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Patient and S.O.P. Protocols

EMS#: 253 Version 3.0

June 1, 2002

Dr. Thomas Gross MD Medical Director Wabasso Ambulance Association

Charles Robasse Director Wabasso Ambulance Association

Wabasso Minnesota

WABASSO AMBULANCE PROTOCOLS

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Quality Assurance and Continuing Education

1) Quality Assurance

a) The Physician Medical Director, the Wabasso Ambulance Training Director and the ambulance crew will periodically review runs at monthly meetings.

b) A review of each call where medications or other devices requiring a variance have been used will take place at each monthly meeting.

c) Using various methods of statistical process control and open “brainstorming” at monthly meetings we strive to be proactive and improve the service to our patients. This is for all aspects of our service.

d) Should a problem arise after a particular run from either the crew member or Medical Director’s standpoint, a special meeting will be called that will include the crew members involved in the run, the Medical Director and the Ambulance Director.

2) Continuing Education

a) Initial training for the semi-automatic defibrillator, medications, and other devices requiring a variance are given to each new ambulance crew member before they are allowed to use these devices. Initial training typically includes lecture and hands on skills assessment.

b) Annual review of crew members skills will be conducted by the ambulance Physician Medical Director or approved training facility approved by the Physician Medical Director.

c) Crew members will review monthly runs that involve medications or devices requiring a variance.

d) Semi annual skills assessment will be performed by the Physician Medical Director on crew members for medications or devices requiring a variance.

e) Based on various statistical process control tools and data collected from run reports, training will be adjusted to best fit the needs of the Wabasso Ambulance Crew and its commitment to quality patient care.


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General Information

1) PATIENT CONSENT AND REFUSAL

a) These medical protocols apply to all patients cared for by the Wabasso Ambulance Association

b) Adult patients are those patients’ 18 years old and older. Pediatric patients are those under 18 years old.

c) Remember: Courtesy to the patient, the patient's family, and other emergency care personnel is of utmost importance.

d) Wabasso Ambulance approved report forms must be completed anytime you arrive at a scene and/or on all patients. A copy must be left with the patient at the receiving facility.

e) The specific conditions listed for treatment in this document, although frequently stated as medical diagnoses, are merely operational diagnoses to guide the EMT in initiating appropriate treatment. The emergency physician, when consulted, will either concur or further evaluate the EMT's clinical findings and suggest an alternate diagnosis treatment.

f) In all circumstances, physicians have latitude in the care they give and may deviate from these medical protocols if they feel such deviation is in the best interest of the patient. Nothing in these protocols shall be interpreted as to limit the range of treatment modalities available to physicians to utilize, other than the modalities and the medications used must be consistent with the EMT's training.

2) PATIENT CONSENT AND REFUSAL

a) Whenever an ambulance is requested for a patient, it is the responsibility of the EMS system to treat and transport that patient with his/her consent.

b) Transport by ambulance should always be offered to a patient.

c) If a competent patient or parents of a minor refuse treatment or transportation, they should sign the refusal statement on the ambulance report form. If they refuse to sign, this should be documented, including witnesses' names if possible.

d) In general, a person is mentally competent if he/she:

e) Is capable of understanding the nature and consequences of the proposed treatment: and,

f) Has sufficient emotional control, judgment, and discretion to manage their own affairs

g) Emergency care for life-threatening conditions should never be delayed or withheld to carry out legal consent procedures.

h) Any time contact with the patient occurs and the patient is not transported, the run is a left, (not a "cancel"). This requires full documentation of all sections of the ambulance report form including what the patient (or parent) was told at the scene regarding non-transport and any other follow-up advice or information given at the scene.


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General Information (continued) 3) RIGHT OF REFUSAL

a) ADULTS: A mentally competent adult has the right to refuse treatment and/or transport, however, the EMT and/or medical control physician (by phone or radio) should explain thoroughly the alternatives and potential consequences of this action. A medical control physician should always be consulted if in doubt as to the mental competency of a patient or if the EMT feels it is detrimental to leave the patient.

b) MINORS: Consent or refusal of treatment/transport of minors (less than 18 years) MUST be given by the child's parent or legal guardian. Although less desirable, consent or refusal may be given by a responsible adult (over 18) caretaker if the parent has deliberately left the minor in the care of this adult and the adult is competent and capable. If unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor, a medical control physician should be consulted. Minors that are parents should be treated as an adult, capable of giving consent for themselves and their child as long as they meet the above competent guidelines.

4) EQUIPMENT: All equipment appropriate to the nature of the call for assessment, treatment and transport should be taken to the site of the patient at the time of initial patient contact. At a minimum, a stretcher and medical or trauma bag must be taken to the patient on all calls, and other equipment as appropriate to the nature of the call.

5) PATIENT DISPOSITION: Patients should be transported to the hospital of their choice unless the gravity of the patient's condition warrants transport to the nearest hospital for stabilization. This decision to transport to the nearest facility or the decision to change destination enroute is ultimately the responsibility of the controlling physician and is based on accurate reporting of physical exam findings, vital signs, and changes in the patient's condition. However, in the case of critical trauma, the EMT may independently decide to divert to the nearest hospital appropriate for care if the patient meets the following trauma triage criteria:

a) Systolic blood pressure less than 85; or

b) Glasgow motor score less than 5 (no purposeful movement in response to pain); or

c) penetrating trauma to head, neck or trunk

d) Note: When circumstances are such that the EMT must make this decision himself / herself, a physician must be advised of the action as soon as possible.

6) PEER COUNSELING AND CRITICAL INCIDENT STRESS DEBRIEFING

a) Paramedics and other EMS personnel are encouraged to familiarize themselves with the causes and contributing factors of critical incident and cumulative stress, and learn to recognize the normal stress reactions that can develop from providing emergency medical services

b) An EMS Peer Counseling Program is available to Wabasso Ambulance crewmembers. The program consists of mental health professionals and trained peer support personnel who develop stress reduction activities, provide training, conduct debriefings, and assist EMS personnel in locating available resources. The team will provide voluntary and confidential assistance to those wanting to discuss conflicts or feelings concerning their work or how their work affects their personal lives.

c) Wabasso Ambulance crewmembers can contact the Ambulance Director whenever a response is considered a critical incident. A critical incident is any response that causes EMS personnel to experience unusually strong emotional involvement. A formal or informal debriefing will be provided at the request of medical authorities, ambulance management, or EMS personnel directly related to the incident.


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General Information (continued)

7) INTERFACILITY TRANSFERS (Not included are transfers from the Wabasso Health Care Center which should be handled as any other routine call.)

a) Wabasso Ambulance Crew Members may be called on to transfer a patient from a local hospital or clinic to a hospital specializing in more advanced care for a specific illness or injury.

b) The local physician should order this transfer.

c) General guidelines and conditions that need to be meet:

d) Unless called on under the conditions of “Mutual Aid” by the Ambulance Service that covers the PSA area the hospital is located in, the following conditions apply:

e) The patient has to have been originally transferred to the current hospital or clinic by the Wabasso Ambulance Service.

f) The patient has to have been seen by the local physician who orders the transfer to another facility rather then admitting the patient into the local hospital.

g) Once the patient has been admitted into the local hospital, any interfacility transfer becomes the responsibility of the ambulance services who responds to the PSA area the hospital is located in. The Wabasso Ambulance Service should NOT take this type of transfer.

h) The primary responsibility of the Wabasso Ambulance Service is to provide ambulance coverage to the PSA area it is responsible for. This needs to be taken into consideration when agreeing to the interfacility transfer. The physicians must believe that the need for immediate transfer is critical for the patient’s health and/or wellbeing.

i) It may be necessary to continue Advanced Life Support procedures begun by the local hospital that are beyond the scope of the Wabasso Ambulances current licensor during the transfer. In this situation it is necessary to have a Registered Nurse or Doctor accompany the patient and attend to patient care during the transfer.

j) The Wabasso Ambulance Medical Director gives permission to have an appropriate Registered Nurse or Doctor employed by the original receiving hospital attend to patient care during the transfer.

k) Make certain to obtain pertinent history of the patient and any orders for treatment during transfer prior to leaving the original hospital.

l) Transfer orders signed by the patient (or representative) and original attending doctor along with written history and orders should accompany the patient on the transfer.

m) Make certain to note any orders for DNR/DNI prior to leaving the hospital.

n) If a patient has a DNR order and suffers a cardiac arrest during the transfer, the crew should stop the ambulance at that point and notify the Law Enforcement Office for the county that they are currently in. Obtain instructions from the local LEC as it may be necessary to have a deputy or other representative of that office investigate the death.

o) If a patient without a DNR order suffers a cardiac arrest or if a patient's condition worsens It may be necessary to deviate the transfer to the nearest appropriate health care facility. The attending EMT, Nurse, or Doctor can make this decision. If at all possible contact via radio or phone should be made with the original physician ordering the transfer or the receiving physician prior to this decision.


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Initial Assessment

1) Scene Size Up

a) A. HAZARDOUS MATERIALS RESPONSE

i) When working at a Hazardous Materials Incident, Wabasso Ambulance crewmembers should station themselves in the HazMat cold zone. All personnel should operate in the cold zone unless they have adequate training and personal protective equipment for operation in the warm zone.

ii) Qualified personnel should appropriately decontaminate patients who have been exposed to a hazardous material. Considerations during decontamination should include:

iii) Weather and other limiting elements

iv) The patient's level and severity of exposure

v) Condition of the victim. Transport those patients who cannot wait for a complete decontamination due to life-threatening injuries or condition.

vi) Contaminated patients being transported for further evaluation or treatment need to be appropriately cocooned to contain any remaining contaminates and EMT's should limit exposure to themselves using appropriate available protective equipment.

vii) ALWAYS take steps to protect yourself, your partners, other responders, the patient, and bystanders at the scene and during transport.

viii) Early hospital notification is VERY important to allow appropriate preparation for the patient.

b) B. INFECTIOUS DISEASE PRECAUTIONS: Refer to the Bloodborne/Airborne Pathogen Standard Compliance Procedure (Appendix C)

c) C. ADDITIONAL ASSISTANCE – As soon as possible it is the responsibility of the ambulance crewmembers at the scene to make certain they have the necessary resources dispatched. This of course depends on the circumstances of each individual call. Some general guidelines to follow include:

2) The ambulance is only equipped to carry 1 seriously injured or ill patient. Ambulances should be called from the list of Wabasso Ambulance approved mutual aid agencies for additional patients (See appendix D for list of Mutual Aid agencies)

3) For serious or critical patients that the EMT feels will possibly need the assistance of Air-Care, call the Sheriff’s Office dispatch and have them start Air-Care to the scene or local hospital the patient will be brought to depending on circumstances. This should be done as early in the call as possible. Give the dispatcher some general information about the patient’s condition so they can relay this to the Air-Care crew. Use Fire Rescue or First Responders to help secure a landing zone.

4) The ambulance crew should NOT place themselves in dangerous or life-threatening situations. The ambulance crew is NOT required to “rescue” victims from situations they are not trained to handle. It is the crew’s responsibility however to make certain that proper resources capable of handling the situation have been notified and are responding to the scene. This needs to be done as early in the call as possible.

5) Any patient that has problems with the Initial Assessment – Consider the use of an ALS Intercept (if available). See Appendix E for ALS Intercept procedure.


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Initial Assessment Continued

6) AIRWAY MANAGEMENT (Includes Combitube Protocol)

a) Oropharyngeal or nasopharyngeal airway insertion should be attempted on all unconscious patients for airway maintenance. EOA, EGTA or Combitube airways are to be inserted only in apneic patients unless ordered verbally by a base physician.

b) In the apneic patient, using proper infectious disease control precautions, begin artificial respiration or CPR. Use a oropharyngeal or nasopharyngeal airway to maintain an open airway until the Combitube is prepared for insertion.

c) Prepare the Combitube for insertion by lubricating the device with a water-based jelly such as K-Y Jelly or Surgi-Lube.

d) Insert the Combitube blindly between ventilations.

e) Insertion should be done with the patient’s head in a neutral position while lifting the tongue and jaw upward.

f) The tube should be inserted so that it curves in the same direction as the natural curvature of the pharynx

g) Insert the tip into the mouth and advance gently until the printed alignment rings are on either side of the teeth. (Caution should be taken not to force the tube. If the tube does not advance easily, redirect it or withdraw and attempt to reinsert.)

h) Use the large syringe to inflate the pharyngeal cuff (Line 1 - Blue) with 100 ml of air. On inflation, the device will seat itself in the posterior pharynx behind the hard palate.

i) Use the small syringe to inflate the distal cuff (Line 2 - White) with 15 ml of air.

j) Using the Bulb Check Device, Deflate bulb and place on Blue Tube. Verify immediate inflation of bulb check device. Remove device, deflate and place over clear tube. Verify bulb check remains deflated.

k) Begin ventilations through the longer blue connecting tube while auscultating for breath sounds and the absence of gastric insufflation. Also look for positive chest expansion.

l) If breath sounds are positive and gastric insufflation is negative, continue to ventilate the patient using the blue tube. The second shorter tube may then be used to suction gastric fluids if needed.

m) If necessary, if auscultation of breath sounds is negative, and gastric insufflation is positive, immediately begin ventilation through the shorter clear connecting tube. Again confirm positive ventilation by auscultation of breath sounds, observing chest expansion and the absence of gastric insufflation.

n) Continue ventilations and CPR as needed using the American Heart Association guidelines.

o) The Combitube is for single patient use. Dispose of the device in appropriate containers after use.

p) CONTRAINDICATIONS FOR COMBITUBE

i) Patients under the age of 16 and under 5 feet tall.

ii) Responsive patients with an intact gag reflex.

iii) Patients with known esophageal disease.

iv) Patients who have ingested caustic substances


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Initial Assessment (continued)

7) BREATHING and AIDS TO BREATHING

a) Airway concerns and treatment for respiratory problems should be handled early during the initial assessment.

b) Oropharyngeal or nasopharyngeal airway insertion should be attempted on ALL unconscious patients for airway maintenance. For Apneic patients, see the Airway Management portion of these protocols for Combitube placement.

c) For all patients complaining of respiratory distress (with no history of C.O.P.D.) or all unconscious patients should be started on oxygen via mask at 10lpm.

d) Patients not breathing adequately should be assisted with positive pressure ventilations with bag-valve-mask

e) Place the patient at rest, reassure and place in position of most comfort (usually sitting upright).

f) Transport patient early!

g) Consider ALS response

8) Special Airway Concerns and Problems

a) Suspected Carbon Monoxide Poisoning

i) Qualified personnel with proper protection should perform rescue!

ii) Complete the Initial Assessment and start the patient on O2 at 15lpm via non-rebreather mask.

iii) If unconscious, administer oxygen and / or assist ventilations with positive pressure device as needed. Apneic patients should have the Combitube placed.

iv) Expedite transport to nearest hospital monitoring vitals closely.

v) Initiate ALS Intercept and Air-Care Notification for transport to hyperbaric chamber.


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Initial Assessment (continued)

9) Circulation and Cardiac Emergencies

a) During the Initial Assessment it is extremely important to treat for shock.

b) Control any external bleeding.

c) Make certain ALL aspects of airway maintenance and breathing control are being managed per protocol.

d) Consider the use of MAST pants per MAST protocol – Appendix A

e) Perform appropriate physical exam to include lung auscultation and observation for jugular vein distention and dependent edema.

f) Keep the patient at rest, reassure, and monitor vital signs closely.

g) Stabilize all fractures to minimize further bleeding.

h) Transport the patient early! Consider ALS Intercept.

i) CARDIAC ARREST

i) Assess patient and begin CPR for those in cardiac arrest if the following criteria is meet.

ii) Patient has not suffered from a traumatic arrest prior to EMS arrival at an accident scene.

iii) Reliable evidence of biological death are not present (I.e. Rigor Mortis, Lavidity, Obvious Fatal Trauma).

iv) At the same time, prepare Semi-Automatic Defibrillator (for use on patients who are at least 100 LBS and over age 15 found in or who progress into cardiac arrest NOT due to trauma). Refer to Appendix F Semi-Automatic Defibrillator Protocol.

v) Prepare and insert Combitube per Airway Management protocol.

vi) If cardiac conversion occurs, check for pulse. If pulse present, treat with high flow oxygen, or positive pressure assist if necessary and continue to assure an open airway. Monitor vital signs closely. Reassess Initial Assessment if any change noted.

vii) Patients who progress into cardiac arrest due to trauma (after EMS arrival at scene) or other hypovolemia states should have MAST applied and inflated and be immediately transported while appropriate airway and CPR steps are being taken. Do not delay CPR to apply MAST. Refer to Appendix A – MAST Protocol

viii) ALS Intercept should be started as soon as possible.

ix) Transport early unless ALS is less then 5 minutes from the scene. If they are, continue Automatic Defibrillator Protocol, good CPR and Airway Management until ALS arrival.


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Medical Emergencies

1) Non-traumatic shock

a) Give oxygen by mask at 10-15 liters per minute.

b) Consider the use of MAST per Appendix A – MAST Protocol

c) If blood pressure is greater than 90 systolic, elevate the feet approximately 20 degrees except in cases of cardiac problems or head injury.

d) Transport as soon as possible and notify the hospital of the problem and its severity so that if indicated, a physician can be called prior to ambulance arrival at hospital.

e) Initiate ALS Intercept.

2) COPD – Known history of emphysema

a) Do Initial Assessment and begin patient on O2 using nasal cannula at 2-3 liters per minute.

b) Be prepared to increase liter flow or move to a mask at 10lpm if the patient’s condition does not improve or worsens.

c) Place patient in position of most comfort and transport early!

d) Consider ALS intercept. 3) Anaphylactic Shock (Severe allergic reaction)

a) Start High flow oxygen 10LPM via non-rebreather mask.

b) Transport quickly and Initiate ALS Intercept Immediately.

c) Consider use of Premeasured Epinephrine Injection Device (Epi-Pen) per Appendix I – Epinephrine protocol

4) Asthma

a) If patient is breathing - Administer oxygen via mask at 10 liters per minute. Quickly do assessment, gathering history concerning medications. Place patient in position of comfort and transport early.

b) If patient is in respiratory arrest – Insert oral or nasal airway and begin positive pressure ventilation per American Heart Association guidelines. Prepare and insert Combitube per guidelines outlined in the Airway Management section.

c) If lung deflation is poor, perform manual exhalation

d) For ALL Asthma patients, transport early and initiate ALS Intercept

e) For patients with known Asthma and in moderate to severe respiratory distress, may administer nebulized Albuterol 2.5mg while enroute to hospital.

f) May repeat nebulized Albuterol 2.5mg x1 if patient in continued respiratory distress

g) If patient is in respiratory arrest, and patient is known asthmatic, may administer nebulized Albuterol 2.5mg

h) May repeat nebulized Albuterol 2.5mg x1 for continued respiratory distress.

i) For adult patient in respiratory arrest after the 2 Albuterol treatments, consider administration of Epi Pen 0.3mg 1:1000 if not already administered.

Please see appendix G for complete Nebulized Albuterol Protocol


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Medical Emergencies Continued

5) Status Epilepticus (continuous seizures or patient doesn’t regain consciousness between seizures)

a) Oxygen per mask at a minimum of 10 liters per minutes.

b) Position patient to establish and maintain airway and to minimize injury to patient.

c) Transport Early and Initiate ALS Intercept.

6) Unconscious, Unknown Etiology

a) Oxygen per mask at a minimum of 10 liters per minute.

b) Position patient to establish and maintain airway.

c) Transport immediately.

d) Initiate ALS Intercept.

7) Symptomatic Diabetic (known or suspected)

a) If conscious and alert, give oral glucose.

b) I patient unconscious or unable to maintain their own airway.

i) Initiate ALS Intercept

ii) Do NOT use oral glucose on patients unable to swallow

iii) If patient is a known diabetic, consider use of Glucagon Injection per Appendix J – Glucagon Protocol

c) Transport.

8) Drug Overdose


b) Place patient on side in anticipation of possible emesis.

c) Initiate ALS Intercept

9) Suspected Cerebrovascular Accident (CVA-STROKE)


b) Position patient to establish and maintain airway.

c) Consider ALS Intercept if airway management is needed.

d) Transport Early


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Medical Emergencies – continued

10) Cardiac – Suspected MI

a) Patients with any of the following chief complaints or presenting problems should be treated as suspected MI’s unless ordered otherwise. If in doubt, contact physician and discuss case:

b) Chest pain or pressure in any patient over age of 30

c) Syncopal episode (fainting) in any patient over age 50 without suspicion of stroke

d) Atypical cardiac pain, ie shoulder, arm, or jaw pain in absence of chest pain especially in patient with past cardiac history

e) Acute onset of fatigue, SOB or diaphoresis in patient with past cardiac history

f) Unexplained respiratory distress

g) Place patient at rest in comfortable position and start patient on High flow 02 via non-rebreather mask.

h) For cardiac pain, administer nitroglycerin .4mg S.L. if patients systolic BP 110 or greater. Check BP immediately prior to and after administration.

i) For any suspected MI, administer or assist patient in taking four (4) 81mg chewable aspirin if no history of allergies to ASA

j) If no pain relief from nitro and patient’s SBP remains 110 or greater, may repeat nitro every five min. X2. Recheck BP before and after administration.

k) Transport the patient early. ALS Intercept SHOULD be activated.

Please reference Appendix H for complete Nitroglycerin Protocol


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Trauma Emergencies

1) Standing Orders for all Trauma Patients

a) Begin oxygen therapy by mask at a minimum of 10 liters per minute as early as possible.

b) Trauma patients with neck pain and patients who are unconscious secondary to trauma should be presumed to have cervical spine injury and should be properly immobilized in a C-collar and on a long backboard.

c) Unless patient condition dictates rapid extrication, a cervical collar should be used on all patients and a short backboard should be used to immobilize patients who must be removed onto a long backboard from a sitting position. Patients in lying positions should also be c-collared before being placed on a long backboard.

d) Manual vital signs should be taken on all trauma patients including pulse, respirations and blood pressure.

e) Except in cases of prolonged extrication, the transport of critical trauma patients should not be delayed for detailed physical examination and/or treatment of non-life threatening injuries.

f) Notify receiving hospital as soon as possible when transporting a critical trauma patient.

g) Initiate ALS Intercept if Airway or Shock Management is a concern.

h) Consider AirCare Scene Flight for all critical trauma patients.

2) Specific conditions:

a) General trauma/traumatic shock

i) Oxygen by mask at 10 liters per minute.

ii) Spinal immobilization as appropriate.

iii) Apply MAST on any patient with significant trauma. --Do not inflate if patient has penetrating trauma to neck or chest unless patient has no BP and not response to verbal stimuli.

iv) Inflate (irrespective of BP) for patients with:

(1) Penetrating abdominal trauma (2) Suspected pelvic fracture

v) Inflate for all other patients if systolic BP is less than 90 or (if BP not practical) if clinical evidence of shock.

vi) Transport

vii) *NOTE: MAST should be applied, but not inflated, on any patient with severe trauma who has a systolic BP greater than 90, but who is likely to develop shock.

viii) Initiate ALS intercept.

ix) Consider Air Care scene flight or have them meet at the local hospital when appropriate.

b) Head and Spinal Cord Injuries

i) Spinal immobilization as appropriate.

ii) Oxygen by mask at 10 liters per minute

iii) Consider Air Care scene flight or meet at local hospital when appropriate.


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Other Emergencies

1) Hypothermia, moderate to severe

a) Oxygen by mask at a minimum of 10 liters per minute.

b) If patient is pulseless, begin CPR.

c) Remove wet garments.

d) Protect against further heat loss.

e) Maintain horizontal position

f) If available, use warm packs at neck, armpits and groin.

g) Initiate ALS intercept.

h) Consider Air Care Scene Flight

2) Hyperthermia (Heat cramps, heat exhaustion, heat stroke)

a) Oxygen therapy.

b) Begin cooling measures.

c) Transport and notify hospital

d) Initiate ALS Intercept

3) Burns

a) Less than 20 percent of body surface—apply sterile dressings and saturate with cool water but not to the point of patient becoming chilled or shivering.

b) More that 20 percent of body surface—

c) Immediately begin oxygen therapy at 10-15 liters per minute by mask.

d) Monitor airway closely. Insect for signs of smoke inhalation or airway burns

e) Remove any non-adherent burned clothing and cover patient with sterile sheet.

f) Do not cool down burn with water unless smoldering clothes, articles or materials adhering to skin that would continue the burning process is present. I.e. hot tar, etc.

g) Order Air Care scene flight or if unavailable initiate ALS intercept.

h) Transport Early


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Special Pediatric Considerations

1) Age limits for pediatric and adult medical protocols must be flexible. For ages less than 13 year, pediatric orders

should always apply. Between the ages of 13 and 18, judgment should be use, although the pediatric orders will usually apply. It is recognized that the exact age of a patient is not always known. Size is you best indication. Follow specific protocols for medication, combi-tube, and defibrillator use.

2) Consent and Refusal of Minors: Whenever an ambulance is requested for a patient, it is the responsibility of the EMS system to treat and transport tat patient with his/her consent. Transport by ambulance should always be offered to a patient. If a competent parent of a minor refuses treatment or transportation, they should sign the refusal statement on the ambulance report form. If they refuse to sign, this should be documented, including witnesses names if possible. The child’s parent or legal guardian must give consent or refusal of treatment/transport of minors (less that 18 years). Although less desirable, consent or refusal may be given by a responsible adult (over 18) caretaker if the parent has deliberately left the minor in the care of this adult and the adult is competent and capable. If unsure whether it is appropriate to allow someone to give consent or refuse treatment of a minor, a medical control physician should be consulted.

3) Parents should be allowed to stay with children during evaluation and transport if appropriate. The parent’s lap is usually the best place for the examination of a stable patient. However, children should be secured in the appropriate manner during transport.

4) Airway Management Special Concerns:

a) Do not hyperextend the neck in newborns and infants

b) Do not use a positive pressure valve on patients less than 6 years of age.

c) If epiglottis is a possibility, do not attempt to visualize the throat or pharynx. However, if a patient with an airway obstruction has a respiratory or cardiac arrest, the airway should be visualized to rule out a foreign body.

d) Oropharyngeal or nasopharyngeal airway insertion should be attempted on all unconscious patients . The Combitube airway may be used on adolescents of adult size, at least five feet in height. The Combitube may be helpful in controlling bleeding from facial trauma.

e) Follow Nebulized Albuterol Protocol Appendix G for pediatric patients with known Asthma in moderate to severe respiratory distress or respiratory arrest.

Childhood Weights and Vital Signs:

Age Weight / LBS Heart Rate Upper Limit Heart Rate Lower Limit Systolic Lower Limit

Newborn 7 -- 80 --

6 Months 15 180 80 --

1 Year 22 180 80 --

2 Years 26 180 80 80

4 Years 35 150 75 80

6 Years 44 150 70 80

8 Years 55 125 60 85

10 Years 75 125 60 90

12 Years 99 125 60 90

14 Years 110 125 60 90


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Appendix A - STANDING ORDERS AND OPERATING PROCEDURES FOR MAST (Medical Anti-Shock Trouser)

1) General MAST Information

a) MAST is to be used in cases of shock with systolic blood pressure less than 90. MAST is not to be used in cardiac related problems unless there has also been significant blood loss (as in from trauma).

b) MAST trousers are to be applied but not inflated on any patient with systolic blood pressure less than 100, that exhibits signs of impending shock.

c) MAST trousers may be used on trauma patients with diffuse bleeding from lower extremity injuries as a method of compression to stop the bleeding if other direct pressure methods have failed.

d) If patient requires CPR, do not delay or stop CPR in order to apply the MAST trousers.

e) Mast pants should be applied but not inflated on ALL patients who show signs of shock or have mechanism of injury such that shock could become a complication.

f) Apply and inflate mast if patient has suffered from trauma and systolic blood pressure is below 90.

g) Apply and inflate mast if patient is suffering from medical induced shock if systolic blood pressure is blow 80.

h) Apply and inflate mast irrespective of blood pressure for suspected AAA (Abdominal Aortic Aneurysm), abdominal trauma, or pelvic instability.

i) MAST should be considered as a useful splint of lower extremities if patient has suffered from severe lower trauma. Other splints would be more appropriate for isolated extremity injuries. (i.e. Traction Splint for isolated femur fracture).

j) Mast should NOT be inflated for Head injuries, chest injuries, or pulmonary edema unless ordered by the Medical Control Physician.

2) CONTRAINDICATIONS:

a) Do not apply the MAST trousers if you suspect the patient to have congestive heart failure and/or pulmonary edema, heart attack or stroke, unless you suspect that the heart attack or stroke was the result of low blood pressure from traumatic bleeding.

b) MAST trousers may be inflated in case of pregnancy with shock and blood pressure less than 80 systolic, though the abdominal compartment must not be inflated.

c) The MAST trousers should not be inflated in the case of shock due to hypothermia without a physician’s order. d) The MAST trousers should not have the abdominal portion inflated without physician order in the case of

abdominal injury with evisceration or abdominal penetration by foreign body such as a bullet, etc.

3) Application of the MAST trousers:

a) Clothing is to be removed when possible, though if not possible sharp or bulky objects should be removed from the patient’s pockets.

b) Garment is placed underneath the patient, pedal pulse is checked prior to enclosing each leg, c) Compartments are inflated simultaneously until air exhaust through relief valves, or Velcro makes a crackling

noise or patient’s systolic blood pressure is stable at 100. d) Patient’s blood pressure and pedal pulses are checked every five minutes while the garment is on. e) The garment is removed only when a physician is present and the physician orders removal of the garment.


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Appendix B – S.T.A.R.T. Triage

1) Survey the scene and report back to dispatch.

a) Give estimate of number of casualties and needed resources.

b) Give initial idea for staging area.

2) Have all wounded or non-wounded capable of walking, move to a place of safety.

a) If a hazardous environment is possible, use your PA system to order all walking to safe haven.

3) Triage patients as you find them - Do not spend more than 15 or 20 seconds on each victim.

a) Check airway patency and breathing.

i) If airway is OK and breathing is less than 30/minute, continue to next step.

ii) If airway is not OK, attempt to open. If successful tag RED, if unable to restore breathing, tag BLACK.

b) Check circulation.

i) Check carotid and radial pulses. If both are present, move to next step.

ii) If carotid is present and radial is absent, tag RED.

c) Assess mental function. i) Ask victim to follow simple command.

ii) If able to follow simple command, tag YELLOW.

iii) If the victim is unable to follow simple command, tag RED.

4) Assure that patient is taken to treatment area or take patient to treatment area.

5) Continue to monitor this patient or return to triage area as you have been assigned.


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Appendix C – Blood Borne Pathogens and Personal Protection

1.0 SCOPE 1.1 Purpose - This procedure defines the requirements and responsibilities to eliminate or minimize employee occupational exposure to HBV, HIV and other Bloodborne Pathogens and to comply with the OSHA Bloodborne Pathogen Standard. 1.2 Applicability - This procedure is applicable to all Wabasso Ambulance Association crew members. 1.3 Effectivity - Immediately, upon release. 1.4 Authority - The enforcement and interpreting authority for this procedure is the Administrator for the Wabasso Ambulance Association in accordance to regulatory statutes. 2.0 Applicable Documents 29 CFR 1910.1030 OSHA Bloodborne Pathogen Standard 29 CFR 1910.20 Employee Exposure and Medical Records Wabasso Ambulance Association Protocol 3.0 Glossary HBV Hepatitis B Virus HIV Human Immune Deficiency Virus - causes AIDS Exposure Incident A specific eye, mouth, other mucous membrane, non intact skin, or other contact with blood or other potentially infectious materials that results from the performance of an Ambulance Crew Member's duties. Occupational Exposure A reasonable anticipated skin, eye, mucous membrane contact with blood or other potentially infectious materials that may result from the performance of an Ambulance Crew Member's duties.


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Blood borne Pathogens (Continued)

Universal Precautions An approach to infectious control that treats all human blood and certain body fluids as if they are infected with HIV or HBV and other Bloodborne Pathogens. Bloodborne Pathogens Viruses or bacteria present in human blood and body fluids which can infect and cause disease in humans. Personal Protective Equipment (P.P.E.) Clothing and equipment worn by a Ambulance Crew Member during activities which may result in exposure to Bloodborne Pathogens. Decontamination Physical or chemical methods of rendering a contaminated item safe for handling, use or disposal. Licensed Health Care Professional A person who’s legally permitted scope of practice allows them to perform activities for HBV vaccinations and post exposure follow up. Receiving Hospital The hospital to which the patient, involved in the exposure incident, has been transferred to. Ambulance Crew Member Any employee or volunteer of the Wabasso Ambulance Association that as part of their responsibility must render medical care to people injured or suddenly taken ill. Regulated Waste Liquid or semi liquid blood or other potentially infectious materials; contaminated - items that would release blood or other potentially infectious materials, liquid or semi liquid states if compressed, items that are cased with dried potentially infectious materials and are capable of releasing those materials during handling. 4.0 REQUIREMENTS 4.1 Exposure Determination 4.1.1 The Wabasso Ambulance Association has determined that all Ambulance Crew Members may be subject to occupational exposure as a result from the performance of their duties.


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Blood borne Pathogens (Continued) 4.2 Training 4.2.1 The Wabasso Ambulance Association shall provide annual mandatory training communicating Bloodborne Pathogen hazards and procedures to all Ambulance Crew Members. 4.3 Vaccinations 4.3.1 All Wabasso Ambulance Association Ambulance Crew Members shall be offered the series of Hepatitis B vaccinations at no cost to the Ambulance Crew Member, unless the crew member has previously received the series or antibody testing has revealed the Ambulance Crew Member is immune. If a Ambulance Crew Member initially declines the vaccination, but at a later date decides to accept, the vaccination shall be made available. 4.3.2 All Ambulance Crew Members who decline the Hepatitis B vaccine offered shall sign the OSHA required waiver indicating their refusal. See appendix A. 4.3.3 If a routine booster dose of vaccine is recommended by the U.S. Public Health Service at a future date, such booster doses shall be made available at no cost to the Ambulance Crew Member. 4.4 Personal Protective Equipment (P.P.E.) 4.4.1 All P.P.E. will be provided without cost to all Ambulance Crew Members 4.4.2 P.P.E. will be chosen and used based on the anticipated exposure to blood or other potentially infectious materials. 4.4.3 P.P.E. will be considered appropriate only if it does not permit blood or other potentially infectious materials to pass through or reach the Ambulance Crew Members clothing, skin, eyes, mouth or other mucous membranes under normal conditions and for the duration of exposure. 4.4.4 All exposed Ambulance Crew Members must wash hands with soap and water immediately after removal of gloves or other P.P.E. 4.4.5 All P.P.E. shall be removed once the risk of occupational exposure has been eliminated. When P.P.E. is removed, it shall be placed in an appropriate container for disposal 4.5 Test Exposure Evaluation and Follow Up 4.5.1 All exposure incidents shall be reported to, investigated and documented by the receiving hospital at the time the patient is delivered.


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Blood borne Pathogens (Continued)

4.5.2 Following the reporting of an exposure incident, the exposed Ambulance Crew Member(s) shall immediately receive a confidential medical evaluation and follow up. The evaluation and follow up are to include: 4.5.2.1 Documentation of the route of exposure and the circumstances under which the incident occurred. 5.4.2.2 Identification of the source individual(s) 4.5.2.3 The receiving hospital will request the source individual(s) consent to test his/her blood in order to obtain HBV and HIV infectivity. If consent is not obtained, the receiving hospital staff shall establish that legally required consent can not be obtained. If the source individual is already known to be infected with HBV or HIV, testing need not be repeated. 4.5.2.4 Results of the source individual's testing shall be made available to the exposed Ambulance Crew Member and he/she shall be informed of laws and regulations concerning disclosure of the identity and infectious status of the source individual. 4.5.2.5 The health care professional's written opinion for post exposure follow up shall be limited to a statement of the results of the evaluation and a statement that the Ambulance Crew Member has been told about medical conditions resulting from the exposure which requires further evaluation and treatment. All other findings or diagnosis shall remain confidential and shall not be included in the report. 4.6 Clean up 4.6.1 Any equipment, materials, clothing, or facilities which has been contaminated shall be thoroughly cleaned and decontaminated prior to use. 4.6.2 Decontamination may only be performed by Ambulance Crew Members that have received the proper Bloodborne Pathogen training. 4.6.3 Materials which may be contaminated with Bloodborne Pathogens ie. band aids, dressings, P.P.E. or other disposable material shall be discarded in appropriate containers at the Hospital per Wabasso Ambulance Association protocol. 4.6.4 Regulated wastes shall be placed in containers at the Hospital which are marked for this purpose per Wabasso Ambulance Association protocol. These waste containers must be color coded, labeled and closed prior to removal to prevent spillage or protrusion of contents during handling, storage, or shipping. Bio-hazard labels shall be attached to all containers of regulated waste. Disposal of regulated waste shall be in accordance with state and local regulations.


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Blood borne Pathogens (Continued) 4.7 Records 4.7.1 Medical records shall be maintained in accordance with OSHA Standard 29 CFR 1910.20. These records shall be kept confidential and must be maintained for at least the duration of the Ambulance Crew Member being involved with the ambulance plus 30 years. The records shall contain the name and social security number of the Ambulance Crew Member, vaccination records, results of examinations, medical testing, and follow-up procedures and any information provided to health care professionals. 4.7.2 Training records shall be maintained for 3 years from the date of training. 5.0 Responsibilities 5.1 Ambulance Crew Member 5.1.1 The Ambulance Crew Member shall immediately report any exposure incident to the emergency room staff of the receiving hospital at the time the patient is delivered. 5.1.2 The Ambulance Crew Member shall treat all blood, body fluids or unknown fluids with universal precautions. 5.1.3 The Ambulance Crew Member shall be responsible to decontaminate any reusable equipment or materials that has been contaminated by blood or other potentially infectious material before the ambulance can be deemed In Service after each run. 5.1.4 The Ambulance Crew Member shall be trained to protect themselves first and treat the victim second. They will be responsible to use the P.P.E. assigned to them for the protection of the victim as well as themselves. 5.1.5 The Ambulance Crew Member will be responsible to dispose of or decontaminate contaminated equipment, tools or materials. they will secure the area/ambulance until decontamination is complete. 5.2 Wabasso Ambulance Association Administrator 5.2.1 The Administrator shall take steps to ensure Wabasso Ambulance Association protocol is being followed in decontamination of equipment, tools. or materials after each exposure incident. 5.2.3 The Administrator shall ensure informational training on the Bloodborne Pathogen Standard and procedures is provided to all Ambulance Crew Members.


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Blood borne Pathogens (Continued) 5.2.4 The Administrator shall ensure that Hepatitis B vaccinations have been offered to all Ambulance Crew Members. 5.2.5 The Administrator shall ensure that P.P.E. and clean up kits are available to the Ambulance Crew Members. 5.2.6 The Administrator shall ensure that records of vaccinations, and training, are maintained per OSHA standard 29 CFR 1910.20. 5.3 Health Care Professional 5.3.1 The Health Care Professional will provide a written opinion of medical testing, examinations and follow up procedures. 5.4 Receiving Hospital 5.4.1 The Receiving Hospital shall ensure all exposure incidents are fully documented, and arrange for medical evaluation and follow up as required. 5.4.2 The Receiving Hospital shall ensure that records of exposure incidents and medical testing and follow up procedures are maintained per OSHA standard 29 CFR 1910.20


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Blood borne Pathogens (Continued) HEPATITIS B VACCINE DECLINATION I understand that due to my occupational exposure to blood or other potentially infectious materials, I may be at risk of acquiring Hepatitis B virus (HBV) infection. I have been given the opportunity to be vaccinated with Hepatitis B vaccine, at no charge to myself. However, I decline Hepatitis B vaccination at this time. I understand that by declining this vaccine, I continue to be at risk of acquiring Hepatitis B, a serious disease. If in the future I continue to have occupational exposure as a member of the Wabasso Ambulance Association to blood or other potentially infectious materials and I want to be vaccinated with Hepatitis B vaccine, I can receive the vaccination series at no charge to me. ___________________________ ____________________________ AMBULANCE CREW MEMBER WITNESS ____________________ DATE


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Appendix D – Mutual Aid Agencies

Listing of EMS agencies and other resources that the Wabasso Ambulance Crew can utilize if needed. This list is placed here only as a reminder and should not limit the resources the on-duty crew can use if needed for a specific call. (In other words, even if it’s not listed here, call them if you need them!)

First Responder Crews 1. Clements First Responders 2. Lucan First Responders 3. Milroy First Responders 4. Sanborn First Responders 5. Vesta First Responders

Ambulance Services (Underlined Services have a signed mutual aid aggreement) 1. Belview Ambulance – Basic Life Support 2. Lamberton Ambulance – Basic Life Support 3. Morgan Ambulance – Basic Life Support 4. North Ambulance – Redwood Falls – Advanced Life Support 5. North Ambulance – Marshall – Advanced Life Support 6. Springfield Ambulance – Basic Life Support 7. Walnut Grove Ambulance – Basic Life Support 8. Westbrook Ambulance – Basic Life Support

Law Enforcement 1. Wabasso Police Department 2. Redwood County Sheriff

Fire Departments 1. Wabasso Fire and Rescue 2. Belview Fire Department 3. Lucan Fire Department 4. Lamberton Fire Department 5. Milroy Fire Department 6. Morgan Fire and Rescue 7. Redwood Falls Fire and Rescue 8. Sanborn Fire Department 9. Seaforth Fire Department 10. Vesta Fire and Rescue


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Mutual Aid Agencies Continued

Other Resources 1. Redwood County Office of Emergency Management (507) 637-4035 2. Emergency Response Trailer – Dispatched via Redwood County Sheriff’s Office (911) 3. Incident Command Trailer – Dispatched via Redwood County Sheriff’s Office (911) 4. North Air-Care (Dispatched via Redwood County Sheriff’s Office (911) 5. ALS Response – North Ambulance Redwood Falls and Marshall (Dispatched via Redwood County Sheriff’s Office (911)


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Appendix E – ALS Intercept Guidelines

1. ALS intercepts can be initiated for ALL patients being transported by the Wabasso Ambulance Service at the discretion of the duty crew.

2. ALS intercepts should be initiated for all serious medical or trauma patients.

3. A general rule of thumb should be used in helping you determine the need for ALS intercept.

a. ALS can be used for any and all calls, but If the patient is going to need Code-3 (Lights and siren) transport to the hospital, an ALS intercept should be used (if available).

b. ALS Intercept (if available) must be initiated any time a medication is used per medication protocols

4. To initiate an ALS intercept, the Sheriff’s office dispatch should be contacted either via radio or telephone 911 and ask for and ALS intercept from either Redwood Falls or Marshall as appropriate for your call.


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Appendix F – Defibrillator Protocol

1) GENERAL GUIDELINES

a) If the EKG rhythm or the patient's condition changes, check for a carotid pulse. If not present, analyze the rhythm and act appropriately.

b) The patient should be defibrillated in a stationary setting free of adverse weather conditions. The patient should not be defibrillated if in a wet area.

c) Children with a body weight of under 90 pounds should not be defibrillated.

d) Except for the determination of the rhythm and delivery of defibrillation, CPR should not be delayed at any time for more than ten (10) seconds.

e) ALS Response should be initiated as soon as possible for all cardiac arrest calls.

2) INDICATIONS

a) Patient believed to be suffering from Cardiopulmonary Arrest (not breathing and no carotid pulse).

3) CONTRA - INDICATIONS

a) A child whose body weight is estimated to be less than 90 pounds. or

b) A patient suffering from a traumatically induced cardiac arrest (vehicular accident, severe fall, farm accident, etc).

4) OPERATION

a) Upon arrival, determine unresponsiveness, establish airway (suction if needed), place an oral airway and ventilate with 100% oxygen

b) Perform CPR as American Heart Association guidelines suggest

c) At the same time, prepare the semi-automatic defibrillator by attaching the pads to the cables, placing them in their proper position on the patient’s chest, and turn on the power switch. These procedures should be performed while SPR is in progress.

d) Stop CPR and press the analyze button. The patient must be stationary and not being touched by anyone.

e) If the defibrillator states "Check Pulse”

f) Recheck the patient's breathing and carotid pulse.

g) If a carotid pulse is not present, resume CPR and prepare the patient for transport on a long backboard.

h) After one (1) minute, stop CPR and press the analyze button with no one touching the patient. If "NO SHOCK INDICATED", continue CPR.

i) If the defibrillator states "SHOCK INDICATED", then:

j) Make sure everyone is away from the patient and not touching them.

k) State "CLEAR" loudly and, after observing that no one is touching the patient, press the shock button.

l) After the shock has been delivered, recheck the patient's carotid pulse.

m) If no carotid pulse is present, allow the defibrillator to repeat the analyze and shock process to a maximum of 3 defibrillation series.

n) If a carotid pulse is present, continue airway and breathing support, monitor vital signs and transport.


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Defibrillator Protocol Continued

o) If after the first three (3) defibrillation the patient does not have a carotid pulse, resume CPR and make the transport decision

p) After performing CPR for one (1) minute, stop CPR and press the analyze button with no one touching the patient. If defibrillator indicates "SHOCK INDICATED", follow steps above. If "NO SHOCK INDICATED", resume CPR.

q) A total of 3 analyze and shock series should be done at the scene prior to transport.

r) Transport Decision

i) ALS Response should be initiated as soon as possible on ALL cardiac arrest calls. Contact the 911 dispatcher to request ALS from Redwood Falls or Marshall as appropriate.

ii) Depending on the location of the call and response time of ALS one of 2 transport decisions would be appropriate. After your series of 3 analyze and shock procedures have been completed, and your patient is ready for transport:

iii) If ALS is 5 minutes or less from the scene, continue to do CPR and airway maintenance via combi-tube until ALS arrival at scene. Allow the defibrillator to continue its analyzation process as programmed.

iv) If ALS is more then 5 minutes from arrival at the scene, shut the lid on the defibrillator to shut off analyzation process and load the patient in the ambulance. Continue CPR and Airway maintenance via combi-tube and arrange to meet ALS as appropriate.


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Appendix G – Nebulized Albuterol

Albuterol (Proventil, Ventolin)

1) Action

a) Bronchodilator (beta-adrenergic agonist)

2) Indications

a) Patient must have history of Asthma. b) Patient should be in moderate to severe respiratory distress or respiratory arrest c) For relief of acute bronchospasm (reversible airway obstruction)

3) Contraindications:

a) Allergy or known hypersensitivity to Albuterol

4) Precautions

a) Beta-receptor blocking agents and Albuterol inhibit the effect of each other. b) Use with caution in patients with heart disease, hypertension, diabet es, the elderly and those being treated with

antidepressants. c) ALS Intercept should be initiated on any run where Albuterol is being considered

5) Adverse Reactions/Side Effects

a) Hypertension and headache b) Arrhythmias and chest pain c) Nervousness and shakiness d) Rare: May produce immediate allergic reactions or paradoxical bronchospasm, which can be life threatening.

Discontinue treatment immediately if this occurs.

6) Administration

a) Dosage for adults: Pour one unit dose bottle (2.5mg = 3 ml of 0.083% solution) into nebulizer reservoir. b) Connect nebulizer to oxygen source at 6 liters per minute. c) Have patient breathe as calmly, deeply and evenly as possible until no more mist is found in the nebulizer

chamber (5 – 15 minutes). Routine nebulizer therapy should be accomplished using the nebulizer unit and instructing the patient to close his/her lips around the mouthpiece. An acceptable alternative to using the mouthpiece would be to attach the nebulizer reservoir to an oxygen mask, i.e. remove the bag from a non-rebreather nebulizer reservoir and do not use the T-piece or the mouthpiece.

d) If patient’s condition has not acceptably improved, may re-administer nebulizer treatment 1 more time. e) Restart patient on oxygen at appropriate concentration. f) Reassess patient, especially lung sounds and vital signs after each treatment.

7) Pediatric Considerations

a) One treatment may be given to children <12 years prior to medical control contact. b) Administer adult strength.

8) Special Notes

a) Nebulizer treatment for patient with active tuberculosis should be performed in well ventilated areas (outside patient compartment if possible).


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Appendix H – Nitroglycerin

1) Action - Antianginal, coronary and peripheral vasodilator

2) Indications

a) Chest pain of suspected cardiac origin

b) Pulmonary edema

c) Hypertension (only on physician order)

3) Contraindications

a) Patients taking Viagra (sildenafil citrate)

b) Allergy or known hypersensitivity to nitroglycern

c) Head Trauma

d) Hypovolemia, hypotension (BP < 90 systolic in adults), and shock

4) Precautions

a) BLS without drug variance – May be administered only to patients for whom it is prescribed

5) Adverse Reactions / Side Effects

a) Headach, dizziness, and weakness

b) Tachycardia, fainting, and hypotension

6) Administration

a) If systolic BP drops <90 systolic after any NTG, discontinue NTG.

b) Basic Life Support with drug variance may administer up to 3 NTG sublingual or spray 3 – 5 minutes apart provided BP is > 110 systolic.

7) Pediatric Considerations

a) Do not give to patients <12 years of age without physician order.

8) Special Notes

a) NTG is effective in relieving angina pectoris. Other conditions such as esophageal spasm can respond well

b) If patient becomes hypotensive (BP < 90 lay patient flat and elevate legs. May consider IV volus per medical control if have IV variance.

c) Initiate ALS intercept as soon as possible and transport early.


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Appendix I – Epinephrine Premeasured Injection Device

1) Indications

a) Patients experiencing a severe allergic reaction from stings or other allergens

2) Precautions

a) Patients who have known allergic reactions to insect bits or other allergens will often have epinephrine prescribed in the form of an Ana-Kit or EpiPen (or other similar device) that delivers an injection of pre-measured epinephrine.

b) Use with caution in patients > 40 years.

c) At the time when a request to deliver or assist a patient with their epinephrine is made, any suspected complication conditions, such as the following should be reported.

Heart Disease Age > 40 Years Pulmonary Edema Psychosis COPD Hyperthyroidism Hypertension History Glaucoma Pregnancy


a) There are no absolute contraindications to the use of epinephrine in a life-threatening situation.

4) Administation

a) EMTs may assist a patient in administering their own prescribed EpiPen or AnaKit following consultation with Medical Control physician.

b) Basic Life Support services with a variance may administer an EpiPen carried by that service.

c) If stinger present, remove it

d) Scrape stinger out with edge of card

e) Avoid using tweezers or forceps as these can squeeze venom from the venom sac into the wound.

5) Assist in administration. Refer to specific manufacturer instructions, but generally:

a) EpiPen Administration

b) Check expiration date

c) Pull off safety cap

d) Wipe injection site with alcohol

e) Place tip of EpiPen on exposed thigh (anterior/lateral) at right angle to the leg. Apply in this area regardless of what area of the body has been stung.

f) Press hard into thigh until autoinjector mechanism triggers, and hold in place for several seconds. Remove EpiPen and discard into sharps container.

g) Massage injection site for 10 seconds to enhance absorption.

6) With persistent severe anaphylaxis, additional injections may be necessary. Consult with medical control if a second dose is indicated.


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Appendix J – Glucagon

1) Action – Antihypoglycemic; converts stored liver glycogen to glucose, resulting in an increase in circulating blood sugar.

2) Indications

a) Known hypoglycemia (BS < 80mg./dL in diabetic patients, if symptomatic.

b) Beta blocker overdose or toxicity; including acebutolol (Sectral), alprenolol, atenolol, (Tenormin), betaxolol (Betoptic, Kerlone), bevantolol, bisoprolol, carteolol, (Cartrol), flestolol, labetalol, (Normadyne, Trandate), levobumolol (Betagan), metoprolol, (Lopressor), nadolol (Corgard), exprenolol, penbutolol (levatol), pindolol (Visken), propranolol (Inderal, Blocadren, Timoptic), sofalol, timolol

c) Calcium channel blocker overdose or toxicity, including: verapamil (Calan, Isoptin), diltiazem (Cardiazem), nigedipine (Procardia, Adalat), nicardipine (Cardene, Vasonase), nimodipine (Nimotop), amlodipine, felodipine, flunarizine, isradipine, nisoldapine, nitrendapine.


a) Allergy or known hypersensitivity to glucagon

b) Adverse Reactions / Side Effects

c) Occasional nausea and vomiting.

4) Administration

a) For Hypoglycemia

(1) Glucagon comes as one unit (1 mg) of powdered glucagon with a vial containing 1 ml of diluting solution.

(2) Inject diluting solution into powdered glucagon vial. Shake gently until solution is clear.

(3) Inject intramuscular into abdomen, buttocks, thigh or upper arm.

(4) Turn patient to one side in case vomiting should occur.

(5) If patient wakes up and is able to swallow, give a fast acting carbohydrate immediately.

b) Suspected Overdose

(1) Do not administer for suspected overdose without on-line medical control.

(2) Further orders must come from monitoring physician.

5) Pediatric Considerations:

a) Do not give to patients < 12 years without physician order. For small children, usual dose is half the adult dose.