corner of the tag is also torn off and saved by the Secondary Triage EMT to help account for all the victims later.
A more advanced guide to victim severity is as follows:
0. zero Priority (Black) --
- These victims have ceased both respirations and heartbeat and no EMT personnel are available to perform CPR without compromising the remainder of the victims.
I. First Priority (Red)
- Asphyxia or mechanical respiratory obstruction.
- Sucking and/or flail chest wounds.
- Severe maxillofacial wounds.
- Recent cardiorespiratory arrest.
- Shock.
- Severe burns greater than 20 percent.
- Psychological reaction of responder.
II. Second Priority (Yellow)
- Abdominal injuries (without shock)
- Genitourinary injuries
- Thoracic wounds without asphyxia
- Vascular injuries
- Head injuries
- Major fractures without shock
- Burns less than 20 percent (critical locations)
III. Third Priority (Green)
- Soft tissue wounds
- Extremity fractures and dislocations
- Facial and eye injuries without airway difficulty
- General burns under 20 percent
- Psychological shock without agitation
3. EVACUATION PERSONNEL - Firefighters and others on-scene who are available to carry victims. If the situation permits, backboards and proper patient handling techniques should be used for loading, carrying and unloading victims at the scene.
4. TRANSPORT TRIAGE - An EMT skilled in radio communication should be appointed to this position by the Secondary Triage EMT if the scene is too large in scope for Secondary EMT to handle this function. This EMT should proceed to the State EMS Communications Van, if present on the site.
This EMT notifies the hospitals via the HEAR system, through the dispatcher, or through the State Communications Van (if present); designates the assembly area for incoming vehicles to park; collects the hospital capacity data and assigns patients to the various hospitals when directed to do so by the Secondary Triage EMT. This usually occurs after most of the Priority One (Red) victims are accounted for so that severe cases are distributed to hospitals both capable and available for them. The individual hospitals are also notified by him as vehicles leave the scene. The remaining tear-off upper corner of the METTAG is removed and saved by the Transport Triage Officer during victim loading.
5. TREATMENT PERSONNEL - Senior EMTs and available EMTs as well as other health care personnel who arrive on-scene. Each is assigned by the Secondary Triage EMT to a color-coded area to provide for stabilization and packaging of victims prior to transportation.
6. TRANSPORT PERSONNEL - After accounting for the severe cases and accumulating hospital data, assignment of cases to hospitals is made. Transport is carried out by available EMTs (some finished with Primary Triage duties) and any available drivers. Unless an unforeseen circumstance arises during transportation, no radio communication is necessary enroute to the assigned hospital. The hospital has been notified by the Transport Triage EMT and the available radio channels are near-jammed already.
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