EMT-BASIC / EMT BASIC INTERMEDIATE TECHNICIAN
EMT-BASIC / EMT BASIC INTERMEDIATE TECHNICIANPROTOCOLSDane County Emergency Medical ServicesUpdated 5/2007Paul M. Stiegler, M.D.Medical Director, Dane County EMSMedical Advisory Chairperson, Dane County EMS
Table of ContentsIntroduction .3Level of Practice .4ALS Equipment Used by EMT-Basic Intermediate Technician .5General Procedures for EMT-Basic Intermediate Technician .6General Patient Care .7Airway Management and Oxygen Therapy Guidelines . .8Protocol for the Use of Pulse Oximetry .9Intravenous Lines for Use by EMT-Basic Intermediate Technician .10Protocol for Use of the Combitube .11Pneumatic Anti-shock Garment (PASG) .14Dextrose Solution, 50% .15Naloxone .16Use of the Blood Glucose Monitor .17Utilizing Medical Control .18Triage Guidelines for Major Trauma .19Determination of Hospital Destination .20Interaction with Physicians at Scene .21Patients Who Refuse Transport .22Use of Restraints .23Guidelines for Termination of Resuscitation in the Field.24Initial Patient Assessment (Trauma Patient).26Multi-Trauma Protocol / Assessment .28Initial Patient Assessment (Medical Patient).29TREATMENT PROTOCOLSTreatment Protocol – Abdominal Pain .30Treatment Protocol – Altered Level of Consciousness.31Treatment Protocol – Anaphylaxis .32Treatment Protocol – Asthma, Chronic Lung Disease (COPD).33Treatment Protocol – Burn Injury – Severe (Chemical or Thermal).341
Treatment Protocol – Carbon Monoxide Poisoning .35Treatment Protocol – Cardiac Arrest Medical.36Treatment Protocol – Cardiac Arrest Due To Trauma or Hypovolemia.37Treatment Protocol –Cardiac Ischemia (Chest Pain) .38Treatment Protocol – Diabetic Emergencies.39Treatment Protocol – Emergency Medical Care of the Pulseless Non-breathing Patient UsingAutomated External Defibrillation .40Treatment Protocol – Continuous Positive Airway Pressure (CPAP) .43Treatment Protocol – Eye Irrigation .44Treatment Protocol – Gynecological Emergency .45Treatment Protocol – Head Injury .46Treatment Protocol – Heat Illness.47Treatment Protocol – Hypothermia .48Treatment Protocol – Mass Exposure to Nerve Agents.49Treatment Protocol – Medicine Overdose / Poisoning .50Treatment Protocol – Obstetrics / Childbirth.51Treatment Protocol – Neonatal Emergency .53Treatment Protocol – Pain Management .54Treatment Protocol – Psychiatric Emergencies.55Treatment Protocol – Pulmonary Edema.56Treatment Protocol – Respiratory Arrest.57Treatment Protocol – Respiratory Distress, Croup / Epiglottis in Infant / Child .58Treatment Protocol – Seizures .59Treatment Protocol – Shock, Hypotension and Hemorrhage.60Treatment Protocol – Stroke / Cerebral Vascular Accident.61GRATEFUL APPRECIATION.622
INTRODUCTIONThis document contains the protocols, guidelines, and instructions for emergent out-of-hospital care for EMTBasic / EMT-Intermediate Technician under the medical control of UW Hospital and Clinics, St. Mary’s HospitalMedical Center, Meriter Hospital, Stoughton Hospital, Fort Atkinson Memorial Hospital, Columbus CommunityHospital, Sauk Prairie Memorial Hospital and The Monroe Clinic.It establishes standards of care that conform to the current guidelines of the State of Wisconsin, EMS Section aswell as that of Dane County Emergency Medical Service. This document also coincides with the recommendationsset forth in the document “EMT-Basic Template for Suggested Minimum Care Guidelines” developed by theWisconsin Physician Advisory Committee (September 2000) as well as “Standards and Procedures of PracticalSkills Manual” (June 7, 2002).The practice of out-of-hospital medicine requires a relative degree of flexibility to adequately address the greatvariability of situations that are part and parcel of working in a relatively uncontrolled environment. As such,circumstances may require occasional deviation from these instructions. The specific goals of any treatment mustalways be improvement in the patient’s condition.The practice of out-of-hospital medicine is also continually changing. As more and more research in this field isperformed, guidelines for care will change. New technology, both in this particular arena and in hospital medicine,will likewise change the manner in which patients and their problems are managed. It is fully anticipated that thisdocument will go through a variety of modifications over time, to make the most of new knowledge and advancesin technology for the benefit of the patient.The protocols are subdivided by the interventions available to each provider. Those of more advanced trainingare expected to ensure that the interventions of the previous levels have been performed. It is expected thateach level will request appropriate additional resources (ALS Intercept, Helicopter) based on dispatch information,mechanism of patient condition/injury. Resource requests should be made as early as possible to maximizepotential interventions and prevent delays in transport.The orders that constitute each protocol are listed in the general order in which they are to be performed, with fullawareness that in any given situation the order in which interventions are performed may change to adapt to thecircumstance. All levels of providers may operate under these protocols without on-line medical control. Theorders that require direct physician communication are indicated:CONTACT MEDICAL CONTROLNo provider may exceed the limits of his or her level of training or certification. Specific medications may not beadministered unless the service’s medical director has specifically included those medications in the ambulanceservice’s protocols.The protocols are meant only to provide an outline of care priorities and do not cover every possible scenario. Theprovider is responsible for all information contained in the appropriate curriculum (EMT-Basic or EMT-BasicIntermediate Technician).All patients are expected to receive standard assessments (including a full set of vital signs) and evaluation of airwaypatency, ventilation and CPR (Cardiopulmonary Resuscitation) when indicated. The protocols assume that all patientswill be transported unless the Refusal of Care/Transportation protocol is initiated. The following protocols indicate thesteps to be taken next. Some protocols indicate attention to airway and oxygen as additional reminders of theirimportance.3
LEVEL OF PRACTICEThese protocols are designed for the EMT-Basic and EMT-Basic Intermediate Technician level and assume that these levels includethe following:SkillEMT-BasicEMT-Basic Intermediate TechnicianOropharyngeal Airway**Nasopharyngeal Airway**Bag-valve-mask**Oxygen Administration**Direct Pressure for bleeding**CPR & Semi-automatic defibrillation**Use of AED to monitor EKG**Dressing & bandaging**Spinal immobilization and splinting**AHA Obstructed airway maneuvers**Use of Magill forceps to relieve obstruction**Epinephrine for anaphylaxis**Combitube placement**Endotracheal intubation* (with additional training)Naloxone (Narcan) administration for overdose*Aspirin administration for chest pain**Assist pt with own bronchodilator use**Assist pt with own nitroglycerine administration**I.V. access and fluid administration*Albuterol administration**Glucagon administration**Glucometer use**Atrovent administration*(optional)*(optional)Dextrose 50% administration*Epinephrine administration for asthma*PSAG placement and inflation**Pulse Oximetry use**Mark I Kit Administration**Nitroglycerine spray*4
ALS EQUIPMENT USED BY THE EMT-BASIC INTERMEDIATE TECHNICIANI.II.III.IV.V.Parenteral Fluids.A.1,000 cc bags of Normal Saline (NS).B.250 cc bags of 5% Dextrose in Water (D5W).IV Equipment.A.I.V. catheters in #14, #16, #18, #20 gauge sizes.B.I.V. administration sets (Maxi drip).C.Accessory I.V. equipment: appropriate disposable gloves, absorbent sheets, face shields, povodineiodine swabs, alcohol swabs, tape, tourniquet, arm boards, sterile dressings, band-aids, and sharpsdisposal containers.Combitube equipment.A.Combitube and Combitube SA .B.Bag-valve-mask.C.Suctioning equipment.Drugs.A.Adult Epipen autoinjector 0.3 mg (0.3cc of 1:1000 epinephrine) and pediatric Epipen autoinjector 0.15 mg (0.3cc of 1:2000 epinephrine).B.Dextrose 25 Gm (50% solution) in 50 cc pre-filled syringes.C.Naloxone (Narcan) 2mg. injection.D.Albuterol inhalation solution 2.5 mg/3cc. for nebulization.E.Nitroglycerin 0.4 mg per spray or tabletF.Aspirin 81 mg chewable tablets –a total of four tablets (unit dose).G.Glucagon 1 mg Emergency Administration Kit for injection.H.Atrovent 500 mcg./2.5 cc. for nebulization.I.Mark I Administration Kit (Atropine and 2PAMCL [Pralidoxime chloride] )Pneumatic antishock garment (PASG).A.David Clark "MAST " products, Adult and Pediatric.VI.Pulse oximeter (optional).VII.Blood Glucose Monitor.VIII.Nebulizer.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
GENERAL PROCEDURES FOR THE EMT-BASIC INTERMEDIATE TECHNICIANThe EMT-Basic-Intermediate Technician (EMT-Basic IV) is an advanced level EMT-B who has completed additionaltraining beyond that of an EMT-Basic, and is authorized under Wis. Stats. 1460.50 (5) and Wis. Admin. Rule 110 to performselected advanced procedures under physician direction. Patient assessment and critical decision-making is heavilyemphasized in the EMT-Basic Intermediate Technician training.I.Apply a process of decision making to use the assessment findings to form a field impression of the patient’scondition.II.Don Personal Protective Equipment (PPE) as indicated.III.Follow EMT-Basic Intermediate Technician Protocols.IV.Make radio contact with Medical Control as soon as needed/possible.V.Report assessment.A.Age and gender of patient.B.Problem or chief complaint. Brief history of illness or injury.C.Level of consciousness, general appearance, degree of distress, skin temperature and color.D.Vital signs including pulse oximetry.1.Check quality of central and peripheral pulses.2.Cardiac monitoring as needed using monitoring electrodes only.E.Physical exam findings.F.Other pertinent information (past medical history, medications, allergies).G.Report any EMT-Basic Intermediate Technician actions taken by protocol.VI.Request and/or receive any orders for ALS procedures requiring voice Medical Control.VII.After receiving order from Medical Control, verify it with Medical Control and initiate procedure.VIII.Document all orders and have the physician in the ED sign the ambulance report form for orders.IX.On all critical patients, particularly those on whom ALS procedures are done monitor vital signs often and reportsignificant changes to Medical Control. Always get at least one set of vital signs after an ALS intervention, if timeallows (five minutes for trauma; ten minutes for medical incidents).X.Consider ALS level tiered response for critical patients if not already sent.XI.Record on the ambulance report form:XII.A.Results of patient assessment.B.Treatment performed / medications administered with dose and route.C.Name of EMT-Basic Intermediate Technician performing treatments.Review performance by performing a run critique with other team members.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
GENERAL PATIENT CAREThis protocol provides general guidelines for patient management. Refer to additional protocols as appropriate fortreatment of specific e scene safety.A.Perform a scene survey to assess environmental conditions and mechanism of illness or injury. Ifhazardous conditions are present (such as swift water, hazardous materials, electrical hazards, orconfined space), contact an appropriate agency before approaching the patient. Wait for thedesignated specialist to secure the scene and patient as necessary.B.Observe Body Substance Isolation.Approach the patient and identify self. Establish patient responsiveness. If cervical spine trauma issuspected, manually stabilize the spine.Assess the patient’s airway for patency, protective reflexes and the possible need for advanced airwaymanagement. Assess for possible airway obstruction. Administer high-flow, 100% concentration oxygenif needed. Use a non-rebreather mask or blow-by as tolerated for the pediatric patient.Assess patient’s breathing, including rate, auscultation, inspection effort, and adequacy of ventilation asindicated by chest rise. Obtain pulse oximeter reading. If signs of respiratory distress, failure or arrest,refer to the appropriate protocol for treatment options.Control hemorrhage using direct pressure or a pressure dressing.Assess circulation and perfusion by measuring heart rate and observing skin color and temperature;capillary refill time, and the quality of central and peripheral pulses.A.Blood pressure should be measured only in children older than three years.B.Initiate CPR using the American Heart Association standard of care for adults and children forpatients with absent pulse.Initiate cardiac monitoring (optional for EMT-Basic).A.EMT-Basic ambulances may only use their AED for “monitoring” purposes if monitoringelectrodes are used. At no time should defibrillation pads be applied to a patient with a palpablepulse.B.Even if familiar with EKG rhythms, the EMT must always “treat the patient, not the monitor”.(As EKG monitoring is not considered part of the “standard of care” by the EMT, it will not beincluded with each of the following protocols but is allowed at the EMT discretion.) DO NOTINTERPRET EKG RHYTHMS.C.Specific emergencies that should include 12 Lead EKG monitoring are: cardiac emergencies,altered level of consciousness, abnormal vital signs, pulse rate below 60 and above 120,respiratory distress, seizures and arrhythmias. 4 Lead monitoring should be used for chest traumaand major multi-system trauma.D.Monitoring must not delay transportation of the patient.Evaluate mental status, including pupillary reaction, distal function and sensation and AVPU assessment.If spinal trauma is suspected, continue manual stabilization, place a rigid cervical collar and immobilizethe patient on long backboard or similar device.Initiate transport, if the patient’s condition is critical or unstable.A.Perform focused history and detailed physical examination en route to the hospital if patient statusand management of resources permit.B.If the patient’s condition is stable, perform focused history and detailed physical examination onscene, and then initiate transport.Reassess vital signs as follows; trauma every 5 minutes, medical emergencies every 10 minutes unlesspatient’s condition changes or deteriorates.CONTACT MEDICAL CONTROL for additional instruction as indicated.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
AIRWAY MANAGEMENT AND OXYGEN THERAPY GUIDELINESRegardless of the nature of the response, the EMT-Basic shall always insure via the Primary Survey that thepatient has an adequate airway. The steps below shall be followed as necessary.I.All patients shall be assessed immediately as to the patency and adequacy of the airway. Follow theAHA guidelines.II.Aggressive airway management is indicated if any of the following exist:A.Cardiac or respiratory arrest.B.Any form of airway obstructionC.Any unconscious patientD.Any patient with labored, shallow, or rapid respirations.III.When breathing is inadequate, but an advanced airway is not (yet) needed, the EMT-Basic shouldassist the patient’s ventilation via:A.Pocket mask with supplemental oxygen –orB.Bag-valve-mask with 100% oxygenC.Airway adjuncts (oral or nasal airways). Never use an oral airway in a patient with anintact gag reflex.D.Consider a non-visualized airway (refer to Combitube Protocol) in patients without agag reflex.IV.If aggressive management is not indicated and airway is intact, administer supplemental oxygenfollowing a pulse oximeter reading to any patient who exhibits any of the following:A.Symptomatic cardio/respiratory problemsB.Altered mental statusC.SeizuresD.Severe traumaE.Signs of shockF.Signs of stroke regardless of SaO2 readingV.Supplemental oxygen is supplied by:A.Nasal cannula at 2-6 liters per minute (oxygen concentration-- 24% - 44%)B.Nonrebreather mask at 8-15 liters per minute (oxygen concentration—80 - 95%)VI.Oxygen should not be withheld from patients with chronic lung disease who are dyspneic. Usepulse oximeter and titrate to condition.VII.Always give 100% oxygen to suspected carbon monoxide poisoning victims. Do not use a pulseoximeter as it may be misleading.VIII.A saturation value of 92% or greater is usually considered adequate, though many patients shouldhave supplemental oxygen regardless of oximetry readings.IX.A saturation value less than 92% is low. “Troubleshoot” for technical problems, and give higherconcentrations of oxygen. Consider assisting ventilations. CONSULT MEDICAL CONTROL.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
PROTOCOL FOR THE USE OF PULSE OXIMETRYI.Purposes for using pulse oximetry in prehospital careA.To be used as an aid in making decisions regarding oxygen therapy and adequacy ofventilation.B.To continuously monitor a patient’s oxygen delivery, particularly in response totherapeutic actions such as oxygen therapy, airway maintenance, ventilation, etc.II.IndicationsA.It should be used in any patient who would be a candidate for oxygen therapy.III.ContraindicationsA.Suspected carbon monoxide poisoning (Oximeter will give a falsely elevated SAO2reading in this situation, and be misleading regarding the patient’s true status.)B.Nail polish.IV.ProcedureA.Assess the patient. Do the primary survey. Obtain vital signs. Assess the rate andquality of respirations.B.Use the pulse oximeter on any patient to whom you would consider administeringoxygen.C.If it doesn’t delay oxygen administration in a critical patient, determine thepatient’s baseline SAO2 reading on room air.D.Administer supplemental oxygen if indicated (see Oxygen Therapy Guidelines).E.Complete the assessment. Perform the secondary survey.F.During the care of the patient, note any changes in oxygen saturation, particularly changesin response to treatment given to the patient.G.Include the oximetry findings, along with the flow-rate and method of delivery ofoxygen, in the report to the hospital.H.Record the oximetry findings, along with the flow-rate and method of delivery of oxygen,on the ambulance run report form.V.TroubleshootingA.Check to see if there is pulsatile blood flow registered by the probe (most oximeters havea way of indicating this).B.Reattach the probe, or change its location.C.Avoid bright light on the sensor. “Shade” the probe with a blanket or sheet ifnecessary to get a reading.D.Remove nail polish or place the probe on another site.E.A cold, vasoconstricted finger may give unreliable readings. Place the probe on anothersite if necessary.F.Check for excessive movement (tremor, seizure activity). Stabilize the site to get areading.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
INTRAVENOUS LINES FOR USE BY THE EMT-BASIC INTERMEDIATE TECHNICIANI.Guidelines for starting intravenous lines.A.An I.V. should be started if there are any signs or symptoms that indicate the possibility of apotential life-threatening condition or if there is an anticipated use for I.V. medications.B.An I.V. should be started if there are any factors that indicate the possibility/potential forhypovolemic shock. Use a large bore I.V. catheter, 16 gauge or greater.C.I.V. lines should be started at the scene (preferably in the ambulance just prior to transport) inorder to give the EMT-Basic Intermediate Technician a good chance at a successful start. If thereis difficulty starting an I.V. in a critical patient, transport should not be delayed and the I.V. shouldbe omitted.D.The EMT-Basic Intermediate Technician should select a vein that looks most favorable forlikelihood of a successful I.V. start. In general, try distal veins first. Antecubital veins are ofteneasily cannulated but the I.V. may be lost if the patient bends his/her arm. If antecubital veins areused, splint the arm in extension with an arm board.E.No more than three I.V. attempts are to be made, unless approved by Medical Control.F.In general, I.V.s will not be started in children or infants. There may be exceptions based on thelikely ease of starting an I.V. and the judgment of the Medical Control physician.II.Rates of I.V. fluids.A.B.TKO (To keep vein open). Slow 30 cc/hr (5 drops/minute) unless rate specified by specificprotocol.Wide open. As fast as possible to infuse volume. Start with an initial “fluid challenge” of200 cc, recheck the BP, then “titrate” to patient’s condition.When this order is given, it is the responsibility of the EMT-Basic Intermediate Technician to monitor thepatient for changes and adjust the flow rate (“titrate”) to the patient's blood pressure and general condition.In general, decrease the flow rate if the patient's BP is greater than 100 systolic and maintained.Note: Intravenous NS given rapidly, to bring blood pressure to 90-100 systolic, is appropriate for allforms of shock except heart failure shock. Breath sounds should be evaluated before rapid I.V. NS isgiven. Any abnormality in the breath sounds, e.g., wheezes or rales (crackles) is an indication thatheart failure shock may be present and the I.V. rate should be TKO. Contact Medical Control if indoubt.C.D.III.Label I.V. sites.A.B.IV.Other rate as directed by the Medical Control physician.Second I.V. line if appropriate, i.e. major trauma or burns.Note type and gauge of needle used, date, and time.Give verbal report of catheter gauge to emergency department personnel.Record on the ambulance report form:A.B.C.D.Note type and name of fluid and rate.Catheter type and gauge, date, and time.Name of person attempting I.V. infusion.Record total number of cc’s infused.Paul M. Stiegler, M.D. Dane County EMS Medical DirectorApproved by Medical Advisory Sub-Committee March 12, 2007Approved by State of Wisconsin EMS May 2007
PROTOCOL FOR USE OF THE COMBITUBE I.Authorization: All Dane County emergency services participate in a state-approved Non-VisualizedAdvanced Airway program. Combitube placement may be performed by EMTs who have been trained inits use and are certified and authorized by the Program or Service Medical Director.II.Purpose: To establish control of the patient's airway and to facilitate ventilation for the listed ions: DO NOT use on patient if.A.B.C.D.E.F.G.V.Cardiac arrest.Respiratory arrest.Unconscious patient with inadequate ventilation and no gag reflex and inability to adequately assistventilations with a bag-valve-mask.Under five (5) feet tall (the Combitube SA can be used in patients four to five [4 to 5] feet tall).Less than sixteen (16) years of age.Have a gag reflex.Have known esophageal disease.Have ingested caustic substance.Have a laryngectomy or tracheostomy stoma.Have a foreign body obstruction (remove first).Medical Control.A.May be inserted without on-line Medical Control as a "standing order" in patients with:1.2.B.VI.Cardiac arrest.Respiratory arrest (the patient is apneic, unconscious, and has no gag reflex).ON-LINE MEDICAL CONTROL IS REQUIRED prior to attempting to insert theCombitube IN ANY PATIENT WITH SPONTANEOUS BREATHING.Preparation.A.Put on protective eyewear, mask, and gloves.B.Prepare equipment.1.2.C.While maintaining ventilatory support, assemble and check equipment. Ensure all necessarycomponents and accessories are at hand.Lubricate tip of the tube and the cuffs with water-soluble
The EMT-Basic-Intermediate Technician (EMT-Basic IV) is an advanced level EMT-B who has completed additional training beyond that of an EMT-Basic, and is authorized under Wis. Stats. 1460.50 (5) and Wis. Admin. Rule 110 to perform selected advanced procedures under physician direction. Patient
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