Montgomery County Hospital District

Emergency Medical Services

Standard Delegated Orders

January 26, 2009
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 Montgomery County Hospital District-EMS TABLE OF CONTENTS
Standard Delegated Orders –
Introduction INTRO 01 Page iii
TOC

INTRODUCTION Page Rev. Date

INTRO-1 Table of Contents i 11/01/2005
INTRO-2 Medical Director Statement xi 02/01/2006
INTRO-3 Standard of Care Statement xiii 11/01/2005
INTRO-4 Standard Delegated Orders and Protocols xiv 11/01/2005
INTRO-5 Definitions xvii 11/01/2005
CLINICAL GUIDELINES
CG 01 General Therapies 02/01/2006
CG 02 Diagnostic Tools and Procedures 11/01/2005
CG 03 Medication Standards 11/01/2005
CG 04 Protocol Deviations 11/01/2005
CG 05 Supervisor Notification 11/01/2005
CG 06 Patient Status 11/01/2005
CG 07 Radio Report and Consult Guidelines 11/01/2005
CG 08 Communications Failure 11/01/2005
CG 09 Chain of Command 11/01/2005
CG 10 Non-MCHD Personnel on Scene 11/01/2005
CG 11 Medical Authorization Levels 11/01/2005
CG 12 PIII and Squad Authorization 11/01/2005
CG 13 Paramedic I Promotional Requirements 11/01/2005
CG 14 Paramedic II Promotional Requirements 01/26/2009
CG 15 Paramedic III Promotional Requirements 11/01/2005
CG 16 Paramedic IV Promotional Requirements 11/01/2005
CG 17 Transfer Care Unit/Special Event Authorization 11/01/2005
CG 18 First Responder Scope of Practice 11/01/2005
CG 19 Encountering Emergencies 11/01/2005
CG 20 Potentially Violent Scenes and Staging 11/01/2005
CG 21 Coordination with Law Enforcement 11/01/2005
CG 22 Requests for Assistance 11/01/2005
CG 23 Transporting Patient Valuables 11/01/2005
CG 24 Organ Donor Procurement – LifeGift 11/01/2005
CG 25 Patient Consent 11/01/2005
CG 26 Patient Refusal 11/01/2005
CG 27 Oxygen 11/01/2005
CG 28 Third Riders 11/01/2005
CG 29 Non-Emergency Assist Calls 11/01/2005
CG 30 Confidentiality 11/01/2005
CG 31 OOH DNR and Death on Scene 11/01/2005
CG 32 Destination Determination 01/11/2010
CG 33 Facility Diversion 11/01/2005
CG 34 Air Medical Utilization 11/01/2005
CG 35 Controlled Substances 11/01/2005
CG 36 Medication Storage 11/01/2005
CG 37 EMD Determinants Version 11 11/01/2005
CG 38 File Transfer of Patient Care Records 11/01/2005
CG 39 Allied Health Care Providers 11/01/2005
CG 40 Primary Survey / CABC‘S 11/01/2005
CG 41 Focused and Detailed Exam 11/01/2005

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CG 42 Documentation Standards 11/01/2005

CG 43 New Employee Orientation Program 11/01/2005
CG 44 Card Courses and Educational Opportunities 11/01/2005
CG 45 Recertification and Upgrade in Certification 11/01/2005
CG 46 Continuous Quality Improvement 11/01/2005
CG 47 Handling Child and Elderly Abuse and Neglect 11/01/2005
CG 48 Care and Transportation of Minors 11/01/2005
CG 49 Department of State Health Minimum Inventory List 06/10/2009
STANDARD DELEGATED ORDERS
ADULT PROTOCOLS – BEHAVIORAL
AB 01 Behavioral Assessment 11/01/2005
AB 02 Abuse / Neglect 11/01/2005
AB 03 Aggressive / Violent Behavior 11/01/2005
AB 04 Anxiety / Emotional Distress 11/01/2005
ADULT PROTOCOLS – CARDIAC
AC 01 Cardiac Assessment 11/01/2005
AC 02 Acute Coronary Syndrome / AMI 08/01/2007
AC 03 Asystole 03/01/2010
AC 04 Bradycardia 11/01/2005
AC 05 CHF / Pulmonary Edema 08/01/2007
AC 06 Hypothermic Induced Arrest 11/08/2006
AC 07-A Narrow Complex Tachycardia – Stable 05/21/2007
AC 07-B Narrow Complex Tachycardia – Unstable 05/21/2007
AC 08 Non-Traumatic Chest Pain 08/01/2007
AC 09 Post Resuscitation Mgmt 01/26/2009
AC 10 Pulseless Electrical Activity 03/01/2010
AC 11 Ventricular Ectopy 11/01/2005
AC 12 Ventricular Fibrillation / Pulseless Vent. Tachycardia 03/01/2010
AC 13-A Wide Complex Tachycardia – Stable 11/01/2005
AC 13-B Wide Complex Tachycardia – Unstable 11/01/2005
ADULT PROTOCOLS – ENVIRONMENTAL
AE 01 Environmental Assessment 11/01/2005
AE 02 Cold Related Emergency 11/01/2005
AE 03 Heat Related Emergency 11/01/2005
AE 04 Insect / Animal / Snake Bite 08/01/2007
AE 05 Near Drowning 08/01/2007
AE 06 Toxicological / HAZMAT 11/01/2005
ADULT PROTOCOLS – MEDICAL
AM 01 Medical Assessment 11/01/2005
AM 02 Allergic Reaction 11/01/2005
AM 03 AMS / Unconscious 08/01/2007
AM 04 Cerebrovascular Accident 11/01/2005
AM 05-A Diabetic – Hyperglycemia 11/01/2005
AM 05-B Diabetic – Hypoglycemia 11/01/2005
AM 06 Dystonic Reaction 11/01/2005
AM 07 Fever 11/01/2005
AM 08 Hypertensive Crisis 11/01/2005

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AM 09 Malnutrition / Dehydration 11/01/2005

AM 10 Non-Traumatic Abdominal Pain 08/01/2007
AM 11 Non-Traumatic Hemorrhage 11/01/2005
AM 12 Non-Traumatic Shock / Hypotension 11/01/2005
AM 13 Overdose / Poisoning 08/01/2007
AM 14 Seizures 08/01/2007
AM 15 Syncope 11/01/2005
ADULT PROTOCOLS – RESPIRATORY
AR 01 Respiratory Assessment 11/01/2005
AR 02 Airway Obstruction 08/01/2007
AR 03 Bronchospasm 08/01/2007
AR 04 COPD 05/21/2007
AR 05 Hyperventilation 11/01/2005
AR 06 Pneumonia 08/01/2007
AR 07 Pulmonary Embolism 06/26/2006
AR 08 Respiratory Distress 11/01/2005
ADULT PROTOCOLS – OB
OB 01 OB Assessment 11/01/2005
OB 02 Abdominal Pain – Female 08/01/2007
OB 03 Pre-Eclampsia / Toxemia 11/01/2005
OB 04 Eclampsia / Toxemia 08/01/2007
OB 05 Labor 11/01/2005
OB 06 Childbirth / Imminent Delivery 11/01/2005
OB 07 Neonate Care 08/01/2007
OB 08 Limb Presentation 11/01/2005
OB 09 Prolasped Umbilical Cord 11/01/2005
OB 10 Spontaneous Abortion 11/01/2005
OB 11 Vaginal Bleeding 11/01/2005
ADULT PROTOCOLS – TRAUMA
AT 01 Trauma Assessment 11/01/2005
AT 02 Amputation 08/01/2007
AT 03 Burns 08/01/2007
AT 04 Taser 11/01/2005
AT 05 Eviseration 08/01/2007
AT 06 Eye Injury 08/01/2007
AT 07 Head Trauma 11/01/2005
AT 08 Multi-System Trauma 11/01/2005
AT 09 Musculoskeletal – Soft Tissue Injury 08/01/2007
AT 10 Penetrating Injury 08/01/2007
AT 11 Sexual Assault 11/01/2005
AT 12 Spinal Trauma 11/01/2005
AT 13 Traumatic Arrest 11/25/2008
PEDIATRIC PROTOCOLS – BEHAVIORAL
PB 01 Behavioral Assessment 11/01/2005
PB 02 Abuse / Neglect 11/01/2005
PB 03 Aggressive / Violent Behavior 11/01/2005
PB 04 Anxiety / Emotional Distress 11/01/2005

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PEDIATRIC PROTOCOLS – CARDIAC

PC 01 Cardiac Assessment 11/01/2005
PC 02 Asystole 11/08/2006
PC 03 Bradycardia 11/01/2005
PC 04 Hypothermia / Hypothermic Arrest 11/08/2006
PC 05 Post Resuscitation Management 08/01/2007
PC 06-A Narrow Complex Tachycardia – Stable 11/01/2005
PC 06-B Narrow Complex Tachycardia – Unstable 11/01/2005
PC 07 Pulseless Electrical Activity 08/01/2007
PC 08 Non-traumatic Chest Pain 08/01/2007
PC 09 Ventricular Ectopy 11/01/2005
PC 10 Ventricular Fibrillation / Pulseless Vent. Tachycardia 08/01/2007
PC 11-A Wide Complex Tachycardia - Stable 11/01/2005
PC 11-B Wide Complex Tachycardia - Unstable 11/01/2005
PEDIATRIC PROTOCOLS – ENVIRONMENTAL
PE 01 Environmental Assessment 11/01/2005
PE 02 Cold Related Emergency 11/01/2005
PE 03 Heat Related Emergency 11/01/2005
PE 04 Insect / Animal / Snake Bite 08/01/2007
PE 05 Near Drowning 11/01/2005
PE 06 Toxicological / HAZMAT 11/01/2005
PEDIATRIC PROTOCOLS – MEDICAL
PM 01 Medical Assessment 11/01/2005
PM 02 Allergic Reaction 11/01/2005
PM 03 AMS / Unconscious 08/01/2007
PM 04 Dehydration 11/01/2005
PM 05 - A Diabetic - Hyperglycemia 11/01/2005
PM 05 - B Diabetic - Hypoglycemia 11/01/2005
PM 06 Dystonic Reaction 11/01/2005
PM 07 Fever 11/01/2005
PM 08 Non-traumatic Abdominal Pain 11/01/2005
PM 09 Non-traumatic Hemorrhage 11/01/2005
PM 10 Non-traumatic Shock / Hypotension 11/01/2005
PM 11 Overdose / Poisoning 08/01/2007
PM 12 Seizures 08/01/2007
PM 13 Syncope 11/01/2005
PEDIATRIC PROTOCOLS – RESPIRATORY
PR 01 Respiratory Assessment 11/01/2005
PR 02 Airway Obstruction 11/01/2005
PR 03 Bronchospasm 11/01/2005
PR 04 Croup 11/01/2005
PR 05 Epiglottis 11/01/2005
PR 06 Pneumonia 11/01/2005
PR 07 Respiratory Distress 11/01/2005
PR 08 Respiratory Failure / Shock 11/01/2005
PEDIATRIC PROTOCOLS – TRAUMA
PT 01 Trauma Assessment 11/01/2005

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PT 02 Amputation 11/01/2005
PT 03 Burns 11/01/2005
PT 04 Evisceration 11/01/2005
PT 05 Eye Injury 11/01/2005
PT 06 Head Trauma 11/01/2005
PT 07 Multi-system Trauma 11/01/2005
PT 08 Musculoskeletal – Soft Tissue Injury 11/01/2005
PT 09 Penetrating Injury 11/01/2005
PT 10 Sexual Assault 11/01/2005
PT 11 Spinal Trauma 11/01/2005
PT 12 Traumatic Arrest 11/25/2008
PROCEDURES
PROC 01 12-Lead ECG Monitoring 11/01/2005
PROC 02 Adenosine Administration 02/01/2006
PROC 03 Basic Airway Management 11/01/2005
PROC 04 Baxter Pump/Administration of IV Medication 11/01/2005
PROC 05 Blood Draw Request by Texas J.P. 11/01/2005
PROC 06 Blood Glucose Analysis 11/01/2005
PROC 07 Chest Decompression 11/01/2005
PROC 08 Combitube 11/01/2005
PROC 09 Continuous Positive Airway Pressure Ventilation (CPAP) 08/01/2007
PROC 10 C-Spine Clearance Procedure 11/01/2005
PROC 11 End Tidal CO2 Detection 11/01/2005
PROC 12 ET Introducer Device 11/01/2005
PROC 13 External Pacing 11/01/2005
PROC 14 Helmet Removal 11/01/2005
PROC 15 Intubation 11/01/2005
PROC 16 Medication Administration 11/01/2005
PROC 17 Nasogastric Tube Insertion & Lavage 11/01/2005
PROC 18 Nitrous Oxide Administration 11/01/2005
PROC 19 Orthostatic Vital Signs 11/01/2005
PROC 20 Pain Management 01/21/2009
PROC 21 ParaPac Ventilator 11/01/2005
PROC 22 Patient Safety Restraint 11/01/2005
PROC 23 Patient Safety Sedation 11/01/2005
PROC 24 Pericardiocentesis 11/01/2005
PROC 25 Pharmacological Assisted Intubation - PAI 06/10/2009
PROC 26 Positive End Expiratory Pressure 11/01/2005
PROC 27 Pulse Oximetry Monitoring 11/01/2005
PROC 28 Spinal Motion Restriction 11/01/2005
PROC 29 Surgical Airway 11/01/2005
PROC 30 Termination of Medical Resuscitation 01/26/2009
PROC 31 Termination of Trauma Resuscitation 01/26/2009
PROC 32 Vagal Manuevers 11/01/2005
PROC 33 Vascular Access 11/01/2005
MEDICINE REFERENCE
MED 01 Acetaminophen 11/01/2005
MED 02 Activated Charcoal 11/01/2005

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MED 03 Adenosine 02/01/2006

MED 04 Aspirin 11/01/2005
MED 05 Atropine Sulfate 11/01/2005
MED 06 Benadryl 11/01/2005
MED 07 Cardizem 05/21/2007
MED 08 Cordarone 02/01/2006
MED 09 Calcium Gluconate 11/01/2005
MED 10 Decadron 11/01/2005
MED 11 Dextrose (25%-50%) 11/01/2005
MED 12 Dopamine HCL 11/01/2005
MED 13 Epinephrine HCL 11/01/2005
MED 14 Etomidate 11/01/2005
MED 15 Fentanyl 06/10/2009
MED 16 Glucagon 02/01/2006
MED 17 Ibuprofen 11/01/2005
MED 18 Labetalol 05/21/2007
MED 19 Lasix 11/01/2005
MED 20 Lidocaine HCL 11/01/2005
MED 21 Magnesium Sulfate 11/01/2005
MED 22 Morphine Sulfate 11/01/2005
MED 23 Narcan 08/01/2007
MED 24 Nitroglycerin 02/01/2006
MED 25 Nitrous Oxide 11/01/2005
MED 26 Normal Saline 11/01/2005
MED 27 Oxygen 11/01/2005
MED 28 Phenergan 11/01/2005
MED 29 Pitocin 11/01/2005
MED 30 Retavase (if available) 01/11/2010
MED 31 Sodium Bicarbonate 11/01/2005
MED 32 Solumedrol 11/01/2005
MED 33 Stadol 11/01/2005
MED 34 Succinylcholine Chloride 11/01/2005
MED 35 Tetracaine Ophthalmic Solution 11/01/2005
MED 36 Thiamine 11/01/2005
MED 37 Valium 11/01/2005
MED 38 Vasopressin 02/01/2006
MED 39 Vecuronium 11/01/2005
MED 40 Versed 08/01/2007
MED 41 Xopenex 11/01/2005
MED 42 Zofran 01/26/2009
APPENDIX
APP 01 12-Lead Guide 11/01/2005
APP 02 Ambulance Acceptable Abbreviations 11/01/2005
APP 03 APGAR 11/01/2005
APP 04 Capnography 11/01/2005
APP 05 Glascow Coma Scale – Adult and Pediatric 11/01/2005
APP 06 Infusion Calculations 11/01/2005
APP 07 Mallampati Signs 11/01/2005

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APP 08 MCHD Stroke Scale 11/01/2005

APP 09 Oxygen Duration 11/01/2005
APP 10 Pain Assessment 11/01/2005
APP 11 Rule of Nines 11/01/2005
APP 12 Subject in Custody Risk Assessment Scale 11/01/2005
APP 13 Trauma Scores 11/01/2005
APP 14 Zoll M Series Quick Reference 11/01/2005
APP 15 EZ IO Humeral Placement Provisional Procedure 11/01/2005
APP 16 Point of Care Cardiac Marker Provisional Procedure 02/01/2006
APP 17 Impedance Threshould Device (ResQPOD®) 11/25/2008
APP 18 Metoprolol 05/21/2007
APP 19 Intranasal Medication Administration 08/01/2007
APP 20 Induced Hypothermia 03/01/2010
APP 21 Zoll Digital 12 Lead Transmission 02/14/2008
APP 22 Implantable Venous Access Device (iVAD) 09/08/2008
APP 23 Controlled Substances 11/25/2008

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Protocol Update Log
Date Protocol Changed Comment
03/29/2006 PROC 02 – Adenosine Adenosine max dose changed
03/29/2006 PROC 25 – Adult PAI Vecuronium moved to Post-intubation Consult
03/29/2006 MED 08 – Cordarone Narrow Complex Tach added as indication
03/29/2006 MED 16 – Glucagon Calcium Channel Blocker added as indication
03/29/2006 MED 24 – Nitroglycerin Hypertension removed as indication
03/29/2006 MED 38 – Vasopressin Indications updated
03/29/2006 PROC 13 – External Pacing Updated
03/29/2006 APP 16 – Point of Care Cardiac Procedure added
Marker
06/26/2006 AR07 – Pulm. Embolism Changed Physical Findings
11/08/2006 APP 17 – ResQPOD Added Procedure
11/08/2006 PROC 30 & 31 Added ResQPOD
11/08/2006 PC 02,04,05,07,10 Added ResQPOD
11/08/2006 AC 03, 06, 09, 10, 12 Added ResQPOD
11/08/2006 AT 09 – Muscluloskeletal Added Compartment Syndrome
11/08/2006 AT 13 – Tramuatic Arrest Added ResQPOD
11/08/2006 PT 12 – Traumatic Arrest Added ResQPOD
05/21/2007 AC 02 – ACS Add Metoprolol/Removed Labetalol
05/21/2007 AC 07A & AC 07B – Narrow Updated Cardizem dosage
Complex
05/21/2007 AR 03, 04, 06 Added CPAP
05/21/2007 APP 18 – Metoprolol Medication Added
05/21/2007 CG 49 – Inventory Min. Updated
05/21/2007 MED 07 – Cardizem Updated Dosage
05/21/2007 MED 18 – Labetalol Updated Indications
05/21/2007 PROC 09 – CPAP Updated Indications
08/01/2007 PROC 09 & 20 Updated Procedure for CPAP and Pain Mgmt
08/01/2007 AC 05, AE 05,AR 03,04,06 CPAP settings changes
08/01/2007 AC 02, 08; AE 04; AM 10; OB Pain Management moved above Consult
02; AT 02, 03, 05, 06, 09, 10;
PC 08; PE 04
08/01/2007 APP 19 Intranasal Medication Administration added
08/01/2007 AC 03,10,12; AM 03,13,14 Narcan IN Administration
08/01/2007 OB 04,07; PC 05, 07,10; PM Narcan IN Administration
03,11,12
08/01/2007 MED 15,23,40 IN Route Added for Fentanyl, Narcan, Versed
08/01/2007 Inventory Minimums Updated
02/14/2008 INTRO 02 New Signature page with proper dates
02/14/2008 APP 20 and 21 Added Zoll 12 Lead and Hypothermia Procedure
02/14/2008 AC 09 Added Consult for shivering control
02/14/2008 OB 06 & OB 10 Removed Pitocin
09/08/2008 APP 22 Implantable Venous Added New Procedure
Access Device (iVAD)
11/25/08 AT 13, PT 12, & APP 17 Deleted references to ResQPod for trauma
11/25/08 APP 23 Controlled Sustances Updated CG 35

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01/21/09 PROC 20 Pain Management Updated Treatment Options
01/26/2009 MED REF 42 Added Zofran to AC 02, AC 08, AE 03, AM 04,
AM 05-A, AM 08, AM 09, AM 10, OB 02, OB 03,
OB 04, OB 05, OB 08, AT 02, AT 03, AT 12, PC
08, PE 03, PE 04, PM 04, PM 05-A, PM 08,
Patient 02, Patient 05, Patient 08.
01/26/2009 AC 09 Clarification when to give Cordarone.
01/26/2009 CG 14 Added Resume‘ to items required.
06/10/2009 CG 49 Minimum List Title changed to: Department of
State Health Minimum Inventory List
06/10/2009 MED REF 15 Amended Fentanyl adult dosages to agree with
Pain Management guidelines.
06/10/2009 PROC 25 Nerve Stimulator may be used if available noted.
1/11/2010 MED REF 30 Retavase may be available
1/11/2010 CG 32 Destination Determination Updated
3/1/2010 AC 03, AC10, AC 12 Change Vasopressin dosage, Revise Epinephrine
dosing, addition of Induced Hypothermia
procedure, minimum 20-minute CPR.
3/1/2010 APP 20 induce in CPR greater than 5 minutes,
Versed/Vecuronium only to control shivering, no
consult for Versed

Revision Date 01/10/2010

 Montgomery County Hospital District-EMS MEDICAL DIRECTOR
STATEMENT
Standard Delegated Orders –
Introduction INTRO 02 Page xii
TOC

All MCHD EMS personnel practice under the delegated authority of the Medical Director (MD-1)
and must function within the approved guidelines as written in the MCHD EMS Clinical Policies,
Procedures and Standing Delegated Orders. These documents define the expected pre-hospital
standard of care for MCHD personnel. These protocols apply exclusively to MCHD personnel in
the pre-hospital setting who are working under the medical direction of the MCHD EMS Medical
Director within the established boundaries of Montgomery County Hospital District-EMS or while
responding to calls dispatched by MCHD Communications for MCHD EMS.

The following treatment and procedure protocols are in effect as of this date, April 1, 2008 through
March 31, 2010. Personnel must exercise prudent judgment and treat patients appropriately.
Each employee of the agency is expected to know and understand these protocols up to their
level of authorization and training.

Advanced protocols may be extended to an attendant partner, EMS student, and First
Responders on occasions deemed appropriate and under the direct supervision of the protocoled
Paramedic.

Jay Lance Kovar, MD

Medical Director
Montgomery Country Hospital District-EMS

Revision Date 01/26/2009 xii

 Montgomery County Hospital District-EMS STANDARD OF CARE
STATEMENT
Standard Delegated Orders –
Introduction INTRO 03 Page xiii
TOC

The public expects a certain level of knowledge and skill from MCHD personnel. Clinical
competence and high standards are vital components in providing quality pre-hospital
emergency medical care to the customers who rely on our service. The general treatment
protocols are in this section of the manual. They represent the level of patient care that is to be
provided whenever there is a request for service. The specific orders for each patient are found
in the Standing Delegated Orders (SDO‘s). The general guidelines discuss treatment and
patient philosophies. MCHD embraces as fundamental components of its standard of care the
following concepts:

The emergent patient benefits from early medical interventions, especially the
early and aggressive application of airway establishment and maintenance, early
administration of oxygen, early protection of the cervical spine and early initiation of
definitive therapies.

The patient defines the emergency. As EMS personnel, you are often called upon
to assist with social or psychological problems therefore you should respond as
professionally and thoroughly to these as you do for medical or trauma patients. When
possible and appropriate, pre-hospital personnel should follow the desires and wishes
of patients and their families. MCHD EMS personnel should be expected to conduct
themselves in a professional manner and treat all patients with dignity and respect.
Our patients‘ medical information should be treated in a confidential manner

Your role as EMS personnel is to truly act as the eyes, ears and hands of the
physician. To successfully do so requires that we educate ourselves beyond first aid
procedures and dedicate ourselves to becoming an integral part of the total health
care team. MCHD EMS personnel are expected to use their knowledge, training,
judgment and expertise in pre-hospital care when caring for patients under these
standing orders.

MCHD EMS personnel‘s first priority in the field should be safety for themselves, patients and
the public. This includes the use of appropriate personal protective equipment. Patients with the
most severe, or life threatening, injuries or illness should be treated first, except in the event of a
multiple patient scene/mass casualty incident where the field resources are overwhelmed. Every
patient contact begins with the ABCs and/or CPR as appropriate. Once adequate life support is
established EMS personnel should perform the primary and secondary survey to determine and
then treat illness or injury.

Standard of Care is dynamic, changing and improving on a regular basis. It is not possible to
produce a written document: that addresses every clinical situation or that is perpetually up to
date. It is therefore necessary for MCHD EMS personnel to continuously update their own
knowledge and, at times, to rely upon clinical judgment not discussed in written policy.
Compassion for the patient tempered by intellectual honesty should direct MCHD EMS
personnel when applying these protocols to patient care.

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 Montgomery County Hospital District-EMS STANDARD DELEGATED
ORDERS AND PROTOCOLS
Standard Delegated Orders –
Clinical Guidelines INTRO 4 Page xiv
TOC

This Manual sets forth Standard Operating Procedures, Policies, and Protocols deemed by
MCHD EMS to be within the acceptable standard of medical care and are the only ones to be
utilized by MCHD personnel. It is specifically recognized that there are acceptable variations from
these procedures and protocols, which may also satisfy the standard of care. Therefore,
variations from these procedures and protocols are not necessarily deemed to be outside the
standard of care.

These are diagnostic-based protocols; meaning that the paramedic should arrive at a working
differential of what the main problem is with the patient and then select the protocol which best
matches that primary differential. Should a patient fall under a given protocol based upon the
paramedic‘s differential, but not fit the criteria and history requirements to activate the standing
orders, EMS personnel shall initiate the most appropriate treatment for the most emergent clinical
problem within their respective scope of practice. Personnel should consult with the on-duty
Supervisor ASAP for any additional assistance or support.

Each patient may be treated with one protocol (for one differential) or with multiple protocols
simultaneously (if the paramedic finds more than one concurrent illness or injury). Should a
paramedic who is treating a patient with more than one simultaneous protocol be faced with
choosing among medications or therapies within those protocols that conflict with one another, the
following guidelines are to be used to determine which therapy shall prevail:

1. Treat the problem that is more life threatening first. Evaluate the problem against the
―ABC‘s‖ and intervene in the one(s) that affect the airway first, then the one(s) that affect
breathing and last the one(s) that affect circulation. For example, if you have a patient
who is suffering from cardiac ischemia and pulmonary edema, treat the pulmonary edema
(―B‖) first then the cardiac ischemia (―C‖).

2. If the above test does not resolve the conflict, treat the problem that is more underlying
first. For example, if assessment of the present history indicates that hypertensive crisis
caused pulmonary edema, then treat the hypertension first.

3. If a dysrhythmia is to be treated, do so in the following order:

First: Treat heart rate
Second: Treat rhythm
Third: Treat B/P.
Note: If hypotension and dysrhythmias are believed to be secondary to low intravascular
volume, IV fluid infusion may be used first.

When a patient changes from one algorithm to another algorithm, do not administer more than the
maximum total dose of a medication.

EKG Monitoring may be initiated and vascular access may be obtained in any patient at the
discretion of the Paramedic. Oxygen may be administered to any patient at any time, but should
be administered to maintain a saturation by pulse oximeter of 95% or greater. In addition to those
therapies expressly listed in the SDOs, the following medications are available for use on standing
order in any cardiac arrest situation where there is evidence that they are indicated:
Narcan, D25% or D50%, Thiamine

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 Montgomery County Hospital District-EMS STANDARD DELEGATED
ORDERS AND PROTOCOLS
Standard Delegated Orders –
Clinical Guidelines INTRO 4 Page xv
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Categorization of SDOs:

The treatment protocols have been divided into groups for ease of utilization. The categories have
been indexed such that any future change in a particular protocol may be performed without
difficulty. The format developed facilitates organization and rapid access to the correct protocol for
a given situation. The treatment categories are the following:

Clinical Guidelines
Adult Behavioral Emergencies Pedi Behavioral Emergencies
Adult Cardiac Emergencies Pedi Cardiac Emergencies
Adult Environmental Emergencies Pedi Environmental Emergencies
Adult Medical Emergencies Pedi Medical Emergencies
Adult Respiratory Emergencies Pedi Respiratory Emergencies
Adult Trauma Pedi Trauma
OB / GYN Emergencies
Procedures
Medication Reference

Structure of Individual Standing Orders:

The outline format of the SDOs is strictly for rapid and uniform reference and does not imply or
direct a mandatory sequence for patient care.

Criteria and History Section:

Outlines clinically important parameters that when assessed will assist in the application of
a specific SDO. It provides a list of possible Historical, Physical and/or EKG findings that
may be present if a specific SDO is applied.
Assessment Section:
Lists and emphasizes the assessment parameters, diagnostic tests and/or devices which
should be a primary consideration for the selected SDO. When obtained, the items listed
could be advantageous in making a competent clinical decision regarding a treatment
path.
Primary Interventions Section:
These are considered essential interventions for the specific SDO in non-sequential order.
The interventions in this section represent the ―priorities‖ that should be considered upon
initial patient contact and reconsidered throughout the call. All Interventions in the Primary
Interventions section are considered standing orders, requiring no on-line consultation.
Secondary Interventions Section:
These are considered optional interventions for the specific SDO in non-sequential order.
All optional Interventions in the Secondary Interventions section are considered standing
orders, requiring no on-line consultation.
Consult Section:
Interventions that require online medical authorization prior to application.
The text on the right side of each guideline represents thoughts or actions that should be
constantly evaluated and play a part in the decision making process.

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 Montgomery County Hospital District-EMS STANDARD DELEGATED
ORDERS AND PROTOCOLS
Standard Delegated Orders –
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Treatment and management principles common to the care of every patient are detailed at the
beginning of each section, and are specific for each section. For example, every trauma patient
should initially be assessed and managed the same way, as should every medical patient and
OB/GYN patient. Therefore, each individual SDO addresses the initial assessment and
management by referring to the general assessment and management SDO for that section
instead of listing the same assessment parameters on each SDO.

While no fixed set of rules can span the variety of situations which may be encountered by EMS
personnel, the following SDOs, protocols, policies and procedures are comprehensive guidelines
covering most situations that are routinely encountered. The implementation of a standing order
is at the discretion of the MCHD employee providing care, or the employee with the highest
ranking medical certification. EMS personnel should use the protocol that is most closely
associated with the patient‘s condition.

Once MCHD personnel begin treatment under a particular SDO, the SDO serves as indirect
medical control and should be used as a guideline for patient care until one of the following
situations occurs:
1. The patient’s condition changes:
If the patient‘s condition changes to another treatable rhythm during or after treatment,
refer to that specific SDO, or contact the on-duty Supervisor for a consult for guidance.
Whenever a patient changes from one algorithm to another algorithm, DO NOT administer
more than the maximum total dose of a medication.
2. The next step in the protocol is inappropriate for the patient:
For example, the medic believes that completing the next step in the SDO may cause
harm to the patient such as giving a medication that the patient is allergic to, or potential
side effects from a medication that may worsen the patient‘s condition. In these
circumstances, contact the on-duty Supervisor for consultation.

If a clinical improvement noted after initial interventions, further standing orders may be withheld
based upon the paramedic‘s clinical judgment. Some situations may necessitate the concurrent
use of more than one SDO.

Always treat the problem which poses the greatest risk to life or loss of limb. If undeterminable,
treat the most underlying problem first.

Initiation of patient transport is always encouraged at the earliest possible time in the flow of
patient care. A delay in transport may occur in rare circumstances; however, the delay should be
well justified and only occur when a treatment considered a "critical intervention" cannot/should
not be performed during transport.

Treat to the point of significant relief or appropriate clinical improvement.

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The following words and terms, when used in this Manual, shall have the following meanings,
unless the context clearly states otherwise.

ABANDONMENT: Leaving a patient without medical care once patient contact has been
established, unless emergency medical services (EMS) personnel are following a physician
directive or the patient signs a release; turning the care of a patient over to an individual of less
training when advanced treatment modalities have been initiated to include, but not limited to,
IV‘s, intubation, and drug therapy. TDSHS Rule §157.2 (1)

A/C: Antecubital fossa

ACLS: Advanced Cardiac Life Support

ADVANCED DIRECTIVE: A legal document which defines a patient‘s wishes for initiation or
withholding life saving interventions, up to and including CPR.

ADVANCED LIFE SUPPORT (ALS): Emergency prehospital treatment that involves invasive
medical interventions including but not limited to, the delivery or assisted delivery of medications,
defibrillation, and advanced airway management.

AFIB: Atrial Fibrillation

AHA: American Heart Association

AIR MEDICAL PROVIDER (AMP): Rotor-wing transport service utilized by field crews for
transportation of patients from scene or nearby landing zone to a medical facility.

ALARM: MCHD‘s communications/dispatch center.

APAP: Acetaminophen

ASA: Aspirin

ASPN: Associated Symptoms and Pertinent Negatives

ATTENDANT: An MCHD employee authorized at the attendant level.

AUTOMATIC VENTILATOR: Time-cycled, pressure-controlled devices used to assist ventilations

when an endotracheal tube is in place.

BASIC LIFE SUPPORT (BLS): Emergency prehospital care involving noninvasive medical
interventions. The provision of basic life support may be under the medical direction and/or
supervision and control of a licensed physician.

BP or B/P: Systolic blood pressure

BRADYCARDIA: Heart rate less than 60 beats/minute

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BSA: Body surface area

BVM: Bag valve mask

CABC: C-spine, Airway, Breathing, Circulation

C-SPINE: Cervical spine

CENTRAL LINES: Means any IV catheter device which gains access to a patient‘s central
circulation.

COPD: Chronic Obstructive Pulmonary Disease

CONSENT: Before providing care to a conscious and alert victim, consent should first be
obtained. To obtain consent you should tell the victim who you are, ask the patient if they are
willing to accept your help, inform them what it is that you plan to do to help them, ensure that
they completely understand what you are saying, and then allow the patient to either give or not
give consent.

CPAP: Continuous Positive Airway Pressure

CPR: Cardiopulmonary resuscitation

DELEGATED PRACTICE: Permission given by a licensed physician either in person, by

treatment protocols or by standing, orders to specific prehospital providers authorizing prehospital
medical care.

DEPENDENT LIVIDITY: Venous pooling of blood in dependent body parts causing purple
discoloration of the skin, which does blanch with pressure.

DUTY TO ACT: Most professional rescuers have a duty to act at the scene of an emergency
(especially if you are being paid or working as a first responder etc...). In other words, for the
exception of safety concerns, one should go to the scene of an emergency when on duty.

EJ: External jugular vein

ECG (EKG): Electrocardiogram

EMERGENCY: Any combination of events or circumstances that results in injury or illness

requiring immediate medical care of a person or persons. Any situation declared an emergency by
a licensed physician should be considered to be an emergency by the MCHD EMS. Situations
where there is doubt about whether an emergency exists should be treated as emergencies.

EMERGENCY MEDICAL CALL: Means a medical situation in which an immediate response to a

scene is required to prevent life or limb-threatening medical deterioration of a person requiring
emergency medical treatment.

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EMERGENCY MEDICAL SERVICES: A service with a coordinated arrangement of resources

(including personnel, equipment. and facilities) organized to respond to medical emergencies
and/or an individual‘s perceived need for immediate medical care.

EMERGENCY MEDICAL PERSONNEL: Those individuals certified or licensed by the

Department of State Health Services (DSHS) to provide emergency medical care. EMT-B; EMT-I;
EMT-P; Lic-P.

EMERGENCY MEDICAL TREATMENT: Means those skills, techniques and judgments, as

defined by the Medical Director, which are intended to maintain, improve or prevent deterioration
of a patient medical due to a medical condition. The treatment has also been deemed appropriate
to be delivered by trained personnel at the scene of a medical emergency outside the hospital
and/or during transportation to the hospital.

EMERGENCY SERVICES: Those health care services provided to evaluate and treat medical
conditions of recent onset and severity that would lead a prudent layperson, possessing an
average knowledge of medicine and health, to believe that urgent and/or unscheduled medical
care is required.

ET: Endotracheal

FIRST AVAILABLE: It is the time after arriving at a destination facility that the medic crew is able
to respond to another call.

FIRST RESPONDER: Individuals who are certified as Emergency Care Attendants or higher by
the Department of State Health Services (DSHS) and approved by the MCHD Medical Director to
become first responders for MCHD. Due to their close proximity to emergency scenes, first
responders may administer either basic or advanced life support prior to arrival of an MICU.

FLUID BOLUS: Administration of 250-500 ml of NaCl 0.9% via rapid infusion in and Adult patient
and 20 ml/kg in a pediatric patient.

GCS: Glasgow Coma Scale

GUIDELINES: Information in protocols and/or standard operating procedures that provide

personnel additional information by which to make sound judgments or
determine a course of action to determine a course of action.

HHN: Hand Held Nebulizer

ICE: In Charge Evaluation

ICP: Intracranial pressure

IN CHARGE: An MCHD employee authorized as the lead medic on a crew

IM: Intramuscular

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INTERVENOR PHYSIClAN: A physician licensed by the Texas Medical Board, who without
having established a prior physician/patient relationship with an emergency patient, accepts
responsibility for the prehospital care, and who shall provide proof of a current medical license
when requested.

IN SERVICE: A vehicle is considered in service if it is capable of response, patient transport or

complete patient care.

IO: lntraosseous

IV: Intravenous

IVP: IV Push for administration of medications

J or j: Joule

JVD: Jugular Venous distension

KVO: Keep vein open; same as TKO.

MASS CASUALTY INCIDENT (MCI): Any single occurrence resulting in multiple victims which
taxes an EMS system‘s ability to handle the victims‘ entire emergency prehospital care needs and
maintain adequate protection for the remainder of its service area.

MCHD EMS: Montgomery County Hospital District— Emergency Medical Services

MCHD EMS PERSONNEL: Individuals employed by the MCHD EMS Department are referred to
in these guidelines as MCHD EMS personnel or employees.

MDI: Metered dose inhaler.

MEDICAL CONTROL: Medical Control is a MD or other authorized person who may authorize
specific treatment of the sick and injured.

MEDICAL DIRECTOR: A physician licensed by the Texas Medical Board who is responsible for
all aspects of the operation of an EMS system concerning the provision of medical care. The
Medical Director is that Physician who provides direction and guidance of the EMS system and
who authorizes EMS personnel to perform specific skills.

MOBILE INTENSIVE CARE UNIT (MICU): A vehicle that is designated for transporting sick or
injured individuals, staffed by at least one EMT-Paramedic and another certified individual at or
above the level of EMT-Basic, and meets minimum equipment requirements established for such
vehicles by the TDSHS.

MONA: Morphine, Oxygen, Nitroglycercin, Aspirin

MUTUAL AID: Emergency prehospital care provided in another EMS provider‘s service area at

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the request of the other EMS provider in order to assist that provider in maintaining adequate
EMS protection in its service area. Assistance provided by one provider to another whose
resources are overwhelmed.

NC: Nasal cannula is an oxygen delivery device used at a flow rate of 2-6 LPM.

NEGLIGENCE: If a failure to follow the standard of care or it a failure to act results in someone
being injured or causes further harm to the victim, then there is negligence. For example—failing
to provide care, providing care beyond your level of training, providing inappropriate care, or
failing to control behaviors that could result in injury are all considered negligence.

NKDA: No Known Drug Allergies

NON-EMERGENCY: Means a situation in which an immediate response to a scene, hospital,

health care facility or other place is not required to prevent life or limb-threatening medical
deterioration of a person. May include responses to assist calls for citizens of other agencies.

NPO: Latin for ‖nil per os‖: nothing by mouth.

NRB: Non-rebreather mask with oxygen at 10-15 LPM or enough to maintain adequate reservoir
bag inflation.

NS: Normal Saline

NTG: Nitroglycerin

N/V: Nausea / vomiting

OFF-LINE MEDICAL CONTROL: Delegated practice through the use of the SDO‘s, Protocols
and Policies and procedures.

ON-LINE MEDICAL CONTROL: Direct communication via either in person, or through the use of
a phone line, radio, or other form of telecommunication.

OOH-DNR: Out of hospital do not resuscitate order

OPQRST: An acronym used to help in the description of pain. O-onset of symptoms; P-

provocation; Q-Quality; R-radiation; S-severity; T-time

OUT OF SERVICE: A vehicle is considered out of service if it is incapable of response, patient

transport or providing patient care.

PATIENT CONTACT: The point when initial contact is made between the EMS provider and the
patient.

PEDIATRIC PATIENT: Patient < 45 kg in weight

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PEEP: Positive end expiratory pressure

PMS: Pulse, Motor, Sensation assessment parameters

PPV: Positive Pressure Ventilation device such as: mouth-to-mask ventilation with oxygen, two-
person bag valve-mask technique with oxygen

PR: Per rectum

PRE-HOSPITAL CARE: Care provided to the sick or injured by EMS personnel in an out-of-
hospital environment.

PRE-HOSPITAL PROVIDERS: All TDSHS certified or licensed personnel providing medical care
in an out-of-hospital environment.

PRN: As needed

PROTOCOLS: Written instructions providing pre-hospital personnel with a standardized

approach to commonly encountered problems in the out-of-hospital setting, typically in regard to
patient care. Protocols may include standing orders to be implemented prior to, or in lieu of,
establishing communication with direct medical control.

q: Every

REFUSAL OF CARE: Every conscious and alert person has the right to refuse medical
treatment. If we treat patients without their consent, this could be interpreted by the patient as
battery. (*Note: Patient should be at least 18 years old or legal adult to give consent. Minors
CANNOT refuse treatment)

ROSC: Return of spontaneous circulation

ROSR: Return of spontaneous respiration

SALINE LOCK: Intravenous access device which allows venous access without the use of IV
tubing or continuous fluids.

SAMPLE: An acronym used to gather patient history during an event. S-signs/symptoms; A-

allergies; M-medications; P-prior history or pertinent past medical history; L-last oral intake; E-
events leading up to the incident

SECOND AVAILABLE: A vehicle and its crew are considered second-available when they are
capable of taking a response, transporting a patient and providing patient care.

SL: Sublingual

S/S: Signs and symptoms

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STANDARD OF CARE: Care equivalent to what any reasonable, prudent person, of like
certification or license level would have performed in a similar situation based on local or
regionally adopted standard emergency medical services curricula.

STANDING DELEGATED ORDERS (SDO’S): Standing Orders are protocols which allow certain
procedures to be carried out by properly certified personnel under certain defined circumstances
before requesting a Supervisor consult for on-line medical direction.

STANDARD OPERATING PROCEDURES (SOP): Standard Operating Procedures are those

methods of operation which provide a consistent form of day to day operation. Standard
Operating Procedures include protocols, special protocols, guidelines, and standing orders and
establish the organizations Standard of Care.

SQ: Subcutaneous Injection

SUPERVISOR CONSULT: Term used to describe On-Line Medical control via MCHD EMS
Supervisory Personnel for the purpose of requesting additional treatment options

TACHYCARDIA: A heart rate > 100 beats/minute

TBSA: Total body surface area

TCA: Tricyclic antidepressant

TCP: Transcutaneous pacing

TC UNIT: Transfer care units. Specifically assigned crews and ambulances whose primary task
is to transfer non-emergency patients.

TDSHS: Texas Department of State Health Services

TRAUMA CENTER: A Hospital who has been specially designated for the care of trauma
patients.

VAGAL MANEUVERS: Having the patient cough, or holding their breath while bearing down in
an attempt to slow their heart rate.

VITAL SIGNS (V/S or VS): A term to indicate taking a patient‘s blood pressure, pulse, respiratory
rate and pulse oximetry.

VOLUNTEER: An individual who provides services without expecting or receiving money, goods,
or services in return for providing those services, except for reimbursement for expenses
necessarily incurred in providing those services.

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The following procedures, therapies, and medications are authorized above and beyond
those noted in a specific protocol for use at the EMS provider‘s discretion.
Thiamine
Thiamine may be administered to any adult patient any adult patient when the provider has
any reason to suspect malnutrition. Thiamine should be given as 50 mg IM and 50 mg
IV/IO. If an IV cannot be established, the provider may administer the entire 100 mg IM.
Thiamine should be given prior to the initial administration of Dextrose administration.
Dextrose
Dextrose may be administered to any patient whose blood glucose determination is < 80
mg/dl. In the hypoglycemic patient with an intact gag reflex when an IV cannot be
establised, dextrose may be given orally as a glucose paste. A patient patient refusal
should not be accepted from any patient whose blood glucose level is < 80 mg/dl without
consult.
Vascular Access
Unless specifically limited or prohibited by a particular protocol, advanced EMS personnel
(EMT-Intermediates, EMT-Paramedics), may obtain vascular access on any patient at their
descretion. EMT-Basics may attend patients from inter-facility transports with a pre-existing
saline lock, as long as there is absolutely no fluid or medications being administered to the
patient through the saline lock.
Oxygen
Oxygen may be administered to any patient. It should be administered to every patient who
demonstrates hypoxemia by clinical presentaion and/or pulse oximetry <95% SaO2.
Endotracheal Intubation
Advanced EMS personnel may secure the airway of any patient they believe is at risk for
airway compromise or who requires positive pressure ventilation. The airway may be
secured with endotracheal intubation, so long as the patient does not have any
contraindications to this procedure. Endotracheal intubation may be by oral or nasal route
based on clinical indications and contraindications. Pharmacologocially Assisted Intubation
and/or surgical airways require consultation and approval prior to application.

Medications may be given via the endotracheal tube if:

a. Vascular access is delayed and intubation is accomplished
b. Auscultation reveals clear lung fields
c. Medications given via the ET tube for the adult require higher doses and
dilution, and are very susceptible to bronchial/alveolar infiltrates and alveolar
wall disturbances.
d. The "bolus" dose of any adult medication given via ET is to be doubled from
the standard IV dose.
e. Medications which may be given via ET are:
i. Naloxone
ii. Atropine
iii. Epinephrine
iv. Lidocaine

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f. These medications should be instilled through a catheter passed beyond the

tip of the Endotracheal Tube, and followed by several positive pressure
ventilation‘s via a bag-valve device attached to the Endotracheal Tube.

Acetaminophen
May be administered PO or PR to any febrile patient (without contraindications) as 975 mg
for adult and as per dosing chart for pediatric patients.

General Pediatric Therapies

The number of encounters with children is far less than with adults. These protocols
therefore address situations where advanced procedures in the field can directly affect a
child's survival.
Control of the airway and rapid transport are the underlying principles of the pediatric
protocols and best serve the needs of the pediatric patient.
1. Airway and Ventilation
A Airway management by mouth-to-mouth-and-nose, mouth-to mask, or bag-valve-
mask ventilation should be used in neonates, infants, and children as a first
maneuver for providing assisted ventilation.
B Remember that the correct position to maintain the optimal airway is age-dependent.
In pediatric patients with suspected trauma, the airway maneuver of choice is a
modified jaw thrust combined with cervical spine stabilization.
C Oxygen should always be provided at high concentration in the pediatric patient and
should be humidified when feasible. There are no contraindications to high
concentration oxygen in the pre-hospital setting for the pediatric patient.
2. Intubation
A When noted in the protocols, or when other maneuvers used to ventilate the pediatric
patient are inadequate, Endotracheal Intubation should be attempted.
B Children suspected of having croup/epiglottitis might experience life threatening
laryngeal spasms and close off their airways exercise extreme caution during
attempts to intubation.
3. Intravenous, Saline Lock or Intraosseous Access
There should limited number of attempts for each method in obtaining access to
pediatric patients. Intravenous attempts should always precede IO access.
4. Pediatric Drug Dosage and Fluid Administration
A For drug dosage and fluid administration, refer to both the Broselow Tape and the
Pediatric Appendix.
B When the patient is intubated and vascular access is not acheived, Lidocaine,,
Epinephrine, Atropine, and Naloxone may be administered via the Endotracheal
Tube. The initial dose of these medications via the Endotracheal Tube is the same
as the IV/IO dose. These medications should be diluted to 3-5 ml total drug volume
with Normal Saline (0.9% NS), instilled through a catheter passed beyond the tip of
the Endotracheal Tube, and followed by several positive pressure ventilation‘s via a
bag-valve device attached to the Endotracheal Tube.
C Initial fluid bolus administration should not exceed 20 ml/kg.

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1. Vital Signs
A A complete set of vital signs should be obtained on all patients assessed,
INCLUDING children and infants, within five (5) minutes of patient contact
unless patient condition does not allow.
B Patients refusing treatment / transport should have one complete set of V/S
taken and charted, if the patient allows.
C Patients transported to a hospital should have a minimum of two complete sets of
V/S obtained and recorded. For patient contact and/or transport times shorter
than 15 minutes in duration, it is acceptable to use vital signs obtained upon
triage at receiving facility.
D ―Stable" patients with non life-or limb-threatening problems shouldhave VS
repeated every 15min.
E ―Urgent‖ to ―critical‖ patients should have V/S taken and documented every 5
min.
a) Patients who are being transferred (Non-Emergency) should have at least
one set of V/S taken. If the initial V/S are out of normal limits, then a second
set should be taken.
b) A complete set vital signs (V/S) are defined as:
Respiratory Rate
Pulse and Heart Rate
The term "heart rate" refers most correctly to the rate of electrical
depolarization (usually ventricular) noted on the ECG monitor. ―Pulse
rate" refers to the palpable rate of perfusion noted at a pulse point or
displayed by the pulse oximeter. While in most patients these are
identical values, this is not always the case. When reporting the rate on
the ECG monitor, use the term ―heart rate." Crews should be certain that
this rate correlates with the perfusing or palpable pulse rate.

Special Allowance: In the critical patient where time is a factor, the EMS
personnel may use palpable pulses to estimate and document blood
pressure. The acceptable values are as follows:
Palpable radial pulse: Systolic of 80 mm/Hg
Palpable brachial pulse: Systolic of 70 mm/Hg
Palpable carotid pulse: Systolic of 60 mm/Hg
Capillary Refill
Capillary Refill may be used as an adjunct to blood pressure in assessing
the perfusion status of any patient.
Capillary refill may be substituted for blood pressure in the infant < 1 year
of age. Capillary refill is not an acceptable substitute for B/P in the patient
> 1 year of age.
Blood Pressure
The accuracy of an obtained blood pressure is influenced by many
factors, such as the size of the cuff used. A cuff too small for the arm will
yield an elevated blood pressure, while one too large will result in a lower

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than normal reading. The cuff should easily go around the patient‘s upper
arm, but the air bladder should not overlap itself. The cuff itself should be
2/3 the length of the patient's upper arm.

A systolic B/P (palpated B/P) is acceptable ONLY:

As an additional vital sign in the non-urgent patient in whom an
auscultated B/P has already been obtained and was within normal
limits.
In the critical trauma patient in whom serial palpated B/P's are being
obtained.
In the patient in whom an auscultated B/P absolutely can not be
obtained.
2. Blood Glucose
A Blood glucose should be assessed on all patients with altered mental status. This
includes patients who experience a seizure or a syncopal episode.
B A blood glucose measurement may be performed on any patient at the discretion
of the EMS personnel.
C Those patients with altered mental status which appears to be secondary to
trauma should also have their blood glucose assessed IF such assessment will
not delay definitive interventions, such as airway management, cervical spine
immobilization, hemorrhage control, transport, or vascular access.
D A patient refusal may not be accepted from any patient whose blood glucose
level is not at least 80 mg/dl. A Medical Consult is required prior to refusing
anyone with a blood glucose of < 80 mg/dI.
E Blood glucose should be assessed on all patients 1 year of age or less in
distress, regardless of findings or complaints. The only exception would be the
pediatric patient who is suspected of having epiglotitis.
F After administering D50%, the blood glucose value will remain elevated for quite
some time as the cells attempt to uptake the glucose. Therefore, blood glucose
measurements taken shortly after the administration of dextrose may not reflect
improvement of the intracellular hypoglycemia. If a repeat blood glucose
measurement is used, wait at least 10 min after D50% administration.
G The patient‘s clinical status as well as serial blood glucose measurements should
be used to determine whether to administer additional dextrose.
3. Temperature
A Temperature should be assessed on the following:
B Pediatric seizure patients
C Patients with suspected diagnosis of sepsis
D Patients whose complaints or findings indicate febrile activity
E Patients whose findings indicate hypothermic or a other hyperthermic states
(Heat Stroke)
F Drowning patients who present in cardiopulmonary arrest.
a) Temperatures should be taken orally in patients who are capable of holding
the thermometer correctly. Temperature should be taken rectally in all other

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patients.
b) Neither a rectal or oral temperatures represent true "core" temperature. For
our purposes, a tympanic (or, secondarily, a rectal) temperature is used to
guide cooling in conjunction with the patient's clinical response.
c) Axillary temperatures are not acceptable.
d) When reporting or documenting a temperature value, indicate the source
(oral, rectal, temporal, or tympanic).
4. ECG Monitoring
A The patients ECG should be assessed with in 5 min if patient condition allows.
B Record a strip of ECG of at least 12 seconds duration.
C Record any changes in rhythm or any significant changes in rate.
D Record "pre" and "post" ECG strips before and after any intervention that should
affect the cardiac rhythm or rate (meds, electrical therapy, etc.)
E 12 LEAD
a) 12-Lead ECG should be assessed on any patient who is experiencing cardiac
related signs and symptoms.
b) 12-Lead ECG should be obtained prior to a 3 lead ECG on any patient who is
experiencing cardiac related signs and symptoms.
c) If possible, a 12-Lead ECG should be obtained prior to any treatment (O2,
NTG, ASA) on patients experiencing cardiac related signs and symptoms.
F 3 LEAD
a) A 3 lead ECG should be assessed on all patients with complaints or
presentation of any of the following:
Chest pain (or other possible myocardial ischemia pain)
Shortness of breath and/or dyspnea
Syncope
Dizziness
Nausea / vomiting
Hypotension/hypertension
Tachycardia, bradycardia, and/or irregular heart beat
Altered mental status
5. Pulse Oximetry
A Pulse Oximetry should be used to evaluate the oxygen saturation status of all
patients in whom hypoxia or ischemia is suspected.
B Pulse oximetry may be used to titrate oxygen delivery, and permits the EMS
personnel to utilize delivery devices or flow rates that are most appropriate for
patient condition.
C Oxygen should be administered as necessary to maintain a SaO2 equal to or >
95%.
Special Allowance: While this may be our goal, it should be noted that
patients with significant COPD history may not be able to achieve SaO2 of
95%.
D Pulse Oximetry readings are accurate only if the probe is able to "see" the
arterial blood flow. The patient is well perfused.

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a) The probe should be firmly attached to a clean finger or toe. Nail polish may
occlude the probe's light beam, so unpolished nails are preferred.
b) Hypotensive, hypoperfused, or peripherally vasoconstricted patients are
generally not good candidates for pulse oximetry. (pulseless or cold
extremities)
c) The heart rate from the pulse oximeter matches the patient's palpable pulse
rate.

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1. Medications may only be given:

a. By an approved MCHD EMS Intermediate or Paramedic.
b. When administered according to MCHD EMS protocol or by specific written
orders.
c. By direct order via a medical consult
2. Medications and IV fluids should be checked prior to administration to the patient to
ensure that they are not expired and that they are clear and free of any
contaminants.
3. All patients SHOULD be asked for their allergies to medications prior to any
medication administration.
4. The crewmember requesting and receiving orders are responsible for confirming the
orders.
5. If, at any time, an order is unclear, ask for clarification.
6. When more than one IV bag is infused in a patient prior to the arrival at the receiving
hospital, IV bags should be labeled to indicate the bag number currently being
infused.
7. Any bag which has medications added shall be clearly labeled with the name of the
drug, the quantity added, the time when the bag was hung, and the initials of the
person preparing the bag for infusion.
8. The In-Charge is responsible for keeping all medications current and up to date as
well as, control of the controlled substance box. (Refer to Transfer Care (TC) /
Special Event Unit Authorization)
9. When any medications are administered, they should be documented on the patient
care report.

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 Montgomery County Hospital District-EMS PROTOCOL DEVIATIONS
Standard Delegated Orders –
Clinical Guidelines CG 04 Page 8
TOC

This policy manual is an overview and summary of MCHD policies and procedures that are
currently in effect. As policies and procedures for the Clinical Department are revised,
changes shouldbe communicated to employees through standard communication channels.

It is difficult to cover all situations that may arise and challenge operations personnel in their
efforts to provide timely, compassionate and quality patient care to residents and visitors of
Montgomery County. Therefore, the policies and procedures contained in this manual
constitute guidelines only. Any significant clinical issues should be considered on a case-by-
case basis and should take into consideration any and all extenuating circumstances
surrounding the event.

In the interest of patient care should any deviation of SDO be preformed, employees shall
complete an Unusual Occurrence Form and forward it to the Clinical Department for review
with the Medical Director. The Medical Director for MCHD EMS is the final authority for
all clinical and patient care issues.

Revision Date 11/10/2005 8

 Montgomery County Hospital District-EMS SUPERVISOR NOTIFICATION
Standard Delegated Orders –
Clinical Guidelines CG 05 Page 9
TOC

MANDATORY SUPERVISOR NOTIFICATION

System certified providers operating within the MCHD EMS System do so under the
authority of the Medical Director. As such, any incident which potentially has an adverse
or negative impact on the patient or system should be immediately reported to the on
duty Supervisor as soon as practical after the completion of the call so that an
investigation may be initiated if warranted.

Supervisor notification should include, but not be limited to the following:

Cardiac and/or respiratory arrest occurring after administration of a controlled
substance.
Cardiac arrest occurring after administration of a paralytic agent.
Cardiac arrest occurring after administration of an antiarrhythmic agent in a
previously stable patient.
Any adverse affect after administration of a thrombolytic agent.
Any attempt (successful or unsuccessful) at needle and/or surgical airways.
Incorrect medication administration or use (i.e., excessive amount, wrong dose,
route, etc).
Any time the Patient Safety Restraint and/or Patient Safety Sedation procedures
are utilized.
Any cardiac and/or respiratory arrest or patient injury while attempting physical
restraint.
Any unusual circumstance or intervention that potentially causes or caused
patient harm.
A provider has operated outside of his/her level of certification, training, and/or
level of authorization (i.e., state certified Paramedic, who is authorized by the
Medical Director at the EMT-B level, initiating an IV or performing endotracheal
intubation).
Any potential employee exposure

If any of the the above incidents occur, the Supervisor is responsible for contacting the
Assistant Director EMS - Clinical Services appropriately.

Revision Date 11/10/2005 9

 Montgomery County Hospital District-EMS PATIENT STATUS
Standard Delegated Orders –
Clinical Guidelines CG 06 Page 10
TOC

Patient status updates allow for the prioritization of the patient's clinical status. When
crews update the patient status it signifies that the crew has recognized the urgency of
their patient. Additionally, it allows supervisory, and alarm personnel, as well as,
receiving facilities to react accordingly.

1. Priority 1 (Critical)
A Critically ill or injured patient (immediately life-threatening illness or injury) needing
immediate intervention.
B Examples might include:
a) Cardiac arrest or post cardiac arrest
b) Head injury with GCS < 8
c) Penetrating trauma to head, neck, chest, or abdomen.
2. Priority 2 (Urgent)
A Potentially life-threatening illness or injury.
B Examples might include:
a) GCS 8 -12
b) Altered level of consciousness
c) Status epilepticus
d) Unresponsive patient
e) Unstable vital signs and/or clinical signs of shock
3. Priority 3 (Stable)
A Non-urgent condition which may require medical attention, but not immediate
treatment.
B Examples might include:
a) GCS 15
b) Stable vital signs
c) Minor Injuries
d) "Hemodynamically stable chest pain with no evidence of ischemia"

Revision Date 11/10/2005 10

 Montgomery County Hospital District-EMS RADIO REPORT AND CONSULT
GUIDELINES
Standard Delegated Orders –
Clinical Guidelines CG 07 Page 11
TOC

The following format should be used when contacting a Supervisor to receive patient
care orders.

1. Badge Number
2. Transport time to facility
3. What orders you are asking for, i.e. c-spine clearance, pain management or any
other below –the –line treatment options (Be specific on type of pain
management wanted).
4. If requesting orders for PAI include Mallampati score.
5. Age of patient
6. Level of Consciousness and GCS.
7. Chief Complaint
8. Pertinent past medical history (specific to patient‘s chief complaint now)
9. Vital Signs including a Blood Glucose Level and ECG rhythm interpretation
10. Treatment administered by EMS

In the event that a consult is required and the EMS provider is unable to make contact
with the Supervisor or receiving facility, the provider should complete an Unusual
Occurrence form and forward it to the Clinical Department for review with the Medical
Director. The Medical Director for MCHD EMS is the final authority for all clinical and
patient care issues.

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 Montgomery County Hospital District-EMS COMMUNICATIONS FAILURE
Standard Delegated Orders –
Clinical Guidelines CG 08 Page 12
TOC

In the event that an EMS unit cannot make contact with the receiving facility or a
Supervisor for specific orders beyond those stated within the intervention section of each
protocol, EMS personnel are required to follow the interventions that are listed in a
particular protocol. Under no circumstances may EMS personnel administer a
drug/narcotic or perform a procedure for which they are not authorized. There are no
exceptions to this policy.

In the interest of patient care should any communications failure occur, employees shall
complete an Unusual Occurrence Form and forward it to the Clinical Department for
review with the Medical Director. The Medical Director for MCHD EMS is the final
authority for all clinical and patient care issues.

Revision Date 11/10/2005 12

 Montgomery County Hospital District-EMS CHAIN OF COMMAND
Standard Delegated Orders –
Clinical Guidelines CG 09 Page 13
TOC

1. Authority
A The In-Charge of the first arriving medic unit is responsible for all patient care
activities and coordination of resources at the scene until that responsibility is
delegated to another In-Charge or assumed by a field Supervisor.
B During MCI‘s and multi-unit responses (> 2 units) the field Supervisor
assumes operational responsibility for coordination of prehospital resources.
At this point incident command procedures are in effect.
2. Management
A The scene of an emergency shall be managed to minimize the risk of further
injury or death to the patient as well to other persons who may be exposed to
the risks as a result of the emergency condition. Priority shall be placed upon
the interests of those persons exposed to the more serious and immediate
risks to life and health.
B Medical management at the scene of a medical emergency includes
a) Medical Evaluation.
b) Medical aspects of extrication and all movement of the patient(s).
c) Medical care
d) Patient destination and transport decisions
C EMS personnel shall not delegate delegate patient care to other EMS
personnel whose scope of practice limits their abilities to treat a patient.
a) Personnel trained in defibrillation may not hand over responsibility for
defibrillation to personnel not trained in defibrillation.
b) ALS Personnel treating a patient requiring ALS intervention, may not
hand over responsibility for the patient to BLS personnel.

Revision Date 11/10/2005 13

 Montgomery County Hospital District-EMS NON-MCHD PERSONNEL ON
SCENE
Standard Delegated Orders –
Clinical Guidelines CG 10 Page 14
TOC

General Information

This policy establishes the guidelines for EMS personnel and identifies the limits
that trained/civilian bystanders may assist during an emergency response.

Certified/Licensed Individuals Wishing to Assist

Individuals who possess valid EMS certification and/or other healthcare license but are
NOT employed by MCHD, may be allowed to assist MCHD EMS personnel in rendering
patient care under the following conditions:
The individual may only participate in patient care under the direct supervision of
MCHD EMS personnel.
Individuals who possess advanced certification should NOT be permitted to
administer invasive treatment UNLESS the Medical Director or Supervisor
specifically approves such treatment. Such treatment should only be approved
during Mass Casualty Incidents (MCI‘s) when MCHD resources are strained.

Non-Certified Bystanders

The use of non-certified bystanders in an emergency situation is not recommended and

should be reserved for instances when their assistance could make a crucial difference
in the outcome of the situation. Common situations in which a non-certified bystander
might assist include but not limited to the following: CPR, manual C-spine stabilization,
and hemorrhage control, etc. It is appropriate to provide PPE to bystanders offering
assistance in patient care activities. Thorough documentation indicating the justification
for such assistance should be documented in the patient care report.

Fire Department/First Responder Personnel

Fire department personnel are responsible for all fire suppression, hazard control and
heavy extrication.

In all rescue and extrication operations, the role of MCHD EMS personnel is to direct
patient care and advise rescue teams on phases of the operation which might
compromise the patient's condition. Unless specifically trained to do so, MCHD EMS
personnel should not direct the technical aspects of patient rescue.

First responder personnel should be utilized in a manner that allows them to practice
their assessment and treatment skills.

Law Enforcement

Law Enforcement is responsible for traffic control, control of disruptive bystanders and
scene security. Law Enforcement personnel with specialized training in First
Response/AED may be utilized in a manner that maximizes their training and best
assists in the positive outcome of the emergency.

Revision Date 11/10/2005 14

 Montgomery County Hospital District-EMS NON-MCHD PERSONNEL ON
SCENE
Standard Delegated Orders –
Clinical Guidelines CG 10 Page 15
TOC

On Scene Physician

Texas State Board of Medical Examiners Rule 197.5 addresses ―On Scene Physician
intervention‖ and shall govern situations involving an on scene physician who offers
assistance in treating patients.

All physicians who are present at the scene of an emergency and who offer assistance
should be treated with professional courtesy. Any physician who offers assistance will
be required to provide proof of identity and credentials before being allowed to provide
patient care on the scene. Below is a summary of the Rules governing Physician on
Scene guidelines.

Patient’s Doctor on Scene

When a patient's private physician is on the scene of an incident and has provided the
appropriate credentials, MCHD EMS personnel should comply with his/her directions
concerning treatment of the patient to the extent that those orders are consistent with
established protocols. On-line medical control should be notified of all on scene
physician contacts wishing to assist.
When a physician elects to accompany his/her patient to the hospital, MCHD
EMS personnel should respect the physician's wishes in the management of the
patient during the entire course of patient care.
When the physician requests that the patient be transported immediately, MCHD
EMS personnel should honor the physician‘s requests with all reasonable haste
after obtaining the patient‘s consent.
It is not appropriate to re-evaluate a patient after the patient has been thoroughly
evaluated by a physician and the physician has made an adequate report
concerning the patient‘s condition to the responding crew prior to transporting the
patient. Additional information concerning the patient should be obtained from
the physician, his/her representative or the patient, if necessary.
If MCHD EMS employees believe that the physician has not properly evaluated
the patient, they should perform an assessment of the patient, provide all
immediately necessary treatment, and move the patient to the ambulance for
further assessment and treatment.
The patient‘s physician may write orders beyond the MCHD EMS standing
delegated orders. Employees shall attempt to carry out the physician‘s orders if
the orders do not extend beyond the employees‘ training, certification, or
capabilities and the employees are in direct contact with the patient.

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 Montgomery County Hospital District-EMS NON-MCHD PERSONNEL ON
SCENE
Standard Delegated Orders –
Clinical Guidelines CG 10 Page 16
TOC

Disagreements with Physician(s) on scene

An employee who disagrees with a patient‘s physician concerning the

management of the patient, or who disagrees with the physician‘s judgment
concerning the use of the EMS system, should NOT express his/her
disagreement to the physician; rather, the employee should discuss the matter
with the on-duty Supervisor.
Advise the physician that all MCHD EMS personnel function under written
standing orders and/or on-line medical direction that have been established by
the MCHD EMS Medical Director.
Advise the physician that he/she may continue to offer assistance by providing
advice to on-scene MCHD EMS personnel or assisting with patient care under
the direction of MCHD EMS current standing delegated orders.
If the physician insists on providing direction outside established guidelines, he or
she should take complete responsibility for the care of the patient, including
accompanying the patient to the hospital. Crew shall document all activities
during transport.
If the physician assumes responsibility for the care of the patient, MCHD EMS
personnel should comply with his/her directions as long as those orders are
consistent with established standing orders.
If the orders proposed by the intervening physician are not consistent with MCHD
standing orders, MCHD EMS personnel shall respectfully decline to participate in
that specific care. In this event, employees shall immediately contact an MCHD
EMS Supervisor.
MCHD EMS personnel should document all events and interaction between an
intervening physician and the crew, including direction given and care provided.

Once direct contact with a physician ends, EMS personnel shall give a progress report to
the receiving Emergency Department and Supervisor by radio or telephone. The
Supervisor may then give additional orders or change previous orders if necessary,
depending on the patient's condition.

Revision Date 11/10/2005 16

 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 17
TOC

General Information

Authorization:

Authorization is separate from certification. Every provider should have a current

certification issued by the Texas Department of State Health (TDSHS). The Medical
Director is responsible for granting authorization.

Authorization is required to provide pre-hospital or out-of-hospital care to any patient

within the MCHD EMS System. Certification level does not necessarily dictate
authorization level. The Medical Director may authorize any provider to function at any
level as per TDSHS Rule 157.11

To Obtain Authorization:

Prior to allowing any provider to function in a patient care delivery role, the applicant
provides the following information:
a. The individual‘s name, date of birth, address, social security number, and home
phone number.
b. The position for which the individual is applying.
c. All applicants should provide a copy of the most current Texas Department of
State Health Services certification/licensure in accordance with the State of
Texas Administrative Code, Title 25, Part I, Chapter 157, Subchapter C, Section
157.33, 157.34, 157.35 or 157.40. -The copy should clearly show the
applicant’s name, certification/licensure number, and expiration date.
d. A copy of a valid drivers license that clearly shows the applicant’s name,
license number and expiration date.
e. All applicants should meet the criteria to be insurable by the current vehicle
insurance vendor contracted to the District.
f. All applicants are required to have a current (less than 2 years) AHA Health
Care Provider CPR OR an equivalent course completion card with legible
signatures and the date of the course.
g. The following certifications are preferred for all applicants or should be obtained
within 6 months of hire or first available class:
Advanced Cardiac Life Support (ACLS) course completion card from the
American Heart Association – for Paramedics only
Basic Trauma Life Support (BTLS) course completion card is
recommended. PHTLS may be substituted – for Paramedics and
recommended for Basic and Intermediates
Pediatric Advanced Life Support (PALS) or an approved equivalent
pediatric course is recommended – for Paramedics only

All initial applicants for employment as pre-hospital care providers with MCHD EMS
will be required to successfully complete a written general knowledge examination from
an approved test bank with an overall score of at least 80% , skills evaluation as per the
Medical Director, interview process, and physical agility/health screening. Additionally,

Revision Date 11/10/2005 17

 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 18
TOC

the applicant will be subject to a background check and verification of insurability with
the contracted vehicle insurance provider. The applicant should be successful at each
phase before moving on to the next phase.

The Skills Evaluation will be scenario-based evaluations with specific skills as per the
Medical Director interjected at key points (i.e. an EMTP skill evaluation might be based
on an AHA-ACLS scenario with skill evaluations for ET Intubation, Defibrillation, Pacing,
or IV establishment).

Medical Authorization will be granted to an employee only after a probationary period in

which the individual‘s assessment, decision making, and treatment skills are evaluated.

The Assistant Director EMS-Clinical Services shall establish a training and evaluation
program for granting medical authorization.

The Medical Director maintains authority over all employees‘ ability to use medical skills.
Therefore, the Medical Director or his designee may deny an employee the right to use
his or her medical skills at any time during the course of employment with MCHD EMS.

The Medical Director or his/her designee may:

Require an employee to undergo counseling;

Require an employee to submit to remediation, including but are not limited to
Retraining, Testing, or Field/hospital preceptorship
Place an employee on medical authorization probation
Reauthorize an employee at another level
Deauthorize an employee,
Recommend to the Texas Department of State Health Services that the
employee be decertified.

To Maintain Authorization:

1. The employee should retain his certification/licensure with TDSHS. If, for any
reason, there is a lapse in certification, the employee will be suspended
immediately. Operations will be notified. The employee may not return to work in a
patient care role until the problem has been rectified. The employee should show
proof that TDSHS has reinstated the EMT certification/license. If any employee
allows his/her certification to expire or be revoked more than once during
employment, he/she will be de-authorized immediately.

2. The employee should maintain all of his/her card courses in current standing. If a
card lapses, the employee will have thirty (30) days to replace that card. After the
thirty (30) day period, the employee may be reauthorized to a lower level of practice
and the Assistant Director EMS-Operations will be notified.

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 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 19
TOC

3. The employee should participate in Continuing Education (CE) in accordance with

the State of Texas Administrative Code, Title 25, Part I, Chapter 157, Subchapter C,
Section 157.38 and in accordance with the defined policies of MCHD EMS.

4. Attend all mandatory MCHD CE offerings.

5. If at any time the employee loses their EMS certification, driver‘s license, or is a part
of an incident that might impact their insurability, the employee shall immediately
notify their immediate Supervisor or Assistant Director EMS-Clinical Services. The
employee may be removed from active duty pending a review of the situation.

6. If at any time the employee is under investigation by a law enforcement agency or

the Texas Department of State Health Services, the EMS Director or designee willd
be notified immediately. The EMS Director shall determine the seriousness of the
allegations as it relates to the individual's function as an employee. The employee
may be removed from active duty pending a review of the situation.

7. No employee will function in an official capacity if they have any physical or mental
impairment or disease which could reasonably be expected to either impair their
ability to function or jeopardize the health and safety of the patient or public or fellow
employees. If such a condition exists, the employee should immediately inform the
On Duty Supervisor or higher authority.

AUTHORIZED INTERVENTIONS BY LEVEL

The following represents patient care activities to be performed by EMS personnel at

their current level of authorization. All BLS activities are authorized on standing orders to
be used as needed. Authorization for ALS activities is indicated in the specific protocol or
procedure for each intervention. All interventions listed below indicated with a (*) require
individual training and authorization by the medical director or his/her designee.

Emergency Care Attendant (Basic Life Support)

Patient assessment
Pulse oximetry
Oxygen administration
Use of oral adjuncts including oral and nasal airways, bag-valve mask device and
oral suctioning.
Provision of CPR as defined by the American Heart Association
Vital signs
Bandaging and splinting including traction splinting
Cervical spine immobilization
Manual techniques for airway provision, maintenance and support, relief of
airway obstruction as prescribed by AHA
Control of external hemorrhage
Use of automatic CPR device* (Thumper)
Automatic external defibrillator*

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 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 20
TOC

Emergency childbirth

Emergency Medical Technician

All skills listed for Emergency Care Attendant
Blood Glucose assessment
Aspirin administration (under direction of In-Charge EMT-P)
Nebulized Metered inhalers(under direction of In-Charge EMT-P)
Administration of oral glucose
Operation of CPAP device / portable ventilator

Special Allowance: If 12-Lead ECG equipment is readily available and patient condition
and time permits, it is appropriate for a properly trained BLS provider to ACQUIRE a
12-Lead ECG on patients (in the presence or at the direction of their In-Charge
Paramedic) treated under the ―Acute Coronary Syndrome‖ SDO.

Emergency Medical Technician-Intermediate

All skills listed for EMT-Basic
Vascular access
Intraosseous infusion
IV Fluid administration
Administration of Nitrous Oxide (under direction of In-Charge EMT-P)
Administration of D50% (under direction of In-Charge EMT-P)
Administration of IV Thiamine (under direction of In-Charge EMT-P)
Administration of IV Narcan (under direction of In-Charge EMT-P)
Orotracheal intubation
Use of Qualitative CO2 Detection *
Use of approved secondary Airway Device (Combitube)*
Use of PEEP
Blood specimen collection
MAST trousers

Personnel authorized at the basic or intermediate level MAY NOT administer any
controlled substance, including Pharmacologically Assisted Intubation (PAI) or
medications that are not specifically approved in the Clinical Policy or the Protocol.

Special Allowance: If 12-Lead ECG equipment is readily available and patient condition
and time permits, it is appropriate for a properly trained ALS provider to ACQUIRE a
12-Lead ECG on patients (in the presence or at the direction of their In-Charge EMT-P)
treated under the ―Acute Coronary Syndrome‖ SDO.

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 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 21
TOC

Emergency Medical Technician-Paramedic

All skills listed above
All routes of medication administration (IV, IO, ET, SQ, SL, PR, IM)
Obtaining and interpreting ECG
Obtaining and interpreting 12-Lead ECG
Vagal maneuvers
Defibrillation / Cardioversion
External Cardiac Pacing
Nebulized bronchodilation
Any other skill as directed by PII

Emergency Medical Technician-Paramedic I or II (In-Charge Paramedic)

All skills listed above
Nasogastric intubation/lavage
External jugular cannulation
Nasotracheal intubation
Chest decompression
Surgical airway (with permission from on-line medical control)*
Pharmacologically Assisted Intubation (with permission from on-line medical
control)
Pericardiocentesis (with permission from on-line medical control)*

Emergency Medical Technician-Paramedic III

All skills listed above
All Therapies within the protocols including extended medical authorization and
other special procedural skills as developed.
Consults while on scene and those related to patients in which PIII contact has
been made (patients assessed by PIII and transported by another unit).

Emergency Medical Technician-Paramedic IV (future level of authorization)

Operations/Clinical Supervisor
All skills listed above
All Therapies within the protocols including extended medical authorization and
other special procedural skills as developed.
On-line medical direction through radio and/or phone consults as requested by
Field staff.

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 Montgomery County Hospital District-EMS MEDICAL AUTHORIZATION
LEVELS
Standard Delegated Orders –
Clinical Guidelines CG 11 Page 22
TOC

EMS Director/Assistant Directors EMS-Clinical Services and Operations

All skills listed above
All Therapies within the protocols including extended medical authorization and
other special procedural skills as developed.
On-line medical direction through radio and/or phone consults as requested by
Field staff.

Attendant level personnel may practice under the supervision of a fully authorized
paramedic to the full extent of their authorization. Clinical authorization is assigned to an
individual, and not the operational position.

Practicing Beyond Your Certification

MCHD EMS personnel who are asked by a physician, nurse, paramedic or other person
to perform procedures that are outside of their level of training, certification, or protocol
should adhere to the following guidelines:

1. Employees should inform the person giving the directive that their training,
certification, and/or protocol does not cover the requested procedure and that
they should respectfully decline to perform the procedure.

2. Employees should document the procedure requested, the name and position of
the person who requested the procedure, and the outcome of the employee‘s
refusal to perform the procedure.

Failure to follow this policy may result in the suspension and/or revocation of an
employee‘s medical authorization.

Employees should not perform any skill that they have not been trained, certified, and
authorized to perform.

Employee – Student Relationship

Employees enrolled in Texas Department of State Health Services (TDSHS) approved

certification courses and assigned to a unit in a student capacity may perform advanced
skills within the scope of the course in which they are enrolled. The skills are to be
performed under the direct supervision of an approved preceptor and/or medical
supervisor. All other rules and regulations regarding student conduct should be
observed.

Employees enrolled in TDSHS approved certification courses should not perform

advanced skills beyond their current certification level while in the course of their normal
job duties.

Revision Date 11/10/2005 22

 Montgomery County Hospital District-EMS PIII AND SQUAD
AUTHORIZATION
Standard Delegated Orders –
Clinical Guidelines CG 12 Page 23
TOC

The Paramedic III position is in place to allow for recognition as well as professional
growth and development for employees who successfully complete this promotional
process. Employees with P-III authorization may perform medical procedures and
administer medications independently and without a Supervisory consult. The Clinical
Department will monitor procedures and treatments performed by individual P-III‘s for
appropriateness as part of the Continuous Quality Improvement Process.

In addition to ―below the line‖ authorization by the Medical Director, P-III‘s working a
Squad unit may consult with field staff on the responding Medic unit WHILE ON SCENE.
Crews are encouraged to utilize the P-III on scene for ―below the line‖ orders to ensure a
smooth transfer of patient care as well as provide additional, appropriate care before
transfer to a medical facility is initiated.

The Medical Director and Assistant Director EMS-Clinical Services have established an
additional level of authorization that allows P-III‘s working on a Squad to provide
consults for a patient they have evaluated and released to a transporting unit. This
authorization is granted after consideration of the following:
Review of responses and treatment provided prior to arrival of transporting unit
Review of treatment/procedure orders provided for staff on the transporting unit
while on scene for appropriateness.
Continued monitoring by the Clinical Department as part of the Continuous
Quality Improvement process

This authorization is in effect ONLY when the authorized individual is working a

Squad unit. P-III’s working or assigned to medic units MAY NOT provide consults for
transporting units in any situation. Clinical and Operations Supervisors, Assistant
Directors EMS-Clinical Services and Operations, the EMS Director and Medical
Director may provide orders for transporting units in any situation.

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 Montgomery County Hospital District-EMS PARAMEDIC I PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 13 Page 24
TOC

This policy establishes guidelines for Attendant Level Paramedics who have successfully
completed the requirements to enter the ICE process and are awaiting final assignment
to a preceptor. It is to be viewed as a provisional in-charge position typically occupied
by an individual for a period of 3 – 6 months and should not to exceed 12 months.

General Information
The purpose of the Paramedic I position is to allow successful ICE candidates to grow
professionally while waiting to complete the In-Charge Evaluation process. These
individuals should have successfully completed each phase of the initial promotional
requirements and have demonstrated Operational and Clinical proficiency as
documented by Field evaluations and testing requirements. Entry into the evaluation
process may be delayed for numerous reasons including but not limited to the following:

The number of employee vacancies in the Operations Division of MCHD may

indefinitely delay assignment to a preceptor
No preceptors are available to evaluate the candidate
The candidate may have personal considerations that delay the evaluation
process

All Paramedic-I candidates completing the promotional requirements will be temporarily

authorized to work at the Paramedic I level and may staff a unit with other employees
within the MCHD organization at the following levels:

Employees authorized at the Paramedic I position

Employees authorized at the Paramedic II position or higher

Under no circumstances will a Paramedic I be allowed to staff an MICU within the 9-1-
1 system with any attendant level employee including EMT-B, EMT-I and EMT-P unless
they are assigned to a transfer unit for a designated shift. While staffing a transfer unit
the Paramedic I should operate within the system under the guidelines already
established by the Assistant Director EMS-Operations.

Once a candidate meets all of these requirements he/she should write a letter to the
Clinical Department that includes:
What skills would you want your ideal P-I to have
What qualities make a good P-I
Why he/she wants to become a P-I
Brief summary of past experiences that might qualify applicants for the position
(may be non-EMS related)
Strengths and weaknesses of the applicant and how they may impact ability to
perform at this level

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 Montgomery County Hospital District-EMS PARAMEDIC I PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 13 Page 25
TOC

When the Clinical Department receives a letter of intent from a P-I candidate the
following should occur:

Verify applicant is in good standing with all MCHD departments

Verify status of DSHS certification on DSHS website
Evaluation of documentation compliance
Verify attendance of all mandatory C.E. Classes
Verification of mandatory card classes as well as number of classes taught
Analyze transport and refusal ratios in relation to peers
Review field and station evaluation scores as documented by supervisors
Review past annual performance evaluations

The following process will be implemented to ensure that each candidate has been
evaluated by a preceptor before receiving Clinical Authorization at the Paramedic I Level
including but not limited to the following:

The Paramedic I candidate is working with a Paramedic II and the preceptor

rides as a third member of the crew to obtain evaluations. In this instance the
Paramedic I candidate should assume the responsibility of patient care for all
responses. The preceptor should be authorized at the Paramedic II level or
higher and is responsible for completing the appropriate evaluation forms that
may include station and truck inspections as well as patient care evaluations.

Two Paramedic I candidates may be assigned to an MICU with a preceptor riding

third for the entire shift. The preceptor should be authorized at the Paramedic II
level or higher and is responsible for completing the appropriate evaluation forms
that may include station and truck inspections as well as patient care. In this
instance the Paramedic I candidates should alternate responsibility for patient
care so evaluations may be obtained on each candidate. When a preceptor is
evaluating two (2) Paramedic I applicants the crew may be evaluated for decision
making as a team as well as individually while providing patient care.

Candidates may be authorized at the Paramedic I level for up to one year at the
discretion of the Medical Director and/or Assistant Director EMS-Clinical Services
if a preceptor identifies areas of improvement for the candidate. During this time
the Paramedic I candidate may have specific goals and tasks to accomplish. At
the end of the recommended time period the candidate may re-enter the formal
ICE process assigned to a preceptor for a final evaluation period. If the candidate
is successful he/she will complete the ICE process and be authorized at the
Paramedic II level with a 90-day probationary period required by policy for all
promotional processes within the MCHD organization. If the candidate is
unsuccessful he/she will be re-authorized at the attendant paramedic level and
cannot re-apply to the Paramedic I or ICE program for one (1) year.

Revision Date 11/10/2005 25

 Montgomery County Hospital District-EMS PARAMEDIC I PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 13 Page 26
TOC

Although the Paramedic I position is not intended to be a permanent assignment there

are other benefits for employees as well as the organization that can be identified
including:

Employees who have successfully completed the required objectives may

request to remain at the Paramedic I level for up to 30-60 days to have an
opportunity to gain additional experience before entering the formal ICE process.
These individuals should have documentation of proficiency from a preceptor at
the Paramedic-II level or higher.

MICU‘s may be staffed with two (2) employees authorized at the Paramedic I
level which allows staff the opportunity to gain additional experience as well as
allowing greater flexibility within the organization for staffing purposes.

It should be noted that all decisions for medical authorization within the organization are
at the discretion of the Medical Director and the Assistant Director EMS-Clinical Services
and may reflect what is in the best interest of the MCHD organization.

Revision Date 11/10/2005 26

 Montgomery County Hospital District-EMS PARAMEDIC II PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 14 Page 27
TOC

The In-Charge Paramedic is an important component of EMS in Montgomery County

and requires a commitment to provide quality care to residents and visitors of the
community. The In-Charge Paramedic is the role model and team leader for other
MCHD employees and first responders, as well as other public safety agencies. Being
an In-Charge Paramedic is not only about providing quality clinical care, but involves
scene management, radio communications, coaching students and partners,
understanding policy and procedure as well as many other non-clinical responsibilities.

The purpose of the In-Charge Evaluation Program is to provide tools and resources for
paramedics within the MCHD EMS system, allowing them an opportunity to develop
professionally as well as personally. Our desire is to provide a program that focuses on
the non-clinical aspects of the in-charge such as leadership abilities, interpersonal
communications and coaching techniques. The clinical aspects of being an In-Charge
Paramedic should be learned and refined while acting as an Attendant Paramedic on the
ambulance. We are fortunate at MCHD to have a Medical Director who allows our In-
Charge Paramedics to delegate authority to attendants. This opportunity allows MCHD
attendants to care for a large variety of patients under the tutelage of an experienced
paramedic. Consequently, it is important that employees seeking authorization at the In-
Charge Paramedic level successfully complete each of the following components before
applying to enter the ICE program.

1. The candidate should have current certification for PALS, BTLS, CPR and ACLS.

2. The candidate should have attended the following mandatory continuing education
classes: Airway management, 12-Lead ECG and the Trauma CE that includes
bilateral chest decompression, Pericardiocentesis, c-spine clearance and trauma
termination. These 3 classes will be made available quarterly for those who were
unable to attend the initial offerings.

3. Internal candidates should have a minimum of six (6) months field experience at the
paramedic attendant level; however a minimum of one (1) year is preferred.

Occasionally, MCHD will have the opportunity to hire experienced paramedics from
outside the organization. It is not the intent of the Clinical Department to prevent
experienced paramedics from entering the program. These applicants will be
reviewed on a case by case basis and should successfully complete the 90-day
probationary period before they will be considered for the program. During the
probationary period they should be given specific goals and objectives to complete
and they should meet all other requirements before entering the program.

Once a candidate meets all of these requirements he/she should submit a current
resume‘ to the Clinical Department.

Revision Date 01/26/2009 27

 Montgomery County Hospital District-EMS PARAMEDIC II PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 14 Page 28
TOC

When the Clinical Department receives a resume‘ from a P-II candidate, the following
should occur:

Verify applicant is in good standing with all MCHD departments

Verify status of DSHS certification on DSHS website
Evaluation of documentation compliance
Verify attendance of all mandatory C.E. Classes
Verification of mandatory card classes as well as number of classes taught
Analyze transport and refusal ratios in relation to peers
Review field and station evaluation scores as documented by supervisors
Review past annual performance evaluations

The candidate will be given written tests that incorporate the Policy & Procedure
manual, general knowledge, current SDO‘s, specific procedures and critical
thinking. The applicant should have a minimum score of 80% in each area to
continue the process. The ICE candidate may take the initial exam a total of two
(2) times and will wait a minimum of thirty (30) days before taking the exam a
second time. If unsuccessful after the second attempt the ICE candidate will not
be eligible to enter the program for a minimum of six (6) months. At the end of
six months it is the decision of the Medical Director and the Assistant Director
EMS-Clinical Services whether or not the candidate may attempt to re-enter the
program.

After successful completion of the written exams, the candidate will complete
scenario testing that incorporates application of SDO‘s, specific procedures as
well as critical thinking skills.

Once the candidate successfully completes each of these components he/she should
enter the program and be assigned a preceptor. This second component of the
evaluation process lasts approximately 4 weeks. (Additional shifts may be recommended
and/or required upon recommendation of the preceptor and/or Assistant Director EMS-
Clinical Services). The Clinical Department should meet regularly with the candidate
and preceptor to provide support and feedback, monitor call volume and types of calls as
well as progress made by the candidate. Upon successful completion of this component,
the candidate should proceed to the final phase of the evaluation process. This
component requires the candidate to assume the lead role on the unit while being
evaluated by a senior in-charge acting as the attendant. This third component lasts
approximately two weeks; however, additional shifts may be recommended/required by
the preceptor or Assistant Director EMS-Clinical Services.

The ICE process is to be viewed as an evaluation period. The candidate should

demonstrate profiency in duties and responsibilities normally associated with In-Charge
position without guidance.

Once successfully completed, the candidate will be released from the ICE program with
the authorization and privileges associated with the In-Charge position. The promotional

Revision Date 01/26/2009 28

 Montgomery County Hospital District-EMS PARAMEDIC II PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 14 Page 29
TOC

date will replace date of hire for annual evaluations and the candidate should complete a
ninety (90) day probation in his new position.

Upon successful completion of the program the applicant should be required to have an
exit interview with members of the Clinical Department. The applicant should be
prepared to provide feedback about his/her preceptor as well as the process they have
just completed.

Note: Candidates MUST pass each phase of the program before continuing. If the
candidate is unable to successfully complete steps 3 or 4 in the process, he/she will wait
90 days before retrying. At the end of 90 days the candidate will be allowed to continue
from the last successfully completed step. However, if the candidate is unable to
complete the requirements the second time, the candidate will wait six (6) months before
re-applying and will be required to repeat the entire process.

Revision Date 01/26/2009 29

 Montgomery County Hospital District-EMS PARAMEDIC III PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 15 Page 30
TOC

Montgomery County Hospital District acknowledges the value of In-Charge Paramedics

who consistently meet or exceed department standards in their daily performance of
patient care as well as performing other duties as asked or assigned. Therefore, a
Paramedic III position has been created to allow for recognition as well as the
professional growth and development of these employees. Requirements for
consideration in this promotional process are as follows:

GED or High School Graduate required, A.A.S. preferred

Current EMT-Paramedic certification required, Licensure preferred verified on
DSHS website
Candidate should be in good standing with the Clinical Department and
Operations
Minimum of 4 years as an In-Charge Paramedic (two (2) years may be as the
lead medic for another 9-1-1 service however two (2) years SHOULD be at
MCHD
ACLS-I Required
BTLS-I Required
PALS-I Required
Texas Department of State Health Services EMS-I preferred
Continual demonstration of exceptional decision making skills, appropriate
patient assessment and development of a patient care plan
Should demonstrate knowledge of MCHD Policies & Procedures and recognize
their importance in decision making
Continual demonstration of Leadership and mentoring skills
Displays ability to work with first responder agencies and other public safety
organizations within Montgomery County
Displays ability to multi-task and delegate tasks appropriately
Should possess good communication skills including, writing and verbal
Should maintain professional appearance and demeanor at all times

Once a candidate meets all of these requirements he/she should write a letter to the
Clinical Department that includes:
What skills would you want your ideal P-III to have
What qualities make a good P-III
Why he/she wants to become a P-III
Brief summary of past experiences that might qualify applicants for the position
(may be non-EMS related)
Strengths and weaknesses of the applicant and how they may impact ability to
perform at this level

Revision Date11/10/2005 30
 Montgomery County Hospital District-EMS PARAMEDIC III PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 15 Page 31
TOC

When the Clinical Department receives a letter of intent from a P-III candidate the
following should occur:
All Applicants should be in good standing with all MCHD departments
Verify status of DSHS certification on DSHS website
Evaluation of documentation compliance
Verfiy attendance of all mandatory C.E. Classes
Evaluation forms will be forwared to First Responder agencies within
Montgomery County for feedback (completed by P-III)
Involvement in community activities
Note: this is solely EMS related. Coachign your child‘s soccer team, participation in
local community activities
Analyze transport and refusal ratios in relation to peers
Review field and station evaluation scores as documented by Supervisors
Review past annual performance evaluations (Manager Only)
Applicants should have two (2) – three P-III‘s assigned to ensure evaluation
forms are completed and returned to the committee in a timely manner

When the evaluations are completed and returned the Paramedic III Committee should
meet to discuss and evaluate information for each applicant. The committee should then
classify the applicants in numerical order. Applicants who have been classified will be
offered the opportunity for the P-III promotional process as positions become available in
numerical order assigned by the Paramedic III committee. These classifications will be
recognized for one (1) year.

After the applicant receives an offer for promotion the following should occur:

A P-III should be assigned to evaluate the applicant. These evaluations may

occur any time the candidate is at work and should include an inspection of the
Medic Unit and/or the station. (Two (2) P-III‘s may be assigned to a candidate to
ensure completion in a timely manner).
During this evaluation the candidate should assume the duties and
responsibilities of a P-III including the performance of any procedures and/or
medications that require a consult. VERBALIZE what treatment and/or procedure
you have determined is appropriate for your patient/s. Your knowledge of the
protocols as well as your thought process are being evaluated.
Your preceptor should also be observing your skills of scene management,
appropriate delegation of treatment and/or procedures when appropriate, as well
as interaction the with the communications center, family members and any non-
MCHD agency on the response.
This process should continue until the preceptor has observed and evaluated the
candidate on several responses with documentation forwarded to the P-III
Committee and Clinical Department. The preceptor should review the outcomes
of the evaluations after each call or when time is available during the shift.

Revision Date11/10/2005 31
 Montgomery County Hospital District-EMS PARAMEDIC III PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 15 Page 32
TOC

Supervisors may assist during your evaluation by performing unit and station
evaluations and observing specific skills performed and forwarding
documentation to the assigned preceptor and the Clinical Department. (The
Supervisor should not inform the applicant that a station and unit inspections will
be performed.)

Upon completion of the evaluation process the applicant may be assigned to work the
Squad and will be evaluated on the following:

Self motivation
Review of equipment and medical supplies unique to the Squad
Knowledge of territory
Ability to key map and respond to a call without assistance from a partner
Communications with Alarm during and after the response
Scene Assessment and Management
Appropriate medical/trauma assessment and treatment performed prior to the
arrival of the medic unit.

(Note) While the organization as a whole strives to allow each individual

employee the flexibility of choosing a schedule or assignment, assignments
may be made or adjusted as required to insure the best interest of the service
are met.

Upon completion of this phase the Paramedic III Committee will schedule an interview
with the candidate. The interview committee should consist of the following members:

Two (2) – three (3)Employees currently authorized by the Medical Director at the
Paramedic III scope of Practice
Assistant Director EMS-Clinical Services
Assistant Director EMS-Operations

Within 7 business days of the interview the candidate should receive written notification
of acceptance into the program or a refusal letter from the Paramedic III Committee.
Candidates who are denied this promotional opportunity will meet with members of the
Paramedic III committee to discuss a strategy plan and the applicant may re-apply in six
(6) months.

Revision Date11/10/2005 32
 Montgomery County Hospital District-EMS PARAMEDIC IV PROMOTIONAL
REQUIREMENTS
Standard Delegated Orders –
Clinical Guidelines CG 16 Page 33
TOC

Under development

Revision Date 11/10/2005 33

 Montgomery County Hospital District-EMS TRANSFER TRUCK / SPECIAL
EVENT AUTHORIZATION
Standard Delegated Orders –
Clinical Guidelines CG 17 Page 34
TOC

Medical Authorization for Attendant Level Paramedics assigned to an MICU for Transfer
Truck, Special Events and/or Standbys

This policy establishes patient care activities for Special Events and/or standbys for
employees currently authorized by the Medical Director as Paramedics and/or EMT-
Intermediates at the attendant level within the MCHD organization.

General Information

All Special Event and/or Standby units should have two- (2) attendant level Paramedics
to be in service. An exception would be an experienced EMT-Intermediate in good
standing with the organization. Approval for an EMT-Intermediate to work a special
event unit with an attendant level Paramedic is at the discretion of the Assistant Director
EMS-Clinical Services or his/her designee. One (1) employee should have a minimum of
six- (6) month‘s employment with MCHD. Optimally, both Attendants should be full time
employees; however, a part-time employee; working the required number of hours to
maintain part-time status and is in good standing in the organization may be approved to
work the special event unit on a case-by-case request. The Supervisors and Alarm
should be notified whenever a Special Event and/or Standby unit is placed in service
with Attendant Level employees as well as the location of the standby.

Controlled Substances should be obtained from the lock boxes outside the Supervisor‘s
office. The employee with the most seniority and/or Paramedic authorization should be
responsible for signing the Controlled Substance sign-in log and maintaining security of
the key.

Units dedicated to any event usually do not transport patients from the site. When the
crew encounters a patient, Alarm should be contacted for a new incident number and, if
the patient requires transport, another unit should be sent to their location.

The following interventions represent patient care that may be performed by Attendant
Level Paramedics assigned to an MICU for Special Events and/or Standbys BEFORE
Supervisor consult.
Patient assessment
Pulse oximetry
Oxygen administration
Use of oral adjuncts including oral and nasal airways, bag-valve mask device and
oral suctioning.
Provision of CPR as defined by the American Heart Association
Vital signs
Bandaging and splinting including traction splinting
Spinal Motion Restriction
Manual techniques for airway provision, maintenance and support, relief of
airway obstruction as prescribed by AHA
Control of external hemorrhage
Use of automatic CPR device* (Thumper)

Revision Date 11/10/2005 34

 Montgomery County Hospital District-EMS TRANSFER TRUCK / SPECIAL
EVENT AUTHORIZATION
Standard Delegated Orders –
Clinical Guidelines CG 17 Page 35
TOC

Automatic external defibrillator*

Emergency childbirth
Blood Glucose assessment
Aspirin administration
NTG administration
Nebulized Metered inhalers
Vascular access
Intraosseous infusion
IV Fluid administration
Administration of Nitrous Oxide
Orotracheal intubation
Use of PEEP
Blood specimen collection
MAST trousers
Versed for Active Seizures, IM/IV/IO
First round of Cardiac Medications via most appropriate route (additional
cardiac medications require consult)
Obtaining and interpreting ECG
Obtaining and interpreting 12-Lead ECG
Vagal maneuvers (Valsalva only)
Defibrillation / Cardioversion
External Cardiac Pacing
Nebulized bronchodilation

The following interventions Require Supervisor Consult

ALL Patient Refusals (each refusal SHOULD have their own incident
number)
Additional Cardiac Medications
Nasogastric intubation/lavage
External jugular cannulation
Nasotracheal intubation
Chest decompression
Surgical airway
Rapid Sequence Intubation
Pericardiocentesis
Retavase Should Not be administered by the Special Event crew unless
Supervisor is on scene with unit

Revision Date 11/10/2005 35

 Montgomery County Hospital District-EMS FIRST RESPONDER SCOPE OF
PRACTICE
Standard Delegated Orders –
Clinical Guidelines CG 18 Page 36
TOC

Current first responders shall provide pre-hospital care at the BLS level only. This
includes those first responders who are currently certified as ALS providers.
Exceptions:
Woodlands Fire Department personnel: Medical control is extended to WFD
personnel practicing within the boundaries of the Woodlands while on-duty. WFD
personnel may function within the scope of practice of their certification and the
policies of MCHD EMS.

Off-Duty MCHD EMS Employees: Medical control is extended to off duty EMS
personnel functioning within the boundaries of Montgomery County.

An approved First responder (FR) may perform BLS skills as listed below under the
following circumstances:
The FR is released by MCHD EMS at the FR level.
The FR carries a current Texas Department of State Health Services
certification at the EMT, EMT-I, or EMT-P level.
A FR is an intern and is under the guidance of an approved preceptor who is
present at all times while a skill is performed.
The procedure being performed is according to MCHD EMS protocols.
While at the scene of an emergency, an approved First Responder is authorized to
perform any of the following:
Evaluation of the sick and injured
Perform the following non-invasive diagnostic procedures:
Temperature
Blood pressure
Pulse
Respiratory rate
Render basic life support, rescue and first aid to patients with one or more of
the following:
Medical Emergencies
Trauma Emergencies
Environmental Emergencies
Psychiatric Emergencies
Obstetrical Emergencies
Perform Cardiopulmonary Resuscitation.
Use the following adjunctive airway devices.
Oropharyngeal Airway
Nasopharyngeal Airway
Suction devices
Basic oxygen delivery devices
Manual ventilating devices
Use various extremity and body immobilization devices.
Optional Skills:
Use of Automatic External Defibrillator (AED) upon completion of an
approved AED class.

Revision Date 11/10/2005 36

 Montgomery County Hospital District-EMS ENCOUNTERING
EMERGENCIES
Standard Delegated Orders –
Clinical Guidelines CG 19 Page 37
TOC

The purpose of this policy is to provide employees with guidelines for taking action when
encountering an emergency while on duty and responding to a call or hospital.

MCHD EMS has a duty to act when confronted with any emergency scene encountered
within its territory.

The following guidelines should be followed if an employee encounters are emergency

while ―on the air.‖

Incidents with no injuries should be reported to Alarm if creating a hazard.

Major accidents or incidents with obvious illnesses or injuries should be reported
to Alarm. The crew should stop and assess, treat and/or transport as necessary.

The following guidelines should be followed if an employee encounters an emergency

while responding to a call or to a hospital:

Incidents with no injuries should be reported to Alarm if creating a hazard.

Major accidents or incidents with obvious illnesses or injuries should be reported
to Alarm.
The dispatcher should determine whether the unit should proceed to the original
call or be assigned to the new incident.
If transporting a non-urgent/non-critical patient, stop, assess the scene for
injuries. At least one crew-member should stay with the patient being
transported.
If transporting an urgent/critical patient, contact Alarm and advise of the incident,
but do not stop and assess.

The following guidelines should be followed if an employee encounters an emergency in

a neighboring service area:
Notify Alarm of the incident and have the appropriate service respond.
Stop and render aid.
Await the arrival of the appropriate unit.
MCHD EMS will transport patients if asked to do so by representatives of the
agency assigned to that territory. All patient care provided by MCHD EMS
personnel should adhere to the Standing Delegated Orders and Guidelines
provided by the MCHD Medical Director.

Revision Date 11/10/2005 37

 Montgomery County Hospital District-EMS POTIENTALLY VIOLENT
SCENES AND STAGING
Standard Delegated Orders –
Clinical Guidelines CG 20 Page 38
TOC

The purpose of this policy is to establish guidelines to be followed by MCHD EMS

personnel when responding to any incident that may place crewmembers in a potentially
dangerous situation.

Staging

Staging refers to the positioning of the medic unit in a secure location until Law
Enforcement has cleared the scene or the crew has assured that the scene is safe.

Alarm may advise a medic unit to stage when it receives information that is indicative of
a hazardous or dangerous situation. If Alarm advises a medic unit to stage, the unit‘s
crewmembers should position the unit at a safe distance from the scene.

Medic units should be staged by Alarm in the following situations:

Assaults/sexual assaults;
Any scene with known or possible firearm involvement;
Known/suspected GSW or stabbing;
Domestic disturbances;
When Violent/Psychiatric/Suicidal patients are involved;
When advised to stage by the sheriff‘s department; and
During other situations deemed dangerous by Alarm;

When a unit has been advised to stage within eight minutes of a certain location
crewmembers shall respond non-emergency to the staging area. If that unit has a
response time over eight minutes to a specified staging area, the crew shall respond
emergency traffic to the staging area.

Revision Date 11/10/2005 38

 Montgomery County Hospital District-EMS POTIENTALLY VIOLENT
SCENES AND STAGING
Standard Delegated Orders –
Clinical Guidelines CG 20 Page 39
TOC

Self Defense

Self-defense is the act or acts of an individual used to defend or protect him/herself from
harm. MCHD EMS personnel can defend themselves against a combative patient but
can only use the amount of force necessary to protect themselves.

MCHD EMS personnel may take any action necessary, including the use of reasonable
force, to protect themselves or others against a combative person. However, MCHD
EMS personnel are not authorized to seek revenge in a punishing manner.

MCHD EMS personnel confronted by a combative individual at the scene of an incident

should make every effort to avoid confrontation by departing the scene and making an
immediate request for law enforcement assistance. If efforts to avoid confrontation
prove unsuccessful and personal injury to MCHD EMS personnel appears imminent,
crewmembers on the scene may have to use reasonable force to address the situation.
Crewmembers should inform Law Enforcement and the Field Supervisor of the situation
as soon as possible.

Reasonable Force

―Reasonable Force‖ is the amount of force necessary to keep an individual from causing
injury to herself/himself or others. Stated differently, the amount of force used by MCHD
EMS personnel cannot exceed the force being used against MCHD EMS personnel.
MCHD EMS personnel should only use reasonable force after efforts to avoid
confrontation have failed.

Patient Restraint

Restraining is an act of force used to prevent someone from doing something,

particularly something that may be physically harmful, or to keep him under control.
EMS personnel should consider restraining a patient when careful assessment of the
patient reveals that the individual, due to a medical or psychiatric condition, is a danger
to him/herself or others.

MCHD EMS personnel should adhere to the following guidelines when restraining
patients:

The objective should be to place whatever reasonable restraints are necessary

on the patient as quickly as possible, with the least amount of discomfort to the
patient, and with the least amount of force.
Restraint should be individualized and afford as much dignity to the patient as the
situation allows.
Any restraint should be humanely and professionally administered.
The method of restraint should be the least restrictive means necessary for the
protection of the patient and others.

Revision Date 11/10/2005 39

 Montgomery County Hospital District-EMS POTIENTALLY VIOLENT
SCENES AND STAGING
Standard Delegated Orders –
Clinical Guidelines CG 20 Page 40
TOC

When encountering a ―pre-violent‖ patient, keep him/her under constant

observation and be alert for signs of escalating anxiety. Do not take personal
chances; never attempt to subdue or physically restrain a person if you are
alone. Never hesitate to back off and obtain adequate assistance. Such a
time-out may promote de-escalation of anxiety.
Remember that the restrained patient has no way of exiting the unit in an
emergency and is therefore totally dependent on the crew for his/her welfare.
The use of restraints should be carefully documented. Such documentation
should include the reason for and means of restraint and the periodic
assessment of the restrained patient.

All patient contacts that fall under this policy require MCHD EMS personnel to contact or
consult a Supervisor.

Revision Date 11/10/2005 40

 Montgomery County Hospital District-EMS COORDINATION WITH LAW
ENFORCEMENT
Standard Delegated Orders –
Clinical Guidelines CG 21 Page 41
TOC

This policy establishes guidelines to be followed by employees responding to or dealing

with any suspected/known criminal activity and/or functioning in or around a crime
scene.

General Information

In order to effectively serve the public, it is necessary for MCHD EMS personnel to
maintain a positive working relationship with all of the Law Enforcement agencies within
Montgomery County.

Patient Interrogation:

Patient care shall always remain the primary concern of MCHD EMS personnel during
any joint EMS/Law Enforcement operation. Law Enforcement officers conducting an
investigation are permitted to detain and question patients at the scene as long as such
questioning does not interfere with the treatment of urgent/critically injured patients or
jeopardizes the patient‘s health.

Patients in Custody / Prisoner Transport

Any patient that is in custody or ―under arrest‖ shall receive the same quality of care
expected to be given to any other patient.

If a patient in custody requires transport or if the arresting officer is requests transport,

MCHD EMS personnel shall transport the patient to the most appropriate facility. If the
arresting officer does not feel that the patient requires transport, and this conflicts with
the opinion of MCHD EMS personnel, crewmembers shall exercise due diligence to
convince the arresting officer of the necessity to transport the patient to a medical
facility. At a minimum, the arresting officer shall follow the patient to the hospital and
have the patient handcuffed during transport. If at all possible, the patient should be
cuffed in front or with hands at his or her side to facilitate vascular access. If
crewmembers become uncomfortable riding alone with the patient, they may request
that an officer accompany them in the back of the ambulance. Any questions should be
directed to the on-duty Supervisor.

Patients / prisoners should never be handcuffed to the stretcher or directly to the

ambulance.

Belligerent and Violent Patients

If not already enroute or on location, Law Enforcement should be called to assist with the
patient. Unless instructed to do so by Law Enforcement or the patient is an obvious
threat to him/herself or employees, belligerent or violent patients should not be
restrained.

Revision Date 11/10/2005 41

 Montgomery County Hospital District-EMS COORDINATION WITH LAW
ENFORCEMENT
Standard Delegated Orders –
Clinical Guidelines CG 21 Page 42
TOC

When the belligerent or violent patient requires transport for any medical, mental, or
safety reason, but refuses to be transported, MCHD EMS personnel should that Law
Enforcement assume responsibility and place the patient in protective custody.
Transportation of the patient shall then occur as with any patient in custody.

A belligerent patient may refuse treatment and transport, and then refuse to sign the
release. MCHD EMS personnel should assure that the patient is competent and not a
threat to him/herself or anyone else prior to letting the patient refuse care. Law
Enforcement should called to the scene and asked to sign as a witness on the release
form.

Intoxicated/Under the Influence

Patients who present to employees ―under the influence‖ and require medical care are
entitled to the same quality of care as given to any other patient. Several disorders,
including hypoglycemia, epilepsy, and even some psychological disorders present as
intoxication. Therefore, employees should not dismiss a patient as ―under the influence‖
unless the patient confirms that the nature of the illness is the result of a moderate
consumption of alcohol or other mind-altering substances.

Any patient that presents with signs of intoxication and does not require medical care
shall be referred to Law Enforcement. If Law Enforcement officers are not on location,
employees should stand-by on location until their arrival.

Preserving Evidence / Crime Scene Management

Upon arriving at the scene of a suspected or known crime prior to Law Enforcement,
employees should assure that the scene is safe. If employees suspect criminal activity,
crews should pay particular attention to the environment and the patient. While the
importance of preserving evidence should be kept in mind, it is emphasized that this
should be secondary to patient care and resuscitative measures.

In an effort to keep disruptions of the crime scene to a minimum, crewmembers should

use the same pathway into and out of the crime scene. Unless necessary for crew
safety or patient care, nothing in the ―crime scene‖ should be touched or moved.

Injured Patient

When patient care necessitates moving the patient, evidence or objects, crew members
should be prepared to make written notes of what was moved, the location of object prior
to moving, who moved object, and why the object was moved.

The following guidelines should be adhered to when moving evidence or objects at a

suspected or known crime scene.

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ENFORCEMENT
Standard Delegated Orders –
Clinical Guidelines CG 21 Page 43
TOC

When evidence is moved, crews should always use gloved hands.

Weapons should be picked up using rough surfaces such as a handle.
Tweezers and hemostats can also be used to pick up evidence.
All evidence should be placed in a paper bag for preservation.
Avoid cutting or tearing areas of a patient‘s clothing that might contain markings
from entrance or exit wounds. The patient‘s clothes should be cut along seams to
prevent disruption of potential evidence.
Place any clothing or other patient belongings into a paper bag to give to the
investigating officer.
Evidence can be very inconspicuous; crewmembers should be observant and
cautious not to disturb any fingerprints, footprints, or other evidence. If
immediate transport is not necessary, crews should remain on scene until the
arrival of Law Enforcement to preserve scene integrity.
All non-essential personnel and onlookers should not be allowed into the crime
scene area.

Dead On Scene (DOS)

If the patient is obviously dead and the death appears to be due to other than natural
causes, the following procedures are to be followed:

Do not touch or move the body.

Immediately request the appropriate Law Enforcement agency, if not already on
the scene.
Do not touch or move any weapons, medication containers, suicide notes or any
other items that may be pertinent to the incident investigation.
Avoid touching doors, windows, light switches, etc.
Scene telephones should only be used after clearance by a Senior Law
Enforcement officer.

Suicides

Law Enforcement should be notified of all suicides or attempted suicides. Upon arriving
at the scene of a suicide do not remove the body unless it is absolutely necessary.
When a body should be moved, a sketch shall be made to help in the investigation of the
suicide. If the suicide was due to hanging and patient assessment or treatment makes it
necessary to cut the patient down, do not cut or untie any knots. If it is determined that
the patient is dead, leave the noose intact about the neck. If the patient is alive and
immediate transport is necessary before Law Enforcement arrives, take any suicide
notes or evidence necessary to preserve your findings and the crime scene. As soon as
possible have Law Enforcement notified of the transport destination. If Law Enforcement
is on the scene, leave the suicide note and any other evidence with the Law
Enforcement officer(s).

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 Montgomery County Hospital District-EMS COORDINATION WITH LAW
ENFORCEMENT
Standard Delegated Orders –
Clinical Guidelines CG 21 Page 44
TOC

Narcotics

Unless a patient‘s condition warrants immediate transport, crews should remain on

scene and await the arrival of Law Enforcement when an incident involves narcotics or
other controlled substances.

When a patient‘s condition warrants immediate transport, if possible,

crewmembers should take a sample of the narcotic as the doctor will need it for
analysis. Crewmembers should never handle an unknown substance with their
bare hands as several street drugs can be absorbed through the skin.
If Law Enforcement is not on location when the patient is transported, they
should be notified as soon as possible as to where the substance will be, how
much was transported, and with whom it will be left at the hospital.
If at all possible, crewmembers should remain at the hospital with the evidence
until the arrival of Law Enforcement.

Requesting Law Enforcement Assistance

Employees should call for Law Enforcement assistance anytime a crewmember
feels threatened or assistance is needed in controlling a scene or combative
patient.

Communications shall Automatically Notify Law Enforcement when any of the

Following Occurs:

Assaults/Sexual assaults;
Domestic disputes/disturbances;
Animal bites;
Motor Vehicle Accidents (MVA‘s);
Overdoses;
Shootings;
Stabbings;
Attempted suicides;
Suspected/Known DOA‘s;
Suspected child and/or elderly abuse; or
Unknown type emergencies.

When crews arrive on the scene of an incident and feel an immediate threat to their own
safety, they should immediately withdraw from the scene to a secure location and notify
Communications.

Jail Responses
When responding to incidents at any detention facility within Montgomery County,
employees should adhere to the following guidelines:

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 Montgomery County Hospital District-EMS COORDINATION WITH LAW
ENFORCEMENT
Standard Delegated Orders –
Clinical Guidelines CG 21 Page 45
TOC

The communications center should only dispatch the medic unit unless the
information received suggests that more personnel may be required;
Equipment brought into the detention facility should never be left unattended in
the prisoner area;
Never proceed through the detention facility unescorted, always have a Law
Enforcement escort both into and out of the facility;
Personnel should never be left unattended at a detention facility;
If the prisoner is transported, a Law Enforcement officer should accompany the
prisoner. All patients who are in custody should be handcuffed and accompanied
by a Law Enforcement officer. If possible, patients should be cuffed with their
arms to their sides to facilitate vascular access. A Law Enforcement officer
should accompany the patient to the hospital. At a minimum, a Law Enforcement
officer shall follow the medic unit to the transport destination. If at anytime the
crew becomes uncomfortable riding alone with the patient, request that a Law
Enforcement officer accompany the patient/prisoner in the back of the
ambulance. Any questions should be directed to an on-duty Supervisor; and
Patients/prisoners should never be handcuffed to the stretcher or directly to the
ambulance.

Revision Date 11/10/2005 45

 Montgomery County Hospital District-EMS REQUESTS FOR ASSISTANCE
Standard Delegated Orders –
Clinical Guidelines CG 22 Page 46
TOC

This policy establishes guidelines to be followed by MCHD EMS personnel needing to

request additional assistance while on the scene of an incident.

General Information

MCHD EMS crews have the authority to call for additional assistance in any situation or
condition in which they do not have the available resources or ability to manage the
scene.

Additional assistance may be requested for any one or more of the following:

Medic Units;
Medical Personnel;
Helicopter Transport;
Fire apparatus;
Rescue equipment;
Law Enforcement; or
Specialized Services (for example, Pastoral, CPS, or APS services).

Upon arriving on location of any incident, MCHD EMS personnel need to determine as
quickly as possible if any additional equipment, supplies, and/or manpower will be
required. Crews shall notify Alarm of their specific needs.

A crew requesting additional assistance should provide alarm with the following
information:

Type of assistance needed;

Reason for request;
Exact location; and
Any special conditions or circumstances.

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 Montgomery County Hospital District-EMS TRANSPORTING PATIENT
VALUABLES
Standard Delegated Orders –
Clinical Guidelines CG 23 Page 47
TOC

It shall be the goal of employees to ensure that all of a patient‘s personal belongings
stay with the patient and arrive at the destination with the patient. If articles are
unintentionally left in the ambulance they should be returned as soon as possible.
MCHD EMS discourages the unnecessary handling of patient belongings.
It is the responsibility of the field crew to ensure that all patient belongings are
appropriately handled.
Employees should document all personal belongings of the patient that are handled by
employees during patient contact. Employees should make an inventory listing of the
items on the computerized patient report in the ―Personal Effects‖ field and obtain a
signature for disposition of the items.
If contact with patient valuables (purse, wallet, etc.) is necessary, it should be done in
the presence of at least one witness not employed by the MCHD, such as a law
enforcement officer or other official.
If removal of patient valuables is justified by a need to reduce possible injury or for a
medical procedure, removal should be witnessed by a law enforcement officer or other
official and placed in a safe location.
In all instances, the handling of valuables (and their description) should be clearly
documented on the ambulance run form and the witness to the handling of the items
should be identified.
Employees should consult local hospital policies regarding valuables because some
hospitals may require that all patient valuables be turned over to hospital security, or
other authorized personnel.

Revision Date 11/10/2005 47

 Montgomery County Hospital District-EMS ORGAN DONOR
PROCUREMENT - LIFEGIFT
Standard Delegated Orders –
Clinical Guidelines CG 24 Page 48
TOC

Donor Referral

In the event MCHD EMS elects to withhold resuscitation, or terminate resuscitation, the
following procedure should occur. This shall also be applicable in situations in which a crew
encounters a death on scene and those in which a patient delivered to an Emergency
Department expires such that the crew has knowledge of the patient‘s demise

The family members should be notified of the lack of resuscitation efforts (if they are
present).

Upon completion of the call and departure from the scene, the In-Charge Paramedic should
call Life Gift at 800.633.6562 and give them the following information:
The location of the incident
Patient Information – Name, Age, Sex, Race
Mechanism of Injury / History of Present Illness
Past Medical History
Next of Kin or responsible party – name and phone number
Any other relevant information
Give Life Gift your contact information (use 936.441.MCHD for your call back).

It is recommended that you do not notify the family about the donor referral.

There is no situation where donor referral should not be done.

Life Gift should provide follow up by phone (within 24 hours) and by letter (within 30 days).

Revision Date 11/10/2005 48

 Montgomery County Hospital District-EMS PATIENT CONSENT
Standard Delegated Orders –
Clinical Guidelines CG 25 Page 49
TOC

This policy establishes guidelines for obtaining patient consent for emergency care.

General Information

MCHD EMS PERSONNEL SHALL NOT REFUSE TRANSPORTATION TO ANY PATIENT,

UNDER ANY CIRCUMSTANCES.

Patient Consent for Service

Texas Health and Safety Code § 773.008 of the provides that consent for emergency care
of an individual is not required if:
Consent for emergency care of an individual is not required if:

(1) the individual is:

(A) unable to communicate because of an injury, accident, or illness or is

unconscious; and

(B) suffering from what reasonably appears to be a life-threatening injury or illness;

(2) a court of record orders the treatment of an individual who is in an imminent emergency
to prevent the individual's serious bodily injury or loss of life; or

(3) the individual is a minor who is suffering from what reasonably appears to be a life-
threatening injury or illness and whose parents, managing or possessory conservator, or
guardian is not present.

Consent to Treatment of Child by Non-Parent

Texas Family Code § 32.001 of the provides that the following persons may consent to
medical treatment of a child when the person having the right to consent as otherwise
provided by law cannot be contacted and that person has not given actual notice to the
contrary:

§ 32.001. Consent by Non-Parent

(a) The following persons may consent to medical, dental, psychological, and surgical
treatment of a child when the person having the right to consent as otherwise provided by
law cannot be contacted and that person has not given actual notice to the contrary:

(1) a grandparent of the child;

(2) an adult brother or sister of the child;

(3) an adult aunt or uncle of the child;

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 Montgomery County Hospital District-EMS PATIENT CONSENT
Standard Delegated Orders –
Clinical Guidelines CG 25 Page 50
TOC

(4) an educational institution in which the child is enrolled that has received written
authorization to consent from a person having the right to consent;

(5) an adult who has actual care, control, and possession of the child and has written
authorization to consent from a person having the right to consent;
(6) a court having jurisdiction over a suit affecting the parent-child relationship of which the
child is the subject;

(7) an adult responsible for the actual care, control, and possession of a child under the
jurisdiction of a juvenile court or committed by a juvenile court to the care of an agency of
the state or county; or

(8) a peace officer who has lawfully taken custody of a minor, if the peace officer has
reasonable grounds to believe the minor is in need of immediate medical treatment.

(b) The Texas Youth Commission may consent to the medical, dental, psychological, and
surgical treatment of a child committed to it under Title 3 when the person having the right to
consent has been contacted and that person has not given actual notice to the contrary.

(c) This section does not apply to consent for the immunization of a child.

(d) A person who consents to the medical treatment of a minor under Subsection (a)(7) or
(8) is immune from liability for damages resulting from the examination or treatment of the
minor, except to the extent of the person's own acts of negligence. A physician or dentist
licensed to practice in this state, or a hospital or medical facility at which a minor is treated is
immune from liability for damages resulting from the examination or treatment of a minor
under this section, except to the extent of the person's own acts of negligence.

Consent to Treatment by Child

Texas Family Code § 32.003 provides that a child may consent to medical treatment
if the child:

§ 32.003. Consent to Treatment by Child

(a) A child may consent to medical, dental, psychological, and surgical treatment for the
child by a licensed physician or dentist if the child:

(1) is on active duty with the armed services of the United States of America;

(2) is:

(A) 16 years of age or older and resides separate and apart from the child's parents,
managing conservator, or guardian, with or without the consent of the parents, managing
conservator, or guardian and regardless of the duration of the residence; and

(B) managing the child's own financial affairs, regardless of the source of the income;

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 Montgomery County Hospital District-EMS PATIENT CONSENT
Standard Delegated Orders –
Clinical Guidelines CG 25 Page 51
TOC

(3) consents to the diagnosis and treatment of an infectious, contagious, or communicable

disease that is required by law or a rule to be reported by the licensed physician or dentist to
a local health officer or the Texas Department of Health, including all diseases within the
scope of Section 81.041, Health and Safety Code;

(4) is unmarried and pregnant and consents to hospital, medical, or surgical treatment, other
than abortion, related to the pregnancy;

(5) consents to examination and treatment for drug or chemical addiction, drug or chemical
dependency, or any other condition directly related to drug or chemical use; or

(6) is unmarried, is the parent of a child, and has actual custody of his or her child and
consents to medical, dental, psychological, or surgical treatment for the child.
(b) Consent by a child to medical, dental, psychological, and surgical treatment under this
section is not subject to disaffirmance because of minority.

(c) Consent of the parents, managing conservator, or guardian of a child is not necessary in
order to authorize hospital, medical, surgical, or dental care under this section.

(d) A licensed physician, dentist, or psychologist may, with or without the consent of a child
who is a patient, advise the parents, managing conservator, or guardian of the child of the
treatment given to or needed by the child.

(e) A physician, dentist, psychologist, hospital, or medical facility is not liable for the
examination and treatment of a child under this section except for the provider's or the
facility's own acts of negligence.

(f) A physician, dentist, psychologist, hospital, or medical facility may rely on the written
statement of the child containing the grounds on which the child has capacity to consent to
the child's medical treatment.

Patient Refusal of Service

All conscious, self-sufficient persons retain the right to refuse service. MCHD EMS
personnel shall attempt to have the patient (if minor: parent, guardian, etc.) read and sign
the statement of refusal of care and transport. Such statement is located on the patient
report. MCHD EMS personnel shall record in their narrative report the refusal and their
statements concerning information provided any attempts at medical aid, and conditions
under which the signature was obtained.

MCHD EMS personnel are charged with the responsibility of assuring that patient are
informed of the reasonable consequences of treatment and refusals. Bystanders shall
witness signatures for such informed refusal, if possible. If there are no bystanders then
signatures for such informed refusal shall be witnessed by another member of the
Department, a Fire or Law Enforcement officer, or other Medical Personnel present at the
scene.

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 Montgomery County Hospital District-EMS PATIENT CONSENT
Standard Delegated Orders –
Clinical Guidelines CG 25 Page 52
TOC

Refusal of Signature

If an individual refuses to sign the refusal of care statement, MCHD EMS personnel should
have the refusal witnessed by a third party, preferably someone not employed by MCHD
EMS. A statement regarding the circumstances of individual‘s refusal to sign the statement
should appear on the patient report accompanied by signature of a witness, if possible.

Refusal of Specific Treatment

Any treatment refused by the patient and ordered by a physician (Standing order or verbal)
shall be reported to the medical control physician prior to acceptance of the refusal
signature. MCHD EMS personnel should explain to the patient complications that may arise
from such refusal. MCHD EMS personnel should record such refusal of specific
treatment(s) and the complications about which the patient was informed. The In-Charge
Paramedic shall attend to the patient during transport.

Revision Date 11/10/2005 52

 Montgomery County Hospital District-EMS PATIENT REFUSAL
Standard Delegated Orders –
Clinical Guidelines CG 26 Page 53
TOC

The purpose of this policy is to provide EMS personnel with clear rules for managing
situations in which the patient or the patient‘s representative declines or refuses care or
transportation by EMS.

If a patient (or legal patient representative) requests evaluation, treatment, and/or transport
from MCHD EMS, they will be actively encouraged to seek medical care from a physician
regardless of the nature of that request.

Under no circumstances will MCHD EMS personnel refuse or deny treatment or EMS
transportation to any patient (or legal patient representative) who requests medical
assistance, through any means, from the agency

MCHD EMS personnel shall not discourage any patient (or legal patient representative) from
seeking medical care from a physician or from accepting EMS transport to a hospital.

All Patient Refusals involving individuals exhibiting deficits in mental capacities, or

with question as to possessing legal custody of themselves, should go through the
current Medical Control system in place (i.e. EMS Supervisor on duty).

All patients should have the following assessment and documentation regardless as to
whether the patient is refusing transport. If the patient meets the criteria below and refuses
to allow part or parts of the patient assessment, the EMS provider shall comply with the
patient‘s request unless otherwise directed by Medical Control or law enforcement. The
patient should then read and sign the Patient Refusal/Non-Transport statement
documenting the fact that he was offered specific treatment and refused to allow that
treatment. If any information that is not available to the medic on-scene, then the narrative
should reflect that in the documentation.

A patient has to meet certain criteria prior to accepting a refusal of care. The patient should
be able to advise the following information and, therefore, be considered competent:
1. His/her own name
2. Where he/she is
3. What day of the week it is OR what month and year it is
4. What happened
5. Patient is without neurological deficit.
6. Patient history does not include recent substance abuse, or alcohol ingestion

If the above criteria are not met, EMS should reject any acceptance of a patient
refusal unless approval is obtained via consult.

There are specific categories of patients that are inherently difficult with which to deal. The
following is a guideline to assist in making the best decision for the patient.

1. Diabetic (hypoglycemic) patients unconscious on scene.

If advanced care is rendered on scene and the patient becomes conscious and had
an obtained blood glucose level of equal or greater than 80 mg/dl and does not wish
to be transported, a Patient Refusal/Non-Transport statement should be filled out
and signed. It is the responsibility of the on-scene medic to attempt to ensure that

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 Montgomery County Hospital District-EMS PATIENT REFUSAL
Standard Delegated Orders –
Clinical Guidelines CG 26 Page 54
TOC

the patient is left in the company/custody of a family member, friend, or other

individual that agrees to watch over that patient and is informed of the potential for
recurrent hypoglycemia. That responsible party should also be aware of the need for
medical evaluation/EMS activation should hypoglycemia return.

2. Suicidal/Threatens himself or others

Make sure the scene is safe and that the crew is safe prior to entry.
If the patient states that he attempted suicide, a patient refusal may not be accepted.
If the patient refuses transport, law enforcement should be called to the scene. Law
enforcement will determine whether to place the patient in protective custody.

If the patient is not placed in protective custody, then Medical Control should be
contacted. Law enforcement should not transport the patient who has ingested
medications or has physical injuries. If law enforcement does transport the patient,
the patient refusal should be signed by the highest-ranking law enforcement officer
on-scene.

3. Patients in Law Enforcement Custody.

Law Enforcement may mandate transport of a patient in custody regardless of the
patient‘s wishes. If the patient is in custody and is in need of transport, Law
enforcement shall provide an officer who should either ride in the ambulance or
follow the ambulance. If the patient determines that he/she wants out of the
ambulance during transport and law enforcement is not available, the patient
should be released from the ambulance at the safest possible time.

4. Incompetent Adult patients (mentally handicapped, mentally ill, Alzheimer‘s, OBS,

etc.)
If the patient‘s guardian is on scene with a Durable Power of Attorney, the patient
may not refuse treatment or transport for himself. If the guardian is not oriented,
Medical Control should be contacted. If the patient‘s guardian cannot prove
Durable Power of Attorney, Medical Control should be contacted. If the patient‘s
guardian is not present, Medical Control should attempt to contact the guardian. If
the patient‘s condition is urgent, the patient should be transported by standing order
prior to guardian contact.

5. Emancipated Child patient

Emancipation is defined as a minor (17 years or less) who is living apart from his
legal guardian and who is not financially supported by his guardians.
 Pregnant female
 Person enlisted or commissioned in the U. S. Armed Forces
 Person legally declared an adult by the courts
 These patients shall be handled as adults.

6. Minor patient - Guardian present (Minor = less than 18 years of age)

If oriented, the guardian should decide all patient care.
If the patient is a refusal, the guardian should be given the instructions and sign the
paperwork. If abuse of the patient is suspected, law enforcement should be notified
by the communication‘s center prior to leaving the scene. Law enforcement should

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 Montgomery County Hospital District-EMS PATIENT REFUSAL
Standard Delegated Orders –
Clinical Guidelines CG 26 Page 55
TOC

make the final determination as to whether there is enough evidence to necessitate

taking the child into protective custody and imposing medical care against the
guardian‘s wishes.

7. Minor patient - Guardian not present (Minor = less than 18 years of age)
Minor patients who need to be transported, but are not urgent or critical, should be
transported if the parent or guardian cannot be contacted after reasonable attempts
have been made. The contact of a parent or guardian should be made through
dispatch on a recorded line to serve as a record of consent or refusal.

Documentation on all patient refusals requires:

1. Demographic and operational information as outlined in the Documentation Policy.
2. Assessment information including the patient‘s/guardian‘s mental status, physical
assessment/general appearance, and vital signs.
3. The patient /guardian was advised of any complications that may arise from not
seeking medical attention.
4. Proper signature from the patient.
5. Medical Control personnel involved if Medical Control is contacted.

No Patient is defined as
1. No patient upon arrival of EMS. OR
2. False call, OR
3. Person or people on scene did not request an ambulance AND
deny any physical complaint AND
EMS personnel cannot visualize any injury or evidence of injury or illness AND
the person on scene is competent to make such a decision.
4. If the patient called for the ambulance, the ―No Patient‖ classification no longer
applies.

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 Montgomery County Hospital District-EMS PATIENT REFUSAL
Standard Delegated Orders –
Clinical Guidelines CG 26 Page 56
TOC

AMA REFUSAL OF CARE/TRANSPORT

The purpose of this policy is to ensure that EMS personnel actively encourage a patient
whose illness or injury is categorized below to accept treatment and transport. Any patient
whose complaint or injury is categorized below should be an AMA refusal if the
patient refuses treatment and/or transport.

1. ANYTIME ONE OF THE EMS CREWMEMBERS BELIEVES TRANSPORT IS

INDICATED.

2. Cardio-respiratory signs and symptoms

3. Abdominal pain

4. Stabbing/Shooting

5. Overdose/Poisoning

6. Neurological
• Seizure
• Dysphasia
• Hypoglycemic patients whose BG determination is < 60 mg/dl and shows signs
and/or symptoms of neuro-deficit. A second BG should be obtained.

7. Pregnancy

8. Elderly (65 years or older)

• Acute medical or surgical problem

9. Deceleration Injury, Near-Drowning, Electrocution

10. Mechanism of Injury

• Fall from > 6 ft requires full spinal motion restriction regardless of complaint
• Damage done to specific area in which the patient was sitting.
• Death of a person in the same vehicle

11. Abuse
• Although these patients may not always be transported, the proper law
enforcement agency should be contacted prior to leaving the scene.

12. Ejection, Rollover, or lateral impact MVAs; or any MVA with significant vehicle damage

Revision Date 11/10/2005 56

 Montgomery County Hospital District-EMS OXYGEN
Standard Delegated Orders –
Clinical Guidelines CG 27 Page 57
TOC

MICU
Oxygen should be maintained at the following levels to perform at peak effectiveness.

Onboard (main) and Portable cylinders:

On-Board Main O2 and all portable oxygen cylinders should have a minimum of 500-
psi. The ventilators should operate 20 minutes for every 400-psi (E cylinder) at
maximum settings. Therefore, anything less than 500-psi does not provide optimum
use.

STATION SUPPLY
Each station is responsible for contacting the current vendor for oxygen replacement used
by the District for re-supply. Station supply should not fall below 1 main cylinder and 3
portable cylinders.

Revision Date 11/10/2005 57

 Montgomery County Hospital District-EMS THIRD RIDERS
Standard Delegated Orders –
Clinical Guidelines CG 28 Page 58
TOC

Third riders are considered to be approved probationary employees, students and/or

observers that are assigned to a particular response vehicle. Only authorized persons will
be allowed to ride on an EMS vehicle.

The following guidelines shall apply:

Riders should be at least 18 years of age, or have expressed WRITTEN permission

from the Operations Manager and a parental release signature on the Waiver of
Liability form.
The department scheduler and/or the Supervisor on duty should approve riders.
Third riders shall be scheduled at least twenty-four hours in advance.
All third riders should sign an Observer‘s Release form prior to riding a shift. A new
release form should be signed each time an individual rides
Third riders should follow all requirements and rules prior to and while riding as an
observer;
It is the responsibility of all EMS personnel to assure that the rider has been
approved to ride and an Observer‘s Release form has been signed and is on file in
the administrative office;
It is the responsibility of all EMS personnel to note the personal appearance of each
rider when she/he reports to the shift. If he/she does not meet the rules and
regulations pertaining to dress, he/she should be advised of such by the EMS
personnel and should not be permitted to ride until she/he has complied with the
rules;
Students and observers may be asked to leave at a moment's notice due to
operations and training requirements.
The department reserves the right to limit the number of shifts of any rider.

Observers

Observers are individuals who for some personal reason may desire the experience of pre-
hospital care by observation. Frequently this is to gain a sense of EMS roles in the
community and to understand the interaction of various agencies. The Assistant Director
EMS-Operations or his/her designee shall approve citizen observers.

Non-certified observers should not be involved in the patient care process, and are only
allowed to observe the EMS personnel render care to the patient. Certified observers may
participate in basic level patient care at the discretion and under the direct supervision of the
In-Charge Paramedic.

Be aware that representatives of the media or legal profession may observe events that they
feel compelled to make public. These persons should be screened carefully and made
aware of the terms of the Observer‘s Release form before being allowed to ride. Observers
are restricted to riding between the hours of 0700-2200. Observers are not allowed later
than 2200 unless prior approval and arrangements have been approved by a Supervisor or
higher management member.

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 Montgomery County Hospital District-EMS THIRD RIDERS
Standard Delegated Orders –
Clinical Guidelines CG 28 Page 59
TOC

NEOP

Probationary members may participate in patient care to their certification level at the
discretion, and under the direct supervision of the senior medical member on their assigned
unit.

Student Interns

TDSHS approved courses wishing to have students ride on MCHD EMS units should have a
signed affiliation agreement on file with the administrative office.

Students from outside organizations should be scheduled in advance. Administration

should ensure the presence of medical liability insurance and student qualifications.

The student‘s role is to interact in the patient care process by performing duties in
accordance with the training program‘s affiliation agreement and/or training objectives. The
amount of involvement is to be determined by the senior medical staff member on the
ambulance. Interns should perform the skills, as determined by the senior medical team
leader, which fall within the practice for the certification the student is obtaining.

Interns are "in training" and should not be left in the role of providing sole care for the patient
except under extraordinary conditions. Interns should not treat patients until the In-Charge
Paramedic approves all decisions concerning treatment.

Acceptable Uniform

EMS third riders are to dress neatly and conservatively at all times. The generic third rider
uniform shall consist of:

Conservative-type shoes including black athletic type shoes or boots may be worn.
It is recommended that sturdy shoes be worn. Sandals are prohibited.
Black or navy EMS type pants should be worn.
White uniform shirt or dress shirt should be worn.
Blue jeans, shorts and t-shirts are prohibited
Hair should be groomed. Cleanliness and appropriate physical hygiene are required
at all times.

Observers from approved first responder organizations will be allowed to wear their
department uniform.

Recognized EMS training programs may negotiate an acceptable, alternative uniform for
EMS students.

The Assistant Director EMS-Operations or his/her designee may approve specific apparel
for special circumstances such as physicians, nurses, or media representatives.

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 Montgomery County Hospital District-EMS THIRD RIDERS
Standard Delegated Orders –
Clinical Guidelines CG 28 Page 60
TOC

Run Records

Students and observers should not complete official run records for MCHD EMS.
Probationary employees may complete records under the direct supervision of their
preceptor. That person should co-sign the run record. All third riders‘ identities should be
documented on medical reporting forms.

Conduct

All EMS observers are to conduct themselves with proper decorum. Observers are to
refrain from the following:

Use of alcoholic beverages 12 hours prior to and during the shift;

Use of profane or abusive language;
Use of excessive conversations which may interfere with radio communications while
riding in unit;
Making remarks, or voicing opinions to patients or family members, bystanders,
police officers, fire personnel, or first responders in any manner, which would tend to
provoke or degrade anyone or escalate tension/anxiety;
Making known to any person not authorized, any information concerning the
emergency call, patient information or outcome;
Using information gained through EMS third rider program for personal gain; and
Wearing on their clothing any article, sign or symbol that advertises any product,
business or organization.

Conclusion

All third riders are subject to removal for any violation of the above rules and regulations.
Crewmembers are responsible for the appearance and conduct of third riders. Should
problems arise, it is recommended that a Supervisor be notified of the incident.

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 Montgomery County Hospital District-EMS NON-EMERGENCY ASSIST
CALLS
Standard Delegated Orders –
Clinical Guidelines CG 29 Page 61
TOC

MCHD EMS will respond to all requests for assistance. In all cases, EMS personnel should
attempt to aid the person requesting assistance.

Non-emergency Assists

MCHD EMS personnel should respond non-emergency to known non-emergency assist

calls. Should there be doubt of the emergency nature of the request, personnel should
respond emergency traffic.

Chronic System Abuse

Instances of repeated abuse of the EMS system by a member of the public should be
reported to the on-duty Field Supervisor. Personnel should make every attempt to
professionally educate the calling party of a more appropriate method of obtaining
assistance.

Repeated EMS system abuse, despite good faith efforts to intervene, should be referred to
the Assistant Director EMS-Operations. If determined necessary, the Assistant Director
EMS-Operations may refer the situation to the Medical Director.

Malicious False Alarms

In instances of malicious false alarms, EMS personnel should advise Alarm of the
nature of the event. Law enforcement assistance should be requested if the calling
party can be identified. MCHD EMS personnel should not confront the alleged calling
party.

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 Montgomery County Hospital District-EMS CONFIDENTIALITY
Standard Delegated Orders –
Clinical Guidelines CG 30 Page 62
TOC

Healthcare professionals have an important ethical and legal duty to guard and respect the
confidential nature of the information conveyed during patient contact. All personnel
implicitly promise to preserve patient confidentiality.

Under the Tex. Health § Safety Code Ann. § 773.091(g), the following items are not
considered confidential information and may be disclosed:

Information regarding the presence, nature of injury or

Illness
Age
Sex
Occupation
City of residence of a patient

Confidentiality is not absolute. Confidential patient information may be disclosed when

patients or their legal guardians agree to the disclosure, when mandated by law, or when
there exist compelling or overriding ground for the disclosure, such as prevention of
substantial harm to identifiable other persons. See Tex. Health & Safety Code Ann. §
773.091-095.

Disclosure of confidential patient information is a serious transgression, and in some cases

is considered a criminal offense. Employees that violate patient confidentiality should be
called upon to justify their actions and may be subject to disciplinary action.

Employees may be questioned about past responses by law enforcement, attorneys,

insurance agencies, or other agencies. When this occurs, those persons should be directed
to a Supervisor or the custodian of records. Patient Care Reports are confidential and can
generally only be released by a subpoena.

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 Montgomery County Hospital District-EMS OOH DNR AND DEATH ON
SCENE
Standard Delegated Orders –
Clinical Guidelines CG 31 Page 63
TOC

Out of Hospital Do Not Resuscitate (DNR) /Dead on Scene (DOS)

Withholding, Terminating and Limiting Resuscitation

This protocol shall provide the guidelines, standards and orders for managing situations
involving the withholding, termination or limitation of resuscitative efforts in the terminally ill
or fatally injured patient. This protocol addresses the following issues:
Apparently non-viable cardiac arrest cases (dead on scene)
Do not attempt resuscitation requests
Directive to physicians, Living Will directives or other directives which limit care to a
terminally ill patient.

Apparently Non-Viable Cardiac Arrest (Dead On Scene)

The criteria for this component of the protocol is a pulseless and apneic patient in whom
there is some question as to whether to initiate or continue resuscitative measures.

MCHD EMS personnel are authorized to withhold or discontinue resuscitative measures in

cases of:
Multi-patient incidents as described in the Multi-patient/Triage protocol
Decapitation
Decomposition
Rigor mortis (in the non-hypothermic patient)
Dependent lividity
Incineration
Visible trauma to the head or chest that is clearly incompatible with life
Valid Do Not Attempt Resuscitation directives as described in this protocol.

When any patient meets the above criteria, access to the scene should be limited as much
as possible with special attention to disturb the scene as little as possible. Every effort
should be made to provide support for the family, friend, survivors as well as any witness to
the event.

A directive to withhold resuscitative measures shall not prevent EMS from providing
appropriate emergency care to ease suffering such as oxygen administration, airway
suctioning, authorized analgesia, and palliative care.

State of Texas Out-of-Hospital Do-Not-Resuscitate Orders:

The individual executing the OOH DNR agrees to have ALL of the following procedures
withheld:

Cardiopulmonary resuscitation
Advanced airway management
Artificial ventilation
Transcutaneous pacing

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Standard Delegated Orders –
Clinical Guidelines CG 31 Page 64
TOC

Other life-sustaining treatment specified by Texas Board of Health.

Palliative Care
The provision of palliative (comfort) care and pain management is acceptable if the patient
presents with a pulse and spontaneous respirations. Examples of palliative care include:

Oxygen therapy
Suction
IV Therapy
Hemorrhage control
Pain management

To withhold resuscitation in the patient who becomes pulseless or apneic the following
criteria SHOULD be met:
An official colored TDSHS OOR DNR identification bracelet or necklace is being
worn by the patient OR
An official or photocopied TDSHS OOH DNR order is presented upon patient
contact with all necessary patient information, signatures and boxes completed and
present on the form. (SB 1260 changes this section to read ―photocopy or other
complete facsimile of the original written out-of-hospital DNR order executed under
this subchapter may be used for any purpose which the original written order may be
used under this subchapter.") OR
The patient‘s private physician is either on-scene or via phone directs the provider to
withhold any resuscitative efforts.

The Texas DNR form is not to be honored and full resuscitative efforts, including BLS and
ACLS are to be initiated, if any of the following conditions exist:
The Patient:

Destroys the form and removes the identification device OR

Directs someone in their presence to destroy the form and remove the identification
device OR
Communicates to the responding health care professionals or attending physician
that it is his/her intent to revoke the order AND
Notifies the attending physician (if not present) that the order has been revoked.

The Person who executed the order:

Destroys the form and removes the identification device OR
Directs someone in their presence to destroy the form and remove the identification
device OR
Notifies the attending physician (if not present) that the order has been revoked.

The attending physician: (or his/her designee)

If present at the time of revocation, records in the patient‘s medical record the time,
date and place of the revocation OR

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Clinical Guidelines CG 31 Page 65
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If not present, records the time, date and place that the physician received notice of
the revocation AND
Enters the word ―VOID‖ on each page of the copy of the order in the person‘s medical
record.

In addition to the above, the Texas DNR order is not to be honored if:
The patient is known to be pregnant
Unusual or suspicious circumstances are involved (suspected homicide or suicide).
Suspected criminal activity involving the patient.

If Any of These Reasons for Revocation Are Met the Provider Should:
Initiate full resuscitative efforts.
Record the time, date and place of the revocation for DNR order revocation incident
reporting to the Texas Department of State Health Services by the MCHD EMS
Clinical Department.

Note: Senate bill 1260 provides for the consolidation of all chapters related to Out-of-
Hospital DNR orders and advanced directives. These changes became effective September
1, 1999.
The person initiating a DNR does not have to be diagnosed with a terminal condition.
The document specifies the treatment rather than the procedures a person or legally
authorized representative directs health care providers in an out-of-hospital setting
not to initiate or continue.
The out-of-hospital setting as a location in which health care professionals are called
for assistance is expanded to include hospital outpatient or emergency departments
and physicians offices.
Requires the form to include certain physicians, a separate section for execution of
the document by at least one, rather than two, qualified relatives and a statement that
allows certain persons to make certain decisions (medical power of attorney).
OUT-of- STATE DNR orders are acceptable if there is no reason to question the
authenticity of the order or device.

All other cases should require authorization from field medical control or an on-line medical
control physician.

In ALL DNAR cases, the EMS crew should be completely confident in the authenticity of the
documentation or device and in the patient's identification. If there is any doubt about the
validity of the paperwork involved, always begin patient care. The on-duty Supervisor should
determine whether to continue or terminate care.

Resuscitation efforts may not be withheld from a person known by the health care
professional to be pregnant.

Documentation requirements for out of hospital DNAR:

1. Assessment of patient‘s physical condition.

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2. Type of device used to confirm DNAR status including patient identification number.

3. Any problems related to the implementation of the DNAR order.

4. Patient‘s attending physician.

5. Full name, address, telephone number and relationship to patient of any witnesses
used to identify the patient.

6. If the patient is transported the original DNAR order should be kept with the patient.

7. If the patient is not transported the original DNAR order should be left with the
concerned parties or health care facility.

Should the patient expire prior to the initiation of transport by EMS, the EMS crew shall:
1. Discontinue all medical care.

2. Prepare the body for viewing by the family and/or friends.

3. Allow the family/friends to view the body as they wish. Answer any questions
regarding the patient‘s clinical status upon your arrival and your actions, to the best
of your ability.

4. Notify field Medical Control of the situation.

5. Notify, via the Communications Center, the appropriate law enforcement agency of
an out-of-hospital death.

6. Complete all appropriate documentation.

7. Release the scene to law enforcement upon their arrival, providing them with a copy
of the documentation.

If a patient who is under a valid DNAR directive becomes pulseless and apneic during
transport, the EMS crew shall:
1. Note the time the patient became pulseless and apneic.

2. Continue any care that is in progress at that point (e.g., oxygen administration, etc.).

3. DO NOT initiate any additional medical care.

4. Continue transport, in non-emergency traffic mode, to the destination facility.

5. Upon arrival at the destination facility, release the patient to the appropriate health
care professional. Notify the receiving health care professionals that the patient

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Clinical Guidelines CG 31 Page 67
TOC

became pulseless and apneic during transport and that, as per the patient‘s binding
directive, EMS did not treat the cardiac arrest.

6. Complete all appropriate documentation and leave copies with the receiving facility.

Limitations of Care
Competent adult patients have the right to select the care they receive from health care
professionals. This right extends to emergency situations, the out-of-hospital care arena
and even to resuscitation and end-of-life cases.

This right may be exercised verbally by a competent adult patient (as described and defined
in the Consent and Refusal policy). This right may also be exercised by written directive,
executed by a patient when s/he was competent, even if that patient is no longer competent
to consent to or refuse care. Last, selection and limitation of healthcare options and
procedures may be exercised by a duly authorized representative of the patient (family
member or representative empowered to do so by a Durable Power of Attorney) in cases
where the patient is incompetent or unable to communicate their wishes.

A directive to withhold or limit resuscitative measures shall not prevent EMS from providing
appropriate emergency care to ameliorate suffering, such as oxygen administration, airway
suctioning, or authorized analgesia.

Should EMS personnel encounter a patient with an apparent terminal condition or in whom
there is reason to believe the patient and/or family may wish to limit the care administered to
the patient by EMS, the EMS personnel shall:
1. Determine the presence or absence of any written or verbal directives pertaining to
limitations of care. If there is a written directive, review it carefully and clarify any
unclear components with the patient and/or patient‘s authorized representative.

2. Discuss the treatment options available to the patient from EMS with either the
patient (if competent and able to communicate) or the patient‘s authorized
representative.

3. Clarify the interventions to which the patient (or representative) does and does not
consent, prior to initiating transport.

4. Comply with the patient‘s limitations and/or directives. If there is any doubt or
concern about the validity or appropriateness of a directive to limit or withhold care,
contact field medical control immediately.

5. Document the directive(s), either written or verbal, received from the patient or
representative on the EMS chart.

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Clinical Guidelines CG 31 Page 68
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Clinical Guidelines CG 31 Page 69
TOC

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 Montgomery County Hospital District-EMS DESTINATION
DETERMINATION
Standard Delegated Orders –
Clinical Guidelines CG 32 Page 70
TOC

APPROVED TRANSPORT FACILITIES

Personnel should consider the needs and desires of the patient as the primary factor in
selecting a destination. They should take into consideration a facilities resources and
capabilities before a final decision is made. To aid them in this decision personnel should
refer to Facility Resources & Capabilities Chart. Also consideration should be given to the
current hospital status listed on EMResource as well as the status of the MCHD EMS
System.

Routine Destinations

The following Hospitals are within our transportation area and are approved for
transport on a routine basis:

Conroe Regional Medical Center

Memorial/Hermann Hospital – The Woodlands
St. Luke‘s – The Woodlands Community Hospital
Houston Northwest Medical Center
Northeast Medical Center
Kingwood Medical Center
Cleveland Regional Medical Center
Tomball Regional Medical Center
Methodist Willow Brook Hospital
Cypress Fairbanks Medical Center
Huntsville Memorial Hospital

Satellite Emergency Rooms

St. Lukes-Crossroads*
Memorial Herman the Woodlands-West *

*Personnel are encouraged to transport patients who have minor illness or minor
trauma to satellite emergencies rooms. Patients who may be admitted or require
resources listed on the Facility Resources & Capabilities Chart should not be
transported to satellite emergency rooms. These facilities have limited staff and
patients who require a sitter, security or physical restraint should not be transported
to satellite emergency rooms.

Requests for transport to other facilities including facilities in the Texas Medical Center in
Houston should be approved by the on-duty Supervisor. The decision to approve such
transport shall be based on the needs of the patient and the status level of the system.

Please refer to the Facility Diversion Guidelines for more specific information on diversion.

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 Montgomery County Hospital District-EMS DESTINATION
DETERMINATION
Standard Delegated Orders –
Clinical Guidelines CG 32 Page 71
TOC

Designated and non-designated facilities play an important integral role in the trauma
system. Patients with multi-system, blunt or penetrating trauma who are hemodynamically
unstable and/or have respiratory compromise or altered mental status should be triaged and
transported by EMS personnel to the nearest appropriate trauma facility. Mechanism of
Injury alone does not mandate transport to a trauma facility in the patient without
hemodynamic or anatomic criteria. The definition of appropriate facility is as follows:

A hospital, not necessarily the nearest hospital, with the resources and capability to care
for a patient based upon the patient‘s medical needs. To better understand the capability
of each facility refer to the Facility Resources & Capabilities Chart.

Patient rights should be respected in the determination of hospital destination. In the event
a competent trauma patient requests a destination discordant with the destination
recommendation the In-Charge Paramedic should consult with the Field Supervisor.

It is important to promptly notify facilities in order to allow for timely facility-specific trauma
team alert mechanisms to be activated.

Trauma Designations of local receiving facilities:

Memorial-Hermann The Woodlands Level IV operating as Level III

Columbia Conroe Regional Hospital No Designation
Columbia Kingwood No Designation
Tomball Regional Hospital No Designation
Northeast Medical Center No Designation
Houston Northwest Medical Center No Designation
Huntsville Memorial Hospital No Designation
LBJ Level III
Ben Taub Level I
Memorial-Hermann Level I

Level I:
Comprehensive trauma facility and tertiary care facility that has the resources
and capability to provide total care for every aspect of injury continuum from
research and prevention through rehabilitation.

Note: Level I facility has neurosurgery available 24 hours/day.

Level II:
Major trauma facility that has the resources and capabilities to provide
definitive trauma care to injury patients but may not be able to provide the
same spectrum of care as a Level I trauma center.

Note: Facility does not do research.

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DETERMINATION
Standard Delegated Orders –
Clinical Guidelines CG 32 Page 72
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Level III:
General trauma facility that has the resources and capabilities to provide
resuscitation, stabilization and assessment of trauma patients and can either
provide treatment or arrange for appropriate transfer to a higher level trauma
facility.

Note: Facility has trauma surgeon available 24 hours/day

Level IV:
Basic trauma facility that has the resources and capability to provide
resuscitation, stabilization or arrange for appropriate transfer of all trauma
patients with major and severe injuries to a higher level trauma facility.

Note: Facility does not have trauma surgeon available 24 hours/day.

All facilities with Level III and Level IV designations are members of a trauma network. They
are able to transfer patients to a more appropriate facility very quickly, often making transfer
arrangements while the patient is being evaluated and stabilized. It is an appropriate use
of resources to transport trauma patients to these facilities for evaluation. This
prevents the Level I and Level II centers from being overwhelmed with patients that are not
seriously injured.

For specialized care such as for Stroke, ACS, and Burns, refer to the Facility Resources
and Capabilities chart.

Burns

Inhalation
Burns to hands
30% TBSA 2nd degree or higher
< 12 or > 65 years of age

1. UTMB (consider AMP)

2. Memorial-Hermann Hospital

Psychiatric Crisis

Tri-County MHMR—ICES ***

***Eligibility is dependent on assessment using MCHD’s Crisis Residential Unit,

Inclusion/Exclusion Criteria. Personnel must contact the ICES nurse to verify
patient meets criteria and facility has space available.

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 Montgomery County Hospital District-EMS DESTINATION
DETERMINATION
Standard Delegated Orders –
Clinical Guidelines CG 32 Page 73
TOC

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 Montgomery County Hospital District-EMS FACILITY DIVERSION
Standard Delegated Orders –
Clinical Guidelines CG 33 Page 74
TOC

Diversion is a courtesy extended by MCHD EMS to a hospital facility, rather than a right to
be demanded by hospitals. This policy reflects the guidelines for diversion established by
the Southeast Texas Regional Advisory Committee on Trauma. The most current status of
a hospital is available on the EMSystem.

Definitions

Appropriate Facility: A hospital, not necessarily located nearest the scene

of an incident, that possesses the resources and capability to care for a
patient based upon the patient‘s specific medical needs.

Bypass: The intentional movement of a patient from the scene of an incident

to a specific hospital, not necessarily the nearest hospital, based upon the
patient‘s medical needs.

Diversion: The intentional movement of a patient from the scene of an

incident to an alternate hospital capable of caring for the patient at the
request of that hospital because they advise that current circumstances
indicate that hospital lacks the available resources or capability to treat the
patient.

Transfer: The movement of a patient from one hospital to another hospital

based upon the patient‘s medical needs. This procedure is also known as
inter-hospital transport.

Diversion Activation

It is the responsibility of the designated hospital administrator to update the EMSystem‘s

status board through their individual log-on entry. The system requires updating every 4
hours. Currently that is the system in place for indicating a hospital status. Only under
specific or catastrophic circumstances should MCHD accept a telephone diversion request
from a facility.

Diversion Activation Categories

A request for diversion may be honored if any of the following conditions is reported by the
requesting hospital:

Emergency Department (ED) saturation;

Intensive Care Unit (ICU) saturation;
Operating Room (OR) saturation;
Equipment repair or maintenance; or
Internal disaster.

MCHD EMS personnel should absolutely honor a hospital‘s diversion requests based on
internal disaster.

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 Montgomery County Hospital District-EMS FACILITY DIVERSION
Standard Delegated Orders –
Clinical Guidelines CG 33 Page 75
TOC

Communication of diversion status

A hospital should update the EMSystem status board every 4 hours.
A hospital should indicate the reason for their listed status.
Alarm should notify the on-duty Supervisor and duty crews diversion status and
reason for diversion.
Alarm shall maintain a data resource of hospital administrators and Trauma Directors
authorized to activate diversion implementation and deactivation. It is the hospitals‘
responsibility to provide this information.

Time Period for Diversion Status

A hospital may deactivate a diversion request at any time.
Diversion requests are effective for up to 4 hours, however, may be extended if
necessary.
A hospital should update EMSystem to indicate continued status.
Failure by a hospital to update the system maybe considered to be off diversion
status.

Authorization for Override of Diversion Requests

When a facility requests to be placed on diversion status, MCHD EMS personnel should
attempt to divert appropriate patients to other facilities whenever possible. MCHD personnel
should consider the condition of the patient, distance to alternate facilities, and the diversion
status of alternate facilities in determining the destination for the patient.

The on-line medical direction source (Supervisor and/or Assistant Director EMS-
Clinical Services) may override a diversion request or a crew’s transport decision
after consideration of the following:

Severity of the patient‘s condition;

Distance and estimated time to an alternate appropriate facility;
Patient‘s request;
Inclement weather conditions;
System Level; and
Whether all potential receiving facilities within a fifteen (15) minute radius of the
patient‘s location have requested diversion consideration.

System Monitoring and QI

MCHD EMS should document and report to the SETTRAC QI Committee those situations in
which a diversion request has not been honored or has been overridden by the on-line
medical direction source.

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 Montgomery County Hospital District-EMS AIR MEDICAL UTILIZATION
Standard Delegated Orders –
Clinical Guidelines CG 34 Page 76
TOC

Due to extended transport times to local trauma centers, it is sometimes in the best interest
of the critically ill and/or injured patient to have them transported via helicopter. The
utilization of helicopters as a means of rapid transport for critically ill or injured patients is an
additional tool that allows MCHD-EMS to provide the highest level of care.

Indication for Air Medical Utilization

Utilization should be based on the following criteria:
The aircraft can deliver the patient to definitive care faster than ground
transportation.
When transportation to a Level I or Level II Trauma Center is indicated and ground
transportation time is greater than 30 minutes.
When specialized services are required that local receiving hospitals are not
equipped to provide.
Severely injured patient(s) with extended extrication times. (> 30 min)
Mass casualty situations where EMS resources are exhausted.
Known or suspected head or spinal injuries with significant neurological deficits.
New neurological deficits/impairment in the presence of signs and symptoms
suggestive of an acute intracerebral process.
Significant (urgent or critical) burns requiring a burn center.
Burns associated with significant injuries.
2nd degree burn involving hands, feet, genitalia and face.
Inhalation burns.
Significant Chemical burns.
Significant Electrical burns.
Pediatric trauma and/or burns of any significance.

Air Medical Resources should not be used in the following instances:

Pending arrest.
Trauma that can be managed at a Level III and/or Level IV facility.

It is acceptable practice to transport a trauma patient to a closer facility for evaluation by the
emergency department physician. Often times patients appear to be more seriously injured
than they actually are. Following these guidelines allows the MCHD-EMS system to utilize
trauma facilities and Air Medical Services in a way that best meets the needs of the patients
and communities they serve.

Coordination of Air Medical Utilization

Responsibility for overall command and controlrests with the Incident Commander (IC) as
outlined in the Joint EMS/Fire Department Operations policy. The highest-ranking MCHD-
EMS on-scene should assume the role of EMS Sector officer and have the ultimate
responsibility for patient care. EMS Sector is responsible for keeping the IC informed of
patient condition and status and any manpower, equipment or other needs that may arise.

An Air Medical Provider (AMP) may be placed on standby by:

Calltaker

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Responding EMS unit

First Responders on scene
Fire personnel on scene
Law enforcement on scene

Air Medical should not be launched until one of the following occurs:
Supervisor on scene requests AMP
EMS unit is on scene and has made a determination that AMP is needed.

The person requesting Air Medical Provider assistance shall provide Alarm with the following
information:
Medic number
Brief report of patient condition
A precise location of the patient
Any unusual circumstances (bad weather, power lines down, etc.,)

Alarm should provide the following information to the AMP communicator:

Requesting agencies name and callback number.
Exact scene location including; key map grid, street address, etc.
Reason for the request.
Type and extent of injury if known.
Number of patients.
Ground contact and the radio frequency to be utilized.

Once the aircraft is enroute, the authority to terminate a request for services shall lie solely
with the EMS sector officer, who, if different from the In-Charge providing primary patient
care, should rely on the judgement of the In-Charge providing primary patient care.

Additionally, the pilot has the authority to terminate the air medical response.

The primary responsibility for patient care lies with the MCHD In-Charge.

The Incident Command is responsible for overall scene safety and may designate a Safety
Sector officer to assist in that role. The IC and or the EMS sector officer should directly
relay patient information to the helicopter when requested by the Air Medical Pilot.

The pilot is responsible for all aspects of the aircraft and shall make the final determination
regarding any safety issues that directly effect safety of the aircraft and crew. (LZ location,
weather, additional riders)

Landing Zone (LZ) Requirements

During normal daylight hours the LZ should be at least 60 x 60 feet. Additionally, it should
be marked with one traffic cone at each corner and one traffic cone on the upwind side.

During nighttime hours the LZ should be at least 100 x 100 feet with lighted cones at each
corner and one lighted cone on the upwind side.

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Additionally, all emergency vehicles should turn off all emergency lights, especially strobe
lights.

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 Montgomery County Hospital District-EMS CONTROLLED SUBSTANCES
Standard Delegated Orders –
Clinical Guidelines CG 35 Page 79
TOC

The scheduled injectables should be signed for at the beginning of each shift with both In-
Charge EMT-P‘s present. The sign-in sheet should reflect the number of scheduled
injectables counted with documentation of the unique number assigned to each one. The
on-coming Paramedic should sign in the appropriate space as receiving the scheduled
injectables and the Paramedic leaving signs as ―off-going‖ to document transfer of meds.
Failure to sign for the scheduled injectables at the beginning of each shift may result in
disciplinary action against both paramedics involved.
1st offense - Written warning
2nd offense - 48 hours off
3rd offense - 96 hours off
4th offense - Termination

Policy violations remain on file for a twelve-month period. If an employee has no other
occurrences during that time the policy violation is expunged from their record.

The on-coming In-Charge EMT-P is responsible for carrying the key for the controlled
injectables on his/her person at all times during the shift.

Controlled Substances should be obtained from the lock boxes outside the Supervisor‘s
office specifically designated for transfer units. The Attendant with Paramedic
Certification/Licensure from TDH should be responsible for signing the Controlled
Substance sign-in log and maintaining security of the key. If both Attendants are paramedics
the employee with the most seniority should be responsible for maintaining the Controlled
Substances.

Scheduled injectables are administered only after a person with extended medical
authorization has received a consult. There are a few exceptions to this rule and they are
addressed within the specific SDOs.

The Medical Director has granted extended medical authorization to the following
employees:

EMS Director
Assistant Director EMS-Clinical Services
Assistant Director EMS-Operations
Clinical Supervisor
Field Supervisors

After administration of a scheduled injectable the Paramedic administering the medication

should fill out the top portion of a Controlled Substance Usage and Tracking Form.
Scheduled Injectables will not be replaced by the supervisory staff without complete
documentation of usage. Contact the Supervisor as soon as possible for replacement.

As long as the scheduled injectable usage has been properly documented, the ambulance
may remain in-service with the minimum of one of each scheduled injectable while awaiting

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Clinical Guidelines CG 35 Page 80
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replacement. A unit should be placed out of service anytime all of one substance has been
used.

All medications should be checked frequently for expiration dates and may be administered
through the end of a month (e.g. expires 6/02), unless the expiration date specifies the day
of the month (e.g. 6/20/02). If possible, medications nearing their expiration date should be
administered first in appropriate situations as scheduled injectables cannot be returned or
exchanged. A Supervisor should be contacted for replacement before the medication
expires. Units/stations with expired medications may result in disciplinary action for all In-
Charge Paramedics who have been responsible for maintaining the chain of custody for the
controlled injectables.

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 Montgomery County Hospital District-EMS MEDICATION STORAGE
Standard Delegated Orders –
Clinical Guidelines CG 36 Page 81
TOC

The Texas Food Drug and Cosmetic Act states that drug or medical device is deemed
adulterated if it is stored under conditions that result in the product‘s safety or effectiveness
being compromised. Drugs and medical devices that are stored in places that do not have
proper environmental controls may become ineffective or dangerous. Products that are
stored improperly in vehicles (i.e. ambulances, personal vehicles) are considered
adulterated products and unsafe for human use. Guidelines for the proper storage of drugs
and medical devices are generally recommended by the manufacturer of the product. Where
no guidelines are listed on drug labels, the United States Pharmacopoeia recommends that
products are stored at room temperature, away from humidity, and where necessary, away
from light. For those devices that are not labeled with storage requirements, care should be
taken to avoid extremes of temperature, humidity and light. All labels should be read and
checked prior to storage. It is the responsibility of the operator to make sure that proper
storage requirements are met. The Texas Department of State Health Services has the
authority to detain and take action against those products that do not meet storage criteria.
Rule Reference: 25TAC 157.11

Interpretation:
The EMS provider licensure or relicensure applicant shall provide evidence of an operational
policy which shall list the pharmaceuticals authorized by the medical director and which shall
define the storage and maintenance procedures for each in accordance with the
manufacturers and/or FDA recommendations. Compliance with the policy shall be
incorporated into the provider‘s Quality Management process and shall be documented on
the unit readiness reports.

MCHD EMS has adopted the following policy to assure compliance with the above
mentioned rule. Medications and medical devices listed within this manual shall make use
of the vehicle climate control system when the vehicle is in operation. During times when
the vehicle is not in use, a generator-powered climate control system shall be utilized to
maintain a constant temperature range. Extra items stored at stations for replacement shall
be stored within a cabinet inside each station. Temperature control shall be maintained by
keeping the thermostat at a consistent setting within the station.

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Card 1- Abdominal Pain/Problems

01A01 Abdominal Pain Card 4-Assault/Sexual Assault (add
01C01 Fainting or near fainting >50 prefix A or R)
01C02 Females w/ faint/near faint 04A01 Not Dangerous body area
12-50 04A02 Non-Recent injuries (>6hrs)
01C03 Males with pain above navel 04B01 Possibly Dangerous body area
> 35 04B02 Serious hemorrhage
01C04 Females with pain above 04B03 Unknown status (3rd party
navel >45 caller)
01D01 Not alert 04D01 Unconscious or Arrest
04D02 Not alert
Card 2-Allergies (Reactions)/Envenom 04D03 Abonormal breathing
(Bites, Stings 04D04 Dangerous body area
02A01 No difficulty breathing or 04D05 Multiple victims
swallowing
02A02 Spider bite Card 5- Back Pain (Non-Trauma or Non-
02B01 Unknown status (3rd party Rec Trauma)
caller) 05A01 Non-Traumatic back pain
02C01 Difficulty breathing or 05A02 Non-Rect trauma back pain
swallowing (>6hrs)
02C02 Special meds or injections 05C01 Fainting or near fainting >50
used 05D01 Not alert
02D01 Severe Respiratory Distress
02D02 Not alert Card 6-Breathing Problems
02D03 Condition worsening 06C01 Abnormal breathing
02D04 Swarming Attack (bee, 06C02 Cardiac history
wasp,hornet) 06D01 Severe Respiratory Distress
02D05 Snakebite 06D02 Not alert
02E01 Ineffective Breathing 06D03 Clammy
06E01 Ineffective Breathing
Card 3-Animal Bites/Attacks
03A01 Not Dangerous body area Card 7-Burns(Scalds)/Explosions
03A02 Non-recent injuries (>6hrs) 07A01 Burns <18% body area
03A03 Superficial bites 07A02 Fire alarm (unknown situation)
03B01 Possibly Dangerous body 07A03 Sunburn or Minor burns
area (<hand size)
03B02 Serious hemorrhage 07B01 Unknown status (3rd party
03B03 Unknown status (3rd party caller)
caller) 07C01 Building fire w/ persons rpted
03D01 Unconscious or Arrest inside
03D02 Not alert 07C02 Difficulty breathing
03D03 Dangerous body area 07C03 Burns >18% body area
03D04 Large animal 07D01 Unconscious or Arrest
03D05 Exotic animal 07D02 Severe Respiratory Distress
03D06 Attack or multiple animals 07D03 Not alert

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Clinical Guidelines CG 37 Page 83
TOC

07D04 Explosion 11E01 Choking/Ineffective Breathing

07D05 Mulitple victims
Card 12-Convulsions/Seizures
Card 8-Carbon 12A01 Not seizing now and breath
Monoxide/Inhalation/Hazmat regularly
08A01 C.O. alarm (w/o priority 12B01 Breathing regularly not verified
symptoms) <35
08B01 Alert without difficulty 12C01 Pregnancy
breathing 12C02 Diabetic
08C01 Alert with difficulty breathing 12C03 Cardiac history
08D01 Unconscious or Arrest 12D01 Not breathing
08D02 Severe Respiratory Distress 12D02 Continuous or Multiple
08D03 Hazmat seizures
08D04 Not alert 12D03 Irregular breathing
08D05 Multiple victims 12D04 Breathing regularly not verified
08D06 Unknown status (3rd party >35
caller)
Card 13-Diabetic Problems
Card 9-Cardiac or Respiratory Arrest / 13A01 Alert
Death 13C01 Not alert
09O01 Expected Death 13C02 Abnormal behavior
(unquestionable) 13C03 Abnormal breathing
09B01 Obvious Death 13D01 Unconscious
(unquestionable)
09D01 Ineffective Breathing Card 14- Drowning (Near)/Diving/SCUBA
09E01 Not Breathing at all Accident
09E02 Breathing uncertain (agonal) 14A01 Alert and breathing normally
09E03 Hanging (no injuries & out of water)
09E04 Strangulation 14B01 Alert and breathing normally
09E05 Suffocation (injuries or in water)
09E06 Underwater 14B02 Unknown status (3rd party
caller)
Card 10-Chest Pain 14C01 Alert with abnormal breathing
10A01 Breathing normally <35 14D01 Unconscious
10C01 Abnormal breathing 14D02 Not alert
10C02 Cardiac history 14D03 Diving or suspected neck injury
10C03 Cocaine 14D04 SCUBA accident
10C04 Breathing normally >35
10D01 Severe Respiratory Distress Card 15-Electrocution/Lightning
10D02 Not alert 15C01 Alert and breathing normally
10D03 Clammy 15D01 Unconscious
15D02 Not disconnected from power
Card 11-Choking 15D03 Power not off or hazard
11A01 Not choking now present
11D01 Not alert 15D04 Long Fall (>6ft/2m)
11D02 Abnormal breathing (Part 15D05 Not alert
obstn) 15D06 Abnormal breathing

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Clinical Guidelines CG 37 Page 84
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15D07 Unknown status (3rd party 19C01 Firing of A.I.C.D.

caller) 19C02 Abnormal breathing
15E01 Not breathing/Ineffective 19C03 Chest Pain >35
breathing 19C04 Cardiac History
19C05 Cocaine
Card 16-Eye Problems/Injuries 19C06 Heart rate <50 bpm and >130
16A01 Moderate eye injuries bpm
16A02 Minor eye injuries 19D01 Severe Respiratory Distress
16A03 Medical eye problems 19D02 Not alert
16B01 Severe eye injuries 19D03 Clammy
16D01 Not alert
Card 20-Heat/Cold Exposure
Card 17-Falls 20A01 Alert
17O01 Public Assist (NOI/ASSO) 20B01 Change in skin color
17A01 Not Dangerous body area 20B02 Unknown status (3rd party
17A02 Non-recent(>6hrs) injuries caller)
17B01 Possibly Dangerous body 20C01 Cardiac history
area 20D01 Not alert
17B02 Serious hemorrhage
17B03 Unknown status (3rd party Card 21-Hemorrhage/Lacerations
caller) 21A01 Not dangerous hemorrhage
17D01 Dangerous body area 21A02 Minor hemorrhage
17D02 Long Fall (>6ft/2m) 21B01 Possibly dangerous
17D03 Not Alert hemorrhage
17D04 Abnormal breathing 21B02 Serious hemorrhage
21B03 Bleeding disorder or blood
Card 18-Headache thinners
18A01 Breathing normally 21C01 Hemorrhage through tubes
18B01 Unknown status (3rd party 21D01 Dangerous hemorrhage
caller) 21D02 Not alert
18C01 Not alert 21D03 Abnormal breathing
18C02 Abnormal breathing
18C03 Speech problems Card 22-Industrial/Machinery Accidents
18C04 Sudden onset of severe pain 22B01 Unknown situation (not caught)
(<3 hrs) 22D01 Life status questionable
18C05 Numbness or paralysis 22D02 Caught in machinery
18C06 Change in behavior (<3 hrs) (unknown)
22D03 Multiple victims

Card 23-Overdose/Poisoning(Ingestion)
23O01 Poisoning (w/o PS)
Card 19-Heart Problems/A.I.C.D 23B01 Overdose (w/o PS)
19A01 Heart rate >50 bpm and 23C01 Violent (police should secure)
<130 bpm 23C02 Not alert
19A02 Chest Pain <35 23C03 Abnormal breathing
19B01 Unknown status (3rd party 23C04 Antidepressants (tricyclic)
caller) 23C05 Cocaine (or derivative)

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23C06 Narcotics (heroin) 26C01 Cardiac HX (cplnt 2-28 not

23C07 Acid or alkali (lye) ident)
23C08 Unknown status (3rd party 26D01 Not alert
caller)
23C09 Poison Control request for Card 27-Stab/ Gunshot /Pentr Trauma
response (prefix S,G,P)
23D01 Unconscious 27A01 Non-recent (>6hrs) Periphl
23D02 Severe Respiratory Distress wounds
27B01 Non-recent (>6hrs) 1 Central
Card 24- wound
Pregnancy/Childbirth/Miscarriage 27B02 Known single Peripheral
24A01 1st Trim hemorrhage or wound
Miscarriage 27B03 Serious hemorrhage
24B01 Lbr (dlvry not imnt, >5 27B04 Unknown status (3rd party
mths/20 wks) caller)
24B02 Unknown status (3rd party 27D01 Unconscious or Arrest
caller) 27D02 Not alert
24C01 2nd Trim hemorrhage or 27D03 Central wounds
Miscarriage 27D04 Multiple wounds
24C02 1st Trimester Serious 27D05 Multiple victims
Hemorrahage
24D01 Breech or Cord Card 28-Stroke (CVA)
24D02 Head visible/out 28A01 Breathing normally<35
24D03 Imnt delivery (>5 months/20 28B01 Unknown status (3rd party
weeks) caller)
24D04 3rd Trimester hemorrhage 28C01 Not alert
24D05 High Risk complications 28C02 Abnormal breathing
24D06 Baby born 28C03 Speech or movement problems
28C04 Numbness or tingling
Card 25-Psychiatric/Abnormal 28C05 Stroke history
Behavior/Suicide 25A01 Non-violent 28C06 Breathing normally>35
and non-suicidal (alert)
25B01 Violent (police should Card 29- Traffic/Transportation Accidents
secure) 29A01 1st party caller with Not Dang
25B02 Threatening suicide Inj
25B03 Near hang, strang, 29B01 Injuries
suffocation (alert) 29B02 Multiple victims (one unit)
25B04 Unknown status (3rd party 29B03 Multiple victims (additional
caller) units)
25D01 Not alert 29B04 Serious hemorrhage
29B05 Unknown status (3rd party
Card 26-Sick Person (Specific caller)
Diagnosis) 29D01 Major Incident (a through e)
26A01 No PS (cplnt 2-28 not ident) 29D02 High Mechanism (a through g)
26A2-28 Non-priority complaints 29D03 Hazmat
26B01 Unknown status (3rd party 29D04 Pinned (trapped) victim
caller) 29D05 Not alert

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33C03 Significant hemorrhage or

Card 30-Traumatic Injuries (Specific) shock
30A01 Not Dangerous body area 33C04 Possible ACS or MI (heart
30A02 Non-recent injuries (>6hrs) attack)
30B01 Possibly Dangerous body 33C05 Acute severe pain
area 33C06 Emergency response
30B02 Serious hemorrhage requested
30D01 Dangerous body area 33D01 Suspect cardiac or respiratory
30D02 Not alert arrest
30D03 Abnormal breathing

Card 31-Unconscious/ Fainting (Near)

31A01 1/near fainting episode &
alert <35
31C01 Alert with abnormal breathing
31C02 Cardiac history
31C03 Multiple fainting episodes
31C04 1/near fainting episode and
alert >35
31C05 Females 12-50 with
abdominal pain
31D01 Unconscious (at end of
interrogation)
31D02 Severe Respiratory Distress
31D03 Not alert
31E01 Ineffective Breathing

Card 32- Unknown Problem (Man

Down)
32B01 Standing,sitting,moving,or
talking
32B02 Medical Alert notifications
32B03 Unknown status (3rd party
caller)
32D01 Life Status Questionable

Card 33-Interfacility/ Palliative Care

33A01 Acuity I (no priority
symptoms
33A02 Acuity II (no priority
symptoms)
33A03 Acuity III (no priority
symptoms)
33C01 Not alert (acute change)
33C02 Abnormal breathing (acute
onset)

Revision Date 11/10/2005 86

 Montgomery County Hospital District-EMS FILE TRANSFER OF PATIENT
CARE RECORDS
Standard Delegated Orders –
Clinical Guidelines CG 38 Page 87
TOC

A Patient Care Record (PCR) shall be accurately completed for each ambulance response
to a 9-1-1 call for service and contain all available requested information regarding call
demographics, patient assessment, care rendered and patient response to care. This also
includes non-emergency responses and dedicated standbys with or without patient
transport, calls where a unit has responded and there is no patient contact or response is
cancelled before scene arrival and all transfers whether scheduled or non-scheduled.
Completed PCR‘s may not be altered or changed unless done by the individual that
completed the form, except to add or change billing information, or add name and other
pertinent demographic information if it was unknown at the time of the call. Intentional
failure to complete a PCR when required may result in disciplinary action.

Completed PCR‘s are confidential patient medical records and access is limited to
responding personnel, State EMS authority as part of an administrative investigative
process, authorized medical facilities that received the transport and ambulance provider
service payor sources. Copies of completed PCR‘s may be provided to other sources only
as legally permitted. The records may also be provided to the patient or patient responsible
party by valid medical record release.

PCR completion and dispersal

1. Documentation of patient assessment and treatment information contained on PCR‘s

is the responsibility of personnel providing patient care. All MCHD employees
providing patient care are required to sign the patient care record.
2. Completed PCR‘s may not be altered or changed except by the individual that
completed the form, except as previously noted. If a paper PCR is utilized, any
documentation error shall be lined through, and the correction shall have the patient
attendant‘s initials beside it. Any changes made to an automated PCR shall have
documentation of those changes retained in the computer data base and correction
logbook.
3. Each PCR shall be accurately completed with all available and relevant information
as described in the documentation standards for MCHD-EMS. Use of usual and
customary abbreviations is permitted in the narrative section of the record or as
defined in automated PCR predesignated picklists.
4. Each PCR shall be accurately completed as soon as possible after the response or
patient transport is completed and copies should be provided to the receiving facility
in the customary manner. If the transport personnel are unable to complete the form
prior to leaving the facility, the PCR shall be completed and returned to the receiving
facility as soon as possible, but in no case later than 24 hours after completion of the
call. If extenuating circumstances prevent this from taking place the Clinical
Department should be notified so that copies of the PCR may be forwarded to the
facility.
5. Wait and return transfers receive two (2) incident numbers (one incident number to
transport patient to destination and the second to return patient to originating
location). Therefore, two (2) reports should be written.

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 Montgomery County Hospital District-EMS FILE TRANSFER OF PATIENT
CARE RECORDS
Standard Delegated Orders –
Clinical Guidelines CG 38 Page 88
TOC

6. File transfers of PCR‘s SHOULD take place daily. This transfer should occur
regardless of any open calls. Crews are encouraged to complete PCR‘s as soon as
possible after the incident occurs.
7. Employees with open calls transferred should report to the Clinical Department within
48 hours to complete the PCR. Failure to complete the PCR within this time may
result in Clinical Suspension of authorization and the employee is not allowed to
return to duty until the PCR has been completed. The employee should not be paid
to complete the report.
8. Employees with reasonable explanations for not completing the PCR may be exempt
from Clinical Suspension. Each incident will be reviewed and exemption determined
on an individual basis by incident.

Daily transfer of the patient care record is important from a Clinical as well as a billing
aspect. Therefore, in an effort to improve this procedure guidelines have been developed
for file transfers to occur.

Units that are on station at shift change should still attempt to file transfer before 0700 hrs.
Units that are responding to emergency calls or posting should have until 0900 hrs. to
complete this procedure. Peak trucks should file transfer before they sign out and go
home.

The Clinical Department performs their daily append at 0930 hrs. File transfers are to
occur daily regardless of any open calls. If the on-coming crew notices calls from the
previous shift they SHOULD perform a file transfer as soon as they are able. If you are
unable to complete the file transfer, please notify someone in the Clinical Department. This
ensures that the Electronic Patient Care Record System server is working properly or has
been reset. Remember you can file transfer as many times per shift as you choose or have
time.

Patient Care Records that are transferred without being closed SHOULD be completed
within two (2) business days or 48 hours after the response. It is the responsibility of
the employee to schedule time to complete the record. Any employees with open calls
after two (2) business days or 48 hours will be placed on Clinical suspension and WILL NOT
be allowed to return to work until all reports are completed. The Assistant Director EMS-
Operations and Supervisory staff will be notified of the employee‘s Clinical suspension and
documentation should be placed in employee files.

When an employee has received two (2) Clinical Suspensions for open calls the third step in
the disciplinary process will be one (1) shift off without pay. The employee MAY NOT be
allowed to use PTO time or work an extra shift during the same week that he/she is
suspended without pay. Once the fourth incident occurs the employee be reported to the
Texas Department of Health for violations of the Texas Administrative Code Rule 157.36 (b),
(1), (2), (3) and (28) and may be subject to a non-emergency suspension, decertification
and revocation of their certification or licensure (see attached TDH Rules).

We understand there will be circumstances when employees may not be able to meet the 2-
business day and/or 48-hour deadline. Each incident be reviewed on a case by case

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 Montgomery County Hospital District-EMS FILE TRANSFER OF PATIENT
CARE RECORDS
Standard Delegated Orders –
Clinical Guidelines CG 38 Page 89
TOC

basis. It is the responsibility of the employee to contact their Supervisor or the Clinical
Department before the deadline occurs to make appropriate arrangements to complete the
documentation process. The Clinical department should document that the employee called
as well as the reason for non-compliance with the deadline time. An appointment should be
made with the employee to complete the report as soon as possible. Documentation of this
interaction will be placed in the employee file. Failure to contact the Clinical department to
initiate this process will result in Clinical suspension until the patient care records are
completed.

It is a requirement of all operation‘s employees to complete reports in a timely manner

during normal shift hours. Overtime will not be paid to complete open calls unless late
calls, posting assignments or Electronic Patient Care Record System failure prohibits the
procedure. Again, each incident will be considered on a case by case basis. If overtime
pay is appropriate for the situation, the Assistant Director EMS-Operations may approve the
employees‘ time to complete the report. The employee SHOULD NOT be paid for time spent
writing the report beyond his/her normally scheduled shift UNLESS there is written
documentation from a Supervisor that authorizes the overtime.

Revision Date 11/10/2005 89

 Montgomery County Hospital District-EMS ALLIED HEALTH CARE
PROVIDERS
Standard Delegated Orders –
Clinical Guidelines CG 39 Page 90
TOC

The purpose of this policy is to ensure compliance with the rules of the Texas State
Board of Medical Examiners, the Texas State Board of Nurse Examiners, and the
Texas Department of State Health Services. In accordance with these rules, Allied
Health Care providers may accompany EMS personnel during the ambulance
transport of a patient for the purposes of:

1. Providing additional personnel to allow the efficient and effective provision of

care to critically ill or injured patients.

2. Monitoring and managing equipment, adjuncts, and medications with which

the EMS personnel are not familiar (e.g.; IV pumps, ventilators, or unusual IV
medications). .

For the purpose of this policy, Allied Health Care providers are defined as:

1. Nursing personnel (LVNs, GN‘s, and RN‘s)

2. Respiratory Therapists or Respiratory Care Practitioners
3. Nurse Practitioners, Physician Assistants

Allied Health Care providers are authorized to accompany ambulances in the MCHD
EMS System when they are requested by the attending EMS personnel, the
transferring physician, or the on-line medical control personnel.

The attending Paramedic is ultimately responsible for the management of the patient
while in the care of the EMS system. Allied Health Care providers may not
independently treat patients while those patients are in the care of the EMS system.

Either the protocols or the on-line physician must authorize all treatments and
therapies. Orders from the transferring physician concerning care to be rendered
during transport that is not in the current protocols must be given as written orders
and turn in the patient care report.

The specialized neonatal/pediatric team will be a recognized exception to this policy.

The Director of the Neonatal/Pediatric Unit and the Medical Director for MCHD EMS
will agree that the EMS personnel will be back up for the nurse(s) on the
Pedi/Neonatal team.

When a transferring physician requires specialized drugs or narcotics that are not in
MCHD EMS stock, the physician shall provide the EMS personnel with the
drugs/narcotics needed. The drugs/narcotics must be accompanied with a written
order from the transferring physician. Drugs/narcotics not used will be wasted as the
Controlled Substance Policy.

The presence of an Allied Health Care provider does not exempt the EMS unit from
proper staffing requirements set forth by TDSHS Rule §157.11 or proper paperwork.

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 Montgomery County Hospital District-EMS PRIMARY SURVEY/CABC’S
Standard Delegated Orders –
Clinical Guidelines CG 40 Page 91
TOC

Through out the Protocols, the acronym ―CABC's‖ is used to indicate the primary
survey of the every patient. Our patient survey consists of the evaluation and, if
needed, management of the following components:
Cervical spine
Level of consciousness
Airway
Breathing
Circulation

The following is an outline for the assessment and management of these

components.
The patient survey includes (in order):
1. Obtain manual control of cervical spine, if indicated
2. Quickly establish level of consciousness (AVPU).
3. Evaluate airway. Establish patent airway if needed.
4. Evaluate breathing. Initiate ventilation or ventilatory assistance if needed.
Assess for open chest wounds. Occlude any found.
5. Check for presence and adequacy of circulation. Initiate chest compressions
if needed. Check for external bleeding. Control any significant bleeding found.
Cervical Spine
If there is any possibility of a spinal injury through mechanism of injury or level of
medic‘s suspicion, the provider should assume that one exists and approach the
patient accordingly. Once permission to assess the patient is obtained, by verbal
consent, the provider's next step on any patient with the possibility of spinal injury is
to manually obtain control of the c-spine. This manual c-spine stabilization should be
maintained until:
1. Further assessment clearly and absolutely rules out any possibility of spinal
injury,
2. The spine is adequately immobilized with adjuncts which relieve the need for
manual stabilization OR
3. The patient refuses further treatment or transport.

According to BTLS, the following are indicators from the mechanism of injury that a
potential spinal injury exists and that these patients should be immobilized:
Blunt trauma above the clavicles
Diving accident
Motor vehicle collision or bicycle accident
Fall
Stabbing or impalement anywhere near the spinal column
Shooting or blast injury to the torso
Any violent injury with forces that could act on the spinal column or cord

Patients who are found unconscious on the floor are considered to have a cervical
spinal injury unless a bystander or family member can give an accurate account of
how the patient got to the floor. Proper cervical spine protection includes manual

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 Montgomery County Hospital District-EMS PRIMARY SURVEY/CABC’S
Standard Delegated Orders –
Clinical Guidelines CG 40 Page 92
TOC

stabilization, C-collar application, patient placement, via logroll, onto long backboard,
webbing application and headbed/towel roll/head block application. Placing patient
in a Scoop Stretcher does not constitute spinal motion restriction. If the patient is
placed in a Scoop Stretcher, then spinal immobilization can be accomplished as
follows: manual stabilization, C-collar application, Scoop stretcher application,
placement of patient and Scoop stretcher onto back board, webbing application, and
headbed/towel roll/headblock application.

Level of Consciousness

The level of consciousness should be briefly assessed next, to determine only the
patient's rating on the ―AVPU‖ scale (Alert, responsive to Pain, responsive to Voice,
Unresponsive). Further assessment of the level of consciousness is to be deferred
until the secondary survey.
Airway
The patient's airway should next be evaluated for patency. If there is any indication
of a compromise in the patient's airway or any threat that such a compromise will
develop, the provider should immediately intervene to secure the airway. Indications
of compromise may be as overt as apnea or a visible obstruction, or may be
indicated by a less obvious sign such as airway noises (stridor, snoring, gurgling,
etc).

The airway should be secured first with positioning, using a jaw-thrust if spinal injury
cannot be ruled out or a head-tilt/chin-lift if spinal injury is not a concern. If material
should be physically removed from the airway, this should be done next using
abdominal or chest thrusts, a finger sweep, and/or oral suctioning as appropriate. If
the patient's level of consciousness is diminished, an airway adjunct should be
placed next. Use an oral airway if the patient will tolerate it, otherwise use a nasal
trumpet. Manual positioning should be maintained concurrently with the use of such
an adjunct. If possible, the airway should next be definitively secured with ET
intubation. Even in the patient whose airway is initially patent, the provider should
continuously reassess and be prepared to intervene against any airway compromise.
Breathing
The next component to be assessed is the patient's respiratory status. If the patient
is not breathing spontaneously, ventilation with supplemental oxygen should be
initiated immediately. If the patient is breathing spontaneously, the adequacy of the
patient's respiratory effort should be evaluated. If the patient's rate or tidal volume is
inadequate, assisted ventilation with supplemental oxygen is to be provided
immediately. The patient's chest should also be rapidly assessed for open wounds
which would compromise respiration. If any open chest wound is found, it should be
immediately occluded, initially with the provider's gloved hand and then with an
occlusive dressing.
The bag-valve-mask device with oxygen at 10-15 l/min and a reservoir bag is the
preferred method of providing ventilation. The demand-valve (oxygen-driven,
manually triggered device) should not be used unless a properly functioning BVM is
not available as the demand-valve offers no sense of compliance or resistance to the

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 Montgomery County Hospital District-EMS PRIMARY SURVEY/CABC’S
Standard Delegated Orders –
Clinical Guidelines CG 40 Page 93
TOC

operator and often results in excessive gastric distention. If possible, the airway
should always be secured with ET intubation if positive pressure ventilation is to be
instituted. As with the airway, the provider should continuously reassess the
ventilatory status of even the most stable patient and be prepared to rapidly
intervene if respiratory compromise develops.

Circulation
The patient shall next be assessed for:
1. Adequate circulation AND
2. For the presence of major external hemorrhage.

If the patient is awake or at least responsive to verbal or physical stimulus, the

provider shall assume that circulation is adequate for the moment and move on. If
the patient is unresponsive, the provider should assess for the presence and
adequacy of a palpable carotid pulse. If the patient does not have a palpable carotid
pulse, or has a pulse of less than 30/min in the adult (less than 40/min in a child or
less than 60/min in an infant), the provider should initiate chest compressions. A
more accurate evaluation of the patient's perfusion status should be done during the
secondary survey. Next, rapidly assess the patient for external bleeding. If major
bleeding is found, it should be immediately controlled with direct pressure.

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 Montgomery County Hospital District-EMS FOCUSED AND DETAILED
EXAM
Standard Delegated Orders –
Clinical Guidelines CG 41 Page 94
TOC

FOCUSED AND DETAILED EXAMINATIONS

The focused exam is an assessment that is pertinent to the patient‘s chief complaint. The
detailed physical exam is a systematic, whole body assessment that evaluates physical
findings and significant history. It is performed after the initial assessment has determined
that there is no life threat, or interventions have been made to lessen that threat. The
amount of time expended or even the necessity of these exams is directly dependent on the
patient‘s condition. All remarkable findings, associated symptoms, and pertinent negatives
(ASPN) are to be documented.

This is also the time that an interview is conducted for history. This information is to be
included in the patient report to the health care provider who receives this patient as well as
in the patient care report. The SAMPLE mnemonic is easily remembered as:

S - Signs/symptoms
A - Allergies
M - Medications (prescribed, over the counter or elicit)
P - Pertinent past medical history
L - Last oral intake
E - Events that lead up to calling EMS

O - Onset of Symptoms A - Associated

P - Provocation S - Symptoms
Q - Quality of pain P - Pertinent
R - Radiation of pain N - Negatives
S - Severity
T - Time

TRAUMA SURVEY

A helpful mnemonic to assess trauma patients comes from the Basic Trauma Life Support
class. Head, Neck, Chest, Abdomen and Extremities can be systematically checked using
DCAP-BTLS, or if you prefer, DCAP-BLSTIC.

D - Deformity B - Burns
C - Contusions L - Lacerations
A - Abrasions S - Stability
P - Penetrations or T - Tenderness
Paradoxical Movement I - Instability
C - Crepitus

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TRAUMA HEAD-TO-TOE SURVEY

Head, Face, Eyes

- Deformities - Foreign Bodies
- Depressions - Penetrations
- Contusions - Burns
- Hematomas/Battle‘s Signs - Facial Symmetry
- Lacerations - Fractures
- Pupil size, equality, reaction to light - Discharge from ears, nose
- Extraoccular motions - Loose teeth, Dentures
- Raccoon‘s eyes - Oral Secretions, vomitus or bleeding
- Blink reflex - Contacts or Glasses

Neck Chest
- Point tenderness - Paradoxical Motion
- Alignment - Breath/Heart Sounds
- Neck Veins: Flat or Distended - Sternal Inspection
- Trachea: Midline or Deviated - Crepitus
- Retractions with Respirations
- Contusions, Abrasions, Hematomas
- Sucking Chest Wounds Phenomenon

Abdomen
- Localized Tenderness - Rigidity
- Rebound Pain/Referred Pain - Bowel Sounds
- Pulsatile Mass - Ecchymosis
- Distention

Pelvis Extremities
- Deformities - Distal Circulation
- Pain on Palpation - Range of Motion
- Contusions, Abrasions, Hematomas - Motor/Sensory Response
- Ecchymosis - Abnormalities/Deformities
- Genitalia Trauma - Contusions, Abrasions, Hematomas
- Skin Color/Tugor

Back
- Pain
- Deformities
- Contusions, Abrasions

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MEDICAL/CARDIAC HEAD-TO-TOE SURVEY

Head, Face, Eyes

- Pupil Size, Equality, Reaction to Light - Skin Color and Quality
- Extraoccular Motions - Discharge form Ears, Nose
- Conjunctiva Color - Mouth Odors
- Blink Reflex - Loose Teeth, Dentures
- Contacts or Glasses - Mucous Membrane Color
- Facial Symmetry

Neck Chest
- Carotid Artery Bruits - Paradoxical Motion
- Neck Veins: Flat or Distended - Breath/Heart Sounds
- Trachea: Midline or Deviated - Retractions with Respirations
- Nuchal Rigidity

Abdomen
- Localized Tenderness - Rigidity
- Rebound Pain/Referred Pain - Bowel Sounds
- Pulsatile Mass - Ecchymosis
- Distention

Extremities
- Distal Circulation
- Range of Motion
- Motor/Sensory Response
- Abnormalities/Deformities
- Skin Color/Tugor
- Cyanosis, Clubbing, Edema

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Occasionally, EMS personnel will encounter a patient whose injury can only be treated
definitively with surgery. When confronted with such a patient, the attending EMS personnel
shall institute the basic interventions noted here and begin transport to an appropriate facility
AS SOON AS POSSIBLE.

Rapid transport includes utilizing the helicopter to transport the patient, when doing so
expedites the transport of the patient to the most appropriate facility. See the ―Air Medical
Utilization‖ protocol for specific guidelines regarding this issue.

ONLY THE FOLLOWING INTERVENTIONS ARE TO BE DONE PRIOR TO INITIATING

TRANSPORT:
Spinal Motion Restriction
Spinal Motion Restriction procedures may need to be modified and
abbreviated to achieve rapid transport in some situations. Such deviations
should be well documented and should still ensure that the patient is
adequately and appropriate secured and immobilized. The KED should not be
used to immobilize sitting patients in a rapid transport situation.
BLS airway and ventiation procedures (Oxygen administration, OPA, BVM, etc.)
Defibrillation (only the initial shock)
Intubation IF it can be accomplished rapidly (two attempts)
Surgical airway
Occlusion of open chest wounds
Vital signs (may use peripheral pulses to estimate—See ―Diagnostic Tools and
Procedures‖ rationale)
Freeing patient from entrapment

All other interventions are to be done once enroute to the hospital. If entrapment delays
transport, other interventions may be instituted on-scene while awaiting the patient to be
freed (e.g., bandaging/splinting, IV initiation, cardiac monitoring, etc.).

The following represent patients for whom rapid transport is suggested:

Patients meeting the BTLS guidelines for ―load and go situation‖

Adult and Pediatric Critical Trauma as defined in "Destination Determination"
protocol
Head Injury or CVA with evidence of increasing ICP
Suspected aortic aneurysm
Suspected ectopic pregnancy, abruptio placenta, or uterine rupture
All abdominal pain patients with unstable vital signs (tachycardia with normotension,
hypotension)
Obstetrical emergencies resulting in possible fetal distress, such as limb
presentation, breech delivery, or prolapsed cord
GI bleeding with unstable vital signs (tachycardia with normotension or hypotension)
Any other patient requiring urgent surgical intervention.

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STANDARDS FOR DOCUMENTATION

All providers shall have the responsibility for ensuring that all EMS incidents to which a unit
is dispatched are documented. This includes all incidents in which a patient is treated
and/or transported by the responding unit; the patient refuses any aspect of EMS service;
the patient has left the scene; unfounded calls; the patient is referred to another unit or
service for transport; and people on scene meeting the definition of ―no patient.‖ The
provider shall have the responsibility for ensuring that a patient care report is prepared. The
patient care report should include signatures where appropriate. ECG data should be
uploaded and linked to the PCR.

Key:
Operations Information
Bold items indicate Componentand should be documented
an “Absolute”
Italicized itemsCompletion
Standard: indicate examples of terminology component
of this documentation that may beshall
usedrequire
to document
properthat
component. documentation of all the absolute criteria listed as follows:
For all required components and criteria that cannot be obtained, place NA for Not
Date
Applicable or ―0‖ of Incident
(zero) for number fields.

Operations Information Component

Standard: Completion of this documentation shall require proper documentation of all
absolute criteria listed as follows:
Location of incident, including street address and city
Unit designation of dispatched unit
Complete and Correct Incident number as assigned by Alarm
Crewmembers assigned to call, identified by employee number and
signature
Destination
If delivered to a hospital other than the ED, document area of hospital (Rm. #,
ICU, L&D)
Dispatch priority
Dispatch Determinant
Transport Priority
Mileage
Appropriate Signatures

Goal: Proper documentation of 100% of the above criteria

Acceptable Terminology:

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Destination (where patient was delivered)

If a patient was not transported, the Call Outcome section should include
the reason. Refusal; Dead on scene; No Injury, etc.

If the chart is generated by a non-transporting unit, the Call Outcome

section should include the patient‘s disposition. Refusal; Dead on scene;
transported by (transporting unit’s service name and designation), etc.
If the patient is delivered to the Emergency Department, the Call
Outcome section should include the name of the facility. Conroe Medical
Center, Houston Northwest, Hermann, etc.

If the patient is delivered to a facility/location other than the Emergency

Department, the Call Outcome section include the name of the
facility/location.
Dr. Jones’s Office, Hermann PICU, Conroe Medical Center CCU, AMP
Landing Zone, etc.

Dispatch Priority
Shall be documented in the Response Screen as how the crew
responded to the call.
Emergency = Priority 1 or 2
Non-Emergency = Priority 3 or 4
Other = Walk in Patient

Dispatch Determinant
Shall be documented in the Response Screen as received from the crew
from Alarm in the format of Dr. Jeff Clawson EMD guidelines.

Transport Priority
Shall be documented in the Call Outcome as follows:
Patient condition (Non-urgent, Urgent, Critical, CPR, etc.)
Transport Status (Non-emergency, Emergency)

Mileage

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Shall be documented as total miles including decimal points from scene

to destination.

Appropriate Signatures
Shall be obtained for Refusals, Refusal of Treatment, No injuries, etc.
If patient cannot sign, select the appropriate option from the ―pull down‖
menu.

Patient Demographics Component

Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all absolute criteria.
Patient name
Patient age
Date of Birth
Patient’s sex
Name of Guardian/Next of Kin
(If applicable for minors and geriatric)
Mailing address, City, State, Zip Code
Home Telephone Number
Social Security Number
“Bill To” Information
Medicare/Medicaid Number (If applicable)
Insurance Company Name (If applicable)
Insurance policy/group number (If applicable)
Insurance Phone Number (If applicable)

Goal: Proper documentation of 100% of the above criteria

Acceptable Terminology:
If information is unobtainable, place “0” (zeros) in number fields.
If patient has no address, use “NFA” for no fixed address.
All minors should have Next of Kin/Guardian documented.

Primary Survey

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Standard: An evaluation of the ―satisfactory‖ completion of this documentation

component shall require the documentation of all of the absolute criteria and
at least 50% of the remaining criteria. The criteria are as follows.
The Primary Assessment should be overly stated as:

Documentation as to the absence, possibility, or presence of an injury to the

patient’s spine. If an injury to the cervical spine is observed or suspected, you should
state when/how you maintained the C-spine manually.

Documentation concerning the patency of the patient’s airway.

Documentation concerning the presence or absence and the quality of the

patient’s breathing.

Documentation concerning the presence or absence of a palpable pulse. If the

patient has palpable pulse, the provider should document at which site the pulse was
palpated.
Documentation as to the presence or absence of visible external bleeding. If
external bleeding is present, the provider should document (in general terms) the rate
and quantity of bleeding.

Documentation of patient’s mental status using the “AVPU” scale. The provider
shall document the highest score on this scale.

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
Airway
If the patient‘s airway is not intact, state the factors which are
contributing to the compromise.
Breathing
In describing the quality of the patient‘s respirations, the following
terms are acceptable:
Uncomplicated, non-labored, labored, snoring, agonal, wheezing,
tachypnic, shallow, Kussmaul, Cheynne-Stokes, gasping, and absent.
Circulation

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When documenting the presence of a pulse, the following terms may

be used:
Faint, weak, thready, rapid, regular, irregular, bounding, slow,
bradycardic, tachycardic, and strong

Bleeding
When documenting the presence and extent of external bleeding, first
state whether the bleeding is venous or arterial. Then describe the
quantity/quality of the bleeding.

Stopped PTA: bleeding that ceased prior to the arrival of EMS units
either by self-clotting or other interventions.
Minimal: slow capillary bleeding easily stopped by direct pressure
Moderate: venous or arterial bleeding that is controlled with firm direct
pressure and bulky dressing.
Severe: venous or arterial bleeding that cannot be controlled by firm
direct pressure, bulky dressing, or utilization of pressure points.
Other terms that may be used include:
Spurting, bright red, dark red, seeping, oozing, and steady.

Chief Complaint
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria.
The chief complaint should be “what the patient states” in
response to the provider’s inquiry. It should not be the
provider’s assessment of what is wrong. If the patient is unable
to verbalize or does not answer the provider’s questions, then
there is no “chief complaint.” This is to be documented as
“patient unable to give chief complaint.”

Goal: Proper documentation of the patient‘s chief complaint as stated by the patient
and not the provider‘s assessment.

Vital Signs
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all the absolute criteria and at least
50% of the remaining criteria. Criteria for the component are as follows.
Blood pressure

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Pulse rate
Respiratory Rate
If the pulse is regular or irregular
The vital signs appropriately obtained.

Goal: Proper documentation of 100% of above criteria.

Vital signs are defined as blood pressure (auscultated if possible with both
systolic and diastolic), capillary refill (in the pediatric patient less than one
year of age), pulse or heart rate, and respiratory rate.

Repeat sets of vital signs should be obtained every 5 minutes in the critical,
or non-stable patient, or every fifteen minutes or less in the stable, non-
critical patient.

Capillary refill (CR) may be used as an adjunct to blood pressure in

assessing/describing the perfusion status of the pediatric patient. CR is to be
charted in terms of seconds (i.e., CR < 2 sec.).

A palpated B/P is acceptable documentation ONLY:

A. As an additional vital sign in the non-urgent patient in whom an
auscultated B/P has already been obtained and was within accepted
normal limits.
B. In the critical trauma patient in whom serial palpated blood pressures
are being obtained.
C. In the patient in whom an auscultated blood pressure ABSOLUTELY
cannot be obtained. In this case, the chart SHOULD reflect the fact
that an auscultated blood pressure was unobtainable and the reason
why.

Patients refusing treatment/transport should have one complete set of vital

signs documented. If the vital signs are not within accepted normal limits, a
second set should be documented, a minimum of five minutes after the first
set. If patient refuses vital signs, document as such in your narrative.

Patients being transported from a medical facility to their home or a nursing

home should have at least one set of vital signs documented. If the initial set
of vital signs are not within accepted normal limits, a second set should be
obtained.

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Patients transported from one hospital to another or from a nursing home or

other facility to a hospital should have a minimum of two sets of vital signs
documented.

All other transported patients should have a minimum of two sets of vital
signs documented.

The chart should reflect the reason(s) for any deviation from the standards
required by the protocol for obtaining vital signs (i.e., patient refusing v/s,
extremely short transport time, etc.).

Secondary Assessment
Standard: An evaluation of "satisfactory" completion of this documentation
component shall require proper documentation of all of the absolute
criteria and 50% of the remaining criteria. The criteria for this component are
as follow:
Level of consciousness
Any findings relating directly to the patient's chief
complaint and/or EMS differential. This may include the Medical
Assessment Screens (i.e. Respiratory, Fibrinolytic, 12-Lead, Cardiac
Arrest, etc.)
The presence or absence of associated findings relating
indirectly to the patient's chief complaint and/or
EMS differential (i.e., injuries commonly found
with a particular mechanism of injury, symptoms
commonly associated with a particular illness, etc.)

A complete "Head-to-toe" exam shall be performed on all

trauma patients to rule out the possibility of
associated injuries secondary to the mechanism.

A focused exam shall be performed on all medical patients to reveal

physical findings associated with the patient‘s medical disease/illness.

Breath sounds (when applicable)

Distal pulses
Neuro sensation
Range of motion of extremities
Skin assessment
Pupillary Response

Goal: Proper documentation of 100% of above criteria.

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Acceptable terminology/parameters:

The patient's level of consciousness should be documented on all patient

contacts, including patient refusals. Full orientation refers to the patient that is
oriented to person, place, time, and event.
Acceptable terms include.
Alert and Oriented to PPTE (Person, Place, Time, and
Event) or X4 (if all four)
Awake and Oriented to_______ only
Obtunded
Decreased level of consciousness AND arousable to (voice,
physical stimulus, pain) only (should chart response to stimulus)
Unresponsive

A complete "Head-to-Toe‖ exam should include the exam and evaluation of

the patient's head, chest, back, abdomen, and extremities for injury and/or
abnormalities.

Assessment of the patient's skin should be charted on all assessed

patients, and includes the evaluation and documentation of the
patient's skin temperature, moisture, color, and turgor.
Temperature may be described as warm, cool, etc..
Moisture may be described as dry, diaphoretic, etc.
Color may be described either by color (i.e., pink) or by
quality of color (i.e. fair, pale, etc.).
Turgor may be described as fair, good etc. or by describing
the degree of skin tenting (right forearm skin tented for 3 seconds).

Breath sounds should be auscultated in all patients with the possibility of

respiratory compromise, either for medical or traumatic reasons. Because
prehospital differentiation of rales versus rhonchi is difficult, breath sounds
should be described as how they sound, such as: wet, coarse, diminished,
absent, wheezing, etc.

Distal pulses refer to the presence or absence of radial and/or pedal pulses
distal to any injury. The distal pulse should be evaluated prior to, and
immediately following, the immobilization and/or bandaging of an injury.

An evaluation of neurological sensation should be obtained secondary to any

injury to check for deficits.

Range of Motion (ROM) should be evaluated secondary to an injury or CVA.

ROM can be described as “full,” “normal,” “decreased,” “absent,” etc.

“Not Assessed” should be documented in all areas of the patient exam

whenever the exam was not performed.

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Mechanism of Injury
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require the proper documentation of all the absolute criteria.
For MVC‘s:
Damage to the windshield, steering wheel, dash, or other
appropriate component of the interior
Direction and nature of impact Location and extent of exterior
damage (using the Vehicle Damage Rating Scale)
Use of, and type of restraint (i.e. seatbelt, airbag)
For other injuries:
Clear description of mechanism such as the device or weapon,
length of knife or implement, speed or force, height of fall, etc.
For all injuries:
Any patient statement as to loss of consciousness or other details
of mechanism (i.e. patient states he did not strike the steering wheel.)

Goal : Proper documentation of 100% of the above criteria.

History of Present Injury/Illness

Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require the proper documentation of all the absolute criteria and at least
50% of the remaining criteria. The criteria for this component are as follows:

Onset of the event or signs/symptoms?

What precipitated the events/symptoms?
How have the symptoms progressed or changed?
What aggravates or alleviates the problem?
Any Third party information (e.g. the nursing home‘s c/c, witness
statements, etc.)
If the patient is returning home (or to a nursing home, etc) the following
information should be included:
When the patient was admitted
Why the patient was admitted
General overview of treatment while in facility

Goal: Proper documentation of 100% of the above criteria.

Previous Medical History (PMHX)

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Standard: An evaluation of ―satisfactory‖ completion of this documentation component

shall require the proper documentation of all the absolute criteria. The criteria
for this component is as follows:
Any previous medical history stated by the patient, family, care givers,
etc. or that is documented in the patient‘s chart or medical record.
Any recent past major surgeries.
Patient‘s private physician (if they have one)

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
*N/A is NOT an appropriate statement as the previous medical history is
applicable to any and all patients.

If the patient has no pertinent previous medical history, document as ―none.‖

If the patient PMHX is unknown, document as ―unknown.‖

Home Medications/Allergies
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require the proper documentation of all the absolute criteria is as
follows:
Should include all of the patient’s prescription medications.
Should include all of the patient’s known allergies to
medications.

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:

*N/A is NOT an appropriate statement as medications and

allergies are applicable to any and all patients.
If the patient does not take any medications, document as none.
Med List with patient is not an acceptable notation of the patient‘s
medications
If the patient does not know the name of a medication, document
why the medication is taken. (E.g. unknown anti-HTN
medication)
If the medication information is not available, document
as unknown. The chart should reflect the reason you
were not able to obtain the medication information.

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*Over the Counter medications taken PRN, unless pertinent

to the present episode, are not required to be noted (e.g.
Advil, Sudafed, etc.)
If the patient has no allergies to medications, document as none,
NKDA, or NDA.
If the patient‘s drug allergies are unknown, document as unknown. The chart
should reflect the reason you were not able to obtain the medication
allergy information.

Other Diagnostics

Standard: An evaluation of ―satisfactory‖ completion of this documentation component

shall require proper documentation of all of the absolute criteria. Criteria for
this component are as follows:

Blood glucose levels should be obtained in accordance with

the standards set by protocol and charted as the numeric value and the units,
which are mg/dl.
Temperature should be obtained/charted on all patients as required per
protocol.
A Pulse Oximetry reading should be obtained/charted on all patients
presenting with a respiratory complaint, chest pain, or any other presentation
of decreased perfusion.

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:

Blood glucose levels should be obtained on all patients who experience a

seizure prior to arrival of EMS or while in EMS care, have diabetic
complications, altered mental status, or any other conditions where glucose
monitoring is necessary.

Blood Glucose levels are to be documented as the numerical value and the
proper units (mg/dl). If Blood Glucose is NOT obtained using an electronic
glucometer, state that the value is estimated.

Temperature should be documented in degrees Fahrenheit. The method by

which the temperature was obtained should document. (Oral, Tympanic,
Rectal, or Temporal).

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Pulse Oximetry readings should be noted as a percentage, and if the reading

was obtained while the patient was on room air or on oxygen. (If on oxygen,
state the device and liter flow)

Airway/Ventilation Management
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria.
Criteria for this component are as follows:
The chart should reflect all airway interventions
performed , if any.
The chart should reflect the field personnel who performed each
intervention.
The number of attempts at obtaining each type of airway.
Confirmation of breath sounds by auscultation.
If manual airway, note method used (e.g. jaw thrust, etc).
If airway is used, note size of airway.
If intubation, document all in the intubation screens.
If suctioning, document type of suction, type/size of
catheter.

Goal: Proper documentation of 100% of above criteria.

Acceptable Terminology:
When documenting breath sounds, document what the Breath sounds sound
like, rather than try to differentiate between Rales and Rhonchi. (E.g. wet,
course, gurgling, wheezes, etc.)

ECG/Electrical Therapy
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component are as follows:
The ECG should be documented for all patients on
whom it is obtained.
The chart should reflect the interpretation of the

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initial rhythm, and all subsequent rhythm changes.

A rhythm strip should be submitted to the Clinical Department with
Incident number on strip.
If Cardioversion or Defibrillation is used, the following information should
be noted:
Electrical Power Setting
If cardioversion is synchronized or non-synchronized.
Field personnel performing cardioversion
If Transcutaneous Pacing (TCP) is used, the following information should
be noted:
Pacing rate
Milliamps used
Presence/absence of electrical capture.
Presence/absence of mechanical capture.
Field personnel applying TCP
If multi lead ECG is used, the following information should be noted:
Leads used (i.e. MCL1)
Interpretation of rhythm
Field personnel performing multi-lead ECG
If 12-Lead ECG is used, the following information should be noted:
Interpretation of the 12-Lead ECG
Field personnel performing 12-Lead ECG

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
When Pacing, state if the Pacer is set to fixed or demand.
Electrical power settings should be in units of joules or
Watts/sec. Non-synchronized cardioversion may be referred
to as Defibrillation.
If obtaining a 12-Lead ECG, it should be noted that the
Interpretation of the 12-Lead is either that of the
machine’s algorithm or the field personnel.

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If the interpretation is that of the attendant, document

the leads the specific findings were found
(e.g. Possible Anterior wall MI with ST segment
elevation in Leads V3 and V4.)

Oxygenation
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component is as follows:
The chart should reflect all oxygen administration to the patient, including:
Delivery device
Liter flow
Any changes in oxygen therapy
Indication

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
Devices may be described as: NRB, NC, SFM, VenturiMask, Tracheal Tube,
Capno Mask etc.
Units should be expressed in lpm.

Spinal Immobilization
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria.
Criteria for this component are as follows:
The chart should reflect any and all spinal restriction procedures.

Goal: The proper documentation of 100% of the above criteria.

Acceptable Terminology:
Full Spinal Motion Restriction is defined as including a
Cervical collar, long board (or equivalent device),
A system for strapping the patient to the long board,

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And some form of head immobilization.

CC=Cervical. Collar
BB=Backboard
KED=Kendrick Extrication Device
CID=Cervical Immobilization Device
HID=Head Immobilization Device

BLS Therapy
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component are as follows:
Control of bleeding (if present)
Type/location of splint/bandage applied
Presence or absence of distal pulse prior to and following the
application of a bandage or splint.
CPR performed (if applicable)
MAST applied and/or inflated
External cooling/warming as required per protocol

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
Control of bleeding may be described by direct pressure,
pressure points, or elevation.
The type of bandage may be documented as pressure,
occlusive, sterile, etc.
The type of splint needs to be described in the chart
(e.g. traction splint applied to left lower extremity)
The time CPR was started, as well as who performed CPR,
needs to be stated in the chart. Document any
pauses for interruptions, delays etc.
External cooling includes the removal of excess clothing,
application of cool, wet compresses, chemical cold

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STANDARDS
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packs, ice packs, etc.

External warming refers to the removal of wet clothing,
use of blankets, chemical heat packs, etc.

IV Therapy
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all the absolute criteria. Criteria for this
component is as follows:
IV site
Size of IV catheter
Number of attempts
IV fluid
Drip rate
Personnel who started the IV line

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
The IV site may be described as left hand, left AC, right wrist, etc.
IV fluid may be abbreviated as follows:
Normal Saline: NS, NaCl, 0.9%NS
Drip rate may be abbreviated as follows: TKO, KVO,
W/O (wide open), ___cc/hr.

Medication Administered
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria
for this component is as follows:
Name of medications being administered
Amount of medication administered
Route medication administered
Field personnel administering the medication

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Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
Medications may be documented as trade or generic names. Amount given
should be in mg, g, etc. and NOT in cc or ml. Route given may be
abbreviated as IV, IO, PO, SL, SQ, IM, PR. Each medication and its
subsequent dose should be charted separately e.g. (The third dose of Epi
1:1,000 in CPR would be a separate entry).

Other ALS Therapy

Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component is as follows:
Procedure or intervention performed
Number of attempts at the procedure or intervention
Field personnel performing the procedure or intervention

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
Other ALS Therapy includes Surgical Airway, Chest Decompression, Naso-
gastric Tubes, and Vagal Maneuvers.
Interventions performed prior to EMS arrival shall be documented as such in
the intervention screen. Additional comments in narrative indicating
procedure was continued or monitored enroute.

Time Intervals
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component is as follows:
Time call received by Dispatch
Time call was dispatched
Time unit responded
Time unit arrived on scene
Time of patient contact

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STANDARDS
Standard Delegated Orders –
Clinical Guidelines CG 42 Page 115
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Time of arrival of transporting unit (if unit

generating the chart is not transporting
the patients in the case of First Responders,
when helicopter ambulances are utilized, etc.)
Time unit cleared from the scene (if not transporting
the patient)
Time enroute to the receiving facility
Time unit arrived at receiving facility
Time available for another call
Times are to be documented with every set of
vital signs
Times are to be documented with all medications are
administered
Times are to be documented with all procedures performed

Acceptable Terminology:
Procedures include ECG, Cardioversion, Defibrillation, Transcutaneous
Pacing (TCP), Surgical Airway, Needle Chest Decompression,
Naso-gastric tube, and Vagal maneuvers.
Consults
Standard: An evaluation of ―satisfactory‖ completion of this documentation
component shall require proper documentation of all of the absolute
criteria.
Criteria for this component are as follows:
If consult was required, reflect that it was made.
All orders requested, received, or denied by Supervisor/Medical
Director should be documented.
The name of Supervisor (or Medical Director,
if contacted) should be noted in the chart.

Patient Disposition
Standard: An evaluation of ―satisfactory‖ completion of this documentation
component shall require proper documentation of all the absolute criteria.
Criteria for this component is as follows:
Patient’s response to therapy

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STANDARDS
Standard Delegated Orders –
Clinical Guidelines CG 42 Page 116
TOC

Patient’s refusal
If patient is refusing transport, the
chart should reflect:
Complete patient assessment, PMHx, etc.
What means taken to convince the patient to allow transport to
the hospital
Instructions given to the patient, possible complications, etc.
Signed patient refusal form

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
If the patient‘s condition does not change during transport, Document as no
change in patient’s condition. If patient is being transported to the hospital by
alternate means, state so in narrative (e.g. pt. going by alternate means).

Differential/ICD-9 Code
Standard: An evaluation of ―satisfactory‖ completion of this documentation component
shall require proper documentation of all of the absolute criteria. Criteria for
this component is as follows:

The EMS provider should indicate in the Diagnosis screen and ICD-9
Code of the EMS report an assessment of what s/he believes to be
wrong with the patient.

Goal: Proper documentation of 100% of the above criteria.

Acceptable Terminology:
This assessment may be in the form of a differential or a set of differentials.
Unless there is absolutely no doubt as to the patient‘s acute diagnosis, the
EMS provider should avoid putting his/her differential in absolute terms (e.g.
AMI) and should instead use more general terminology (e.g. Possible AMI or
abdominal pain-unknown etiology)

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STANDARDS
Standard Delegated Orders –
Clinical Guidelines CG 42 Page 117
TOC

Avoid using R/O or Rule Out when stating your differential assessment.
Doctors use this terminology when developing a series of tests to confirm
their diagnosis.
The EMS provider should avoid simply putting the patient‘s chief omplaint as
his/her assessment: Do not use Shortness of Breath, instead using
something more definitive (e.g. Possible pulmonary edema secondary to
CHF.)

The charted differential should reflect which protocol(s) were used to manage
the patient.

Abbreviations

Acceptable Terminology:
See Appendix for a list of accepted medical abbreviations according to
Medicare.

Documentation of patient refusals should include the following additional information:

Pt/guardian has metal capacity to make informed decision as to
consent/refusal
aid/transport was necessary
Aid/transport was offered
Pt‘s response to offer of aid/transport
Consequences of refusal clearly explained to patient or guardian
Pt/guardian understands consequences of refusal
Pt/guardian still refuses aid/transport after being informed of
consequences
Signature of patient/witness
Disposition of patient upon release
Pt advised to call EMS back at any time if condition changes or they
change their mind

“No Patient” or “No Sick or Injured”

In order for an EMS unit to clear with "no patient" or "no sick or injured", the following
criteria should be met:
The patient should have left the scene prior to EMS arrival, OR
The call itself should have been false (no such incident) OR
The people or person in question should deny ANY physical complaint to the
EMS personnel's direct questioning AND

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The EMS personnel should not be able to visualize ANY injury or evidence of
injury or illness AND
The people or person should appear competent to make such an assessment
of themselves.

If the patient is the individual who actually called for or requested the ambulance, a
―no patient‖ designation cannot be employed. Such a patient should have a refusal
executed, as described previously in this policy.

Documentation
EMS shall document all demographic and operational information as outlined in the
"Documentation Requirements" policy.

EMS shall clearly document that the above criteria were present.

The term Assist Only is not to be used on any call where a patient assessment has taken
place. This term is used for lift assist or moving assistance of a person only. Any response
that a chief complaint was given, a complete refusal document or complete patient care
report should be obtained without exception.

An assist call occurs when an individual requires aid in completing a task but does not have
a medical emergency. Examples might include help getting from their bed into a wheelchair
or from a vehicle into a residence. Upon arrival the crew should investigate the reason why
the response was initiated and determine if the caller has a medical emergency. A good
example might be the ―caller‖ cannot get from the bed to the restroom. You should ask if this
is normal for the patient or what prohibits the ―caller‖ from accomplishing the task. Do they
get short of breath? Are they unsteady on their feet or have dizziness when they get up? DO
NOT ASSUME that assist calls may not require medical treatment and transport. As a pre-
hospital care provider you should assess the condition of the individual requiring assistance-
and if indicated –offer care, treatment and transport. If you have indications that a medical
condition exists and the ―caller‖ refuses transport a patient refusal should be obtained. This
includes a complete set of vital signs and appropriate documentation of the assessment as
well as any instructions you gave the ―caller‖.

After you have determined it is truly an assist call and not a medical emergency the
documentation should include the following information:

1. Required operational information

2. Name, address and phone number of person requesting assistance.
3. The exact reason you were called for the assist documented in the narrative.
4. How you concluded that a medical emergency did not exist.
5. What actions were performed or what assistance was provided.
6. Disposition of the person requesting assistance.

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 Montgomery County Hospital District-EMS NEW EMPLOYEE
ORIENTATION PROGRAM
Standard Delegated Orders –
Clinical Guidelines CG 43 Page 119
TOC

New Employee Orientation Program (NEOP)

The purpose of the MCHD EMS New Employee Orientation Program is to provide new
employees the opportunity to become acquainted with policies and procedures as well as
promote a team approach to patient care for the citizens and visitors of Montgomery County.

General Information
Each employee should receive the appropriate paperwork, including copies of the current
Standing Delegated Orders, Medication References, Medical Procedures currently
performed by MCHD field staff as well as Clinical and Operations Policies & Procedures.
This packet should also include paperwork to be completed by the preceptor.

The Clinical Department monitors the New Employee Orientation Program. All paperwork
pertaining to evaluations and patient care documentation is to be faxed or delivered to the
Clinical Department at the end of each shift. In addition to furnishing copies of this
paperwork to the Clinical Department the employee should maintain the original. Failure to
comply with this requirement could result in extended time in the orientation program and
documentation will be placed in the employee‘s file.

The initial orientation consists of two days of classroom instruction that may include
organizational history and structure, employee benefits, patient care reporting and Westech
training, introduction to the driver-trainer program, as well as Clinical and Operations
Policies and Procedures. Additional topics covered in the remainder of the week include,
but are not limited to: introduction to the Road Safety Program currently in use by MCHD,
as well as driving time in an MCHD ALS unit with a certified trainer.

Currently new employees are required to ride a minimum of five (5) 24-hour shifts (or
equivalent hours) with a preceptor. After completion of these shifts the employee should be
evaluated for competency at the attendant level and a recommendation should be made by
the preceptor to release the employee or continue the evaluation process. If the employee
is released the Assistant Director EMS-Operations should assign him a schedule. If the
recommendation is made to continue the evaluation process, the employee may be
assigned to another preceptor with a written plan identifying specific areas of improvement.
The employee will be re-evaluated at the end of three (3) 24-hour shifts (or equivalent time).
At that time a recommendation may be made by the Assistant Director EMS-Clinical
Services to continue the process or terminate the employee.

In addition to the above five shifts, the new employee should schedule one (1) 12-hour shift
with a Supervisor and complete four (4) hours as an observer in the communications office.
Additionally, all new employees SHOULD pass a Policy & Procedures Manual (Clinical and
Operations) test, an SDO test to their level of authorization and a territory test. Passing
scores on these exams are 80%. The employee should not be released at the attendant
level until these requirements have been completed.

All new employees have a 90-day probationary period. If clinical or operations issues arise
that result in counseling or disciplinary action the probation may be extended at the

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ORIENTATION PROGRAM
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TOC

discretion of the Assistant Director EMS-Clinical and/or Assistant Director EMS-Operations.

Documentation will be placed in the employees‘ file describing the reason for the extended
probationary period and what requirements should be fulfilled by the employee as well as
management for successful completion.

Paramedics with previous experience as the lead medic on an MICU in a 9-1-1 setting may
be considered for the In-Charge Evaluation Program. Entrance into this program requires
successful completion of the NEOP training at the attendant level as well as the 90-day
probationary period. (See In-Charge Evaluation Program policy).

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 Montgomery County Hospital District-EMS CARD COURSES AND
EDUCATIONAL
OPPORTUNITIES
Standard Delegated Orders –
Clinical Guidelines CG 44 Page 121
TOC

MCHD offers many card courses for our employees, some of which are required. These
courses are offered several times throughout the year and are free to MCHD employees.

It is the employee’s responsibility to maintain current certifications.

Note: Since all card courses are offered by MCHD, employees who attend classes
elsewhere are not reimbursed for the cost of the course.

CPR is required for all field personnel. CPR, ACLS and BTLS are required for attendant
EMT-P. CPR, ACLS, BTLS and PALS are required for In-Charge paramedics.

In the event a certification expires, the employee should receive written notification from the
Clinical Department that the certification has lapsed and that proof of current certification
should be presented to the Clinical Department within 30 days. If current certification is not
received within 30 days, the employee can be placed on clinical suspension or de-
authorized to a level in which that particular certification is not required until a current
certification is received.

COURSE ATTENDANCE
When taking advantage of a class being offered by MCHD EMS, the employee should
request a place in the class in writing. The class coordinator should make verification of
placement.

If cancellation is necessary it should be done within 48 hours of the scheduled class time.
All attempts to cancel should be done through the coordinator of the class.

If the employee fails to attend the class without prior cancellation, a written notification will
be sent to the employee and a copy of that notification will be placed in the employee‘s
personnel file. After such an occurrence the employee may be asked to put up a deposit on
any further classes. This deposit should be returned upon completion of the class.

As with anything there may be exceptions to the above. Those situations will be considered
on a case by case basis.

INSTRUCTOR REQUIREMENTS
MCHD EMS offers many teaching opportunities to those employees who are or wish to be
instructors. In order to offer quality education to our employees as well as our community it
is necessary to establish guidelines for our Instructors.

The requirements necessary to maintain Instructor status with MCHD are to teach a
minimum of two classes per year in each Instructor certification area.

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OPPORTUNITIES
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Instructors will not be required to attend provider courses for those card courses in which
they are MCHD EMS instructors, providing they maintain current Instructor certifications.

Cancellation of a teaching assignment should be done no less than one week prior to the
scheduled class. If cancellation occurs less than one week prior to class time, the Instructor
is responsible for finding an equivalent replacement. If a replacement is not found by the
Instructor, a written notification of the infraction will be sent to the Instructor with a copy
being placed in their personnel file. If it occurs a second time, instructing privileges as well
as its rewards may be revoked.

INSTRUCTOR CRITERIA
For those employees interested in becoming Instructors the following requirements are
necessary:

CPR INSTRUCTOR
Current CPR certification
Score of 90% or greater on CPR examination
Attendance in a CPR instructor course
Monitored during at least one class
Final appointment of instructor status is the decision of the Education Department

ACLS INSTRUCTOR
EMT-P, RN, MD
CPR-I or EMS-I
Current ACLS certification
Score of 90% on ACLS examination
Attendance in an ACLS instructor course
Monitored during at least one class
Final appointment of instructor status is the decision of the Education Department

PALS INSTRUCTOR

EMT-P, RN, MD

CPR-I or EMS-I
Current PALS certification
Score of 90% or greater on PALS examination
Attendance in a PALS instructor course
Monitored during at least one class
Final appointment of instructor status is the decision of the Education Department

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EDUCATIONAL
OPPORTUNITIES
Standard Delegated Orders –
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TOC

BTLS INSTRUCTOR

EMT – EMT-P, RN, MD

CPR-I or EMS-I
Current BTLS certification
IP in last BTLS class
Attendance in a BTLS instructor course
Monitored during at least one class
Final appointment of instructor status is the decision of the Education Department

EQUIPMENT AND RESOURCES MATERIALS

MCHD EMS has purchased equipment and resource materials in an effort to provide as
many educational opportunities as possible for its Employees. These resources are
available to each employee.

When requesting resource materials (books, software, etc.) please see the Clinical
Department Clerk for the proper forms.

When requesting equipment, please see the Education Specialist. This equipment shouldbe
checked out for clinical practice or to instruct classes for MCHD EMS. When instructing for
outside entities, use of MCHD EMS equipment requires approval by the Clinical Department.

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 Montgomery County Hospital District-EMS RECERTIFICATION AND
UPGRADE IN CERTIFICATION
Standard Delegated Orders –
Clinical Guidelines CG 45 Page 124
TOC

Employees recertifying their Texas Department of State Health Services certification through
examination should have scored a minimum of 70% on their National Registry Examination
and provide the Clinical Department with a copy of their Texas Department of State Health
Services certification.

Upgrading Authorization
In order for an employee to upgrade his/her certification from EMT to EMT-Intermediate or
EMT-Intermediate to EMT-Paramedic, he/she should provide the Clinical Department with a
copy of the new TDSHS certification and test scores. If a deficiency is detected on one or
more subscales, a Personal Improvement Plan should be developed for the individual that
should outline a remediation plan to correct the deficiency.

As a final step, the employee is expected to successfully complete a protocol exam at the
new level of certification to verify a firm understanding of the clinical practices of MCHD
EMS.
Authorization is separate from certification. Every provider should have a current
certification. The Medical Director is responsible for granting authorization.

Authorization is required to provide pre-hospital or out-of-hospital care to any patient

within the South Texas Medical Control System. Certification level does not
necessarily dictate authorization level. The Medical Director may authorize any
provider to function at any level as per TDH Rule 157.11

AT NO TIME prior to receipt of the Letter of Authorization will the employee be

permitted to perform any procedure or treatment modality which is reserved for the
new level of authorization as outlined in the protocols. This may be considered
practicing beyond the scope of his authorization, and may be considered to be a
termination offense, and one that is reportable to Texas Department of State Health
Services.

Upon successful completion of these steps, a letter of authorization will be placed in the
employee‘s file. Only when the authorization process is complete, paperwork be submitted
to Human Resources for consideration of potential wage increase.

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 Montgomery County Hospital District-EMS CONTINUOUS QUALITY
IMPROVEMENT (CQI)
Standard Delegated Orders –
Clinical Guidelines CG 46 Page 125
TOC

Total Quality Management

Although Quality Improvement (QI) is relatively new to pre-hospital emergency medicine,
Montgomery County Hospital District embraces the opportunity to continuously monitor and
improve the standards that have been established by MCHD for the delivery of pre-hospital
health care. Furthermore, MCHD believes that all employees want to do the best they can
for every patient and should provide a high level of pre-hospital care to every patient they
encounter as long as the following are intact:

The acceptable standard of care as well as employee performance expectations are

clearly defined and measurable AND

The employee/s are provided adequate and appropriate equipment and/or tools to
adhere to MCHD standards

Quality Improvement is a non-punitive process designed to provide opportunities for

personal and/or professional growth for the individual as well as the agency.

Additionally, Quality Improvement within the MCHD system is established upon the
principles of raising standards in all departments - patient care, vehicle maintenance,
communications, operations and clinical, as well as billing and community outreach
programs. This approach to QI relies upon the participation of all MCHD employees to be
successful.

Quality Improvement within the MCHD system is based on the following components:
1. Training and education of all levels of field personnel, directed at documented
needs.
2. Assessment and evaluation of all patient-care oriented activities.
3. Involving all levels of personnel in establishing and ensuring the standard of care,
protocols, procedures, and the assessment of care.
4. Effective hiring and selection process, orientation and training procedures, and
evaluation of new personnel.
5. Effective training procedures and evaluation of In-Charge Evaluation candidates.
6. Establish regular review of patient-care-oriented standards, protocols, and
evaluation systems.

The goals of the clinical QI program are to:

1. Continuously and accurately evaluate the patient care oriented activities of all the
EMS personnel in the system.
2. Continuously and accurately evaluate the operational, administrative, and
procedural activities of our system as they relate to the delivery of patient care.
3. Accurately determine the training and educational needs of both individual EMS
providers and the EMS system as a whole.
4. Provide continuous training and education to our providers which addresses their
actual training and educational needs.
5. Identify and address areas of potential improvement in our system in all areas of
patient care and operation.

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IMPROVEMENT (CQI)
Standard Delegated Orders –
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TOC

6. Respond to complaints or concerns from both outside and inside the system
about patient care or related activities in a timely and satisfactory manner.
7. Regularly evaluate and re-evaluate protocols, procedures, and patient care
standards, and improve and update them as needed.
8. Allow the field personnel at all levels to actively influence the system‘s operations
as they relate to patient care.
9. Provide organizational management and administration with an accurate
assessment tool for evaluating employee‘s performance in patient care related
activities.

This approach to a successful QI program requires that MCHD make and maintain a
commitment to continuous evaluation and improvement focused on response to such
evaluations. The following are critical to the success of the program:
1. Utilization of objective assessment criteria.
2. Assessment of methods of patient care by comparing documented and observed
clinical care to established criteria.
3. Utilization of appropriate methods to solve the identified problem with the focus
being on improving individuals as well as the service as a whole.
4. Reassessment of the problem area identified to ensure that the problem has, in
fact, been corrected.

Critical QI functions extending beyond routine evaluation of field clinical performance and
clinical care include:
1. An interface with continuing education that the findings of the QI process contribute
materially to the content of the continuing education program.
2. Evaluation of on-line medical consults.
3. Incident investigations.

The above items are accomplished from a proper mixture of the following:

1. Prospective: defined as actions that take place prior to the actual patient encounter
(i.e. education, continuing education, development of stand delegated orders,
medication and supply inventory requirements, etc).
2. Intermediate: evaluation of medical consults, on-scene evaluations by a preceptor
or Supervisor, or scenario/realism training.
3. Retrospective: consisting of clinical chart audits for documentation and treatment
as well as accurate and complete performance evaluations of each employee.

If an audit (chart or field) finds no procedural or clinical exceptions, an audit report shall be
filed as support evidence of the employees‘ performance for inclusion in the annual
performance appraisal.

If an audit (chart or field) finds clinical exceptions, then copies and the audit report should be
reviewed by the Medical Director, thus beginning the exercise of problem solving. The
Medical Director or his/her designee should consider the following minimum factors during
his/her review of the case:
1. Was the exception a system failure?

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IMPROVEMENT (CQI)
Standard Delegated Orders –
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TOC

2. Were there extenuating circumstances on scene or enroute that contributed to the

situation?
3. Did lack of training contribute to the situation?
4. Did the treatment and/or procedure cause permanent harm or injury to the patient?
5. Was the treatment and/or procedure performed appropriate for the patients
illness/injury?
6. Was the employee authorized to provide the treatment and/or procedure performed?

Once the factors and principles have been identified, the administrative staff should carry
out action and/or training as recommended by the Medical Director. Each investigation is
conducted on a case-by-case basis with consideration given to each of the previously listed
items.

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 Montgomery County Hospital District-EMS HANDLING CHILD AND
ELDERLY ABUSE AND
NEGLECT
Standard Delegated Orders –
Clinical Guidelines CG 47 Page 128
TOC

General Information

State law requires all professionals to report suspected cases of abuse (Texas Family Code
§ 261.101). Therefore, all employees are required to report actual and suspected cases of
abuse. However, it is not the responsibility of MCHD EMS personnel to confront and
attempt to remediate abusive situations. When abuse is suspected, provide all assessment
and treatment as indicated. Attempt to persuade the patient to be transported to the
hospital regardless of the severity of the injuries.

Transport Situations – Upon arrival at the emergency room, privately and discreetly advise
the nurse and/or physician of your suspicions.
Non-transport Situations – If transport is refused, leave the scene and request to meet with
law enforcement and a Supervisor to meet at a near by location. When law enforcement
and the Supervisor arrive, advise them of your suspicions.
In either situation Child Protective Services or Adult Protective Services should be contacted
by the MCHD employee(s) responding to the call and or witnessing the event.

Documentation

In all cases, employees should include a detailed assessment of the actual or suspected
abuse situation in the patient‘s report. The assessment should describe the patient‘s
condition, emotional state, and the surrounding environment. Also, employees should
include details in the patient‘s report concerning the circumstances that created their
suspicions of abuse and the employees‘ actions. The appropriate agency should be
contacted within 24 hours after the employee witnesses the actual or suspected abuse.

Child and Elderly Abuse should be reported to Adult Protective Services (AS) or
Child Protective Services (CPS): 1-800-252-5400 or https://www.txabusehotline.org

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 Montgomery County Hospital District-EMS CARE AND TRANSPORTATION
OF MINORS
Standard Delegated Orders –
Clinical Guidelines CG 48 Page 129
TOC

Minors may only receive the treatment necessary to preserve life and prevent further injury
in the absence of a consenting parent, guardian, or adult family member. Parents and
guardians retain the right to consent to and refuse treatment for minors in their charge who
are under eighteen (18) years of age unless the minor qualifies to consent to treatment.
When a minor‘s parent(s) or guardian(s) refuse treatment for the minor, MCHD-EMS
personnel should not force any treatment but shall encourage treatment or recommend that
the minor patient be transported to a hospital. If a minor‘s life is endangered by the parent‘s
or guardian‘s refusal for treatment, or if personal abuse is suspected, the supervising
Emergency Department physician shall be notified immediately and his or her instructions
followed. MCHD-EMS personnel are required by law to report all cases of suspected abuse.
Refer to the MCHD-EMS Field Operations Guidelines concerning Child Abuse for further
guidance.

Married Minors

Married minors reserve the right to consent to or refuse treatment.

Unmarried, Pregnant Minors

Unmarried, pregnant minors may consent to or refuse treatment for pregnancy-related

conditions only, treatment for other conditions require parental consent or refusal of
treatment.

Abandoned Children

Section 262.301 of the Texas Family Code, as amended, requires MCHD-EMS personnel,
without a court order, to take possession of a child who is thirty (30) days old or younger if
the child is voluntarily delivered to the employee by the child‘s parent and the parent did not
express an intent to return for the child.

A MCHD-EMS employee who takes possession of a child under these circumstances shall
perform any act necessary to protect the physical health or safety of the child. The
employee should notify his or her Supervisor of the situation as soon as possible.

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 Montgomery County Hospital District-EMS DEPARTMENT OF STATE HEALTH
MINIMUM INVENTORY LIST
Standard Delegated Orders –
Clinical Guidelines CG 49 Page 130
TOC

Airway and Oxygen Supplies Amount Airway and Oxygen Supplies Amount
Oropharyngeal Airways (5 total) 1 set
Nasopharyngeal Airways (6 total) 1 set Lidocaine Jelly 1
BVM Adult, Child, Neonate 1 ea KY Jelly 2
PEEP Valve 1 Laryngoscope Handle 1
Nasal Cannula 3 Mac Blades #1,3,4 1 ea
Non-Rebreather Mask 3 Miller Blades #0,1,3,4 1 ea
Pedi Face Mask 1 Laryngoscope Bulbs large/small 1 ea
Infant Face Mask 1 Magill Forceps Adult, Pedi 1 ea
Oxygen Tubing 1 Bulb Syringe 1
Adult Nitronox Mask 1 Capno2 Mask Adult 2
Pedi Nitronox Mask 1 Capno2 Mask Pedi 1
Nebulizer 1 SpO2 Sensors Adult, Pedi 1 ea
Nebulizer Mask Adult 1 NG Tube 18 fr 1
Nebulizer Mask Pedi 1 Rigid Suction Catheter with tubing 2
Endotracheal Tube 2.0 - 8.5 1 ea Suction Catheters 5/6, 8, 10, 14, 18fr 1 ea
Endotrol 7.0, 8.0 1 ea
Endotracheal Tube Securing Device 1 60 cc Syringe with Cath Tip 1
QuickTrach 1 On Board suction and liner/canister 1
Tube Check Bulb 1 Portable Suction Unit 1
ET Introducer 1 Suction Cannister/liner port. & on board 1 ea
Adult Easy Cap 1 On Board O2 Cylinder with Regulator 1
Pedi Easy Cap 1 Spare Portable O2 Cylinder 1
Large Stylette 1 Portable O2 Cylinder with Regulator 1
#11 Scalpel 1 Ohio Wall Adaptor 1
Rubber Core O2 Rings 2 Portable Ventilator with Ohio Adapter 1
O2 "Christmas Tree" 1 Nitronox with Ohio Adapter 1
Pneumothorax Kit 1 Spare Nitrous Oxide Bottle 1
Portable O2 Key 1 EtCO2 Airway Adapter Adult, Pedi 1 ea
Vent Circuit Tubing 1
IV Equipment Amount IV Equipment Amount
0.9% NaCl IV fluid (500 or 1,000 ml) 4 20 cc Syringe 1
0.9% NaCl IV fluid (100 ml) 1 30 cc Syringe 1
IV Start Kit 3 Intraosseous Needles 1
Blood Draw Kit 2 3" 18 ga Spinal Tap Needle 1
5‖ extension 2 Vial Access Cannula 4
Alcohol Swabs/Iodine Preps 15 Syringe Cannula 4
10 gtt/ml Primary IV Set 3 Luer Adapter 3
60 gtt/ml Primary IV Set 3 10cc 0.9%NaCl Flush 2
Buretrol IV Set 1 Injection Port 3
IV Extension Tubing 3 Tubex Injector 1
1 cc Syringe 3 18 ga Needle 5
3 cc Syringe 3 22 ga Needle 2

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MINIMUM INVENTORY LIST
Standard Delegated Orders –
Clinical Guidelines CG 49 Page 131
TOC

IV Equipment Amount IV Equipment Amount

5 cc Syringe 3 25 ga Needle 2
10 cc Syringe 3 18 ga IV Catheter 2
14 ga IV Catheter Short 2 20 ga IV Catheter 2
16 ga IV Catheter Short 2 22 ga IV Catheter 1
24 ga IV Catheter 1
Medications Amount Medications Amount
0.9% NaCl fluid (500 or 1,000 ml) 1 Labetalol 20mg/4ml 1
Acetaminophen Elixir 325ml/10.15ml 2 Lasix 100mg/10ml 1
Activated Charcoal 25g/100ml 1 Lidocaine 2% 100mg/5ml 2
Adenosine 6 mg/1ml 2 Lidocaine Pre-mix infusion 4g/250ml 1
Amiodarone 150mg/3ml 3 Magnesium Sulfate 1g/2ml 2
Ammonia Inhalants 0.33ml 3 Narcan 2mg/2ml 2
Atropine Sulfate 1mg/10ml 2 Nitroglycerin Spray 0.4mg/metered dose 1
Atropine Sulfate Multi-dose 8mg/20ml 1 Oral Glucose 15g 1
Baby Aspirin 81mg/tablet 10 tab. Phenergan 2mg/1ml 1
Calcium Gluconate 1g/10ml 1 Sodium Bicarbonate 4.2% 5mEq/10ml 1
Cardizem 25mg/5ml 1 Sodium Bicarbonate 8.4% 50mEq/50ml 2
Dextrose 25% 2.5g/10ml 1 Solumedrol 125mg/1ml 1
Dextrose 50% 25g/50ml 1 Succinylcholine 200mg/10ml 1
Diphenhydramine 50mg/1ml 1 Tetracaine Drops 0.50% 1
Dopamine pre-mix 400mg/250ml 1 Thiamine 100mg/1ml 1
Epinephrine 1:1,000 1mg 1mg/1ml 1 Valium 10mg/2ml 1
Epinephrine 1:1,000 Multi-dose 30mg/30ml 1 Vasopressin 20unit/1ml 2
Epinephrine 1:10,000 1mg/10ml 3 Vecuronium w/Sterile H2O 10mg/10ml 1 ea
Etomodate 20mg/10ml 1 Versed 5mg/ml 1
Fentanyl 100mcg/2ml 2 Xopenex (pedi) 0.63 mg/3ml 1
Glucagon 1mg/1cc 1 Xopenex (adult) 1.25mg/3ml 1
Monitoring Devices Amount Monitoring Devices Amount
Monitor/Defibrillator with cables 1 Thermometer 1
ECG Electrodes 20 BP Cuff Adult 1
ECG Paper 1 BP Cuff Large Adult 1
Defib/Pacer Pads (adult) 1 BP Cuff Thigh Cuff 1
Defib/Pacer Pads (pedi) 1 BP Cuff Child 1
Prep Razor 1 BP Cuff Infant 1
Spare Monitor Battery 1 Stethoscope 1
BLS Equipment Amount BLS Equipment Amount
Kerlex 3 Padded arm board 1
Triangular Bandages 3 Triage Tags 5
Bandaids 10 OB Kit 1
Cold Packs 2 Foil Blanket 1
Heat Packs 2 Sterile Water for irrigation 1
Tape 3" 1 Sterile Saline for irrigation 1

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MINIMUM INVENTORY LIST
Standard Delegated Orders –
Clinical Guidelines CG 49 Page 132
TOC

Tape 1" 1 Disposable Rescue Blanket 1

4x4 Sterile Tubs 3 Benzoin Swabs 2
BLS Equipment Amount BLS Equipment Amount
4x4 Nonsterile Loaf 1/2 loaf KED 1
Multi-trauma dressings 1 Traction Splint (adult/pedi) 1 ea
ABD pads 2 SAM plint 2
Adaptic Dressings 2 Backboard 1
Burn Sheets 1 Scoop Stretcher 1
Paper/Styrofoam cups 1
Miscellaneous Equipment Amount Miscellaneous Equipment Amount
Stretcher/stretcher mount 1 Isolyzer 1
IV Pump 1 Hepa Masks 2
C-cell Batteries 2 Personal Protection Packs 2
AA cell Batteries 2 Small Sharps Container 1
Penlight 1 Medium Sharps Container 1
Towels 2 Biohazard Bag 1/2 roll
Broom or whisk broom 1 Traffic Triangle Set 1
Fitted Sheets 2 EMS Safety vests 2
Paper towels 1 roll Pillows 1
Disinfectant/cleaning solution 1 Flashlight 1
Gloves X-small 1 box Fire Extinguisher 1
Gloves Small 1 box Montgomery County Key Map 1
Gloves Medium 1 box No Smoking Signs 2
Gloves Large 1 box Two-way radio 1
Gloves X-large 1 box Hazardous Materials Quick Ref. 1
Hand Cleaner Gel 1 Inventory Lists 1
Goggles 2 Toughbook or clipboard with reports 1
Emesis Bags 2 SDO Manual 1
Gowns 2
Primary Kit Amount Primary Kit Amount
Triangular Bandages 2 Lancets 5
Tape 3" 1 Glucometer Test Strips 5
Tape 1" 1 Oropharyngeal Airways (5 total) 1 set
4x4 Sterile Tub 1 Nasopharyngeal Airways (6 total) 1 set
ABD pads 1 Bite Stick 1
Kerlex 2 KY Jelly 1
Multi-trauma dressing 1 Magill Forceps Adult/Pedi 1 ea
Adaptic Dressings 1 Laryngoscope Handle 1
Small Sharps Container 1 Mac Blades #1,3,4 1 ea
24 ga IV Catheter 1 Miller Blades #0,1,3,4 1 ea
22 ga IV Catheter 1 Tube Check Bulb 1
20 ga IV Catheter 1 Adult EtCO2 Color Metric Device 1
18 ga IV Catheter 1 Endotracheal Tube Securing Device 1

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 Montgomery County Hospital District-EMS DEPARTMENT OF STATE HEALTH
MINIMUM INVENTORY LIST
Standard Delegated Orders –
Clinical Guidelines CG 49 Page 133
TOC

Primary Kit Amount Primary Kit Amount

16 ga IV Catheter 1 Large Stylette 1
14 ga IV Catheter 1 NG Tube 18 fr 1
14 ga IV Catheter (long) 1 Endotracheal Tube 2.0 - 8.5 1 ea
IV Start Kit 1 Endotrol 7.0, 8.0 1 ea
Blood Draw Kit 1 Adenosine 6mg/1ml 4
IO Device/needle set 1 Amiodarone 150mg/3ml 2
10 gtt/ml Primary IV Set 1 Ammonia Inhalants 0.33ml 3
0.9% NaCl IV fluid (500 or 1,000 ml) 1 Atropine Sulfate 1mg/10ml 2
Alcohol Swabs/Iodine swabs 5 Baby Aspirin 81 mg/tablet 10 tab.
1 cc Syringe 1 Calcium Gluconate 1g/10ml 1
3 cc Syringe 1 Cardizem 1
Trauma Shears 1 Dextrose 50% 25g/50ml 1
Penlight 1 Diphenhydramine 50mg/1ml 1
5 cc Syringe 1 Epinephrine 1:1,000 1mg/1ml 1
10 cc Syringe 1 Epinephrine 1:10,000 1mg/10ml 3
20 cc Syringe 1 Glucagon 1mg/1ml 1
30 cc Syringe 1 Lidocaine 2% 100mg/5ml 2
18 ga Needle 1 Magnesium Sulfate 1g/2ml 1
22 ga Needle 1 Narcan 2mg/2ml 1
25 ga Needle 1 Nitroglycerin spray 0.4mg/metered dose 1
Emesis Bag 1 Oral Glucose 15g 1
Biohazard Bag 1 Phenergan 25mg/1ml 1
BP Cuff 1 Sodium Bicarbonate 8.4% 50mEq/50ml 1
Stethoscope 1 Solumedrol 125mg/ml 1
Glucometer 1 Thiamine 100mg/ml 1
60 cc Syringe 1 Vasopressin 20unit/1ml 2
Airway Kit Amount Airway Kit Amount
Portable O2 Cylinder with regulator 1 Nasal Cannula 1
ET Introducer 1 Non-Rebreather Mask 1
Combitube 1 Pedi Face Mask 1
Nebulizer with Adult, Pedi Mask 1 ea EtCO2 Mask 1
Xopenex (Adult) 1.25mg/3ml 1
Pedi Kit Amount Pedi Kit Amount
Infant BP Cuff 1 Broselow Tape 1
Child BP Cuff 1 Atropine Sulfate 1mg/10ml 1
Stethoscope 1 Dextrose 25% 2.5g/10ml 1
Infant Face Mask 1 Epinephrine 1:10,000 1mg/10ml 1
Pedi Face Mask 1 Lidocaine 2% 100mg/5ml 1
Endotracheal Tube 2.0 - 5.0 1 ea Multi-dose Epinephrine 1:1000 30mg/30ml 1
Suction Catheters 5/6, 8 fr 1 ea Sodium Bicarbonate 4.2% 5mEq/10ml 1
Pedi Kit Amount Pedi Kit Amount
KY Jelly 1 Xopenex (Pedi) 0.63mg/3ml 1

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 Montgomery County Hospital District-EMS DEPARTMENT OF STATE HEALTH
MINIMUM INVENTORY LIST
Standard Delegated Orders –
Clinical Guidelines CG 49 Page 134
TOC

Meconium Aspirator 1 Pedi EZ-IO 1 ea

Laryngoscope Handle 1 24 ga IV Catheter 1
Miller Blades #0, 1 1 ea 22 ga IV Catheter 1
Mac Blade #1 1 20 ga IV Catheter 2
Endotracheal Tube Securing Device 1 18 ga IV Catheter 2
Tape 1" 1 5 cc Syringe 1
Buretrol IV Set 1 18 ga Needle 1
IV Start Kit 1 Alcohol Swabs/Iodine Preps 3
BVM Child 1 Nebulizer with mask 1
BVM Infant/neonate 1 Pedi Capno2 mask 1
Oropharyngeal Airways #40 & 60 1 ea Biohazard Bag 1
IO Needle 1 Small Sharps Container 1
10 gtt/ml Primary IV Set 1 0.9% NaCl IV fluid (500 or 1,000 ml) 1
Liquid Ibuprofen 100mg/5ml 1
PAI Kit Amount PAI Kit Amount
Etomidate 20mg/10ml 1 5 cc syringe 2
Succinylcholine 200mg/10ml 1 18 ga Needle 2
Vecuronium w/Sterile H2O 10mg/10ml 1 ea 3 cc syringe 1
Lidocaine 2% 100mg/10ml 1 Alcohol Swabs 4
10 cc syringe 3
C-Collar Kit Amount C-Collar Kit Amount
Multi-size C-Collar Adult 2 Multi-Size C-collar Pedi 2
Disposable Head Immobilizer 2 Tape 3" 1
Webbing 2
Controlled Medications** Amount Controlled Medications** Amount
Fentanyl 100mcg/2ml 1 Valium 10mg/2ml 1
Versed 5mg/5ml 1
** These medications are not required for units designated as reserve status.
They are transferred on to Reserve units upon being placed in service.
***
These medications are optional.

I verify that the above Inventory and Medication List consists of all equipment, supplies,
and medication items and specify a variety of sizes and types of equipment adequate to
meet the needs of patients ranging in size from newborn to large adult and specify
quantities appropriate to the provider‘s call volume. This standard shall be in effect from
April 01, 2008 through March 31, 2010.

________________________________ _______________
Jay L. Kovar, Medical Director Date

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ADULT BEHAVIORAL
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 Montgomery County Hospital District-EMS BEHAVIORAL ASSESSMENT
Policy and Procedure Manual –
Adult Behavioral AB 01 Page 137
TOC

Criteria and History :

 Historical Findings:
- PMHx of psychiatric
problems
- Use of psychiatric
medications
- Substance abuse
 Physical Findings:
- Altered mental status
- Evidence of trauma
- Fear, anger, confusion, or
hostility

Assessment:
Glascow Coma Scale
 Determine that the scene is safe Eye Response Verbal Response Motor Response
before entering
4 Spontaneous 5 Orientated 6 Obeys
 GCS
3 To verbal 4 Confused 5 Localizes
 C.A.B.C.
2 To pain 3 Inappropriate 4 Withdraws
 Secondary Assessment
1 No response 2 3 Flexion
 Vital signs Incomprehensible
 Blood glucose 1 No response 2 Extension
 Pertinent PMHx 1 No response
- Does the patient have
previous suicide attempts or
ideations?
- Is the patient under care of a
psychologist / psychiatrist?
- Is the patient cared for by
others or self-reliant?
 SUBECT IN CUSTODY RISK
ASSESSMENT SCALE
(SICRAS)

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ABUSE / NEGLECT
Standard Delegated Orders –
Adult Behavioral AB 02 Page 138
TOC

Criteria and History :

 Historical Findings:
- Recent events

 Physical Findings:
- Contusions at different healing stages
- Malnourished appearance
- Withdrawn

Assessment:

 Behavioral Assessment

Primary Interventions:

 Apply pressure to any hemorrhage

 O2 via most appropriate method
 Spinal Motion Restriction, if
indicated

Secondary Interventions:

 Bandaging / splinting Contact information for APS:

 Vascular Access 1-800-252-5400 or
 Report abuse to APS https://www.txabusehotline.org

Consult:
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS AGGRESSIVE / VIOLENT
BEHAVIOR
Standard Delegated Orders –
Adult Behavioral AB 03 Page 139
TOC

Criteria and History :

 Historical Findings:
- Known violence
- Aggression

 Physical Findings:
- Agitation
- Offensive posture
- Combative
- Hallucinations

Assessment:

 Behavioral Assessment

Primary Interventions:
 Reassure patient
 If patient is physically harmful, soft restraints
 O2 via most appropriate method
 Spinal Motion Restriction, if indicated

Secondary Interventions:
 Vascular Access

Consult:

 Versed 2 – 10 mg IV/IM/IO
 Valium 2 – 10 mg IV/IO
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ANXIETY / EMOTIONAL
DISTRESS
Standard Delegated Orders –
Adult Behavioral AB 04 Page 140
TOC

Criteria and History :

 Historical Findings:
- History of Recent Traumatic
Event
- Post Trauma Stress Disorder
 Physical Findings:
- Agitation
- Hyperventilation
- Hallucinations

Assessment:

 Behavioral Assessment

Primary Interventions:

 O2 via most appropriate method

Secondary Interventions:

 Vascular Access

Consult:

 Versed 2 – 10 mg IV/IM/IO
 Valium 2 – 10 mg IV/IO
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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ADULT CARDIAC
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS CARDIAC ASSESSMENT
Standard Delegated Orders –
Adult Cardiac AC 01 Page 143
TOC

Criteria and History:

 Historical Findings:
- Preceding Symptoms
- CPR and/or Treatment PTA
- PMHx
- Elderly, female, diabetic
 Physical Findings:
- Altered mental status
- Slow, fast or absent pulse
- Irregular pulse
- Dyspnea/Apnea
- Chest pain/Palpitations
- Diaphoresis
- Pale, ashen or mottled skin
Assessment:
 C. A. B. C. Fibrinolytic Inclusion/Exclusion Checklist
 Secondary Assessment
Inclusion
 Vital Signs
- 18 years or older
 ECG 3-Lead and 12-Lead - Ischemic discomfort 30 minutes – 12 hours
- Right sided 12-Lead if indicated - ST Elevation > 1mm in 2 or more
 Blood glucose contiguous limb leads or > 2mm in
 Lung sounds contiguous precordial leads
 GCS - Presumed new LBBB
Exclusion
 Retavase inclusion/exclusion - Hx of CVA or TIA
criteria - Intracranial neoplasms, aneurysm
 OPQRST - Recent surgery or trauma, or active internal
 ASPN hemorrhage
 SAMPLE - B/P > 180/110
- Include history of Viagra, - Cardiogenic shock/ PE with intubation
Levitra, Cialis, or similar - Use of oral anticoagulants within 3 days
medications within last 48 hours - Suspected AAA
(Do not Administer NTG) - Use of cocaine or amphetamines within 3
days
- Pregnancy

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ACUTE CORONARY
SYNDROME / AMI
Standard Delegated Orders –
Adult Cardiac AC 02 Page 144
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Chest discomfort
- Back, shoulder, neck, jaw, epigastric discomfort
- Discomfort suggestive of AMI with associated symptoms: dyspnea, nausea,
diaphoresis, weakness

Assessment:

 Cardiac Assessment
 Transmit 12-Lead to receiving
facility from land line or stationary
vehicle

Primary Interventions:
Nitroglycerin, in any form, is not to be
 O2 via most appropriate method administered to patients that have taken
 Vascular Access Viagra (Sildenafil citrate) or Levitra (Vardenafil
 ASA 324 mg PO regardless of prior HCl) within the last 24 hours.
ASA use
 NTG 0.4 SL Nitroglycerin is not to be administered to
- Use with caution in Right-sided patients who have taken Cialis (Tadalafil)
AMI within the last 48 hours.
- q 5 min x 3 prior to IV if B/P >
100 mmHg Fatal hypotension has been reported when
- Once IV established, NTG can Nitroglycerin or other Nitrates are given to
be administered q 5 min if B/P patients who have used Viagra or Levitra in
>100 mmHg last 24 hours, and in patients who have used
 Right sided AMI Cialis in the last 48 hours.
- Fluid Bolus
 Fibrinolytic Inclusion/Exclusion If Right sided AMI is suspected, IV should be
checklist established prior to administration of NTG.

Atropine should be used with caution in the

setting of an ACS and should be avoided
unless systolic BP is < 80 mmHg and/or heart
rate <40 bpm

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 Montgomery County Hospital District-EMS ACUTE CORONARY
SYNDROME / AMI
Standard Delegated Orders –
Adult Cardiac AC 02 Page 145
TOC

Fibrinolytic Inclusion/Exclusion Checklist

Inclusion
- 18 years or older
- Ischemic discomfort 30 minutes – 12
hours
- ST Elevation > 1mm in 2 or more
contiguous limb leads or > 2mm in
contiguous precordial leads
- Presumed new LBBB
Exclusion
- Hx of CVA or TIA
- Intracranial neoplasms, aneurysm
- Recent surgery or trauma, or active
internal hemorrhage
- B/P > 180/110
- Cardiogenic shock/ PE with intubation
- Use of oral anticoagulants within 3 days
- Suspected AAA
- Use of cocaine or amphetamines within 3
days
- Pregnancy
Secondary Interventions:
 Secondary Vascular Access Contraindications for Metoprolol
 Zofran 8 mg oral disintegrating Absolute:
- Heart Rate < 60 bpm
tablet (ODT) PO - Systolic Blood Pressure < 100 mmHg
May be repeated every 15 min - 2nd and 3rd degree heart block
 Phenergan 12.5 mg IV/IO/IM - 1st degree heart block with PR interval
- May be repeated x 1 if N/V > 0.24 sec
persists after 15 minutes - STEMI precipitated by cocaine use
 Pain Management Relative:
- Pregnancy – 2nd and 3rd trimester
- Cardiogenic Shock
- Active CHF
- Active Asthma
- COPD
Consult:
 Retavase 5 –10 unit bolus per Transport to appropriate facility
physician order, repeated in 30 Conroe Regional Medical Center
minutes if available Tomball Regional Medical Center
 Metoprolol 5 mg IV Memorial Hermann – The Woodlands
- Repeat q 5 minutes x 2 to a St. Luke‘s – The Woodlands
total of 15 mg Consult with receiving physician for
Retavase
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ASYSTOLE
Standard Delegated Orders –
Adult Cardiac AC 03 Page 146
TOC

Criteria and History :

 Historical Findings:  Determine if resuscitation is medically
- Medical etiology inappropriate
 Physical Findings: - Normothermic rigor-mortis
- Unconscious - Injuries Incompatible with life
- Pulseless - Decomposition
- Agonal respirations; apnea - Lividity
 ECG Findings: - Pulseless, apneic patients in multiple
casualty situations
- Asystole confirmed in two or
- Proper DNR documentation
more leads
Assessment:
 Cardiac Assessment
Perform at least 20 minutes of quality compressions (verified by CPR feedback device if available) prior
to moving patient unless environment is unsuitable.
Do not interrupt compressions for ALS procedures.
Primary Interventions:
 Continuous CPR ET Tube Confirmation:
Confirm with 5 methods as per procedure
 BVM Ventilation with high-flow O
Capnometry Reference:
 Maintain airway with OPA EtCO2 readings consistently > 0 indicate
 Intubate tube is not in the esophagus. Verify tube
 Pacing as soon as possible placement is not right mainstem. In the
 Vascular Access cardiac arrest, through quality CPR and
- Induce hypothermia if arrest continues > 5 controlled ventilation attempt to maintain
minutes EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
 Epinephrine 1:10,000 1 mg IV/IO or 2 mg ET poor survivability. EtCO2 readings of 0
(do not repeat) mmHg after six breaths indicate an
 Vasopressin 40 U IV/IO q 5 min unsuccessful intubation.
 Atropine 1 mg IV/IO or 2 mg ET q 3 - 5 min if
beneficial response is seen Max dose of 0.04
mg/kg
Secondary Interventions:
 Narcan 2 – 8 mg IV/IO/IN for suspected
overdose
 Sodium Bicarbonate 1 mEq/kg IV/IO If you suspect acidosis, use Sodium
Bicarbonate early in treatment plan.
 #18 fr Nasogastric tube placement
 Calcium Gluconate 4.65 mEq 10 ml / 10%
Solution IV/IO
Consult:
After 20 minutes of quality chest compressions refer to medical termination procedure
 Consider field termination if patient meets criteria per medical termination procedure
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS BRADYCARDIA
Standard Delegated Orders –
Adult Cardiac AC 04 Page 147
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Weak, dizzy
- Chest pain
- Pulmonary edema
- AMS
- Systolic blood pressure < 90 mmHg
 ECG Findings:
- Any underlying cardiac rhythm or a ventricular rate < 60 bpm

Assessment:

 Cardiac Assessment

Primary Interventions:

 O2 via most appropriate method

 Vascular Access

Secondary Interventions:

 Consider Pacing Bradycardia may be seen in the presence of

AMI. You should treat the original pathology
 Atropine 0.5 mg – 1mg IV/IO rather than the after-effect (MONA before
- q 3 – 5 min if beneficial Atropine) in most cases.
response seen
- Max dose of 0.04 mg/kg High degree blocks with wide complexes will
 Versed 2 – 5 mg IV/IM/IO most likely respond to pacing.
- For sedation prior to pacing
High degree blocks with narrow complexes
may respond to atropine.

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 Montgomery County Hospital District-EMS BRADYCARDIA
Standard Delegated Orders –
Adult Cardiac AC 04 Page 148
TOC

Consult:
 Dopamine Infusion 5-20 mcg/kg/min Dopamine Chart (gtts/min)
- Use IV pump (400mg/250 ml Normal Saline)
- Administer If patient remains
KGS 40 50 60 70 80 90 100
hypotensive 5 minutes after fluid
bolus MCG/MIN
5 8 10 12 13 15 17 19
10 15 19 22 26 30 33 37
15 22 28 33 39 44 50 56
20 30 37 44 52 59 67 74
25 37 46 56 65 74 82 93
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS CHF / PULMONARY EDEMA
Standard Delegated Orders –
Adult Cardiac AC 05 Page 149
TOC

Criteria and History :

 Historical findings:
- Prior history Obtain temperature to rule out pneumonia
- Orthopnea
- Acute difficult breathing at night
 Physical Findings:
- Dyspnea with auscultated
findings of pulmonary edema
- Systolic B/P > 90 mmHg
 ECG Findings:
- Atrial Fibrillation may be present
Assessment:
If patient is hemodynamically unstable,
 Cardiac Assessment consider RVI or other causes

Primary Interventions:

 O2 via most appropriate method

 Vascular Access

Secondary Interventions:

 NTG 0.4 – 0.8 SL q 5 min x 3 prior to Vascular Access if B/P > 100 mmHg
- Once vascular access established, NTG can be administered q 5 min if B/P >100
mmHg
- Administer prior to Lasix
 CPAP 3 – 10 cmH O
 Lasix as noted:
- Should not administer in presence of fever
- Administer after NTG
- If patient is taking Lasix, give patient‘s total daily dose
- If patient is not taking Lasix, administer 40 mg SLOW IV
 Morphine Sulfate 2 - 5 mg IV/IO
- q 5 minutes

Consult:
 Consider need for PAI
 Consult for additional Morphine
Sulfate

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HYPOTHERMIC INDUCED
ARREST
Standard Delegated Orders –
Adult Cardiac AC 06 Page 150
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Pulseless
- Agonal respirations; apnea
- Environmental evidence of
hypothermia
 ECG Findings:
- Any pulseless rhythm

Assessment:
 Cardiac Assessment
 Core Temperature

Primary Interventions:
 CPR Defibrillation Reference
- BVM ventilation with warm 100% - 1 defibrillation at 200 j.
O2 Humidified Do not repeat defibrillation and do not
medicate if temperature is below 85° F
- ResQPOD
- Maintain open airway OPA Remove ResQPOD if ROSC occurs
 Intubation immediately
 Vascular Access
- Use warm fluid ET Tube Confirmation:
Confirm with 5 methods as per procedure
 Warm patient
Capnometry Reference:
- Remove wet clothing EtCO2 readings consistently > 0 indicate
- Heat packs to arm pits and tube is not in the esophagus. Verify tbe
groins placement is not right mainstem. In the
 If V-Fib: cardiac arrest, through quality CPR and
- Biphasic defibrillation controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Secondary Interventions:
 Refer to appropriate rhythm protocol for medication reference
Critical Points:
 Any changes in patient condition or rhythm refer to appropriate protocol

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TACHYCARDIA - STABLE
Standard Delegated Orders –
Adult Cardiac AC 07 - A Page 151
TOC

Criteria and History :

 Historical Findings:
- History of SVT/ use of
Adenosine
- History of A-Fib or A-Flutter or
WPW
 Physical Findings:
- Systolic B/P > 90 mmHg
Chest pain with dyspnea,
lethargy, dizziness, pulmonary
edema, or AMS
 ECG Findings:
- Narrow Complex SVT (rate >
150 and QRS < 0.12 seconds)
Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
- Fluid Bolus if B/P is < 90 mmHg

Secondary Interventions:
 Valsalva maneuver by patient
 Adenosine 12 mg RAPID IV/IO
followed by 20 ml flush
- May repeat x 1 as 12 mg RAPID
IV/IO followed by 20 ml flush of
NS
 Cardizem 10 – 20 mg IV
- Followed by infusion of 80 – 90
mg at 5mg/hr
 Cordarone 150 mg IV/IO over 10
min
- Use IV pump
- Mix 150 mg in 100 ml of NS

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NARROW COMPLEX
TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Adult Cardiac AC 07 - B Page 152
TOC

Criteria and History :

 Historical Findings:
- History of SVT/ use of Adenosine
- History of A-Fib or A-Flutter
 Physical Findings:
- Systolic B/P < 90 mmHg and/or
any of the following:
• Chest pain
• Dyspnea
• Lethargy
• Dizziness
• Pulmonary edema
• AMS
 EKG Findings:
- Narrow Complex SVT (rate >
150 and QRS < 0.12 seconds)

Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method Cardioversion reference:
 Cardioversion - 75 j
- 120 j
 Versed 2 – 5 mg IV/IM/IO if patient
- 150 j
condition allows - 200 j
 Vascular Access
- Fluid Bolus if B/P is < 90 mmHg

Secondary Interventions:

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TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Adult Cardiac AC 07 - B Page 153
TOC

 Adenosine 12 mg RAPID IV/IO

followed by 20 ml flush
- May repeat x 1 as 12 mg RAPID
IV/IO followed by 20 ml flush of
NS
 Cardizem 10 – 20 mg IV
- Followed by infusion of 80 – 90
mg at 5 mg/hr
 Cordarone 150 mg IV/IO over 10
min
- Use IV pump
- Mix 150 mg in 100 ml of NS
Consult:

Critical Points: Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NON-TRAUMATIC CHEST PAIN
Standard Delegated Orders –
Adult Cardiac AC 08 Page 154
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Chest discomfort
- Back, shoulder, neck, jaw,
epigastric discomfort
 ECG Findings:
- No evidence of ischemia or
injury
Assessment:

 Cardiac Assessment

Primary Interventions:

 O2 via most appropriate method

 Vascular Access

Secondary Interventions:
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes
 Pain Management

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS POST RESUSCITATION MGMT
Standard Delegated Orders –
Adult Cardiac AC 09 Page 155
TOC

Criteria and History :

 Historical Findings:
- Post cardiac arrest
 Physical Findings:
- Patient with spontaneous circulation (palpable carotid/radial pulse) AFTER being
treated for any non-perfusing rhythm
 ECG Findings:
- Any perfusing rhythm
Assessment:
 Cardiac Assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Induce Hypothermia
Secondary Interventions:
 Cordarone loading dose of 150 mg IV Dopamine Chart (gtts/min)
over 10 min
(400mg/250 ml Normal Saline)
- Use IV pump
- Mix 150 mg in 100 ml of NS KGS 40 50 60 70 80 90 100
- If ventricular rhythms MCG/MIN
 Cordarone infusion 1 mg/min
- Use IV pump 5 8 10 12 13 15 17 19
- Mix 150 mg in 100 ml of NS 10 15 19 22 26 30 33 37
- If patient previously treated with 15 22 28 33 39 44 50 56
Cordarone for ventricular rhythms
 Lidocaine 1 – 1.5 mg/kg IV 20 30 37 44 52 59 67 74
- If patient did not previously receive 25 37 46 56 65 74 82 93
and converted from a ventricular
rhythm WITHOUT bradycardia
 Lidocaine Infusion 2 – 4mg/min Remove ResQPOD if ROSC occurs
- Use IV pump immediately
- If patient received Lidocaine prior to
ROSC IF INDICATED
 Fluid Bolus  Cordarone 150 mg over 10 minutes if
 Dopamine Infusion 5 – 20 mcg/kg/min no bolus was given.
- Use IV pump  Cordarone 1 mg/min for a maintenance
- Administer If patient remains infusion.
hypotensive 5 minutes after fluid
bolus
 Control shivering with:
- Versed 0.1 mg/kg IV/IO
- Vecuronium 0.1 mg/kg IV/IO (Max 10 mg) (only if Versed does not control
shivering)
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS PULSELESS ELECTRICAL
ACTIVITY
Standard Delegated Orders –
Adult Cardiac AC 10 Page 156
TOC

Criteria and History :

 Historical Findings:
- Medical etiology Perform at least 20 minutes of quality
 Physical Findings: compressions (verified by CPR feedback
- Unconscious device if available) prior to moving patient
- Pulseless unless environment is unsuitable.
- Agonal; apnea
Do not interrupt compressions for ALS
 ECG Findings: procedures.
- Pulseless rhythm; not V-fib, V-Tach,
Asystole
Assessment:

 Cardiac Assessment

Primary Interventions:
 Continuous CPR ET Tube Confirmation:
Confirm with 5 methods as per procedure
 BVM Ventilation with high-flow O
Capnometry Reference:
 Maintain airway with OPA EtCO2 readings consistently > 0 indicate
 Intubate tube is not in the esophagus. Verify tube
 Vascular Access placement is not right mainstem. In the
- Induce hypothermia if arrest cardiac arrest, through quality CPR and
continues > 5 minutes controlled ventilation attempt to maintain
 Epinephrine 1:10,000 1 mg IV/IO or EtCO2 levels as close to 35 – 45 mmHg as
2 mg ET (do not repeat) possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
 Vasopressin 40 U IV/IO q 5 min
Administer Epinephrine ET ONLY if NO
IV/IO ACCESS
Secondary Interventions:
 Atropine 1 mg IV/IO or 2 mg ET if Consider all other treatable causes
heart rate < 60 - Hypoxia - ventilation
- q 3 – 5 min if beneficial - Hypothermia - warming
response is seen - Hyperkalemia – calcium gluconate and
sodium bicarbonate
- Max dose 0.04 mg/kg - Acidosis – ventilation and sodium
 Chest Decompression if bicarbonate
pneumothorax is present - Massive MI – heart cath
 Fluid Bolus - Hypovolemia/hypotension – fluid
 Narcan 2 – 8 mg IV/IO/IN replacement
 Consider Pacing for heart rate < 60 - Pulmonary embolism – surgery
- Cardiac tamponade – pericardiocentisis
 Sodium Bicarbonate 1 mEq/kg IV/IO
- Drug overdose - narcan
 #18 fr Nasogastric tube placement - Tension pneumothorax – chest

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 Montgomery County Hospital District-EMS PULSELESS ELECTRICAL
ACTIVITY
Standard Delegated Orders –
Adult Cardiac AC 10 Page 157
TOC

 Calcium Gluconate 4.65 mEq 10 ml decompression

/ 10% Solution IV/IO
Consult:
After 20 minutes of quality chest compressions refer to medical termination procedure
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS VENTRICULAR ECTOPY
Standard Delegated Orders –
Adult Cardiac AC 11 Page 158
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:  Potential for the occurrence of R-on-T
- Chest pain with weakness, phenomenon
dizziness, dyspnea, irregular  If patient’s pulse is < 60 BPM, treat
rhythm bradycardia first
 ECG Findings:
- Six or more PVC‘s per minute
- Multiform PVC‘s
- Couplets, triplets
- Evidence of AMI in the absence
of bradycardia

Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
Secondary Interventions:
 Cordarone 150 mg IV over 10 min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Cordarone infusion 1 mg/min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Lidocaine 1 mg/kg IV
- q 5 minutes as 0.5 mg/kg up to 3
mg/kg total
 Lidocaine Infusion 2 – 4 mg/min
- Use IV pump
- If successful conversion of the
rhythm with lidocaine bolus
Consult:
 Magnesium Sulfate 1 – 2 g dilute in
10 ml of NS SLOW IV/IO

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS VENTRICULAR FIBRILLATION /
PULSELESS VENTRICULAR
TACHYCARDIA
Standard Delegated Orders –
Adult Cardiac AC 12 Page 159
TOC

Criteria and History :

 Historical Findings:
- Medical etiology Perform at least 20 minutes of quality
compressions (verified by CPR feedback
 Physical Findings:
device if available) prior to moving patient
- Unconscious unless environment is unsuitable.
- Pulseless
- Agonal respiration; Apnea Do not interrupt compressions for ALS
 ECG Findings procedures.
- V-Fib or Pulseless V-Tach
Assessment:
 Cardiac Assessment Consider all potential non-cardiac causes
Remove False Teeth, Secretions, or any
vomitus
Primary Interventions:
If witnessed, immediate defibrillation Defibrillation Reference
If arrest is not witnessed by responding Biphasic defibrillation at 200 j should be
unit done during rotation of compressor to
reduce hands off period
Continuous chest compressions 1-2
minutes prior to defibrillation and ET Tube Confirmation:
medication
Confirm with 5 methods as per procedure
BVM Ventilation with high-flow O
Maintain airway with OPA Capnometry Reference:
Continuous CPR EtCO2 readings consistently > 0 indicate
Deliver defibrillation q 2 minutes tube is not in the esophagus. Verify
tube placement is not right mainstem.
Intubate; respiratory rate 8 breaths per In the cardiac arrest, through quality
minute CPR and controlled ventilation attempt
Vascular Access to maintain EtCO2 levels as close to 35
Induce hypothermia if arrest – 45 mmHg as possible. Values under
continues > 5 minutes 15 mmHg indicate poor survivability.
Epinephrine 1:10,000 1 mg IV/IO or 2 Unsuccessful: 0 mmHg
mg ET (do not repeat)
Vasopressin 40 U IV/IO q 5 min Administer Epinephrine ET ONLY if NO
IV/IO ACCESS
Cordarone 300 mg IV/IO

Secondary Interventions:
 Lidocaine 1.5 mg/kg IV/IO or 3 Only Administer Magnesium Sulfate with:
mg/kg ET • Refractory V-Fib
 Magnesium Sulfate 1 – 2g dilute in • Torsades Des Pointes

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 Montgomery County Hospital District-EMS VENTRICULAR FIBRILLATION /
PULSELESS VENTRICULAR
TACHYCARDIA
Standard Delegated Orders –
Adult Cardiac AC 12 Page 160
TOC

10 ml of NS SLOW IV/IO Narcan for suspected Drug Overdose

 Sodium Bicarbonate 1mEq/kg IV/IO Sodium Bicarbonate for Acidosis and TCA
 Calcium Gluconate 4.65 mEq 10 ml overdose
/ 10% Solution IV/IO
 Narcan 2 – 8 mg IV/IO/IN
Calcium Gluconate for Renal Dialysis
 #18 fr Nasogastric tube placement Patients or suspected hyperkalemia

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS WIDE COMPLEX
TACHYCARDIA - STABLE
Standard Delegated Orders –
Adult Cardiac AC 13 - A Page 161
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Hemodynamically stable
- Palpitations
 ECG Findings:
- Ventricular Tachycardia, Wide Complex (QRS > 0.12 seconds)
Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Cordarone 150 mg IV/IO over 10 min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Cordarone infusion 1 mg/min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Lidocaine 1 mg/kg IV/IO
- q 5 minutes as 0.5 mg/kg up to 3 mg/kg total
 Lidocaine Infusion 2 – 4 mg/min
- Use IV pump
- If successful conversion of the rhythm with lidocaine bolus
 Magnesium Sulfate 1 – 2 g dilute in 10 ml of NS SLOW IV/IO

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS WIDE COMPLEX
TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Adult Cardiac AC 13 - B Page 162
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Systolic B/P < 90 mmHg and/or any of the following:
Chest pain
Dyspnea
Lethargy
Dizziness
Pulmonary edema
AMS
 ECG Findings:
- Ventricular Tachycardia, Wide Complex (QRS > 0.12 seconds)
Assessment:
 Cardiac Assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Versed 2 – 5 mg IV/IM/IO
- For sedation prior to
cardioversion
 Synchronized Cardioversion
- 75j
- 120j
- 150j
- 200j
Secondary Interventions:
 Cordarone 150 mg IV over 10 min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Cordarone infusion 1 mg/min
- Use IV pump
- Mix 150 mg in 100 ml NS
 Lidocaine 1 mg/kg IV
- q 5 minutes as 0.5 mg/kg up to 3
mg/kg total
 Lidocaine Infusion 2 – 4 mg/min
- Use IV pump
- If successful conversion of the
rhythm with lidocaine bolus
 Magnesium Sulfate 1 – 2 g dilute in
10 ml of NS SLOW IV/IO

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TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Adult Cardiac AC 13 - B Page 163
TOC

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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ADULT ENVIRONMENTAL
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS ENVIRONMENTAL
ASSESSMENT
Standard Delegated Orders –
Adult Environmental AE 01 Page 167
TOC

Criteria and History :

 Historical Findings:
- Exposure to extreme
temperatures
- Envenomation
- Wilderness exposure
- Exposure to hazardous
materials
 Physical Findings:
- Hyperthermia/Hypothermia
- Altered Mental Status
Shivering
- Frostbite
- Dyspnea
- Evidence of bite, sting or
exposure to chemicals
- Nausea/Vomiting
- Dizziness/Weakness
- Sweating
- Abdominal pain
Assessment
 C. A. B. C. Glascow Coma Scale
 Secondary Assessment Eye Response Verbal Response Motor Response
 Vital Signs 4 Spontaneous 5 Orientated 6 Obeys
 ECG 3-Lead and 12-Lead if
3 To verbal 4 Confused 5 Localizes
appropriate
2 To pain 3 Inappropriate 4 Withdraws
 Blood glucose
1 No response 2 Incomprehensible 3 Flexion
 Temperature
1 No response 2 Extension
 Lung sounds
1 No response
 GCS
 OPQRST
 ASPN
 SAMPLE

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS COLD RELATED EMERGENCY
Standard Delegated Orders –
Adult Environmental AE 02 Page 168
TOC

Criteria and History :

 Historical Findings:
- Immersion or exposure to cold temperatures

 Physical Findings:
- Core temperature < 96 degrees F
- Shivering
- Altered mental status
- Cyanosis

Assessment:
 Environmental Assessment

Primary Interventions:
 O2 via appropriate method Passive rewarming:
 Prevent further heat loss Remove wet clothing
 Passive rewarming Warm blankets
 3-Lead ECG Wrap heat packs and apply to axillary and groin
 12-Lead ECG regions
Secondary Interventions:
 Vascular Access Use warm IV fluids

For persistent shivering or active seizures, refer

to Seizure protocol
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HEAT RELATED EMERGENCY
Standard Delegated Orders –
Adult Environmental AE 03 Page 169
TOC

Criteria and History :

 Historical Findings:
- Exposure to heat
 Physical Findings:
- Environmental potential of heat
related emergency
- Normothermic or hyperthermic
with weakness, dizziness, N/V,
syncope, sweating
 ECG Findings:
- Tachycardia
Assessment:
 Environmental assessment Heat Cramps
- Cramps in extremities or abdomen
Heat Exhaustion
- Temperature normal or 1 – 2 degrees
above normal with weakness, dizziness,
nausea, syncope, profuse sweating,
tachycardia
Heat Stroke
- Temperature of 105 degrees F or greater
and any of the following: AMS, Sz activity,
lack of sweating, cardiac arrest

Primary Interventions:
 O2 via most appropriate method Remove patient‘s clothing
 External Cooling Apply cold packs to axillary and groin regions
Avoid excessive cooling
Secondary Interventions:
 Vascular Access For persistent shivering or active seizures, refer
 Fluid Bolus to Seizure protocol
 Trendelenburg
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM for N/V
- May be repeated x 1 if N/V
persists after 15 minutes
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HEAT RELATED EMERGENCY
Standard Delegated Orders –
Adult Environmental AE 03 Page 170
TOC

Revision Date 01/26/2009 170

 Montgomery County Hospital District-EMS INSECT / ANIMAL / SNAKE
BITE
Standard Delegated Orders –
Adult Environmental AE 04 Page 171
TOC

Criteria and History :

 Historical Findings:
- Preceding event
 Physical Findings:
- Pain to location of bite/sting
- Known or suspected
envenomation by an insect or
snake

Assessment:
 Environmental assessment

Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access For active seizures, refer to Seizure protocol
 Nitrous Oxide
 Pain Management
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 171

 Montgomery County Hospital District-EMS NEAR DROWNING
Standard Delegated Orders –
Adult Environmental AE 05 Page 172
TOC

Criteria and History :


Historical Findings:
- Water submersion without
cardiopulmonary arrest and
without evidence of hypothermia
 Physical Findings:
- Dyspnea, difficulty breathing
Assessment:
 Environmental assessment

Primary Interventions:
 Remove from water ET Tube Confirmation:
 O2 via most appropriate method Confirm with 5 methods as per procedure
 Intubate Capnometry Reference:
- If unconscious and unable to EtCO2 readings consistently > 0 indicate
protect airway tube is not in the esophagus. Verify tbe
 External warming if indicated placement is not right mainstem. In the
 Vascular Access cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Secondary Interventions:
 CPAP 3 – 10 cmH O PEEP:
Use with caution in low perfusion state
 Tracheal suctioning via ETT
 PEEP usage during ventilation 5 –
10 cm H O

Consult:
Mallampati Classification
 Consider PAI Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS TOXICOLOGICAL / HAZMAT
Standard Delegated Orders –
Adult Environmental AE 06 Page 173
TOC

Criteria and History :

 Historical Findings: Hazardous Materials may fall under the
- Determine type of exposure & following categories:
refer to USDOT-ERG for initial Chemical
assessment and management. Biological
 Physical Findings: Nuclear
Radioactive
- Findings will vary based upon
Explosive
contaminant.
 If Organophosphates (OGP’s) Most common OGP‘s are pesticides and
- SLUDGE-BM produce an exaggerated parasympathetic
• Salivation, Lacrimation response.
(Tearing), Urination,
Diarrhea/Defecation, GI
Distress, Emesis,
Bradycardia, & Miosis
(Pinpoint pupils)
Assessment:
 Ensure that the patient has been Medical Care should be coordinated with a
decontaminated. Hazardous Materials Response Team
 At NO TIME SHOULD EMS
personnel enter the HOT or WARM Appropriate PPE may be either Level B
Zone, unless wearing appropriate partially encapsulated suits with PAPR
PPE. (Positive Air Purifying Respirators) or Level A
 If exposure is localized and not Fully encapsulated suits with SCBA.
generalized:
- Dry Chemical:
Brush the chemical off and flush Water should be from a steady stream, for at
with copious amounts of water. least 15 – 20 minutes into a sanitary sewer
- Wet Chemical:
Irrigate with copious amounts of
water.
Primary Interventions:
 Assure scene and personal safety.
 Assure that patient has been
decontaminated appropriately.
 Provide for oxygenation and ensure
patent airway
 Vascular Access
Secondary Interventions:
 Evaluate ECG as appropriate Doses in excessive of 5 – 10 mg may be
 For OGP, administer Atropine 2 mg required to resolve Bradycardia in OGP.
repeated frequently until
Bradycardia has resolved.

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 Montgomery County Hospital District-EMS TOXICOLOGICAL / HAZMAT
Standard Delegated Orders –
Adult Environmental AE 06 Page 174
TOC

Consult:
 PAI
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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ADULT MEDICAL
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS MEDICAL ASSESSMENT
Standard Delegated Orders –
Adult Medical AM 01 Page 178
TOC

Criteria and History :

 Historical Findings:
- Recent events
- PMHx
 Physical Findings:
- Pain
- Non-traumatic hemorrhage
- Itching, swelling, hives
- Altered mental status
- Fever
- Headache
- Dyspnea

Assessment:
 C. A. B. C.
 Secondary Assessment
 Vital Signs (orthostatic)
 ECG 3-Lead and 12-Lead if
appropriate
 Blood glucose
 Temperature
 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE

Critical Points:

 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ALLERGIC REACTION
Standard Delegated Orders –
Adult Medical AM 02 Page 179
TOC

Criteria and History :

 Historical Findings:
- Previous history
- Exposure to allergen
 Physical Findings:
Mild Reaction – contact dermatitis
(rash) and/or urticaria (hives),
dermal itching
Moderate Reaction – mild reaction
symptoms with dyspnea
Anaphylaxis – severe reaction
symptoms with hypotension,
difficulty swallowing, generalized
edema, stridor

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
Mild:
 Vascular Access
 Benadryl 50 mg IV/IM/IO

Moderate:
 ―Mild reaction‖ treatment in addition
to:
 Xoponex 1.25 mg/3 ml via nebulizer
- May repeat x 2 q 15 minutes
 SoluMedrol 125 mg IV/IO
OR
Decadron 10 mg IV/IO
 Epinephrine 1:1,000 0.3 mg SQ

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 Montgomery County Hospital District-EMS ALLERGIC REACTION
Standard Delegated Orders –
Adult Medical AM 02 Page 180
TOC

Anaphylaxis
 ―Moderate reaction‖ treatment in
addition to:
 Epinephrine 1:10,000 0.5 – 1 mg
IV/IO
- If pt is unconscious with vascular
collapse

Consult:
 Additional Epinephrine 1:10,000 0.5 Mallampati Classification:
– 1 mg IV/IO Class I: soft palate, fauces, uvula, pillars visible
- If pt is unconscious with vascular Class II: soft palate, fauces and uvula visible
collapse Class III: soft palate, base of uvula visible
 Epinephrine 1:1,000 0.5 mg SL Class IV: soft palate not visible
- If pt is unconscious with vascular
collapse ET Tube Confirmation:
 Consider PAI Confirm with 5 methods as per procedure

Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to the appropriate protocol

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 Montgomery County Hospital District-EMS AMS / UNCONSCIOUS
Standard Delegated Orders –
Adult Medical AM 03 Page 181
TOC

Criteria and History :

 Historical Findings: Consider causes:
- Medical etiology - CVA
- Hypoglycemia/hyperglycemia
 Physical Findings: - Drug/ Alcohol use
- Unresponsive, disoriented - Recent trauma
WITHOUT a clear mechanism - Hepatic disease
for AMS - Acidosis/electrolyte imbalance
- Sepsis
- Hypotension
- Hypoxemia
Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
Secondary Interventions:
 Vascular Access - Do not administer Narcan if pt is intubated
 Narcan 2 – 8 mg IV/IO/IN for
respiratory depression

Consult:
 Consider PAI Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible

ET Tube Confirmation:
Confirm with 5 methods as per procedure

Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 181

 Montgomery County Hospital District-EMS CEREBROVASCULAR
ACCIDENT
Standard Delegated Orders –
Adult Medical AM 04 Page 182
TOC

Criteria and History :

 Historical Findings:
- Time of onset
 Physical Findings:
- AMS
- B/P > 200 mmHg and/or diastolic > 110 mmHg
- Unilateral weakness
- Paralysis
- Facial drooping
- Ataxia
- Aphasia/dysphasia
- Headache
- Visual disturbance

Assessment:
 Medical Assessment
 Neurological Exam using MCHD
Prehospital Stroke Scale

Primary Interventions:
 O2 via most appropriate method  Known onset < 180 minutes, patient eligible
 Vascular Access for acute stroke intervention at appropriate
facility
 For Systolic B/P > 200 mmHg
and/or Diastolic B/P > 110 mmHg, - Conroe Regional Medical Center
reassess B/P - Memorial Hermann – The Woodlands
 Rapid transport to appropriate - Houston Northwest
facility supine with head of stretcher
at 15 degrees  Known onset < 9 hours, patient eligible for
 Contact receiving facility and report acute stroke intervention at appropriate
pt status facility

Methodist – Main

 Consider AMP

Secondary Interventions:
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM

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 Montgomery County Hospital District-EMS CEREBROVASCULAR
ACCIDENT
Standard Delegated Orders –
Adult Medical AM 04 Page 183
TOC

- May be repeated x 1 if N/V

persists after 15 minutes

Consult:
 Labetalol 10 mg over 2 minutes Mallampati Classification:
IV/IO q 15 minutes if B/P remains > Class I: soft palate, fauces, uvula, pillars visible
160/100 Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
 Consider PAI Class IV: soft palate not visible

ET Tube Confirmation:
Confirm with 5 methods as per procedure

Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 183

 Montgomery County Hospital District-EMS DIABETIC - HYPERGLYCEMIA
Standard Delegated Orders –
Adult Medical AM 05 - A Page 184
TOC

Criteria and History :

 Historical Findings:
- Known history
- New onset
 Physical Findings:
- BGL > 180 mg/dL with one of
the following:
- AMS, tachypnea, abdominal
pain, hypotension and
tachycardia
- Polyuria, Polyphagia, Polydipsia
Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Fluid Bolus
 Continued infusion of NS 500 ml/hr
- Discontinue if pulmonary edema
develops
Secondary Interventions:
 Obtain blood sample for lab analysis
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
May be repeated x 1 if N/V
persists after 15 minutes

Consult:
 Sodium Bicarbonate 1 mEq/kg IV Consider when pt is tachycardic, tachypneic,
- If metabolic acidosis is altered mental status
suspected

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DIABETIC - HYPOGLYCEMIA
Standard Delegated Orders –
Adult Medical AM 05 - B Page 185
TOC

Criteria and History :

 Historical Findings:
- Known history
- New onset
 Physical Findings:
- BGL < 80 mg/dL
- Signs and symptoms suggestive of
Hypoglycemia: AMS, tremors, weakness, N/V, intense hunger, diaphoresis
- BGL < 40 mg/dL should be treated, regardless of presence of other
signs/symptoms

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Oral glucose 40% 15 g PO
- Only in patients with intact gag
reflex and able to follow
commands to swallow
medication
 Thiamine 50 mg IV/IO and 50 mg IM
- Prior to D50% administration
 D50% 25 – 50 g IV
- May be repeated x 1 q 5 if
symptoms persist
- Repeat BG in 10 minutes after
administration of D50%
 Glucagon 1 mg IM/SQ if unable to
obtain vascular access
- Should be followed by Oral
glucose once patient can follow
commands and swallow

Consult:
 Additional D50% 25 – 50 g IV

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DYSTONIC REACTION
Standard Delegated Orders –
Adult Medical AM 06 Page 186
TOC

Criteria and History :


Historical Findings:
- Recent ingestion of Phenergan
phenothiazines, fluphenazines, Reglan (Metoclopramide)
other neuroleptics or related Propulsid
drugs used as antipsychotics Haldol
and also to treat GI disorders
and nausea
 Physical Findings:
- Protrusion of the tongue, twisted
neck or facial spasms, roving or
deviated gaze, abdominal
rigidity or pain, spasm of the
entire body, twitching
Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Benadryl 50 mg IV/IM/IO
Secondary Interventions:

Consult:

 Versed 2 – 5 mg IV/IM/IO if no
response is seen from Benadryl

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 186

 Montgomery County Hospital District-EMS FEVER
Standard Delegated Orders –
Adult Medical AM 07 Page 187
TOC

Criteria and History :

Historical Findings:
- Evidence of determinable - Use of full PPE is recommended
source for sepsis
 Physical Findings:
- AMS
- Weakness
- Temperature > 101 degrees F
Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Fluid Bolus Refer to Heat Related Emergency protocol
 Acetaminophen 975 mg PO if no
N/V For persistent shivering or active seizures, refer
to Seizure protocol
 External cooling
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 187

 Montgomery County Hospital District-EMS HYPERTENSIVE CRISIS
Standard Delegated Orders –
Adult Medical AM 08 Page 188
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Systolic B/P >200 mmHg and/or
Diastolic B/P > 110 mmHg
- Evidence of end-organ
dysfunction including:
Chest pain
Dyspnea
Severe headache
Nausea/Vomiting
Epistaxis
Assessment:
 Medical Assessment
 Neurological Exam using MCHD
Prehospital Stroke Scale
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 For Systolic B/P >200 mmHg and/or
Diastolic B/P > 110 mmHg,
reassess B/P
 If pt has NO clinical evidence of end
organ dysfunction, transport with
supportive treatment

Secondary Interventions:
 Zofran 8 mg oral disintegrating Chest pain, Abdominal Pain, Shortness of
tablet (ODT) PO Breath, and CVA – Refer to appropriate
protocol
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
May be repeated x 1 if N/V
persists after 15 minutes

Consult:
 Labetalol 10 mg over 2 minutes IV q
15 minutes if B/P remains > 160/100

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 Montgomery County Hospital District-EMS HYPERTENSIVE CRISIS
Standard Delegated Orders –
Adult Medical AM 08 Page 189
TOC

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS MALNUTRITION /
DEHYDRATION
Standard Delegated Orders –
Adult Medical AM 09 Page 190
TOC

Criteria and History :

 Historical Findings: Compensated Hypovolemia
- Recent illness - Normotension and tachycardia
Uncompensated Hypovolemia
- Poor nutrition
- Hypotension and tachycardia
- Anorexia
- ETOH abuse
 Physical Findings:
- Poor skin turgor
- Dizziness
Assessment:
 Medical Assessment Contact information for APS:
1-800-252-5400 or
https://www.txabusehotline.org
Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Fluid Bolus
- q 5 – 10 minutes if pt is
symptomatic and there is no
evidence of pulmonary edema
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes
 Thiamine 50 mg IV/IO and 50 mg IM

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NON-TRAUMATIC ABDOMINAL
PAIN
Standard Delegated Orders –
Adult Medical AM 10 Page 191
TOC

Criteria and History :

 Historical Findings: - Females of reproductive age who complain
- Medical etiology of abdominal pain are managed with the
OB Abdominal Pain protocol
 Physical Findings:
- Abdominal pain with rebound - Abdominal pain secondary to trauma is
tenderness, increased pain on managed with the Multi-system trauma
palpation, increased pain on protocol.
movement
- Symptoms of Renal calculi

Assessment:
 Medical Assessment
 Auscultation of bowel sounds and
history of bowel movement
 Palpate for pulsating masses

Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access Assess, document location, type, radiation,
 Zofran 8 mg oral disintegrating migration, response to palpation, treat,
assess, retreat and reassess if necessary.
tablet (ODT) PO Pain reduction should be offset with a good
May be repeated every 15 min assessment and documentation pre and
 Phenergan 12.5 mg IV/IO/IM post drug administration.
- May be repeated x 1 if N/V
persists after 15 minutes
 Pain Management

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 191

 Montgomery County Hospital District-EMS NON-TRAUMATIC
HEMORRHAGE
Standard Delegated Orders –
Adult Medical AM 11 Page 192
TOC

Criteria and History :

 Historical Findings: Consider all possible causes
- Medical etiology - Abdominal aortic aneurysm (AAA)
- Ulcers/Diverticulitis/GI bleed
 Physical Findings:
- Hypovolemia secondary to blood
loss due to medical etiology
- ―Coffee ground‖ emesis
- Blood in stool
- Epistaxis

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Fluid Bolus x 2 q 5 minutes
- Discontinue if pulmonary edema
develops
 Consider Trendelenburg
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 192

 Montgomery County Hospital District-EMS NON-TRAUMATIC SHOCK /
HYPOTENSION
Standard Delegated Orders –
Adult Medical AM 12 Page 193
TOC

Criteria and History :

 Historical Findings: Evidence of sepsis can include any of the
- No evidence of blood loss or following:
trauma  Fever
 Physical Findings:  Recent wound or surgery
 Recent URI/UTI symptoms
- Systolic B/P < 90mmHg
 Urinary catheter
- AMS  Petechia or rash
- Sepsis
- Tachycardia

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Fluid Bolus x 2 q 5 minutes
- Discontinue if pulmonary edema
develops
 Consider Trendelenburg
Consult:
 Dopamine Infusion 5 – 20 Dopamine Chart (gtts/min)
mcg/kg/min (400mg/250 ml Normal Saline)
- Use IV pump
KGS 40 50 60 70 80 90 100
- Administer if patient remains
hypotensive 5 minutes after fluid MCG/
bolus MIN
 Consider PAI 5 8 10 12 13 15 17 19
10 15 19 22 26 30 33 37
15 22 28 33 39 44 50 56
20 30 37 44 52 59 67 74
25 37 46 56 65 74 82 93
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 193

 Montgomery County Hospital District-EMS OVERDOSE / POISONING
Standard Delegated Orders –
Adult Medical AM 13 Page 194
TOC

Criteria and History :

 Historical Findings:
- Known use of drug or alcohol
use
- Known or suspected ingestion or
injection of pharmacoactive
substance, whether intentional
or accidental
- Ingestion, inhalation or
absorption of potentially harmful
non-pharmaceutical substance
 Physical Findings:
- Lethargy, AMS, combative,
unresponsive
Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method 100% O for Carbon monoxide
Consider Hyperbaric Therapy

Secondary Interventions:
 Vascular Access Tricyclic Antidepressants include:
 Narcan 2 – 8 mg IV/IO/IN - Elavil
- Amitriptyline
- May repeat - Imipramine
- For suspected narcotic overdose - Doxepin
with respiratory depression - Nortriptyline
 Sodium Bicarbonate 0.5 – 1 mEq/kg
IV/IO
- For Tricyclic anti-depressant Calcium Channel Blockers include:
(TCA) overdose with AMS and - Amlodipine
tachycardia and/or widened - Diltiazem
QRS complexes - Nifedipine
- For ethylene glycol ingestion - Verapamil
(antifreeze, detergents, paints)
 Atropine 2 mg IV/IM/IO
- For OGP poisoning with
parasympathetic symptoms
- Repeat q 5 as needed
 Charcoal 50 – 100 grams PO within
1 hour of ingestion

Revision Date 08/01/2007 194

 Montgomery County Hospital District-EMS OVERDOSE / POISONING
Standard Delegated Orders –
Adult Medical AM 13 Page 195
TOC

 Calcium Gluconate 4.65 mEq IV/IO

- For calcium channel blocker Beta Blockers include:
overdose - Atenolol
- Metoprolol
- Propranolol
 Glucagon 1 mg IV/IM/SQ/IO - Corgard
- Beta blocker or calcium channel - Inderal
blocker overdose - Lopressor
 Consider contacting Poison control - Tenormin
(1-800-POISON-1 or - Trandate
1-800-764-7661)

Consult:
 Versed 2 – 5 mg IV
- For cocaine or
methamphetamine overdose
 Valium 5 – 10 mg IV
- For cocaine or
methamphetamine overdose
 PAI

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 195

 Montgomery County Hospital District-EMS SEIZURES
Standard Delegated Orders –
Adult Medical AM 14 Page 196
TOC

Criteria and History :

 Historical Findings:
- History of seizures
- Head trauma
- New onset
 Physical Findings:
- Post-ictal
Witnessed, reported or suspected seizure prior to EMS arrival
- Active
Actively seizing patient upon EMS arrival
Assessment:
 Medical Assessment Consider possible causes:
- Head trauma
- Febrile
- Epilepsy
- Overdose
- Withdrawals
- Hypoglycemia
- Unknown etiology
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 External cooling, if febrile

Secondary Interventions:
Active
 Versed 2 – 5 mg IV/IM/IO/IN
- Repeat x 1, Versed 2 – 5 mg
IV/IM/IO q 5 min
 Valium 2 – 10 mg IV/IO
 Valium 4 – 20 mg PR
- If unable to establish IV
Consult:
 Additional Versed 2 – 5 mg IV/IM/IO
 Additional Valium 2 – 10 mg IV/IO
 Additional Valium 4 – 20 mg PR if
unable to establish IV

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 196

 Montgomery County Hospital District-EMS SYNCOPE
Standard Delegated Orders –
Adult Medical AM 15 Page 197
TOC

Criteria and History :

 Historical Findings:
- History of loss of consciousness
 Physical Findings:
- Common ―faint‖ (vasovagal syncope)
- Postural ―faint‖ (orthostatic syncope)
- Hyperventilation syncope
 ECG Findings:
- No evidence of cardiac ischemia

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method Syncope is arrthymia related until proven
 Once you have completed a patient otherwise. Maintain high index of of suspicion.
assessment, and a cause of
syncope has been determined, refer
to the appropriate protocol.
Secondary Interventions:
 Vascular Access

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 197

This Page Intentionally Left Blank
ADULT RESPIRATORY
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS RESPIRATORY ASSESSMENT
Standard Delegated Orders –
Adult Respiratory AR 01 Page 201
TOC

Criteria and History :

 Historical Findings:
- Use of inhaled medications, Consider all possible causes and refer to
steroids, diruretics, anti- appropriate protocol:
hypertensive medications - Pulmonary Embolism
- Anxiety
- Smoking - COPD
- Fever - Asthma
- Productive cough - Airway obstruction
- Recent surgery - Pneumonia
 Physical Findings: - CHF
- Pneumothorax
- Dyspnea, tachypnea
- Allergic reaction
- Cyanosis - Aspiration
- Clubbing
- Edema (Pulmonary, pedal,
ascites, presacral)
- Wheezing, rales, rhonchi,
absent/decreased breath
sounds, stridor
- Chest pain
- Bronchoconstriction
- Jugular venous distention (JVD)

Assessment:
 C. A. B. C. Mallampati Classification:
 Secondary Assessment Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
 Vital Signs (orthostatic) Class III: soft palate, base of uvula visible
 ECG 3-Lead and 12-Lead if Class IV: soft palate not visible
appropriate
 Blood glucose
 Temperature
 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE
 Capnography
 Mallampati score

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 201

 Montgomery County Hospital District-EMS RESPIRATORY ASSESSMENT
Standard Delegated Orders –
Adult Respiratory AR 01 Page 202
TOC

Revision Date 11/01/2005 202

 Montgomery County Hospital District-EMS AIRWAY OBSTRUCTION
Standard Delegated Orders –
Adult Respiratory AR 02 Page 203
TOC

Criteria and History :

Historical Findings:
- Recent event
 Physical Findings:
- Partial or complete airway
obstruction
- Secondary to foreign body
aspiration
- Decreased LOC
- Cyanosis
- Obvious inadequate air
exchange
Assessment:
 Respiratory assessment

Primary Interventions:
 Abdominal/chest thrusts
- If patient is conscious
 Direct laryngoscopy and removal of
foreign object with Magill forceps or
suction
- If patient is unconscious and
there is a complete obstruction
 O2 via most appropriate method
Secondary Interventions:
 Vascular Access
Consult:
 Consider surgical airway if
obstruction is not relieved by other
means

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 203

 Montgomery County Hospital District-EMS BRONCHOSPASM
Standard Delegated Orders –
Adult Respiratory AR 03 Page 204
TOC

Criteria and History :

 Historical Findings:
- History of asthma
 Physical Findings:
- Dyspnea with wheezing or prolonged expiratory phase
Assessment:
 Respiratory assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Fluid Bolus
Secondary Interventions:
 Xopenex 1.25 mg / 3ml via nebulizer
- May repeat x 2 q 15 minutes CPAP settings not to exceed 8 cmH2O for
Bronchospasm
 CPAP 3 – 8 cmH2O
 Solumedrol 125 mg IV/IO
OR
Decadron 10 mg IV/IO

Consult:
 Epinephrine 1:1,000 0.3 mg SQ Magnesium Sulfate Infusion
 Consider PAI Mix 1 g in 100 ml NS and infuse over 10
 Magnesium Sulfate 1 g IV/IO minutes using pump
infusion
- May be repeated x 1 Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 204

 Montgomery County Hospital District-EMS CHRONIC OBSTRUCTED
PULMONARY DISEASE
Standard Delegated Orders –
Adult Respiratory AR 04 Page 205
TOC

Criteria and History :

 Historical Findings:
- History of COPD COPD - Chronic Obstructed Pulmonary
Disease
- Chronic bronchitis or
emphysema
 Physical Findings:
- Abnormal breath sounds
Assessment:
 Respiratory assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Fluid Bolus

Secondary Interventions:
 Xopenex 1.25 mg / 3 ml via
nebulizer
- May repeat x 2 q 15 minutes
 CPAP 3 – 10 cmH2O
 Solumedrol 125 mg IV/IO
OR
 Decadron 10 mg IV/IO
Consult:
 Consider PAI Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 205

 Montgomery County Hospital District-EMS HYPERVENTILATION
Standard Delegated Orders –
Adult Respiratory AR 05 Page 206
TOC

Criteria and History :

 Historical Findings:
- Stress or anxiety
 Physical Findings:
- Increased rate/depth of
respiration without evidence of
hypoxemia
- Facial/peripheral tingling
- Extremity cramping or
carpopedal spasm
- Dizziness
 ECG Findings:
- Tachycardia
Assessment:
 Respiratory assessment
Primary Interventions:
 O2 via most appropriate method
 Psychological support

Secondary Interventions:
 Vascular Access

Consult:
 Versed 2 – 5 mg IV/IM/IO If unable to control hyperventilation within 10
- For extreme anxiety minutes, consult for sedation and see adult
behavioral protocol

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 206

 Montgomery County Hospital District-EMS PNEUMONIA
Standard Delegated Orders –
Adult Respiratory AR 06 Page 207
TOC

Criteria and History :

Historical Findings:
- Recent upper respiratory illness
 Physical Findings:
- Fever
- Productive cough
- Wheezing, rhonchi or rales
Assessment:
 Respiratory assessment

Primary Interventions:
 O2 Via most appropriate method
 Vascular Access
 Xopenex 1.25 mg / 3 ml via
nebulizer
- May repeat x 2 q 15 minutes
Secondary Interventions:
 CPAP 3 – 10 mmHg
 Fluid Bolus
 Acetaminophen 975 mg PO
Consult:
Mallampati Classification:
 Consider PAI Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 207

 Montgomery County Hospital District-EMS PULMONARY EMBOLISM
Standard Delegated Orders –
Adult Respiratory AR 07 Page 208
TOC

Criteria and History :

 Historical Findings:
- Recent surgery
- Thrombosis/Embolism
- Recent travel
 Physical Findings:
- Dyspnea, sudden onset
- Leg pain / swelling
- Chest pain
- Hemoptysis
- JVD
 ECG Findings:
- A-fib
- Tachycardia

Assessment:
 Respiratory assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Fluid Bolus if B/P < 90 mmHg
 Rapid transport
Secondary Interventions:
 Intubate ET Tube Confirmation:
- If patient is in severe distress or Confirm with 5 methods as per procedure
unable to protect airway Capnometry Reference:
EtCO2 readings consistently > 0 indicate
 Place patient in left lateral
tube is not in the esophagus. Verify tbe
recumbent position placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Revision Date 06/26/2006 208

 Montgomery County Hospital District-EMS PULMONARY EMBOLISM
Standard Delegated Orders –
Adult Respiratory AR 07 Page 209
TOC

Consult:
 Consider PAI Mallampati Classification:
 Dopamine Infusion 5 – 20 Class I: soft palate, fauces, uvula, pillars visible
mcg/kg/min Class II: soft palate, fauces and uvula visible
- Use IV pump Class III: soft palate, base of uvula visible
- Administer if patient remains Class IV: soft palate not visible
hypotensive 5 minutes after fluid
bolus Dopamine Chart (gtts/min)
(400mg/250 ml Normal Saline)
KGS 40 50 60 70 80 90 100
MCG/
MIN
5 8 10 12 13 15 17 19
10 15 19 22 26 30 33 37
15 22 28 33 39 44 50 56
20 30 37 44 52 59 67 74
25 37 46 56 65 74 82 93
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 06/26/2006 209

 Montgomery County Hospital District-EMS RESPIRATORY DISTRESS
Standard Delegated Orders –
Adult Respiratory AR 08 Page 210
TOC

Criteria and History :

 Historical Findings:
- Significant respiratory history
- New onset
 Physical Findings:
- Dyspnea without a clear etiology
- Abnormal breath sounds

Assessment:
 Respiratory assessment
Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access If no beneficial response seen with
 Xopenex 1.25 mg/ 3ml via nebulizer Xopenex, consider other causes and
treatment.

Consult:
 Xopenex 1.25 mg / 3 ml via Mallampati Classification:
nebulizer Class I: soft palate, fauces, uvula, pillars visible
 Consider PAI Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 210

OBSTETRICAL
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 Montgomery County Hospital District-EMS OB ASSESSMENT
Standard Delegated Orders –
Adult Obstetrical OB 01 Page 213
TOC

Criteria and History :

 Historical Findings:
- Pregnancy, spontaneous
abortion
 Physical Findings:
- Abdominal pain
- Abnormal vaginal hemorrhage

Assessment:
 C. A. B. C.
 Secondary Assessment
 Vital Signs
 ECG 3-Lead and 12-Lead if
appropriate
 Blood glucose
 Temperature
 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE
 Physical exam including palpation of
all abdominal regions
 Determination of para and gravida
and estimated date of confinement
 Check for Vaginal discharge /
hemorrhage / crowning/ limbs
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 213

 Montgomery County Hospital District-EMS ABDOMINAL PAIN - FEMALE
Standard Delegated Orders –
Adult Obstetrical OB 02 Page 214
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Any female of child-bearing age
complaining of abdominal pain
without evidence of labor or
trauma.

Assessment:
 OB Assessment

Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access Assess, document location, type, radiation,
 Zofran 8 mg oral disintegrating migration, response to palpation, treat,
assess, retreat and reassess if necessary.
tablet (ODT) PO Pain reduction should be offset with a good
May be repeated every 15 min assessment and documentation pre and
 Phenergan 12.5 mg IV/IO/IM post drug administration.
- May be repeated x 1 if N/V
persists after 15 minutes
 Pain Management

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 214

 Montgomery County Hospital District-EMS PRE-ECLAMPSIA / TOXEMIA
Standard Delegated Orders –
Adult Obstetrical OB 03 Page 215
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intra-uterine
pregnancy with greater than 20
weeks gestation
 Physical Findings:
- Persistent hypertension of
systolic of 140 and/or diastolic of
90 or greater
- One or more of:
 Peripheral edema
 Nausea/vomiting
 Headache

Assessment:
 OB Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access Outside sensory stimulation should be
MINIMAL
 Place patient in left lateral
recumbent position

Secondary Interventions:
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes

Consult:
 Magnesium sulfate 1 g infusion Magnesium sulfate
- May be repeated x 1 Mix 1 g in 100 ml NS and infuse over 10
 Labetelol 10 mg SLOW IV/IO minutes using pump
- If hypertension persists
refractory to Magnesium sulfate

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/2/2009 215

 Montgomery County Hospital District-EMS ECLAMPSIA / TOXEMIA
Standard Delegated Orders –
Adult Obstetrical OB 04 Page 216
TOC

Criteria and History :


Historical Findings:
- Gravid female with intra-uterine
pregnancy with greater than 20
weeks gestation
 Physical Findings:
- Active seizures
- Persistent hypertension of
systolic of 140 and/or diastolic of
90 or greater
- One or more of:
 Peripheral edema
 Nausea/vomiting
 Headache
Assessment:
 OB Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Versed 2 – 5 mg IV/IO/IM/IN
 Place patient in left lateral
recumbent position

Secondary Interventions:
 Magnesium Sulfate 1 g IV infusion Magnesium sulfate
- May be repeated x 1 Mix 1 g in 100 ml NS and infuse over 10
minutes using pump
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes

Consult:
 Labetelol 10 mg SLOW IV/IO
- If hypertension or seizures
persist refractory to Magnesium
sulfate

Critical Points:

Revision Date 01/26/2009 216

 Montgomery County Hospital District-EMS ECLAMPSIA / TOXEMIA
Standard Delegated Orders –
Adult Obstetrical OB 04 Page 217
TOC

 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 217

 Montgomery County Hospital District-EMS LABOR
Standard Delegated Orders –
Adult Obstetrical OB 05 Page 218
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intrauterine
pregnancy > 20 weeks
 Physical Findings:
- Back and/or abdominal pain
which occurs periodically, at
regular intervals
- ―Bag of waters‖ intact or
ruptured

Assessment:
 OB Assessment

Primary Interventions:
 O2 via most appropriate method
 Place patient in left lateral
recumbent position

Secondary Interventions:
 Vascular Access
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 218

 Montgomery County Hospital District-EMS CHILDBIRTH / IMMINENT
DELIVERY
Standard Delegated Orders –
Adult Obstetrical OB 06 Page 219
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intrauterine
pregnancy > 20 weeks
 Physical Findings:
- Presentation of a viable fetus
through cervix

Assessment:
 OB Assessment

Primary Interventions:
O2 via most appropriate method
Control delivery
Deliver neonate
Refer to post-delivery care of
neonate protocol
 Fundus massage post delivery
hemorrhage
Secondary Interventions:
 Vascular Access

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 219

 Montgomery County Hospital District-EMS NEONATE CARE
Standard Delegated Orders –
Adult Obstetrical OB 07 Page 220
TOC

Criteria and History :

 Historical Findings:
- Neonate less than 12 hours old
 Physical Findings:
- Viable baby

Assessment:
 C.A.B.C.
 APGAR
 Vital signs
 Blood glucose; if < 40, refer to
pediatric hypoglycemia protocol
 ECG
Primary Interventions:
 Dry, Warm, Position, Suction and - BVM assist if apneic OR heart rate < 100
Stimulate
 O2 via most appropriate method
 Chest compressions if heart rate <
60
Secondary Interventions:
 Vascular Access - Do not administer Narcan if patient is
 Narcan 0.1 mg/kg IV/IO/IN intubated.
- Max single dose of 2 mg
- Repeat every 2 – 3 minutes
Consult:
 Epinephrine 0.01 mg/kg (0.1 ml/kg
1:10,000) IV/IO
- q 3 – 5 min

 IF NO VASCULAR ACCESS,
Epinephrine 0.1 mg/kg (0.1 ml/kg
1:1,000) ET
- q 3 – 5 min

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 220

 Montgomery County Hospital District-EMS LIMB PRESENTATION
Standard Delegated Orders –
Adult Obstetrical OB 08 Page 221
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intrauterine
pregnancy > 20 weeks
 Physical Findings:
- Limb presentation at vaginal
opening

Assessment:
 OB Assessment

Primary Interventions:
 RAPID TRANSPORT
 O2 via most appropriate method
 Place patient in left lateral
recumbent position

Secondary Interventions:
 Vascular Access
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 221

 Montgomery County Hospital District-EMS PROLASPED UMBILICAL CORD
Standard Delegated Orders –
Adult Obstetrical OB 09 Page 222
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intrauterine
pregnancy > 20 weeks
 Physical Findings:
- Presentation of umbilical cord
through vaginal opening

Assessment:
 OB Assessment

Primary Interventions:
 RAPID TRANSPORT
 O2 via most appropriate method
 Wrap umbilical cord in moist sterile
dressing
 Insert gloved hand into vagina and
move neonate‘s head so it does not
compress umbilical cord

Secondary Interventions:
 Place mother prone, in knee – to –
chest position
 Vascular Access

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date11/01/2005 222

 Montgomery County Hospital District-EMS SPONTANEOUS ABORTION
Standard Delegated Orders –
Adult Obstetrical OB 10 Page 223
TOC

Criteria and History :

 Historical Findings:
- Known or suspected intrauterine pregnancy
 Physical Findings:
- Vaginal hemorrhage that is non-menstrual
- Abdominal or back cramping or pain
- Tissue passing with blood

Assessment:
 OB Assessment

Primary Interventions:
 O2 via most appropriate method
 Control hemorrhage

Secondary Interventions:
 Vascular Access
 Collect all passed tissue, if
possible
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date11/01/2005 223

 Montgomery County Hospital District-EMS VAGINAL BLEEDING
Standard Delegated Orders –
Adult Obstetrical OB 11 Page 224
TOC

Criteria and History :

 Historical Findings:
- Gravid female with intrauterine pregnancy > 20 weeks
- Non-pregnancy related
 Physical Findings:
- Vaginal hemorrhage that is non-menstrual without:
- Labor
- History of trauma
- or evidence of spontaneous abortion

Assessment:
 OB Assessment

Primary Interventions:
Place patient in left lateral
recumbent position
 O2 via most appropriate method
 Rapid transport
Secondary Interventions:
 Vascular Access
 Fluid Bolus, titrate to systolic
pressure of 90 mmHg
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date11/01/2005 224

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Revision Date11/01/2005 225

ADULT TRAUMA
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS TRAUMA ASSESSMENT
Standard Delegated Orders –
Adult Trauma AT 01 Page 228
TOC

Criteria and History :

 Historical Findings:
- History of recent trauma
- MOI indicative of trauma
 Physical Findings:
- Evidence of trauma
Assessment:
 C. A. B. C. Glascow Coma Scale
 Secondary Assessment Eye Response Verbal Response Motor Response
 Vital Signs 4 Spontaneous 5 Orientated 6 Obeys
 ECG 3-Lead and 12-Lead if
3 To verbal 4 Confused 5 Localizes
appropriate
2 To pain 3 Inappropriate 4 Withdraws
 Blood glucose
1 No response 2 Incomprehensible 3 Flexion
 Temperature
1 No response 2 Extension
 Lung sounds
1 No response
 GCS
 OPQRST
 ASPN
 SAMPLE
 Trauma Score

Critical Points:
 Any changes in patient condition, refer to appropriate protocol
 Refer to destination criteria guidelines for appropriate facility.

Revision Date 11/01/2005 228

 Montgomery County Hospital District-EMS AMPUTATION
Standard Delegated Orders –
Adult Trauma AT 02 Page 229
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- A severed part that is completely
separated from the body
Assessment:
 Trauma assessment
Primary Interventions:
 O2 via most appropriate method To care for amputated part
 Control hemorrhage
- Rinse with sterile water
 Vascular Access - Place in a bag
 Fluid Bolus if severe blood loss has - Keep cool but do not place directly on
occurred ice

Secondary Interventions:
 Splint any associated fracture or Consider pressure points or tourniquet if
dislocation hemorrhage cannot be controlled by direct
 Zofran 8 mg oral disintegrating pressure
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May repeat x 1 if N/V persists
after 15 minutes
 Nitrous Oxide
 Pain Management
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 229

 Montgomery County Hospital District-EMS BURNS
Standard Delegated Orders –
Adult Trauma AT 03 Page 230
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
Tissue injury from direct contact with:
- Heat source
- Chemical reaction
- Inhalation
- Electrical / lightning contact

Inhalation Injuries/Burns with any one of the following:

- Singed nasal hairs or oral mucosa
- Erythema of the palate, soot in the mouth, larynx or sputum
- Rapid, shallow ventilation with tachypnea > 40 AND decreased mental status
- Respiratory rate < 8
- Mechanical airway obstruction from trauma, edema, or laryngospasm
- Signs of respiratory distress such as nasal flaring, respiratory crowing or stridor,
anxiety, agitation, or combativeness
- Edema associated with a burn of the face or neck
- Unconsciousness
Assessment:
 Trauma assessment Rule of Nines: refer to appendix
Primary Interventions:
 Remove the burn source
 O2 via most appropriate method - Remove jewelry and resticting clothing
 Vascular Access - Brush off any powdered chemical
- Irrigate chemical burn site with water, if
appropriate to chemical
- V (fluids volume)= TBSA of burn (%) x
weight (kg) x 4

Revision Date 01/262/009 230

 Montgomery County Hospital District-EMS BURNS
Standard Delegated Orders –
Adult Trauma AT 03 Page 231
TOC

Secondary Interventions:
 Treat Underlying Injuries - Do not administer MS to patients with
 Dress burns as follows severe respiratory burns unless airway is
secured
- TBSA < 15% use burn gel
- Initial dose of MS for severe burns should
- TBSA > 15% use dry sterile be 3 – 5 mg IV
dressing or burn sheet - Keep the patient warm after removing burn
 Pain Management source and possibly contaminated clothing
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May repeat x 1 if N/V persists
after 15 minutes

Consult:
 PAI for respiratory burns Mallampati Classification
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible

Critical Points:
 Any changes in patient condition, refer to appropriate protocol
 Appropriate Destination : UTMB or Hermann Hospital
- For inhalation / hands;
- >30% TBSA 2nd degree and/or higher;
or <12 and > 65 years of age

Revision Date 01/262/009 231

 Montgomery County Hospital District-EMS TASER
Standard Delegated Orders –
Adult Trauma AT 04 Page 232
TOC

Criteria and History :

 Historical Findings:
- Patient shot with a taser gun
 Physical Findings:
- Taser probe imbedded in a
patient
Assessment:
 Trauma assessment
Primary Interventions:
 Assure scene and personal safety. To remove probe, hold skin taut, grasp probe
 Assure electrical output is no longer between thumb and forefinger, and pull straight
surging through the probe out.
 Remove probe from patient unless
embedded in breast area, groin, or
face
Secondary Interventions:
 Wound care
Consult:

Critical Points:
 Any changes in patient condition refer to appropriate protocol

Revision Date 11/01/2005 232

 Montgomery County Hospital District-EMS EVISCERATION
Standard Delegated Orders –
Adult Trauma AT 05 Page 233
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- Protrusion of internal organs
through a wound
Assessment:
 Trauma assessment
Primary Interventions:
 Spinal motion restriction if indicated
 O2 via most appropriate method
 Occlude wound with a sterile, moist
dressing and bandage

Secondary Interventions:
 Vascular Access
 Pain Management

Consult:

Critical Points:
 Any changes in patient condition refer to appropriate protocol

Revision Date 08/01/2007 233

 Montgomery County Hospital District-EMS EYE INJURY
Standard Delegated Orders –
Adult Trauma AT 06 Page 234
TOC

Criteria and History :

 Historical Findings:
- Decreased or loss of vision
- Mechanism of injury
- Sprayed with CS spray

 Physical Findings:
- Injury to the globe, open or closed, including:
 Corneal abrasion
 Foreign body in eye
 Chemical bum
 Lacerated or avulsed globe
 "Arc" burn of globe
- Excessive tearing and burning of the eyes, nasal drainage, salivation

Assessment:
 Trauma assessment
Primary Interventions:
 Spinal motion restriction if indicated
 Dress and bandage wound as
appropriate
Secondary Interventions:
 IF chemical bum/ CS or OC Spray:
- Flush continuously with copious amounts of water or NS
 IF open injury to globe:
- Shield both eyes
 IF corneal abrasion, arc bum, or foreign body:
- Tetracaine 1 – 2 gtt in affected eye Repeat as needed
- Remove foreign body if globe not penetrated
- Shield affected eye
 Vascular Access
- If severe pain or nausea and/or vomiting present and able to accomplish without
increasing Intraocular pressure
 Nitrous Oxide (Self-administered)
 Pain Management
Consult:

Critical Points:

Revision Date 08/01/2007 234

 Montgomery County Hospital District-EMS HEAD TRAUMA
Standard Delegated Orders –
Adult Trauma AT 07 Page 235
TOC

Criteria and History :

Historical Findings:
- Recent event
- Mechanism of injury
 Physical Findings:
- Altered mental status
- Loss of consciousness
Assessment:
 Trauma assessment Glascow Coma Scale
Eye Response Verbal Response Motor Response

4 Spontaneous 5 Orientated 6 Obeys

3 To verbal 4 Confused 5 Localizes
2 To pain 3 Inappropriate 4 Withdraws
1 No response 2 Incomprehensible 3 Flexion
1 No response 2 Extension
1 No response

Primary Interventions:
 Helmet Removal Elevate head to 30 degree angle
- For airway management if Inline Intubation
clinically indicated - Limit 2 attempts then use Combitube
 Spinal Motion Restriction
Helmet Removal
 O2 via most appropriate method Maintain neutral alignment with padding as
 Inline intubation, if needed needed after removal
Secondary Interventions:
 Vascular Access If patient is hypotensive, look for and treat other
injuries as well

Revision Date 11/01/2005 235

 Montgomery County Hospital District-EMS HEAD TRAUMA
Standard Delegated Orders –
Adult Trauma AT 07 Page 236
TOC

Consult:
 PAI Mallampati Classification:
 Versed 2 – 5 mg IV/IM/IO for Class I: soft palate, fauces, uvula, pillars visible
patient safety sedation in Class II: soft palate, fauces and uvula visible
combative patient Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate tube is
not in the esophagus. Verify tbe placement is
not right mainstem. In the cardiac arrest,
through quality CPR and controlled ventilation
attempt to maintain EtCO2 levels as close to 35
– 45 mmHg as possible. Values under 15
mmHg indicate poor survivability. Unsuccessful:
0 mmHg
Critical Points:
 Rapid transport to appropriate facility is crucial
 Any change in patient condition refer to appropriate protocol

Revision Date 11/01/2005 236

 Montgomery County Hospital District-EMS MULTI-SYSTEM TRAUMA
Standard Delegated Orders –
Adult Trauma AT 08 Page 237
TOC

Criteria and History :

Historical Findings:
- Mechanism of injury
 Physical Findings:
- Injury to the chest, abdomen or
pelvis
- Multiple soft-tissue or musculo-
skeletal injuries
Assessment:
 Trauma assessment

Primary Interventions:
 Spinal Motion Restriction Inline Intubation
 O2 via most appropriate method - limit 2 attempts then use Combitube
 Inline intubation, if needed
 Occlude open chest wounds

Secondary Interventions:
 Chest Decompression as needed
 Vascular Access
- Bilateral, using large bore catheters
- Consider Blood-Y
 Fluid Bolus to systolic B/P of 90 mmHg
 Fentanyl only from Pain Management
Consult:
 PAI Mallampati Classification:
 Pericardiocentesis Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any change in patient condition refer to appropriate protocol

Revision Date 11/01/2005 237

 Montgomery County Hospital District-EMS MUSCULOSKELETAL-SOFT
TISSUE INJURY
Standard Delegated Orders –
Adult Trauma AT 09 Page 238
TOC

Criteria and History :

 Historical Findings: If patient is found to have lain motionless in one
- Mechanism of injury position for a period equal to or greater than 6
hours as a result of a fall or otherwise, be
 Physical Findings:
cautious for development of compartmental
- Pain on palpation or movement syndrome. Patients meeting this criteria should
- Ecchymosis, swelling, deformity have gentle handling and be transported for
evaluation.

Assessment:
 Trauma assessment

Primary Interventions:
 O2 via most appropriate method
 Spinal motion restriction Check PMS before and after applying splint
 Control hemorrhage
 Splint
Secondary Interventions:
 Vascular Access
 Cooling of injury site
 Nitrous Oxide (self administered)
 Pain Management
 Fracture reduction by inline traction
if no pulse is detected and if is a
closed fracture
- If still no pulse, splint in position
Consult:

 C-spine clearance

Critical Points:
 Any change in patient condition refer to appropriate protocol

Revision Date 08/01/2007 238

 Montgomery County Hospital District-EMS PENETRATING INJURY
Standard Delegated Orders –
Adult Trauma AT 10 Page 239
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
- Note ballistics
 Physical Findings:
- A penetrating injury to any body part
- Entrance/ exit wounds
Assessment:
 Trauma assessment
Primary Interventions:
 O via most appropriate method
 Occlude chest wounds
 Control hemorrhage
 Vascular Access
 Spinal Motion Restriction
 Chest decompression as needed
Secondary Interventions:
 Stabilize impaled objects
 Bandage and dress open wounds
 Pain Management

Consult:

Critical Points:
 Any change in patient condition refer to appropriate protocol

Revision Date 08/01/2007 239

 Montgomery County Hospital District-EMS SEXUAL ASSAULT
Standard Delegated Orders –
Adult Trauma AT 11 Page 240
TOC

Criteria and History :

 Historical Findings:
- Report of recent sexual assault
 Physical Findings:
- Signs of assault or injury
Assessment:
 Trauma assessment
Primary Interventions:
 Assure scene and personal safety Do not let patient bathe or change clothing.
 Provide emotional support Collect any pertinent items in an unused
biohazard bag, and transport with the patient.
 O2 via most appropriate method Any blankets or sheets used by or on patient
during transport should accompany patient into
the receiving facility.

In the event of hostile family or caregivers,

avoid confrontations that might interfere with
removing patient from the environment.
Secondary Interventions:
 Treat underlying injuries
Consult:

Critical Points:
 Any changes in patient condition refer to appropriate protocol
 Appropriate destination: Memorial Hermann – The Woodlands
 Refer to appropriate protocol for specific injuries or conditions.

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 Montgomery County Hospital District-EMS SPINAL TRAUMA
Standard Delegated Orders –
Adult Trauma AT 12 Page 241
TOC

Criteria and History :


Historical Findings:
- Mechanism of injury
 Physical Findings:
- Presence of decreased neurological function below site of injury
- Loss of sensation
- Inability to move
- Hypotension
Assessment:
 Trauma assessment
Primary Interventions:
 Spinal Motion Restriction
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access
 Fluid Bolus to systolic B/P of 90
mmHg
 Zofran 8 mg oral disintegrating
tablet (ODT) PO
May be repeated every 15 min
 Phenergan 12.5 mg IV/IO/IM
- May repeat x 1 if N/V persists
after 15 minutes

Consult:
 PAI Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:

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 Montgomery County Hospital District-EMS SPINAL TRAUMA
Standard Delegated Orders –
Adult Trauma AT 12 Page 242
TOC

 Any change in patient condition refer to appropriate protocol

 Transport to appropriate facility

Revision Date 01/26/2009 242

 Montgomery County Hospital District-EMS TRAUMATIC ARREST
Standard Delegated Orders –
Adult Trauma AT 13 Page 243
TOC

Criteria and History :

 Historical Findings:
- Recent events
- Surgical problem
 Physical Findings:
- Trauma
- Pulseless
- Apneic
 ECG Findings:
- Any non-perfusing rhythm
Assessment:
 Trauma assessment
Primary Interventions:
 CPR Mallampati Classification:
- BVM ventilation with 100% O2 Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
- Maintain open airway with OPA Class III: soft palate, base of uvula visible
 Inline intubation Class IV: soft palate not visible
 Spinal Motion Restriction ET Tube Confirmation:
 Chest Decompression Confirm with 5 methods as per procedure
 Occlude open chest wounds
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Inline Intubation
- Limit 2 attempts then use Combitube

Secondary Interventions:

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 Montgomery County Hospital District-EMS TRAUMATIC ARREST
Standard Delegated Orders –
Adult Trauma AT 13 Page 244
TOC

 Vascular Access
- Bilateral, using large bore
catheters
- Consider blood-Y
 Fluid Bolus to systolic B/P of 90
mmHg
 Dysrhythmia treatment per specific
protocol
 #18 fr Nasogastric tube placement

Consult:

 Pericardiocentesis
 Pre-Hospital Trauma Termination
Critical Points:
 Any changes in patient condition refer to appropriate protocol

Revision Date 11/25/2008 244

PEDIATRIC BEHAVIORAL
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 Montgomery County Hospital District-EMS BEHAVIORAL ASSESSMENT
Standard Delegated Orders –
Pediatric Behavioral PB 01 Page 247
TOC

Criteria and History :

 Historical Findings:
- PMHX of psychiatric
problems
- Use of psychiatric
medications
- Substance abuse
 Physical Findings:
- Altered Mental Status
- Evidence of trauma
- Fear, anger, confusion, or
hostility

Assessment:
 Determine that the scene is Glascow Coma Scale
safe before entering Eye Response Verbal Response Motor Response
 GCS
4 Spontaneous 5 Orientated 6 Obeys
 C.A.B.C.
3 To verbal 4 Confused 5 Localizes
 Secondary Assessment
2 To pain 3 Inappropriate 4 Withdraws
 Vital signs
1 No response 2 Incomprehensible 3 Flexion
 Blood glucose
1 No response 2 Extension
 Pertinent PMHx
1 No response
- Does the patient have
previous suicide attempts
or ideations?
- Is the patient under care of
a psychologist /
psychiatrist?
- Is the patient cared for by
others or self-reliant?
 SUBECT IN CUSTODY RISK
ASSESSMENT SCALE
(SICRAS)

Critical Points:
  Any changes in patient condition refer to appropriate protocol

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 Montgomery County Hospital District-EMS ABUSE / NEGLECT
Standard Delegated Orders –
Pediatric Behavioral PB 02 Page 248
TOC

Criteria and History :

 Historical Findings:
- Recent events
 Physical Findings:
- Contusions at different healing stages
- Malnourished appearance
- Withdrawn

Assessment:

 Behavioral Assessment

Primary Interventions:

 Apply pressure to any hemorrhage

 O2 via most appropriate method
 Spinal Motion Restriction, if
indicated

Secondary Interventions:

 Bandaging / splinting
Contact information for CPS:
 Vascular Access
1-800-252-5400 or
 Report abuse to appropriate https://www.txabusehotline.org
agencies

Consult:
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition refer to appropriate protocol

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 Montgomery County Hospital District-EMS AGGRESSIVE / VIOLENT
BEHAVIOR
Standard Delegated Orders –
Pediatric Behavioral PB 03 Page 249
TOC

Criteria and History :

 Historical Findings:
- Known violence
- Aggression

 Physical Findings:
- Agitation
- Offensive posture
- Combative
- Hallucinations

Assessment:

 Behavioral Assessment

Primary Interventions:
 Reassure patient
 If patient is physically harmful, soft restraints
 O2 via most appropriate method
 Spinal Motion Restriction, if indicated

Secondary Interventions:

 Vascular Access

Consult:

 Versed 0.1 mg/kg IV/IM/IO

 Valium 0.2 – 0.3 mg/kg IV/IO
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS ANXIETY / EMOTIONAL
DISTRESS
Standard Delegated Orders –
Pediatric Behavioral PB 04 Page 250
TOC

Criteria and History :

 Historical Findings:
- History of Recent Traumatic
Event
- Post Trauma Stress Disorder
 Physical Findings:
- Agitation
- Hyperventilation
- Hallucinations

Assessment:

 Behavioral Assessment

Primary Interventions:

 O2 via most appropriate method

Secondary Interventions:

 Vascular Access

Consult:

 Versed 0.1 mg/kg IV/IM/IO

 Valium 0.2 – 0.3 mg/kg IV/IO
 C-spine clearance, if indicated

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 250

PEDIATRIC CARDIAC
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS CARDIAC ASSESSMENT
Standard Delegated Orders –
Pediatric Cardiac PC 01 Page 253
TOC

Criteria and History:

 Historical Findings:
- Preceding Symptoms
- CPR and/or Treatment
PTA
- PMHx
 Physical Findings:
- Altered mental status
- Slow, fast or absent pulse
- Irregular pulse
- Dyspnea/Apnea
- Chest pain/Palpitations
- Diaphoresis
- Pale, ashen or mottled skin
Assessment:
 C. A. B. C. Glascow Coma Scale
 Secondary Assessment Eye Response Verbal Response Motor Response
 Vital Signs 4 Spontaneous 5 Orientated 6 Obeys
 ECG 3-Lead and 12-Lead
3 To verbal 4 Confused 5 Localizes
- Right sided 12-Lead if
2 To pain 3 Inappropriate 4 Withdraws
indicated
1 No response 2 Incomprehensible 3 Flexion
 Blood glucose
1 No response 2 Extension
 Lung sounds
1 No response
 GCS
 OPQRST
 ASPN
 SAMPLE

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 Montgomery County Hospital District-EMS ASYSTOLE
Standard Delegated Orders –
Pediatric Cardiac PC 02 Page 254
TOC

Criteria and History :

 Historical Findings: Determine if resuscitation is medically
- Medical etiology inappropriate
 Physical Findings: Normothermic rigor-mortis
- Unconscious Injuries Incompatible with life
- Pulseless Decomposition
- Agonal respirations; apnea Pulseless, apneic patients in multiple
 ECG Findings: casualty situations
Proper DNR documentation
- Asystole confirmed in two or
more leads
Assessment:

 Cardiac Assessment

Primary Interventions:

 CPR ET Tube Confirmation:

Confirm with 5 methods as per procedure
- BVM with high-flow O2
- ResQPOD Remove ResQPOD if ROSC occurs
- Maintain open airway with OPA immediately
 Intubate
 Vascular Access Capnometry Reference:
EtCO2 readings consistently > 0 indicate
 Epinephrine 0.01 mg/kg (0.1 ml/kg
tube is not in the esophagus. Verify tbe
1:10,000) IV/IO
placement is not right mainstem. In the
- q 3 – 5 min cardiac arrest, through quality CPR and
 IF NO VASCULAR ACCESS, controlled ventilation attempt to maintain
Epinephrine 0.1 mg/kg (0.1 ml/kg EtCO2 levels as close to 35 – 45 mmHg
1:1,000) ET as possible. Values under 15 mmHg
- q 3 – 5 min indicate poor survivability. Unsuccessful:
0 mmHg

Look for causes for asystolic rhythm

Secondary Interventions:
 Fluid Bolus
- May repeat x 2
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS BRADYCARDIA
Standard Delegated Orders –
Pediatric Cardiac PC 03 Page 255
TOC

Criteria and History :

Historical Findings:
- Medical etiology
 Physical Findings:
- Weak, dizzy
- Chest pain
- Pulmonary edema
- Altered Mental Status
- Hemodynamically unstable
 ECG Findings:
- Any underlying cardiac rhythm with a bradycardic rate
Assessment:
 Cardiac Assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
Secondary Interventions:
 Epinephrine 0.01 mg/kg (0.1
ml/kg 1:10,000) IV/IO
- q 3 – 5 min
 IF NO VASCULAR ACCESS,
Epinephrine 0.1 mg/kg (0.1
ml/kg 1:1,000) ET
- q 3 – 5 min
 Atropine 0.02 mg/kg IV/ET/IO
- Minimum single dose 0.1 mg
- Maximum single dose 0.5 mg
for a pediatric patient
- May be repeated x 1

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 Montgomery County Hospital District-EMS BRADYCARDIA
Standard Delegated Orders –
Pediatric Cardiac PC 03 Page 256
TOC

Consult:
 Epinephrine Infusion 0.1 – 1 mcg/kg/min
 If refractory to Epinephrine IV/IO
To mix Epinephrine infusion:
- 0.6 multiplied by the child‘s weight in kg. This amount (in mg) is then added to
enough IV solution to equal a total volume of 100 ml.
- Infuse at 20 ml/hr via infusion pump until clinical response (increased heart
rate OR blood pressure OR improved systemic perfusion)
- Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump
- 1 ml/hr equals 1 mcg/kg/minute
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HYPOTHERMIA /
HYPOTHERMIC ARREST
Standard Delegated Orders –
Pediatric Cardiac PC 04 Page 257
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Pulseless
- Agonal respirations; apnea
- Environmental evidence of hypothermia
 ECG Findings:
Any pulseless rhythm
Assessment:
 Cardiac Assessment
 Core temperature
Primary Interventions:
 CPR Defibrillation Reference
- BVM ventilation with warm 100% 3 ―stacked‖ Defibrillations in progressive
O2 Humidified order
2 j/kg
- ResQPOD
4 j/kg
- Maintain open airway OPA
4 j/kg
 Intubation NO pulse checks or resumption of CPR in
 Vascular Access between; UNLESS THERE IS
- Use warm fluid CONVERSION
 Warm patient Do not repeat defibrillation and do not
medicate if temperature is below 85° F
- Remove wet clothing
ET Tube Confirmation:
- Heat packs to arm pits and Confirm with 5 methods as per procedure
groins Remove ResQPOD if ROSC occurs
 If V-Fib: immediately
- Biphasic ―stacked‖ defibrillation Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Secondary Interventions:
 Refer to appropriate rhythm protocol for medication reference
Consult:

Critical Points:
 Any changes in patient condition or rhythm refer to appropriate protocol.

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 Montgomery County Hospital District-EMS POST RESUSCITATION MGMT
Standard Delegated Orders –
Pediatric Cardiac PC 05 Page 258
TOC

Criteria and History :

 Historical Findings:
- Post cardiac arrest
 Physical Findings:
- Patient with spontaneous circulation (palpable carotid/ radial pulse) AFTER being
treated for any non-perfusing rhythm
 ECG Findings:
- Any pulseless rhythm

Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Lidocaine 1 mg/kg IV/IO
- If patient did not previously
receive and converted from a - Do not administer Narcan if patient is
ventricular rhythm WITHOUT intubated.
bradycardia
 Lidocaine Infusion 20 – 50 Remove ResQPOD if ROSC occurs
mcg/kg/min immediately
- Use IV pump
- If patient received Lidocaine
prior to ROSC
 Fluid Bolus
 Narcan 0.1 mg/kg IV/IO/IN
- Max single dose of 2 mg
- Rrepeat every 2 – 3 minutes

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 Montgomery County Hospital District-EMS POST RESUSCITATION MGMT
Standard Delegated Orders –
Pediatric Cardiac PC 05 Page 259
TOC

Consult:
 Epinephrine Infusion 0.1 – 1 mcg/kg/min
 If refractory to Epinephrine IV/IO
To mix Epinephrine infusion:
- 0.6 multiplied by the child‘s weight in kg. This amount (in mg) is then added to
enough IV solution to equal a total volume of 100 ml.
- Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate
OR blood pressure OR improved systemic perfusion)
- Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump
- 1 ml/hr equals 1 mcg/kg/minute
 Sodium Bicarbonate 1 mEq/kg IV/IO
- If evidence of metabolic acidosis
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NARROW COMPLEX
TACHYCARDIA - STABLE
Standard Delegated Orders –
Pediatric Cardiac PC 06 - A Page 260
TOC

Criteria and History :

 Historical Findings:
- History of SVT
- History of A-Fib or A-Flutter
 Physical Findings:
- Hemodynamically stable
 ECG Findings:
- Narrow Complex Tachycardia
(refer to assessment chart for
rate parameters
- QRS < 0.12 seconds)

Assessment:
 Cardiac Assessment

Primary Interventions:
O2 via most appropriate method
Vascular Access
Fluid Bolus
- May repeat x 2
Secondary Interventions:
 Valsalva maneuver by patient
 Adenosine 0.1 mg/kg mg RAPID
IV/IO followed by 10 ml flush
- May repeat x 1 as 0.2 mg/kg
RAPID IV/IO followed by 10 ml
flush of NS
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NARROW COMPLEX
TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Pediatric Cardiac PC 06 - B Page 261
TOC

Criteria and History :

 Historical Findings:
- History of SVT/ use of
Adenosine
- History of A-Fib or A-Flutter or
WPW
 Physical Findings:
- Hemodynamically unstable
and/or any of the following:
 Chest pain
 Dyspnea
 Lethargy
 Dizziness
 Pulmonary edema
 AMS
 EKG Findings:
- Narrow Complex Tachycardia
(refer to assessment chart for
rate parameters QRS < 0.12
seconds)
Assessment:
 Cardiac Assessment
Primary Interventions:
 Vascular Access Cardioversion Reference:
 Synchronized Cardioversion - 0.5j/kg
- 1 j/kg
- 2 j/kg
- 4 j/kg

Secondary Interventions:
 Adenosine 0.1 mg/kg RAPID IV/IO
followed by 10 ml flush
- May repeat x 1 as 0.2 mg/kg
RAPID IV/IO followed by 10 ml
flush of NS
Consult:
 Versed 0.1 mg/kg IV/IM/IO
- For sedation prior to
cardioversion

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS PULSELESS ELECTRICAL
ACTIVITY
Standard Delegated Orders –
Pediatric Cardiac PC 07 Page 262
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Unconscious
- Pulseless
- Agonal; apnea
 ECG Findings:
- Pulseless rhythm; not V-fib, V-
Tach, Asystole
Assessment:
 Cardiac Assessment

Primary Interventions:
 CPR ET Tube Confirmation:
 BVM Ventilation with high-flow O2 Confirm with 5 methods as per procedure
 ResQPOD Remove ResQPOD if ROSC occurs
 Maintain airway with OPA immediately
 Intubate
 Vascular Access Fluid Bolus prior to Capnometry Reference:
Epinephrine EtCO2 readings consistently > 0 indicate
 Epinephrine 0.01 mg/kg (0.1 ml/kg tube is not in the esophagus. Verify tbe
1:10,000) IV/IO placement is not right mainstem. In the
cardiac arrest, through quality CPR and
- q 3 – 5 min
controlled ventilation attempt to maintain
 IF NO VASCULAR ACCESS, EtCO2 levels as close to 35 – 45 mmHg as
Epinephrine 0.1 mg/kg (0.1 ml/kg possible. Values under 15 mmHg indicate
1:1,000) ET poor survivability. Unsuccessful: 0 mmHg
- q 3 – 5 min

Secondary Interventions:
 Chest Decompression if Consider all other treatable causes
pneumothorax is present - Hypoxia - ventilation
 Narcan 0.1 mg/kg IV/IO/IN - Hypothermia - warming
- Hyperkalemia – calcium gluconate and
- Max single dose of 2 mg sodium bicarbonate
- Repeat every 2 – 3 minutes - Acidosis – ventilation and sodium
 Sodium Bicarbonate 1 mEq/kg IV/IO bicarbonate
- Massive MI – heart cath
- Hypovolemia/hypotension – fluid
replacement
- Pulmonary embolism – surgery
- Cardiac tamponade – pericardiocentisis

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 Montgomery County Hospital District-EMS PULSELESS ELECTRICAL
ACTIVITY
Standard Delegated Orders –
Pediatric Cardiac PC 07 Page 263
TOC

- Drug overdose - narcan

- Tension pneumothorax –chest
decompression
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 263

 Montgomery County Hospital District-EMS NON-TRAUMATIC CHEST PAIN
Standard Delegated Orders –
Pediatric Cardiac PC 08 Page 264
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Chest discomfort
- Back, shoulder, neck, jaw,
epigastric discomfort
- Hemodynamically stable
 ECG Findings:
- No evidence of ischemia or
injury
Assessment:

 Cardiac Assessment

Primary Interventions:
Identify and treat other causes.
 O2 via most appropriate
method
 Vascular Access

Secondary Interventions:
 Pain Management

Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg
ODT PO
Weight >30kg 8mg ODT
PO
May be repeated every 15
min
 Phenergan 0.5 mg/kg IV/IO/IM
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose of
12.5 mg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 01/26/2009 264

 Montgomery County Hospital District-EMS VENTRICULAR ECTOPY
Standard Delegated Orders –
Pediatric Cardiac PC 09 Page 265
TOC

Criteria and History :

 Historical Findings:
- Medical etioology
 Physical Findings:
- Chest pain with weakness,
dizziness, dyspnea, irregular
rhythm
 ECG Findings:
- Six or more PVC‘s per minute
- Multiform PVC‘s
- Couplets, triplets
- Evidence of AMI in the absence
of bradycardia

Assessment:
 Cardiac Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
Secondary Interventions:
 Lidocaine 1 mg/kg IV/IO
- q 5 minutes as 0.5 mg/kg up to 3
mg/kg total
 Lidocaine Infusion 20 – 50
mcg/kg/min
- Use IV pump
- If successful conversion of the
rhythm with lidocaine bolus
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 08/01/2007 265

 Montgomery County Hospital District-EMS VENTRICULAR
FIBRILLATION/PULSELESS
VENTRICULAR TACHYCARDIA
Standard Delegated Orders –
Pediatric Cardiac PC 10 Page 266
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Unconscious
- Pulseless
- Agonal; Apnea
 ECG Findings
- V- Fib or Pulseless V-Tach
Assessment:
 Cardiac Assessment Consider all potential non-cardiac causes
Remove any secretions, or any vomitus

Primary Interventions:
 Defibrillation Defibrillation Reference
 BVM ventilation with 100% O2 3 ―stacked‖ Defibrillations in progressive
order
 ResQPOD 2 j/kg
 Maintain open airway with OPA 4 j/kg
 Continuous CPR 4 j/kg
 Deliver 3 ―Stacked‖ defibrillations NO pulse checks or resumption of CPR in
 Intubate; respiratory rate 8 breaths between; UNLESS THERE IS
per minute CONVERSION
Do not repeat defibrillation and do not
 Vascular Access
medicate if temperature is below 85° F
 Epinephrine 0.01 mg/kg (0.1 ml/kg
1:10,000) IV/IO Remove ResQPOD if ROSC occurs
- q 3 – 5 min immediately
 IF NO VASCULAR ACCESS,
Epinephrine 0.1 mg/kg (0.1 ml/kg ET Tube Confirmation:
1:1,000) ET Confirm with 5 methods as per procedure
- q 3 – 5 min
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

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 Montgomery County Hospital District-EMS VENTRICULAR
FIBRILLATION/PULSELESS
VENTRICULAR TACHYCARDIA
Standard Delegated Orders –
Pediatric Cardiac PC 10 Page 267
TOC

Secondary Interventions:
 Lidocaine 1 mg/kg IV/IO/ET Only Administer Magnesium Sulfate with:
 Sodium Bicarbonate 1mEq/kg IV/IO Refractory V-Fib
Torsades Des Pointes
 Narcan 0.1 mg/kg IV/IO/IN Narcan for suspected Drug Overdose
- Max single dose of 2 mg Sodim Bicarbonate for Acidosis and TCA
- Rrepeat every 2 – 3 minutes overdose

Consult:
 Cordarone 5 mg/kg IV/IO
- For refractory V-Fib

 Magnesium Sulfate 25 – 50 mg/kg

IV/IO
- For Torsades de Pointes or
Hypomagnesia
- Maximum dose of 2 grams

Critical Points:

 If VF or pulseless VT reoccurs after transiently converting, defibrillate at whatever

energy level has previously been successful for defibrillation.

 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS WIDE COMPLEX
TACHYCARDIA - STABLE
Standard Delegated Orders –
Pediatric Cardiac PC 11 - A Page 268
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Palpitations
 ECG Findings:
- Ventricular Tachycardia, Wide
Complex (QRS > 0.12 seconds)

Assessment:
 Cardiac Assessment

Primary Interventions:
 O via most appropriate method
 Vascular Access

Secondary Interventions:
 Lidocaine 1 mg/kg IV/IO
- q 5 minutes as 0.5 mg/kg up to 3
mg/kg total
 Lidocaine Infusion 20 – 50
mcg/kg/min
- Use IV pump
- If successful conversion of the
rhythm with Lidocaine bolus
Consult:
 Cordarone 5 mg/kg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/01/2005 268

 Montgomery County Hospital District-EMS WIDE COMPLEX
TACHYCARDIA - UNSTABLE
Standard Delegated Orders –
Pediatric Cardiac PC 11 - B Page 269
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
 Physical Findings:
- Hemodynamically unstable
and/or any of the following:
 Chest pain
 Dyspnea
 Lethargy
 Dizziness
 Pulmonary edema
 AMS
 ECG Findings:
- Wide complex tachycardia
Complex (QRS > 0.12
seconds)

Assessment:
 Cardiac Assessment
Primary Interventions:
 O via most appropriate method Cardioversion Reference:
 Vascular Access - 0.5j/kg
 Synchronized Cardioversion - 1 j/kg
- 0.5j /kg - 2 j/kg
- 1 j/kg - 4 j/kg
- 2 j/kg
- 4 j/kg

Secondary Interventions:
 Lidocaine 1 mg/kg IV/IO
- q 5 minutes as 0.5 mg/kg up to 3 mg/kg total
 Lidocaine Infusion 20 – 50 mcg/kg/min
- Use IV pump
- If successful conversion of the rhythm with Lidocaine bolus
Consult:
 Versed 0.1 mg/kg IV/IO
- For sedation prior to
cardioversion

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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PEDIATRIC ENVIRONMENTAL
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 Montgomery County Hospital District-EMS ENVIRONMENTAL
ASSESSMENT
Standard Delegated Orders –
Pediatric Environmental PE 01 Page 273
TOC

Criteria and History :

 Historical Findings:
- Exposure to extreme
temperatures
- Envenomation
- Wilderness exposure
- Exposure to hazardous
materials
 Physical Findings:
- Hyperthermia/Hypothermia
- Altered Mental Status
- Shivering
- Frostbite
- Dyspnea
- Evidence of bite, sting, or
exposure to chemicals
- Nausea/Vomiting
- Dizziness/Weakness
- Sweating
- Abdominal pain
Assessment:
 C. A. B. C. Glascow Coma Scale
 Secondary Assessment Eye Response Verbal Response Motor Response
 Vital Signs 4 Spontaneous 5 Orientated 6 Obeys
 ECG 3-Lead and 12-Lead
3 To verbal 4 Confused 5 Localizes
- Right sided 12-Lead if
2 To pain 3 Inappropriate 4 Withdraws
indicated
1 No response 2 Incomprehensible 3 Flexion
 Blood glucose
1 No response 2 Extension
 Lung sounds
1 No response
 GCS
 OPQRST
 ASPN
 SAMPLE
 Length of Exposure

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS COLD RELATED EMERGENCY
Standard Delegated Orders –
Pediatric Environmental PE 02 Page 274
TOC

Criteria and History :

 Historical Findings:
- Immersion or exposure to cold
temperatures

 Physical Findings:
- Core temperature < 96 degrees F
- Shivering
- Altered mental status
- Cyanosis

Assessment:
 Environmental Assessment

Primary Interventions:
 O via appropriate method Passive rewarming:
Remove wet clothing
 Prevent further heat loss
Warm blankets
 Passive rewarming Wrap heat packs and apply to axillary and groin
regions

Secondary Interventions:
 Vascular Access Use warm IV fluids

For persistent shivering or active seizures, refer

to Seizure protocol
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HEAT RELATED EMERGENCY
Standard Delegated Orders –
Pediatric Environmental PE 03 Page 275
TOC

Criteria and History :

 Historical Findings:
- Exposure to heat
 Physical Findings:
- Environmental potential of heat
related emergency
- Normothermic or hyperthermic
with weakness, dizziness, N/V,
syncope, sweating
 ECG Findings:
- Tachycardia
Assessment:
 Environmental assessment Heat Cramps
- Cramps in extremities or abdomen
Heat Exhaustion
- Temperature normal or 1 – 2 degrees
above normal with weakness, dizziness,
nausea, syncope, profuse sweating,
tachycardia
Heat Stroke
- Temperature of 105 degrees F or greater
and any of the following: AMS, Sz activity,
lack of sweating, cardiac arrest

Primary Interventions:
 O2 via most appropriate method Remove patient‘s clothing
 External Cooling Apply cold packs to axillary and groin regions

Secondary Interventions:
 Vascular Access For persistent shivering or active seizures, refer
 Fluid Bolus to Seizure protocol
 Trendelenburg
Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes

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 Montgomery County Hospital District-EMS HEAT RELATED EMERGENCY
Standard Delegated Orders –
Pediatric Environmental PE 03 Page 276
TOC

- Maximum single dose 12.5 mg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS INSECT / ANIMAL / SNAKE
BITE
Standard Delegated Orders –
Pediatric Environmental PE 04 Page 277
TOC

Criteria and History :

 Historical Findings:
- Preceding event
 Physical Findings:
- Pain to location of bite/sting
- Known or suspected
envenomation by an insect or
snake
Assessment:
 Environmental assessment
Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access For persistent shivering or active seizures, refer
 Nitrous Oxide (Self-administered) to Seizure protocol
 Pain Management

Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NEAR DROWNING
Standard Delegated Orders –
Pediatric Environmental PE 05 Page 278
TOC

Criteria and History :

 Historical Findings:
- Water submersion without
cardiopulmonary arrest and
without evidence of hypothermia
 Physical Findings:
- Dysnpea, difficulty breathing

Assessment:
 Environmental assessment

Primary Interventions:
 Remove from water ET Tube Confirmation:
 O2 via most appropriate method Confirm with 5 methods as per procedure
 Intubate Capnometry Reference:
- If unconscious and unable to EtCO2 readings consistently > 0 indicate
protect airway tube is not in the esophagus. Verify tbe
 Capnography placement is not right mainstem. In the
 External warming cardiac arrest, through quality CPR and
 Vascular Access controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Secondary Interventions:
 Tracheal suctioning via ETT Acceptable PEEP limits: 2 – 5 cm
 PEEP usage during ventilation
Consult:
 Consider PAI Mallampati Classification
- See Pediatric PAI Procedure Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS TOXICOLOGICAL / HAZ-MAT
EXPOSURE
Standard Delegated Orders –
Pediatric Environmental PE 06 Page 279
TOC

Criteria and History :

 Historical Findings: Hazardous Materials may fall under the
- Determine type of exposure & following categories:
refer to USDOT-ERG for initial Chemical
assessment and management. Biological
 Physical Findings: Nuclear
Radioactive
- Findings will vary based upon
Explosive
contaminant.
 If Organophosphates (OGP’s) Most common OGP‘s are pesticides and
SLUDGE-BM produce an exaggerated parasympathetic
- Salivation, Lacrimation response.
(Tearing), Urination,
Diarrhea/Defecation, GI
Distress, Emesis, Bradycardia, &
Miosis (Pinpoint pupils)
Assessment:
 Ensure that the patient has been Medical Care should be coordinated with a
decontaminated. Hazardous Materials Response Team
 At NO TIME SHOULD EMS
personnel enter the HOT or WARM Appropriate PPE may be either Level B
Zone, unless wearing appropriate partially encapsulated suits with PAPR
PPE. (Positive Air Purifying Respirators) or Level
 If exposure is localized and not A Fully encapsulated suits with SCBA.
generalized:
- Dry Chemical:
Brush the chemical off and flush Water should be from a steady stream, for
with copious amounts of water. at least 15 – 20 minutes into a sanitary
- Wet Chemical: sewer
Irrigate with copious amounts of
water.
Primary Interventions:
 Assure scene and personal safety.
 Assure that patient has been
decontaminated appropriately.
 Provide for oxygenation and ensure
patent airway
 Vascular Access

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 Montgomery County Hospital District-EMS TOXICOLOGICAL / HAZ-MAT
EXPOSURE
Standard Delegated Orders –
Pediatric Environmental PE 06 Page 280
TOC

Secondary Interventions:
 Evaluate ECG as appropriate Doses in excessive of Atropine 0.02 mg/kg may
 For OGP, administer Atropine 1 mg be required to resolve Bradycardia in OGP.
repeated frequently until
Bradycardia has resolved.

Consult:
 PAI
- See Pediatric PAI Procedure

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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281
PEDIATRIC MEDICAL
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 Montgomery County Hospital District-EMS MEDICAL ASSESSMENT
Standard Delegated Orders –
Pediatric Medical PM 01 Page 284
TOC

Criteria and History :

 Historical Findings:
- Recent events
- PMHx
 Physical Findings:
- Pain
- Non-traumatic hemorrhage
- Itching, swelling, hives
- Altered mental status
- Fever
- Headache

Assessment:
 C. A. B. C.
 Secondary Assessment
 Vital Signs (orthostatic)
 ECG 3-Lead and 12-Lead
- Right sided 12-Lead if indicated
 Blood glucose
 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE

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 Montgomery County Hospital District-EMS ALLERGIC REACTION
Standard Delegated Orders –
Pediatric Medical PM 02 Page 285
TOC

Criteria and History :

 Historical Findings:
- Medical etiology
- Exposure to allergen
 Physical Findings:
- Mild Reaction – contact
dermatitis (rash) and/or urticaria
(hives), dermal itching
- Moderate Reaction – mild
reaction symptoms with dyspnea
- Anaphylaxis – severe reaction
symptoms with hypotension,
difficulty swallowing, generalized
edema, stridor

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
Mild:
 Vascular Access
 Benadryl 1 mg/kg IV/IO/IM
- Max single dose of 25 mg
Moderate:
 ―Mild reaction‖ treatment in addition
to:
 Xopenex 1.25 mg/3 ml by nebulizer
 Xopenex 0.63 mg/3 ml by nebulizer
- for children < 4 years old
 Solumedrol 2 mg/kg IV/IO
OR
 Decadron 0.2 – 0.5 mg/kg IV/IO
may repeat x 2 in 15 minutes
 Epinephrine 1:1,000 0.01 mg/kg SQ
up to 0.3 mg

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 Montgomery County Hospital District-EMS ALLERGIC REACTION
Standard Delegated Orders –
Pediatric Medical PM 02 Page 286
TOC

Anaphylaxis
 ―Moderate reaction‖ treatment in
addition to:
 Epinephrine 1:10,000 0.01 mg/kg
IV/IO
 Epinephrine 1:1,000 0.01 mg/kg SQ
- Maximum dose of 0.3 mg

Consult:
 Continued age appropriate Xopenex Mallampati Classification:
dose Class I: soft palate, fauces, uvula, pillars visible
- If beneficial response is seen Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
 Epinephrine 1:10,000 0.01 mg/kg
Class IV: soft palate not visible
IV/IO
ET Tube Confirmation:
- If not resolved Confirm with 5 methods as per procedure
 Epinephrine 1:1,000 0.01 mg/kg SL Capnometry Reference:
- If patient is obtunded or EtCO2 readings consistently > 0 indicate
unconscious and vascular tube is not in the esophagus. Verify tbe
access cannot be established placement is not right mainstem. In the
rapidly cardiac arrest, through quality CPR and
- Inject directly into the sublingual controlled ventilation attempt to maintain
tissue EtCO2 levels as close to 35 – 45 mmHg as
 Consider PAI possible. Values under 15 mmHg indicate
- See Pediatric PAI Procedure poor survivability. Unsuccessful: 0 mmHg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS AMS / UNCONSCIOUS
Standard Delegated Orders –
Pediatric Medical PM 03 Page 287
TOC

Criteria and History :

 Historical Findings: Consider causes:
- Medical etiology - CVA
- Hypoglycemia/hyperglycemia
 Physical Findings:
- Drug/ Alcohol use
- Unresponsive, disoriented - Recent trauma
WITHOUT a clear mechanism - Hepatic disease
for AMS - Acidosis/electrolyte imbalance
- Sepsis
- Hypotension
- Hypoxemia
Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method
Secondary Interventions:
 Vascular Access - Do not administer Narcan if pt is intubated
 Narcan 0.1 mg/kg IV/IO/IN
- Max single dose of 2 mg
- Repeat every 2 – 3 minutes

Consult:
 PAI Mallampati Classification:
- See Pediatric PAI Procedure Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DEHYDRATION
Standard Delegated Orders –
Pediatric Medical PM 04 Page 288
TOC

Criteria and History :

 Historical Findings: Compensated Hypovolemia
- Recent illness (vomiting, - Normotension and tachycardia
diarrhea, fever) Uncompensated Hypovolemia
- Hypotension and tachycardia
 Physical Findings:
- Poor Skin turgor
- Little or no urine output
- Dry mucous membranes
Assessment:
 Medical Assessment
Primary Interventions:
 O via most appropriate method
 Vascular Access
Secondary Interventions:
 Fluid Bolus
- May repeat x 2 to maintain
adequate B/P
- If patient condition improves
repeat fluid bolus unless patient
develops pulmonary edema
Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DIABETIC - HYPERGLYCEMIA
Standard Delegated Orders –
Pediatric Medical PM 05 - A Page 289
TOC

Criteria and History :

 Historical Findings: Blood glucose < 80 refer to hypoglycemia
- Medical etiology protocol
Blood glucose < 40 in the neonate (<1 month
 Physical Findings:
old) refer to hypoglycemia protocol
- BGL > 180 mg/dL with one of
the following:
- AMS, tachypnea, abdominal
pain, Hypotension and
tachycardia
Assessment:
 Medical Assessment
Primary Interventions:
O via most appropriate method
Vascular Access
Fluid Bolus
- May repeat x 2
- Maintenance infusion 20 ml/kg
with Baxter Pump
Secondary Interventions:

Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DIABETIC - HYPOGLYCEMIA
Standard Delegated Orders –
Pediatric Medical PM 05 - B Page 290
TOC

Criteria and History :

 Historical Findings:
- Known history
- New onset
 Physical Findings:
- BGL < 80 mg/dL ( < 40 mg/dL for newborns)
- Signs and symptoms suggestive of Hypoglycemia:
AMS, tremors, weakness, N/V, intense hunger, diaphoresis
BGL < 40 mg/dL should be treated, regardless of presence of other
signs/symptoms
Assessment:
 Medical Assessment
Primary Interventions:
 O via most appropriate method
 Vascular Access
- Do Not delay transport to
establish

Secondary Interventions:
 Oral Glucose 7.5 – 15 g Oral Glucose
 D50% 0.5 g/kg IV for children > 10 - In minimally symptomatic patients who
kg or 2 years of age are old enough and capable of taking
OR oral glucose solutions
 D25% 0.5 g/kg IV for infants < 10 kg - Able to follow commands
- May be repeated once in 5 min if
symptoms not resolved
- Repeat BG in 10 min after
D50%/D25% administration
Thiamine
 Thiamine 10 – 25 mg IV/IO or IM - For older children/teenagers with a
significant history of alcohol use/abuse
or malnourished children
Consult:
 Repeat D50%/D25% administration
if continued evidence of
hypoglycemia on basis of persistent
symptoms and glucometer reading
 Glucagon 0.5 mg IM/SQ if unable to
obtain vascular access
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS DYSTONIC REACTION
Standard Delegated Orders –
Pediatric Medical PM 06 Page 291
TOC

Criteria and History :

 Historical Findings: Phenergan
- Recent ingestion of Reglan (Metoclopramide
phenothiazines, fluphenazines, Propulsid
other neuroleptics or related Haldol
drugs used as antipsychotics
and also to treat GI disorders
and nausea
 Physical Findings:
- Protrusion of the tongue, twisted
neck or facial spasms, roving or
deviated gaze, abdominal
rigidity or pain, spasm of the
entire body, twitching
Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Benadryl 1 mg/kg IV/IM/IO
- Max single dose of 25 mg

Secondary Interventions:

Consult:
 Versed 0.1 mg/kg IV/IM/IO if no
response is seen from Benadryl
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS FEVER
Standard Delegated Orders –
Pediatric Medical PM 07 Page 292
TOC

Criteria and History :

 Historical Findings:
- Evidence of determinable - Use of full PPE is recommended
source for sepsis
 Physical Findings:
- AMS
- Weakness
- Temperature > 101 degrees F
Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Acetaminophen – refer to dosing
chart
 Ibuprofen – refer to dosing chart
Secondary Interventions:
 Fluid Bolus Remove patient‘s clothing
- May repeat x 2 Apply cold packs to axillary and groin regions
Avoid excessive cooling
 External cooling
For persistent shivering or active seizures, refer
to Seizure protocol
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NON-TRAUMATIC ABDOMINAL
PAIN
Standard Delegated Orders –
Pediatric Medical PM 08 Page 293
TOC

Criteria and History :

 Historical Findings: Abdominal pain secondary to trauma is
- Medical etiology managed with the Multi-system trauma
protocol.
 Physical Findings:
- Abdominal pain with rebound
tenderness, increased pain on
palpation, increased pain on
movement
Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access
 Fluid Bolus
- If hypotensive and/or signs of
hypoperfusion
- May repeat x 2

Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg
 Repeat Fluid Bolus
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NON-TRAUMATIC
HEMORRHAGE
Standard Delegated Orders –
Pediatric Medical PM 09 Page 294
TOC

Criteria and History :

 Historical Findings: Consider all possible causes
- Medical etiology - Abdominal aortic aneurysm
(AAA)
 Physical Findings:
- Ulcers/Diverticulitis/GI bleed
- Hypovolemia secondary to blood
loss due to medical etiology
―Coffee ground‖ emesis
- Blood in stool
- Epistaxis

Assessment:
 Medical Assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access

Secondary Interventions:
 Fluid Bolus x 2 q 5 minutes
- Discontinue if pulmonary edema
develops
 Consider Trendelenburg

Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS NON-TRAUMATIC SHOCK /
HYPOTENSION
Standard Delegated Orders –
Pediatric Medical PM 10 Page 295
TOC

Criteria and History :

 Historical Findings: Evidence of sepsis can include any of the
- No evidence of blood loss or following:
trauma  Fever
 Physical Findings:  Recent wound or surgery
 Recent URI/UTI symptoms
- Hemodynamically unstable
 Urinary catheter
- AMS  Petechia or rash
- Sepsis
- Tachycardia

Assessment:
 Cardiac Assessment
Primary Interventions:

 O2 via most appropriate method

 Vascular Access

Secondary Interventions:
 Vascular Access
- Do Not delay transport to
accomplish
 Fluid Bolus
- May repeat x 2
Consult:
 Consider need for PAI
 Epinephrine Infusion 0.1 – 1 mcg/kg/min
 If refractory to Epinephrine IV/IO
To mix Epinephrine infusion:
- 0.6 multiplied by the child‘s weight in kg. This amount (in mg) is then added to
enough IV solution to equal a total volume of 100 ml.
- Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate
OR blood pressure OR improved systemic perfusion)
- Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump
- 1 ml/hr equals 1 mcg/kg/minute
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS OVERDOSE / POISONING
Standard Delegated Orders –
Pediatric Medical
PM 11 Page 296
TOC

Criteria and History :

 Historical Findings:
- Known or suspected ingestion or
injection of pharmacoactive
substance, whether intentional
or accidental
- Ingestion, inhalation or
absorption of potentially harmful
non-pharmaceutical substance
 Physical Findings:
- Lethargy, Altered Mental Status,
combative, unresponsive
Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method 100% O for Carbon monoxide
Consider Hyperbaric Therapy
Secondary Interventions:
 Vascular Access - Do Not administer Narcan if patient is
 Narcan 0.1 mg/kg IV/IO/IN intubated
- Max single dose of 2 mg
- Repeat every 2 – 3 minutes
 Sodium Bicarbonate 0.5 – 1 mEq/kg
IV/IO
- For known Tricyclic
Antidepressant OD IF
- Wide QRS > 0.12 sec
- Infant 0 – 1 year receive 4.2%
Sodium Bicarbonate
- Child 1 – 8 year receive 8.4%
Sodium Bicarbonate
- Ethylene glycol ingestion
(Antifreeze, De-Icing agents,
Paints, Detergents)
 Atropine 0.02 mg/kg IV/IM/IO
- For Organophosphate Poisoning
With parasympathetic
symptoms
- q 5 minutes as needed

 Consider consult with physician at

receiving facility

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 Montgomery County Hospital District-EMS OVERDOSE / POISONING
Standard Delegated Orders –
Pediatric Medical
PM 11 Page 297
TOC

 Consider contacting Poison control

(1-800-POISON-1 or 1-800-764-
7661)

Consult:
 Charcoal PO if oral Overdose
- 1 g/kg if < 1 yr. old
- 25 – 50 g if age 1 –12 yr.
- May mix with juice or water

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS SEIZURES
Standard Delegated Orders –
Pediatric Medical PM 12 Page 298
TOC

Criteria and History :

 Historical Findings:
- History of seizures
- Head trauma
- New onset
 Physical Findings:
- Post-ictal
 Witnessed, reported or
suspected seizure prior to
EMS arrival
- Active
 Actively seizing patient upon
EMS arrival

Assessment:
 Medical Assessment Consider possible causes:
- Febrile
- Epilepsy
- Overdose
- Withdrawals
- Hypoglycemia
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
- If prolonged post-ictal state
- If need for IV/IO meds
- Do Not delay transport to
accomplish

Secondary Interventions:
 Versed 0.1 mg/kg IV/IM/IO/IN for For Fever, refer to Fever protocol
ACTIVE seizures
- Max. dose 5 mg – if patient < 2
years
- Max. dose 10 mg – if patient >
10 years

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 Montgomery County Hospital District-EMS SEIZURES
Standard Delegated Orders –
Pediatric Medical PM 12 Page 299
TOC

Consult:
 Valium 0.2 – 0.3 mg/kg IV/IO for
ACTIVE seizures
 Valium 0.4 – 0.6 mg/kg PR for
ACTIVE seizures and unable to
establish IV
 Narcan 0.1 mg/kg IV/IO/IN
- Do Not administer Narcan if patient is
- Max single dose of 2 mg
intubated
- Repeat every 2 – 3 minutes
 PAI
- For status seizures
- See PAI Pediatric Procedure Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS SYNCOPE
Standard Delegated Orders –
Pediatric Medical PM 13 Page 300
TOC

Criteria and History :

 Historical Findings:
- History of loss of consciousness
 Physical Findings:
- Common ―faint‖ (vasovagal
syncope)
- Postural ―faint‖ (orthostatic
syncope)
- Hyperventilation syncope

Assessment:
 Medical Assessment
Primary Interventions:
 O2 via most appropriate method
 Once you have completed a patient
assessment, and a cause of
syncope has been determined, refer
to the appropriate protocol.
Secondary Interventions:
 Vascular Access
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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PEDIATRIC RESPIRATORY
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 Montgomery County Hospital District-EMS RESPIRATORY ASSESSMENT
Standard Delegated Orders –
Pediatric Respiratory PR 01 Page 304
TOC

Criteria and History :

 Historical Findings:
- Use of inhaled medications, Consider all possible causes and refer to
steroids appropriate protocol
- Pulmonary Embolism
- Fever - Anxiety
- Productive cough - Asthma
- Recent surgery - Airway obstruction
 Physical Findings: - Pneumonia
- Dyspnea, tachypnea - Pneumothorax
- Allergic reaction
- Cyanosis
- Aspiration
- Edema
- Wheezing, rales, rhonchi,
absent/decreased breath
sounds, grunting, stridor
- Use of accessory muscles,
grunting
- Chest pain
- Bronchoconstriction

Assessment:
 C. A. B. C. Mallampati Classification:
 Secondary Assessment Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
 Vital Signs Class III: soft palate, base of uvula visible
 ECG 3-Lead and 12-Lead Class IV: soft palate not visible
- Right sided 12-Lead if indicated
 Blood glucose
 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE
 Mallampati score
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS AIRWAY OBSTRUCTION
Standard Delegated Orders –
Pediatric Respiratory PR 02 Page 305
TOC

Criteria and History :

 Physical Findings:
- Partial or complete airway
obstruction
- Secondary to foreign body
aspiration
- Decreased LOC
- Cyanosis
- Obvious inadequate air
exchange
Assessment:
 Respiratory assessment

Primary Interventions:
 Abdominal/chest thrusts Responsive Infant: Back blows and chest
- If patient is conscious thrusts
Responsive Child: Abdominal (Heimlich)
 Direct laryngoscopy and removal of thrusts
foreign object with Magill forceps or
suction
- If patient is unconscious and
there is a complete obstruction
 O2 via most appropriate method
Secondary Interventions:
 Vascular Access
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS BRONCHOSPASM
Standard Delegated Orders –
Pediatric Respiratory PR 03 Page 306
TOC

Criteria and History :

 Historical Findings:
- History of asthma
 Physical Findings:
- Dyspnea with wheezing or
prolonged expiratory phase
Assessment:
 Respiratory assessment

Primary Interventions:
 O2 via most appropriate method
 Vascular Access
 Fluid Bolus
Secondary Interventions:
 Xopenex 1.25 mg/3 ml by nebulizer
Solumedrol Dosing Chart
- For mild/moderate dyspnea
Weight Dose Volume
- May repeat x 2 in 15 minutes (kg) (mg) (ml)
 Xopenex 0.63 mg/3 ml by nebulizer 5 10 0.2
- For children < 4 years of age 10 20 0.3
- May be repeated x 2 in 15 15 30 0.5
minute 20 40 0.6
 Solumedrol 2 mg/kg IV/IO 25 50 0.8
OR 30 60 1.0
 Decadron 0.2 – 0.5 mg/kg IV/IO 35 70 1.1
40 80 1.3
45 90 1.4
50 100 1.6
55 110 1.8
60 120 1.9
65 130 2.1

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 Montgomery County Hospital District-EMS BRONCHOSPASM
Standard Delegated Orders –
Pediatric Respiratory PR 03 Page 307
TOC

Consult:
 Continued Xopenex treatment for Mallampati Classification:
appropriate age Class I: soft palate, fauces, uvula, pillars visible
- If beneficial response is seen Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
 Epinephrine 1:1,000 0.01 mg/kg
Class IV: soft palate not visible
(0.01 ml/kg) SQ
ET Tube Confirmation:
- For severe dyspnea or near Confirm with 5 methods as per procedure
respiratory failure Capnometry Reference:
- Max single dose 0.3 mg EtCO2 readings consistently > 0 indicate
 Repeat Epinephrine 1:1,000 0.01 tube is not in the esophagus. Verify tbe
mg/kg (0.01 ml/kg) SQ placement is not right mainstem. In the
- If no relief of dyspnea cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
 PAI
EtCO2 levels as close to 35 – 45 mmHg as
- See Pediatric PAI Procedure possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS CROUP
Standard Delegated Orders –
Pediatric Respiratory PR 04 Page 308
TOC

Criteria and History:

 Historical Findings:
- History of recent upper
respiratory illness
 Physical Findings:
- Difficulty breathing with barking
cough
- Dyspnea
- Inspiratory stridor
- Recent history or current
symptoms of URI
- Croup is a viral infection
usually seen in children 18
months – 3 years of age

Assessment:
 Respiratory assessment

Primary Interventions:
 O2 via most appropriate method -  It is IMPERATIVE that oxygen
humidified administration not result in increased
agitation. Allow parent to assist with
administration.

Secondary Interventions:
 Vascular Access
 Fluid Bolus
 Xopenex 1.25 mg/3 ml by nebulizer
- For mild/moderate dyspnea
- May repeat x 2 in 15 minutes
 Xopenex 0.63 mg/3 ml by nebulizer
- For children < 4 years of age
- May be repeated x 2 in 15
minute
 Solumedrol 2 mg/kg IV
OR
 Decadron 0.2 – 0.5 mg/kg IV
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS EPIGLOTTIS
Standard Delegated Orders –
Pediatric Respiratory PR 05 Page 309
TOC

Criteria and History:

 Historical Findings:
- History of recent upper
respiratory illness
 Physical Findings:
- Dyspnea
- Evidence of upper airway
obstruction (inspiratory stridor,
drooling, or hoarseness)

Any one or more of the

following:
- Fever
- Recent history of URI symptoms
- Dysphasia or severe sore throat
- Drooling
- Epiglotitis is a bacterial
infection often seen in
children 3 – 7 years of age

Assessment:
 Respiratory assessment

Primary Interventions:
 O2 via most appropriate method –  It is IMPERATIVE that oxygen
humidified administration not result in increased
 TRANSPORT ASAP in a position agitation. Allow parent to assist with
of comfort, usually sitting upright administration.
 DO NOT attempt an IV or airway
manipulation unless COMPLETE airway
obstruction occurs
 Pre-oxygenate patient with BVM and 100%
Oxygen prior to intubation attempt

Secondary Interventions:
 Vascular Access
 Fluid Bolus
Consult:

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS PNEUMONIA
Standard Delegated Orders –
Pediatric Respiratory PR 06 Page 310
TOC

Criteria and History :

 Historical Findings:
- Recent upper respiratory illness
 Physical Findings:
- Fever
- Productive cough
- Wheezing, rhonchi or rales
Assessment:
 Respiratory assessment

Primary Interventions:
 O Via most appropriate method
 Vascular Access
 Xopenex 1.25 mg/3 ml by nebulizer
- For mild/moderate dyspnea
- May repeat x 2 in 15 minutes
 Xopenex 0.63 mg/3 ml by nebulizer
- For children < 4 years of age
- May be repeated x 2 in 15 min

Secondary Interventions:
 Fluid Bolus For Fever, refer to Fever protocol

Consult:
Mallampati Classification:
 PAI Class I: soft palate, fauces, uvula, pillars visible
- See Pediatric PAI Procedure Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS RESPIRATORY DISTRESS
Standard Delegated Orders –
Pediatric Respiratory PR 07 Page 311
TOC

Criteria and History :

 Historical Findings:
- New onset
- Pre-existing condition
 Physical Findings:
- Dyspnea without a clear etiology
- Increased respiratory effort

Assessment:
 Respiratory assessment
Primary Interventions:
 O2 via most appropriate method
Secondary Interventions:
 Vascular Access If no beneficial response seen with
 Xopenex 1.25 mg/ 3 ml by nebulizer Xopenex, consider other causes and
treatment.
- For mild/moderate dyspnea
 Xopenex 0.63 mg/ 3 ml by nebulizer
- For children < 4 years of age
Consult:
 Xopenex 1.25 mg / 3 ml by nebulizer Mallampati Classification:
 PAI if appropriate Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
- See Pediatric PAI Procedure Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS RESPIRATORY FAILURE /
SHOCK
Standard Delegated Orders –
Pediatric Respiratory PR 08 Page 312
TOC

Criteria and History :

 Historical Findings:
- No evidence of blood loss or trauma
 Physical Findings:
- Failure to oxygenate or ventilate or both
Respiratory Failure:
- Dyspnea (Tachypnea or Bradypnea, accessory muscle use )
- Cyanosis or
- Agitation / Obtundation
- Nasal Flaring
- Grunting
Shock:
- Apathy and listlessness
- Diminished peripheral pulses
- Prolonged capillary refill
- Cool, pale, or mottled skin

- Doesn‘t respond to parents or painful stimuli

Assessment:
 Medical assessment
Primary Interventions:
 O2 via most appropriate method
 Vascular Access
- Do Not delay transport to
accomplish
 Fluid Bolus
- May repeat x 2 unless
pulmonary edema develops
Secondary Interventions:

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 Montgomery County Hospital District-EMS RESPIRATORY FAILURE /
SHOCK
Standard Delegated Orders –
Pediatric Respiratory PR 08 Page 313
TOC

Consult:
 PAI If narcotic overdose is suspected, see
- See Pediatric PAI Procedure Overdose\Poisoning Protocol
 Chest Decompression
- If pneumothorax suspected Mallampati Classification:
Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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PEDIATRIC TRAUMA
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 Montgomery County Hospital District-EMS TRAUMA ASSESSMENT
Standard Delegated Orders –
Pediatric Trauma PT 01 Page 316
TOC

Criteria and History:

 Historical Findings:
- History of recent trauma
- MOI indicative of trauma
 Physical Findings:
- Evidence of trauma
Assessment:
 C. A. B. C. Glascow Coma Scale
 Physical exam Eye Response Verbal Response Motor Response
- Focused or rapid trauma 4 Spontaneous 5 Orientated 6 Obeys
assessment
3 To verbal 4 Confused 5 Localizes
 Vital Signs
2 To pain 3 Inappropriate 4 Withdraws
 ECG 3-Lead and 12-Lead
1 No response 2 Incomprehensible 3 Flexion
- Right sided 12-Lead if
indicated 1 No response 2 Extension

 Blood glucose 1 No response

 Lung sounds
 GCS
 OPQRST
 ASPN
 SAMPLE
 Pediatric Trauma Score

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 Montgomery County Hospital District-EMS AMPUTATION
Standard Delegated Orders –
Pediatric Trauma PT 02 Page 317
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- A severed part that is completely
separated from the body
Assessment:
 Trauma assessment
Primary Interventions:
 O2 via most appropriate method To care for amputated part
 Control hemorrhage Rinse with sterile water
Place in a bag
 Vascular Access
Keep cool but do not place directly on ice
- Fluid Bolus if severe blood loss
has occurred
Secondary Interventions:
 Consider pressure points or a Consider pressure points or tourniquet if
tourniquet. hemorrhage cannot be controlled by direct
- If hemorrhage can not be pressure
controlled:
 Splint any associated Fractures /
Dislocations
 Rinse amputated part with sterile
water, placed in a bag and kept
cool. DO NOT:
- Soak in water
- Cover with wet gauze or towels
- Place directly on ice
 Nitrous Oxide (Self-administered)
 Pain Management
Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg

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 Montgomery County Hospital District-EMS AMPUTATION
Standard Delegated Orders –
Pediatric Trauma PT 02 Page 318
TOC

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS BURNS
Standard Delegated Orders –
Pediatric Trauma PT 03 Page 319
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
Tissue injury from direct contact with:
- Heat source
- Chemical reaction
- Inhalation
- Electrical / lightning contact

Inhalation Injuries/Burns with any one of the following:

- Singed nasal hairs or oral mucosa.
- Erythema of the palate, soot in the mouth, larynx or sputum.
- Rapid, shallow ventilation with tachypnea of >40 AND decreased mental status.
- Respiratory rate < 14 in pediatric patient
- Mechanical airway obstruction from trauma, edema, or laryngospasm.
- Signs of respiratory distress such as nasal flaring, respiratory crowing or stridor,
anxiety, agitation, or combativeness.
- Edema associated with a burn of the face or neck.
- Unconsciousness.
Assessment:
 Trauma assessment Rule of Nines: refer to appendix
Primary Interventions:
 Remove the burn source - Remove jewelry and resticting clothing
 O via most appropriate method - Brush off any powdered chemical
 Vascular Access - Irrigate chemical burn site with water, if
 Intubation for respiratory burns appropriate to chemical
- V (fluids volume)= TBSA of burn (%) x
weight (kg) x 4
Secondary Interventions:
 Treat Underlying Injuries - Do not administer MS to patients with
 Dress burns as follows severe respiratory burns unless airway is
secured
- TBSA < 15% use burn gel
- Keep the patient warm after removing burn
- TBSA > 15% use dry sterile source and possibly contaminated clothing
dressing or burn sheet
 Nitrous Oxide (Self-administered)
- If no inhalation/respiratory burns
 Pain Management
 All other injuries should be treated
en-route to the hospital if feasible

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 Montgomery County Hospital District-EMS BURNS
Standard Delegated Orders –
Pediatric Trauma PT 03 Page 320
TOC

Any changes in condition/rhythm refer

to appropriate Pediatric Protocol

Consult:
Mallampati Classification:
 PAI Class I: soft palate, fauces, uvula, pillars visible
- If needed for Intubation Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol
 Appropriate Destination : UTMB or Hermann Hospital
- For inhalation / hands;
- >30% TBSA 2nd degree and/or higher;
- or <12 and > 65 years of age

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 Montgomery County Hospital District-EMS EVISCERATION
Standard Delegated Orders –
Pediatric Trauma PT 04 Page 321
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- Protrusion of internal organs
through a wound
Assessment:
 Trauma assessment
Primary Interventions:
 Spinal motion restriction if indicated
 O2 via most appropriate method
 Occlude wound with a sterile, moist
dressing and bandage

Secondary Interventions:
 Vascular Access
 Pain Management

Consult:

Critical Points:
 Any changes in patient condition refer to appropriate protocol

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 Montgomery County Hospital District-EMS EYE INJURY
Standard Delegated Orders –
Pediatric Trauma PT 05 Page 322
TOC

Criteria and History :

 Historical Findings:
- Decreased or loss of vision
- Mechanism of injury
 Physical Findings:
- Injury to the globe, open or closed, including:
 Corneal abrasion
 Foreign body in eye
 Chemical bum
 Lacerated or avulsed globe
 "Arc" burn of globe
- Excessive tearing and burning of the eyes, nasal drainage, salivation

Assessment:
 Trauma assessment
Primary Interventions:
 Spinal motion restriction if indicated
 Dress and bandage wound as
appropriate
Secondary Interventions:
 IF chemical bum:
- Flush continuously with NS
 IF open injury to globe:
- Shield both eyes
 IF corneal abrasion, arc bum, or foreign body:
- Tetracaine 1 – 2 gtt in affected eye Repeat as needed
- Remove foreign body if globe not penetrated
- Shield affected eye
 Vascular Access
- If severe pain or nausea and/or vomiting present and able to accomplish without
increasing Intraocular pressure
 Nitrous Oxide (Self-administered)
 Pain Management
Consult:
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V

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 Montgomery County Hospital District-EMS EYE INJURY
Standard Delegated Orders –
Pediatric Trauma PT 05 Page 323
TOC

persists after 15 minutes

- Maximum single dose 12.5 mg

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS HEAD TRAUMA
Standard Delegated Orders –
Pediatric Trauma PT 06 Page 324
TOC

Criteria and History :

 Historical Findings:
- Recent event
- Mechanism of injury
 Physical Findings:
- Altered mental status
- Loss of consciousness
Assessment:
 Trauma assessment Glascow Coma Scale
Eye Response Verbal Response Motor Response

4 Spontaneous 5 Orientated 6 Obeys

3 To verbal 4 Confused 5 Localizes
2 To pain 3 Inappropriate 4 Withdraws
1 No response 2 Incomprehensible 3 Flexion
1 No response 2 Extension
1 No response
Primary Interventions:
 Spinal Motion Restriction
 O2 via most appropriate
method
 Inline intubation, if needed

Secondary Interventions:
 Helmet Removal If patient is hypotensive, look for and treat other
- For airway management if injuries as well
clinically indicated
Helmet Removal
 Vascular Access
Maintain neutral alignment with padding as needed
 Fluid Bolus after removal
- Repeat x 1

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 Montgomery County Hospital District-EMS HEAD TRAUMA
Standard Delegated Orders –
Pediatric Trauma PT 06 Page 325
TOC

Consult:
 PAI if appropriate Mallampati Classification:
- See Pediatric PAI Class I: soft palate, fauces, uvula, pillars visible
Procedure Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate tube is
not in the esophagus. Verify tbe placement is not
right mainstem. In the cardiac arrest, through
quality CPR and controlled ventilation attempt to
maintain EtCO2 levels as close to 35 – 45 mmHg
as possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Rapid transport to appropriate facility is crucial
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS MULTI-SYSTEM TRAUMA
Standard Delegated Orders –
Pediatric Trauma PT 07 Page 326
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- Injury to the chest, abdomen or pelvis
- Multiple soft-tissue or musculo-skeletal injuries
Assessment:
 Trauma assessment
Primary Interventions:
 Spinal Motion Restriction
 O2 via most appropriate method
 Inline intubation, if needed
 Occlude open chest wounds

Secondary Interventions:
 Vascular Access
- Enroute
 Fluid Bolus
- Repeat as needed unless pulmonary edema develops
 Any changes in condition/rhythm refer to appropriate Pediatric Protocol
All other injuries should be treated en-route to the hospital if feasible
Consult:
 PAI if appropriate Mallampati Classification:
- See Pediatric PAI Procedure Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
- EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS MUSCULOSKELETAL – SOFT
TISSUE INJURY
Standard Delegated Orders –
Pediatric Trauma PT 08 Page 327
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- Pain on palpation or movement
- Ecchymosis, swelling, deformity
Assessment:
 Trauma assessment

Primary Interventions:
 O2 via most appropriate method
 Spinal motion restriction Check CMS before and after applying splint
 Control hemorrhage
 Splint
Secondary Interventions:
 Vascular Access if:
- Open fracture
- Femur fracture
- Pelvic fracture/Hip dislocation
- Signs of hypotension and/or
hypoperfusion
 Cooling of injury site
 Nitrous Oxide (Self-administered)
 Pain Management
Consult:
 C-spine clearance
 Fracture reduction by inline traction
if no pulse is detected and if is a
closed fracture
- If still no pulse, splint in position
 Zofran oral disintegrating
tablet (ODT) PO
Weight 8 kg-30 kg 4mg ODT PO
Weight >30kg 8mg ODT PO
May be repeated every 15 min
 Phenergan 0.5 mg/kg IV/IO/IM
- For N/V
- May be repeated x 1 if N/V
persists after 15 minutes
- Maximum single dose 12.5 mg

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 Montgomery County Hospital District-EMS MUSCULOSKELETAL – SOFT
TISSUE INJURY
Standard Delegated Orders –
Pediatric Trauma PT 08 Page 328
TOC

Critical Points:
 Any changes in patient condition, refer to appropriate protocol

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 Montgomery County Hospital District-EMS PENETRATING INJURY
Standard Delegated Orders –
Pediatric Trauma PT 09 Page 329
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
- Note ballistics
 Physical Findings:
- A penetrating injury to any body part
- Entrance / exit wounds
Assessment:
 Trauma assessment
Primary Interventions:
 O via most appropriate method
 Occlude chest wounds
 Control hemorrhage
 Vascular Access
 Spinal Motion Restriction
 Chest decompression as needed
Secondary Interventions:
 Stabilize impaled objects
 Bandage and dress open wounds
 Pain Management

Consult:

Critical Points:
 Any change in patient condition refer to appropriate protocol

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 Montgomery County Hospital District-EMS SEXUAL ASSAULT
Standard Delegated Orders –
Pediatric Trauma PT 10 Page 330
TOC

Criteria and History :

 Historical Findings:
- Report of recent sexual assault
 Physical Findings:
- Signs of assault or injury
Assessment:
 Trauma assessment
Primary Interventions:
 Assure scene and personal safety Do not let patient bathe or change clothing.
 Provide emotional support Collect any pertinent items in an unused
biohazard bag, and transport with the patient.
 O via most appropriate method Any blankets or sheets used by or on patient
during transport should accompany patient into
the receiving facility.

In the event of hostile family or caregivers,

avoid confrontations that might interfere with
removing patient from the environment.
Secondary Interventions:
 Treat underlying injuries

Consult:

Critical Points:
 Any changes in patient condition refer to appropriate protocol
 Appropriate destination: Texas Children’s Hospital
 Refer to appropriate protocol for specific injuries or conditions.

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 Montgomery County Hospital District-EMS SPINAL TRAUMA
Standard Delegated Orders –
Pediatric Trauma PT 11 Page 331
TOC

Criteria and History :

 Historical Findings:
- Mechanism of injury
 Physical Findings:
- Presence of decreased neurological
function below site of injury
- Loss of sensation
- Inability to move
Hypotension
Assessment:
 Trauma assessment
Primary Interventions:
 Spinal Motion Restriction
 O2 via most appropriate method

Secondary Interventions:
 Vascular Access
- Fluid Bolus if neurogenic shock
is present or anticipated
- Repeat x 2 if no signs of
pulmonary edema
Consult:
 PAI if appropriate Mallampati Classification:
- See Pediatric PAI Procedure Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
Class III: soft palate, base of uvula visible
Class IV: soft palate not visible
ET Tube Confirmation:
Confirm with 5 methods as per procedure
Capnometry Reference:
EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Critical Points:
 Any change in patient condition refer to appropriate protocol
- Transport to appropriate facility

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 Montgomery County Hospital District-EMS TRAUMATIC ARREST
Standard Delegated Orders –
Pediatric Trauma PT 12 Page 332
TOC

Criteria and History :

 Historical Findings:
- Underlying multi-system trauma
- Surgical problem
 Physical Findings:
- Multi-system trauma
 ECG Findings:
- Any non-perfusing rhythm
Assessment:
 Trauma assessment
Primary Interventions:
 CPR Mallampati Classification:
- BVM ventilation with 100% O2 Class I: soft palate, fauces, uvula, pillars visible
Class II: soft palate, fauces and uvula visible
- Maintain open airway with OPA Class III: soft palate, base of uvula visible
 Inline intubation Class IV: soft palate not visible
 Spinal Motion Restriction ET Tube Confirmation:
 Chest Decompression Confirm with 5 methods as per procedure
- If signs/symptoms of tension Capnometry Reference:
pneumothorax EtCO2 readings consistently > 0 indicate
tube is not in the esophagus. Verify tbe
 Occlude open chest wounds
placement is not right mainstem. In the
cardiac arrest, through quality CPR and
controlled ventilation attempt to maintain
EtCO2 levels as close to 35 – 45 mmHg as
possible. Values under 15 mmHg indicate
poor survivability. Unsuccessful: 0 mmHg
Secondary Interventions:
 Dysrhythmia treatment per specific
Pediatric Protocol
 Vascular Access
- Fluid Bolus
- Repeat as needed unless
pulmonary edema develops
 All other injuries should be treated
en-route to the hospital if feasible
Consult:
 PAI Pediatric patients Are Not candidates for
Trauma Termination
Critical Points:
 Any changes in patient condition, refer to appropriate protocol

Revision Date 11/25/2008 332

PROCEDURES
This Page Intentionally Left Blank
 Montgomery County Hospital District-EMS 12 LEAD ECG MONITORING
Standard Delegated Orders –
Procedures PROC 01 Page 335
TOC

General:
Prehospital 12–lead electrocardiograms (ECG) benefit patient care by alerting
receiving physicians to potential fibrinolytic candidates, by decreasing the time to in-
hospital fibrinolytic administration, and by providing a baseline ECG for comparison.

Indications:
Patients presenting with:
 Chest pain or pressure of presumed cardiac etiology, and/or
 Shortness of breath of presumed cardiac etiology

Contraindications:
 Unstable patients
 Patients who have been subjected to trauma (relative)

Precautions:
 Obtaining a baseline 12-Lead ECG is preferred before treatment is initiated.
However, Do Not significantly delay treatment and/or transport to conduct test.
 When placing electrodes on female patients, always place leads V3 – V6 under
the breast rather than on the breast.
 Never use the nipples as reference points for electrode location as nipple
locations may vary widely.

Procedure:
1. Whenever possible, attempt to obtain 12-Lead with patient in supine position.
2. If patient does not tolerate, place in semi-reclining or sitting position.
3. Input patient name, sex, and age. Leave ECG size preset at x 1. (Do Not
compromise patient care to input this information).
4. Prep the skin and shave hair as necessary.
5. Apply electrodes as follows and attach the appropriate lead to each electrode:

Limb Leads: Extremities Precordial Leads: Chest

(RA) Right arm V1– Fourth intercostal space to the right of the sternum
(RL) Right leg V2 – Fourth intercostal space to the left of the sternum
(LA) Left arm V3 – Directly between leads V2 and V4
(LL) Left leg V4 – Fifth intercostal space at midclavicular line
V5 – Level with V4 at left anterior axillary line
V6 – Level with V5 at left midaxillary line

6. Secure the cable with the cable clasp to an item of the patient‘s clothing.
7. Attempt to obtain the 12-Lead while the vehicle is not moving.
8. Ask the patient to remain motionless for 20 seconds.

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 Montgomery County Hospital District-EMS 12 LEAD ECG MONITORING
Standard Delegated Orders –
Procedures PROC 01 Page 336
TOC

9. Acquire and print two copies of the 12-Lead ECG report.

10. If the monitor detects signal noise (e.g., patient motion or a disconnected
electrode), the 12-Lead acquisition is interrupted until noise is removed.
Take appropriate action as required (e.g., reconnecting leads).
11. Attach a copy to ECG Strip Form and submit with your patient run report.
12. Remember to include the incident # and/or patient name on the ECG strip.

Considerations:
Chest Lead Positioning:
Locating the V1 position (fourth intercostal space) is critically important
because it is the reference point for locating the placement of remaining V
leads. To locate the V1 position:
 Place your finger at the notch in the top of the sternum.
 Move your finger slowly downward about 1.5 inches until you feel a slight
horizontal ridge or elevation. This is the "angle of Louis" where the
manubrium joins the body of the sternum.
 Locate the second intercostal space on the right side, lateral to and just
below the angle of Louis.
 Move your finger down two more intercostal spaces to the fourth
intercostal space, which is the V1 position.

Right Sided 12-Leads:

 When a 12-Lead is obtained with ST and T wave changes that are highly
suggestive of Inferior wall involvement, move Chest Leads V-3, V-4, V-5,
V-6 to the exact location of the R side of the patients chest.
 When documenting on the ECG strip add ―R side‖ to each lead that was
moved.

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 Montgomery County Hospital District-EMS ADENOSINE ADMINISTRATION
Standard Delegated Orders –
Procedures PROC 02 Page 337
TOC

Indication:
 SVT
 Undifferentiated tachycardia as specified in the SDO.
Contraindication:
 Sick-sinus syndrome (except in the presence of a functioning artificial
pacemaker).
 Second or third degree heart block
Equipment:
 A total of 30 mg of Adenosine for an adult patient or 15 mg for a pediatric patient
 2 – 3 ml syringes
 2 – 5 ml (or 10 ml) syringes
 3 – 10 ml syringes
 ECG monitoring.
 18 ga syringe needle
 10 ml sterile NS
 Oxygen
 IV start Kit
 IV catheters –16 ga -18 ga or use largest bore possible
 Tape or securing device

Procedure:
1. Verify cardiac rhythm and patient status indicating adenosine administration.
2. Ensure that patient is on ECG monitor and is receiving O2.
3. Establish two IV's (see appropriate procedures):
Saline lock, no more distal than the antecubital fossa
NS infusion TKO
4. Draw up 12 mg of Adenosine in 3 ml syringe or 1 – 12 mg pre-filled syringe.
5. Draw up 10 ml NS in another syringe in 10 ml syringe.
6. Instruct patient that they feel a short period of chest heaviness, chest pain, SOB,
etc.
7. Prepare injection lock with alcohol or iodine.
8. Begin continuous recording of ECG.
9. Rapidly push the Adenosine through saline lock.
10. Immediately flush with 10 ml of NS (Should be placed in same port as the
Adenosine)
11. If no conversion in exactly two minutes, repeat steps #4–10 once.
12. If the patient becomes hypotensive, support with positioning and a fluid bolus.
13. Record ECG for entire medication administration sequence.
14. Re-evaluate vital signs and patient status after Adenosine administration.

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 Montgomery County Hospital District-EMS BASIC AIRWAY MANAGEMENT
Standard Delegated Orders –
Procedures PROC 03 Page 338
TOC

General:
Conscious patients with a patent airway should be placed in position of comfort
consistent with their illness or injury.
Patients with compromised airway should be managed in a manner consistent with
their illness or injury.

Procedure for Establishing and Maintaining an Airway:

1. Open patient‘s airway using the appropriate technique for the patient‘s condition.
 Medical patient: Head tilt-Chin lift or Head tilt-Jaw thrust
 Trauma patient: Modified Jaw thrust (jaw thrust with neutral neck
alignment)
2. The patient‘s airway should be maintained and secured using the appropriate
airway device
 Oropharyngeal Airways should be used in unconscious patients or patients
without a gag reflex.
 Nasopharyngeal Airways are better tolerated in conscious patients or in the
presence of gag reflex.
Do not use in small infants. Bleeding may occur in children with large
adenoids.
Do not force. Always use lubricant.
 If necessary refer to individual advanced airway procedures.

Procedure for Suctioning the Airway:

1. Turn patient to side if possible, maintaining spinal immobilization in trauma
patient.
2. Suction the oropharynx with a large bore rigid or flexible catheter.
3. Suction the lower airway with a flexible catheter down the ET tube and utilize a
sterile technique.
4. Limit to 10 – 15 sec. at a time. Suctioning may cause bradycardia.
5. Hyperventilate patient prior to and in between procedure if possible.

Procedure for Airway Obstruction:

The following techniques for management of obstructed airway apply to adults
as well as children and infants with the following exceptions in infants:
 Five back blows followed by five chest thrusts are to be used - No Abdominal
thrusts.
 Finger sweep should only occur if foreign body is visualized. Blind finger
sweeps are NOT performed in infants.

Complete Airway Obstruction:

1. Reposition the airway (jaw thrust or head-tilt/chin-lift).
2. Foreign body maneuvers as indicated.
 Infant: 5 back blows, 5 chest thrusts.
 Child / Adult: 5 Abdominal thrusts (supine position)

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 Montgomery County Hospital District-EMS BASIC AIRWAY MANAGEMENT
Standard Delegated Orders –
Procedures PROC 03 Page 339
TOC

 If the patient is still conscious perform the heimlich maneuver

3. In the event abdominal thrusts are unsuccessful at removing the obstruction and
the patient’s airway remains completely obstructed.
 Insert a laryngoscope gently into oropharynx to visualize any foreign body.
 If a foreign body can be visualized, magill forceps may be used to assist in
removal of the foreign body.
4. If the obstruction is not relieved:
 Proceed to needle cricothyroidotomy as outlined in the appropriate procedure.
5. When the obstruction is relieved:
 Apply high flow oxygen per airway/oxygenation procedure.
 Assess the adequacy of ventilations and support as needed.
 Consider intubation if appropriate.
 Suction aggressively. Vomiting and aspiration commonly occur after relief of
an airway obstruction. Be prepared to quickly and aggressively suction the
patient.

Partial Airway Obstruction:

1. Have patient assume a position of comfort, unless risk of spinal injury, then
immobilization is indicated.
2. Apply high flow O2 at 10 to 15 lpm by a non-rebreather mask.
3. Suction upper airway secretions as appropriate.
4. As long as the patient is moving air or coughing, no attempts should be made to
relieve a partial airway obstruction.
5. Abdominal thrusts will not be effective and may be injurious to the patient who is
still moving air.
6. If patient demonstrates evidence of deterioration (change in mental status, inability
to ventilate), treat as complete airway obstruction.

Pediatric Considerations

Anatomic and Physiologic Features Unique to Children:

1. Large tongues which may occlude the airway and are difficult to sweep away
during intubation.
2. Small airway diameter. Minimal edema and swelling may obstruct the airway.
3. Short trachea that predisposes for extubation during transport or head extension.
4. Anterior larynx which often makes intubation difficult. Cricoid pressure should aid
in visualization.
5. Infants have large heads that cause a sniffing position. These patients may
require a towel roll under their backs to correct the airway position.
6. The epiglottis is soft and ―U‖ or omega shaped.
7. The smallest diameter of the airway is at the cricoid ring, below the cords. This is
why uncuffed ET tubes are used in small children.
8. The pediatric airway approaches the size of an adult airway at age 8 or 9 years
of age.

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 Montgomery County Hospital District-EMS BASIC AIRWAY MANAGEMENT
Standard Delegated Orders –
Procedures PROC 03 Page 340
TOC

9. Infants are obligate nose breathers until 2 – 6 months of age.

10. The diaphragm is the main muscle used for breathing in infants due to the
undeveloped intercostal muscles. This may cause inflated stomachs secondary
to crying.

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 Montgomery County Hospital District-EMS BAXTER
PUMP/ADMINISTRATION OF IV
MEDICATIONS
Standard Delegated Orders –
Procedures PROC 04 Page 341
TOC

General:
The Baxter Volumetric Infusion Pump should be used to administer medications that
require continuous monitoring during transport.

Equipment:
 All equipment as noted for intravenous access.
 Medication and IV fluid for infusion (as specified in protocol or Med Reference).

Procedure:
Selecting a Pump Personality Screen
1. Check the current Pump Personality on the power-on screen.
2. To use the pump in the current Personality, press the ―Main Display‖ key to
advance to a programming screen. If no keys are pressed, the pump will
automatically change to the ―Main Display Screen‖ after 8 seconds.
3. To choose a different Personality, select the ―Change Personality‖ soft key.
4. Use the Arrow keys to select from the list of available Personalities.
5. Press the Select key to select a Personality and advance to a programming screen.
Note: Changing the Personality feature set also clears the volume history and
the programming parameter settings such as rate and Volume to be
Infused values.

IV Set Loading Procedure:

1. Prepare the fluid container and Baxter standard IV administration set with ―s‖ suffix
according to the product directions. Close regulating (roller) clamp on the IV
administration set.
Warning: This device should only be used with Baxter “s” suffix sets
equipped with keyed On/Off slide clamps listed in the Operator’s
manual.
2. Press On/Off Charge key. After the self-diagnostic tests have been completed,
press the Open key. The automatic tube loading will open and the administration
set can be loaded.
3. Loading from left to right, position the On/Off slide clamp into the keyed slot on the
left-hand side of the loading channel.
4. Pulling the tube taut, slide it all the way into and along the tube-loading channel.
5. Once the pump detects the tubing, the mechanism will automatically close and load
the tubing into the pump drive mechanism.
6. After the tubing is loaded, confirm that it is entering the pump module on the left
side and that the patient end of the tubing exits the pump on the right side.
7. Open the regulating (roller) clamp. Verify that NO drops are falling from the drip
chamber.
Caution: If flow is observed, close the regulating (roller) clamp immediately and
remove pump from service.

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 Montgomery County Hospital District-EMS BAXTER
PUMP/ADMINISTRATION OF IV
MEDICATIONS
Standard Delegated Orders –
Procedures PROC 04 Page 342
TOC

8. Attach the IV administration set to the patient access site.

9. Press the ―Vol‖ key or use the UP/DOWN arrow keys to highlight the Volume to be
Infused field for programming.
10. Program the desired Volume to be Infused using the keypad.
11. Verify programmed information before starting the pump.

PiggyBack Infusion Procedure for Baxter Pump

1. Prepare secondary fluid container and IV administration set according to product
directions.
2. Lower the primary container using the hanger provided with the secondary set.
3. To perform automatic piggybacking, use only Baxter‘s Continu-Flo ―s‖ suffix
administration sets as the primary line.
4. To program the piggyback infusion, press the ―Piggyback‖ soft key.
5. Enter the rate and Volume to be Infused in the same manner as the primary.
6. After confirming the programming values, press the Start key and open the ON/OFF
clamp on the secondary medication set to begin the piggyback infusion.
7. Confirm that flow is occurring from the piggyback solution container by observing
drops falling in the secondary drip chamber. The primary infusion will resume
once the piggyback container empties.
8. Pump will automatically revert to the primary rate or to KVO if no primary infusion
exists.
Note: Always enter entire amount in piggyback container, including additive. Hang
primary container using the hanger provided in the secondary administration
so that it is below the level of the piggyback container.

IV Set Unloading Procedure

1. After stopping the pump, close the regulating (roller) clamp on the IV administration
set.
2. Press the OPEN key.
3. Grasp the IV administration set on both sides of the pump and remove it from the
pump. the loading mechanism should automatically close when the IV
administration set is removed or after 60 seconds have elapsed.

Manual Tube Release:

Note: This function is used when the Automatic Tube Release is not functioning.

1. Close the regulating (roller) clamp on the IV administration set.

2. Locate the Manual Tube Release mechanism on the right side of the pump, as
you face the front panel.
3. Push and grasp the release tab, turning it out.
4. Rotate the tab counterclockwise to its stop.
--- This closes the keyed On/Off slide clamp and opens the pump mechanism,
allowing removal of the IV administration set.

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 Montgomery County Hospital District-EMS BAXTER
PUMP/ADMINISTRATION OF IV
MEDICATIONS
Standard Delegated Orders –
Procedures PROC 04 Page 343
TOC

Trouble-Shooting Alerts
Alerts call attention to conditions that may require user intervention without
stopping the infusion. During an alert condition the device displays a message in
the Main Display‘s status line and on the pump channel display. In addition, the
yellow ALERT LED lights and alert tone sounds. The alert tone can be silenced
for two minutes by pressing the “Silence” key.

Advance Air Alert Pump Channel Display Message: ADV AIR

Cause: The device is in Advance Air mode. The Advance Air message screen is
displayed.
Correction: Release the Advance Air soft key when the bubble can be seen or fluid is
detected.

Battery Low Alert Pump Channel Display Message: BATT

LOW
Cause: The charge remaining in the battery has approximately 30 minutes of infusion
time left.
This alert occurs BEFORE the battery depleted alarm condition is signaled.
Correction: Plug the pump into an AC power source.

Changing Piggyback Alert Pump Channel

Display Message: (xx.x or xxx) ml/hr
(xx.x or xxx=infusion rate)
Cause: The piggyback rate is being changed during a piggyback infusion.
Correction: Finish the piggyback data entry and press the START key.

Changing Primary Alert Pump Channel

Display Message: (xx.x or xxx) ml/hr
(xx.x or xxx=infusion rate)
Cause: The device is on and the infusion is not running.
Correction: Finish the primary data entry and press the START key.

Channel Stopped Alert Pump Channel Display Message: STOPPED

Cause: The device is on and the infusion is not running.
Correction: Complete remaining programming steps and press the START key or power
off the pump.

KVO Alert Pump Channel Display Message: KVO+x.x/Label

(xx.x=infusion rate)
Cause: The Volume to be Infused has decremented to zero and the device is infusing at
the KVO rate (or programmed rate, whichever is lower).
Correction: Prepare a new infusion or power off the pump.

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 Montgomery County Hospital District-EMS BAXTER
PUMP/ADMINISTRATION OF IV
MEDICATIONS
Standard Delegated Orders –
Procedures PROC 04 Page 344
TOC

Prime Alert Pump Channel Display Message: PRIMING

Cause: The Prime soft key is being pressed.
Correction: Release the Prime soft key after the set is primed.

Programming Piggyback Alert Pump Channel Display Message: (xx.x or

xxx)ml/hr
(xx.x or xxx=infusion rate)
Cause: Programming of the piggyback function is occurring during the primary infusion.
Correction: Complete the piggyback program and press the START key.

Trouble-Shooting Alarms
Alarm conditions automatically stop the infusion and require immediate attention
BEFORE the infusion can be restarted. An alarm condition displays a message in the
Main Display‘s status line and on the Pump Channel Display. In addition, the red
ALARM LED on the pump Module lights and the alarm tone sounds.

An alarm will override an existing alert condition.

The alarm tone can be silenced for two minutes by pressing the Silence key.

Air Detected Alarm Pump Channel Display Message: AIR/Label

Cause: An air bubble has been detected on a configured setting.
Correction:

1. When the air alarm occurs, a pop-up window is displayed. Press the Arrow key
next to the Yes label for pump assisted viewing of the air detected.
2. Press and hold the Advance Air soft key. The device should pump at the currently
programmed rate. The pump will stop when the Advance Air soft key is released.
3. Once the fluid icon appears the alarm condition is reset. Visually inspect the air
bubble and remove the air from the IV administration set according to local protocol.

When the air has been removed, the infusion may be restarted by pressing the Start key.

Note: Pressing the No key and unloading the set to manually purge the air will exit
the advance air screen.

Battery Depleted Alarm Pump Channel

Display Message: BATTERY
Cause: The battery charge has diminished below the level necessary to continue
operation.
Correction:

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 Montgomery County Hospital District-EMS BAXTER
PUMP/ADMINISTRATION OF IV
MEDICATIONS
Standard Delegated Orders –
Procedures PROC 04 Page 345
TOC

1. Plug the device into an AC power supply.

2. Press the appropriate Primary or Piggyback soft key (if available).
3. Press the Start key.

Down-Stream Occlusion Alarm Pump Channel

Display Message: DWN CC/Label
Cause: A closed distal clamp, stopcock, clogged filter or other occlusion is downstream
of the pump.
Correction:
1. Clear the problem causing the occlusion.
2. Press the appropriate Primary or Piggyback soft key (if available).
3. Press the Start key to resume infusion.

Note: When the pump is configured with the Auto Restart feature on, the pump
can automatically restart if the occlusion is removed within one minute after
detection.

Reset Manual Tube Release Alarm Pump Channel Display Message: RESET
Cause: The manual tube release was activated.
Correction: Remove the IV administration set and reset the manual tube release.

Tube Not Loaded Alarm Pump Channel

Display Message: NO TUBE
Cause: The IV administration set has not been loaded prior to pressing the Start key.
Correction:
1. Load the IV administration set.
2. Press the appropriate Primary or Piggyback soft key (if available).
3. Press the START key.

Out of Range Alarm Pump Channel Display Message: STOPPED

(Piggyback, Primary)
Cause: A programming value outside the programming range allowed has been entered.
This alarm appears as soon as the Confirm Settings soft key or START key is
pressed.
Correction:
1. Verify the appropriate values have been entered.
2. Press the Confirm Settings soft key, if required, and the START key to begin
the infusion.
3. If alarm reoccurs, the value range available in your current personality setting
may not be broad enough to accommodate your entries. Check the current

Personality feature set configuration.

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 Montgomery County Hospital District-EMS BLOOD DRAW REQUEST BY
TEXAS J.P.
Standard Delegated Orders –
Procedures PROC 05 Page 346
TOC

General:
 Per HB 3775 of the State of Texas, a Justice of the Peace in the State of Texas
can order a paramedic to draw blood for the purpose of determining the alcohol
content or the presence of chemical substances. This bill became effective
09/01/99.
 A certified paramedic acting at the request of a Justice of the Peace shall not
incur any civil or criminal liability as a result of the blood draw.
 If, for any reason, an MCHD paramedic feels uncomfortable performing this
procedure, he/she should contact a Supervisor immediately. If a Supervisor is
unavailable, ask Alarm to contact one of the following individuals via the 688
paging system:
- Assistant Director EMS-Operations
- Assistant Director EMS-Clinical
- EMS Director
- Any off-duty Supervisor immediately available

Procedure:
1. Blood draw should be under the supervision of the requesting Justice of the
Peace.
2. Use the blood draw kit as supplied by the Justice of the Peace.
3. Don appropriate personal protective equipment.
4. Cleanse the venipuncture site using the providine-iodine prep pad from the kit.
Do not use alcohol preps-this will alter accuracy of the test results.
5. Make venipuncture with an 18 or 20 ga catheter.
6. Withdraw blood into two (2) gray top tubes using the needleless vacutainer
equipment.
7. Slowly invert the tubes at least 5 times to assure proper mixing of the blood and
the anticoagulant powder. The paramedic should write his initials, date and time
on the tube before handing the tubes to the Justice of the Peace.
8. Discontinue the I. V. unless otherwise indicated.
9. The paramedic who drew the blood sample should sign any required forms or
labels and observe the blood tubes being sealed by the officer.
10. If not already done, an incident number should be generated from the alarm
office.
11. Accurate and thorough documentation of the circumstances and events should
be recorded including name of JP and Peace Officer requesting procedure, site
of the blood draw, time performed and time the blood sample was released to the
Peace Officer.
12. Have the Officer or other authorized individual sign as having received the blood
sample to document chain of custody after being drawn by EMS. This
documentation is important so that the integrity of the blood draw by MCHD-EMS
is not in question.
13. Include documentation of site preparation as well as use of Betadine or
providine solutions. This documentation is important in the event the procedure
and/or outcome of the test results are challenged in a court of law.

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 Montgomery County Hospital District-EMS BLOOD GLUCOSE ANALYSIS
Standard Delegated Orders –
Procedures PROC 06 Page 347
TOC

General:
Treat patient per appropriate Treatment SDO. See the Adult Medical and Pediatric
Hypoglycemia and Hyperglycemia SDO's.

Indications:
Patients with a known history of hypoglycemia or diabetes mellitus.
Any patient presenting with altered mental status or other signs/symptoms of
hypo/hyperglycemia, including:
 Tremors
 Weakness
 Nausea
 Abdominal Pain
 Unconscious/unresponsive

Procedure:
1. Gather and prepare equipment.
2. Don appropriate protective gear.
3. Wipe pad of finger with alcohol prep.
4. Stick finger with the lancet device and press finger to form a small drop of blood.
- Blood samples can be obtained from site used to establish an intravenous
access, or from a separate venipuncture site.
5. Touch and hold the Test End (tip) of the Test Strip to the drop of blood until after
the meter "beeps."
6. Blood will automatically be drawn into the Test Strip and the timer will begin
down from "60" seconds.
7. After "60" seconds the blood glucose result will appear in the display window.
8. Document the glucometer reading and treat the patient as indicated by the
analysis and protocol.
- If "Hi" appears your BG level may be above 600 mg/dI.
- If "Lo" appears in the display, your BG level may be below 20 mg/dI.
9. Repeat glucose analysis as indicated for reassessment after treatment and as
per protocol.
10. Dispose of the used Glucolet device in the sharps container. Remove the Test
Strip from the Glucometer and dispose in biohazard bag.

Considerations:
 It is imperative that the Glucometer is calibrated correctly with the appropriate
control code.
 In the event that the control code is different from the regent strip code a false
reading may be displayed.

Revision Date 11/01/2005 347

 Montgomery County Hospital District-EMS CHEST DECOMPRESSION
Standard Delegated Orders –
Procedures PROC 07 Page 348
TOC

General:
Tension Pneumothorax is a life threatening condition. Decompressing the chest is
considered potentially life saving and may be performed on any patient found in
cardiac arrest or multi-system trauma WITH signs of hemodynamic instability
(Hypotension and/or falling systolic blood pressure, Narrowing pulse pressure), AND
one or more of the following indications.

Indications:
 Increased respiratory difficulty / increased difficulty in bagging
 Sudden decrease in level of consciousness
 Loss of peripheral pulses
 Pale and/or cyanotic with diaphoretic skin
 Diminished or Absent unilateral breath sounds
 Distended neck veins
 Tracheal deviation (often a late sign)
 Pulseless electrical activity
 Subcutaneous Emphysema

Equipment:
 Cook Pneumothorax Kit or other appropriate equipment including:
 10, 12, 14 or 16 ga over-the- needle catheters
 Number 10 scalpel
 Heimlich valve or Rubber glove (for flutter valve)
 10 ml syringe
 Betadine swabs
 Dressing and tape
 Stethoscope
 ECG monitoring supplies and equipment
 Oxygen
 Appropriate ventilation equipment

Precautions:
 Crepitus and/or subcutaneous air may be present with a tension pneumothorax.
 Always insert needle over (cephalic) rib to avoid neurovascular bundle.

Complications:
 Creation of a Pneumothorax if not already present.
 Laceration of blood vessels and/or nerves
 Laceration of Lung
 Infection due to poor aseptic technique.

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 Montgomery County Hospital District-EMS CHEST DECOMPRESSION
Standard Delegated Orders –
Procedures PROC 07 Page 349
TOC

Procedure:
1. Don appropriate personal protective gear including eyewear, mask, and gloves.
2. Evaluate and maintain the airway, provide oxygenation and support ventilations.
3. Assemble and prepare equipment.
4. Attach appropriate size needle to 10 ml syringe
 In adults, use a 10 ga needle
 In children < 12 years, use a 14 ga needle.

ON THE AFFECTED SIDE:

5. Identify intercostal space at mid-clavicular line, between the 2nd and 3rd ribs
(Alternatively, the fifth intercostal space at mid-axillary line may be used).
6. Swab with Betadine at midclavicular line.
7. Position tip of needle just over top of the 3rd rib at the midclavicular line. Insert
needle into the chest at 45° angle to the chest wall and parallel to sternum. At
the pleural cavity a slight "give" is felt. Advance further into chest until bevel of
needle clears the pleura.
8. Advance the catheter over the needle and then remove needle.
9. If decompression occurs a rush of air may be heard
10. Connect Heimlich valve tubing, making sure to pay attention to proper flow
direction of the valve.
11. Secure catheter to chest.
12. Catheter may be connected to LOW suction intermittently to assist evacuation of
pneumothorax.

SPECIAL NOTES:
 Individuals who have chronic COPD may have a spontaneous pneumothorax
that progresses to a tension pneumothorax.
 A tension pneumothorax may be precipitated by the occlusion of an open chest
wound dressing.
 Rush of air and/or patient improvement indicates correct placement.
 If the patient has sustained multi-system trauma, bilateral decompression may be
required.
 Once needle is placed, Prehospital personnel should not remove it. If the
needle has been improperly placed, tape the needle to the patients chest and
repeat the procedure.
 Remember to go just above the rib due to all of the major structures (arteries,
veins, and nerves) which lie below the rib. The closer you stay to the top of the
rib, the less chance of complication

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 Montgomery County Hospital District-EMS COMBITUBE
Standard Delegated Orders –
Procedures PROC 08 Page 350
TOC

Indications:
 In an apneic patient when endotracheal intubation is unsuccessful
 Patient ≥ 5 feet tall
 Patient should be unconscious

Contraindications:
 Responsive patients with an intact gag reflex.
 Patients with known esophageal disease.
 Patient who have ingested caustic substances.
 Patients under 5 feet tall.

Complications:
 Blue pilot is inflated but air is heard leaking from mouth. Insert up to 20 ml
 of additional air in #1 blue pilot.
 Both pilots are inflated but chest does not rise and no air is heard when
ventilating in either tube. Deflate cuffs and withdraw airway 1 – 2 cm; re-inflate
cuffs and repeat steps as listed in the procedure.
 Pilot bulbs do not remain inflated. Remove airway.

Equipment:
 Combitube
 KY Jelly or other water soluble lubricant
 Securing device
 Syringe 20 ml
 Syringe 100 ml
 Suction apparatus
 Bag valve mask with oxygen source
 Bulb device
 End-tidal CO2 detector, or other approved device

Procedure:
1. Personal protective equipment including gloves, eye protection and mask.
2. Prepare, position, and oxygenate patient.
3. Provide suction as necessary.
4. Test cuffs by inflating 100 ml and 15 ml of air into the cuffs of the Combitube. The
cuffs are labeled with the correct amount of air for each cuff.
5. Hyperoxygenate for 30 seconds prior to insertion.
6. Assure c-spine stabilization if necessary.
7. Place patient‘s head in a neutral position.
8. Lubricate ET tube generously with water-soluble lubricant.
9. Perform tongue-jaw lift.
10. Insert Combitube until the teeth are aligned between the two black lines. Avoid
cuff contact with teeth. Limit placement attempt to 30 seconds.

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 Montgomery County Hospital District-EMS COMBITUBE
Standard Delegated Orders –
Procedures PROC 08 Page 351
TOC

11. Inflate proximal cuff (blue pilot).

12. Inflate distal cuff (white pilot).
13. Ventilate through blue #1 tube. Listen for epigastric and lung sounds. Watch for
chest rise. Utilize bulb check and EtCO2 detector to confirm tube placement.
14. If no chest rise is noted, inappropriate air sounds are heard, or bulb check
remains deflated, ventilate through clear #2 tube and confirm tube placement
with EtCO detector.
15. Gastric suctioning may be done by inserting a French suction catheter into #2
tube while continuing to ventilate through #1 blue tube.
16. Gastric suctioning is not possible through #1 blue tube.

Revision Date 11/01/2005 351

 Montgomery County Hospital District-EMS CONTINUOUS POSITIVE
AIRWAY PRESSURE
VENTILATION (CPAP)

Standard Delegated Orders –

Procedures PROC 09 Page 352
TOC

Pre-CPAP Patient Assessment

 Assess patient, record vital signs and pulse oximetry at room air
 Apply Capno-Mask to evaluate Capnography waveform
 Administer O by non-rebreather mask while preparing equipment

Indications for Use

 Adult patient able to fit mask with proper seal
 Systolic BP > 90
 GCS > 10
 Significant respiratory distress that is not responsive to conventional therapy
 AND two or more of the following:
 SpO2 < 92%
 Respiratory Rate > 25/minute
 Use of Accessory muscles or retractions

Contraindications for Use

 Inability to maintain open airway
 Respiratory Arrest/apnea
 Inadequate respiratory effort
 Suspected pneumothorax or chest trauma
 Excessive secretions
 Tracheostomy
 Patients at risk for aspiration (nausea/vomiting, foreign body airway obstruction,
etc.)
 Facial trauma that would interfere with proper fit of mask

CPAP Procedure (CPAP)

1. Place the patient in a seated position with legs dependant (if possible)
2. Monitor ECG and vital signs --B/P, heart rate, Respiratory rate, SpO
3. Verify that the CPAP Adjustment Knob is turned all the way to the left (off)
4. Attach CPAP unit to an Oxygen source
a. Ensure the tank valve is fully open
b. Verify that the liter flow to Oxygen barb is set to zero
5. Connect Locking Bayonet Outlet Adapter to CPAP unit
a. Both bayonet tabs should disappear once adapter is turned clockwise
6. Size Mask for patient (Medium will accommodate most patients)
7. Attach Mask to Exhalation Valve
8. Attach head strap to one side of the Face Mask
9. Inform patient of procedure
10. Open Adjustment Knob slowly to begin a slight flow of oxygen
11. Gently apply Face Mask to the patient
a. Instruct patient to breath in through their nose slowly and exhale
through their mouth as long as possible (count slowly and aloud to
four (4) then instruct to inhale slowly)

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 Montgomery County Hospital District-EMS CONTINUOUS POSITIVE
AIRWAY PRESSURE
VENTILATION (CPAP)

Standard Delegated Orders –

Procedures PROC 09 Page 353
TOC

12. Completely attach the head strap to the other side of the CPAP Mask
a. Ensure a tight seal and adjust as necessary
b. Explain to the patient that you will begin to slowly increase the
pressure and to continue exhaling out against the pressure as long
as possible before inhaling
13. Increase CPAP by turning the Adjustment Knob to the right
14. Increase CPAP to achieve an initial CPAP of 3 cmH2O
15. Once the patient is compliant with the procedure, slowly increase CPAP to 10
cmH2O if needed. Tirate to effect.

Critical points and Special Notes

 Success is highly dependent upon patient tolerance, and EMT-P ability to coach
 Instruct patient to breath in through nose and exhale through mouth as
long as possible
 Deterioration on CPAP mechanical ventilation/intubation
 Significant respiratory distress that is not responsive to conventional therapy
 Deterioriation of mental status
 Increase of the EtCO2
 Decline of SpO2
 Progressive fatigue
 Monitor closely for development of pneumothorax and or hypotension
 Patients should be closely monitored with SpO2, EKG, BP, ETCO2
 Monitor patients closely for vomiting and or gastric distention
 Inline nebulization may be utilized with CPAP in place

Revision Date 08/01/2007 353

 Montgomery County Hospital District-EMS C-SPINE CLEARANCE
Standard Delegated Orders –
Procedures PROC 10 Page 354
TOC

Indication for C-Spine Clearance in Pre-hospital Setting

All patients that are candidates for pre-hospital C-Spine clearance by MCHD-EMS
personnel SHOULD have a Negative (no) response to ALL of the following:

1. Patient < 6 years of age

2. Altered mental status and/or decreased level of consciousness
3. Suspected alcohol intoxication and/or drug abuse
4. Presence of neurological deficit or complaint
5. Presence of C-Spine pain and/or point tenderness
6. Distracting injuries of any kind. (e.g., long bone fractures, abdominal pain, chest
pain, crushing injuries, extensive BSA burns, etc.)
7. Language barrier between Paramedic and patient
8. Strong evidence of potential spinal injury based on mechanism of injury (e.g.,
high-speed rollover MVC, diving accident, fall >20 feet, etc.)
9. Voluntary range of motion with pain

Any patient with a Positive (yes) response to ANY ONE of the above items
SHOULD receive C- Spine Restriction prior to transport by MCHD-EMS personnel.

Note: If at anytime the paramedic feels uncomfortable clearing the c-spine, the
patient should be fully immobilized.

Revision Date 11/01/2005 354

 Montgomery County Hospital District-EMS END TIDAL CO DETECTION
Standard Delegated Orders –
Procedures PROC 11 Page 355
TOC

General:

Capnometry involves the continuous measurement of carbon dioxide

concentrations (CO2) in respiratory gases of mechanically ventilated patients.
Capnometry reflects CO2 elimination.

Indications:

Indicated to verify and maintain tracheal intubation.

Procedure:
 Endotracheally intubate the patient
 Attach End-Tidal CO detector to endotracheal tube.
 Note color change on each respiratory failure or cardiac arrest patient.

- More Purple: Less CO2

- More Yellow: More CO2
 The CO detector shall remain in place with the airway and monitored throughout
the prehospital care and transport.
 Tube placement should be verified frequently and always with each patient move
or loss of color change in the End-Tidal CO2 detector.

Contraindications:
There are no absolute contraindications to capnometry in mechanically ventilated
patients if the data obtained is evaluated in conjunction with other diagnostic test and
the patients overall clinical condition.

Considerations:
 It is important to note that although the capnometry provides valuable information
about correct tube placement and the efficiency of ventilation, it is not a
replacement or a substitute for a complete respiratory assessment.
 Low or absent cardiac output may negate its use for placement verification.
 Certain situations may affect the reliability of the capnometer. The extent to
which the reliability is affected varies somewhat among types of devices.
 The infrared spectrum of CO2 has some similarities to the spectra for both
oxygen and nitrous oxide. High concentrations of either or both oxygen or nitrous
oxide may affect the capnometer results. Other gases which could cause false
readings: Helium and Freon.

Note:
Contamination of the monitor by secretions or condensate, a sample tube of
excessive length, a sampling rate that is too high, obstruction or decreased
perfusion of the sampling chamber may lead to unreliable results.

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 Montgomery County Hospital District-EMS ET INTRODUCER DEVICE
Standard Delegated Orders –
Procedures PROC 12 Page 356
TOC

Indication:
Difficult intubation with a restricted view of the glottic opening.
Contraindications:
Pediatric patients under the age of 14.
Equipment:
 ET introducer device
 Laryngoscope
 ET tube
 Suction
Procedure:
1. Ensure patient is well oxygenated prior to procedure.
2. Don personal protective equipment.
3. Prepare suction.
4. Prepare ET tube for insertion without stylet.
5. Prepare ET introducer device for insertion by curving the bougie and ensuring
the distal tip is formed into a J shape.
6. Perform laryngoscopy, obtaining the best possible view of the glottic opening.
7. Advance the bougie, continually observing its distal tip, with the concavity facing
anteriorly.
8. Visualize the tip of the bougie passing posteriorly to the epiglottis where possible,
and anterior to the aryteniod cartilages.
As the tip of the bougie enters the glottic opening you should either feel ‗clicks‘ as
it passes over the tracheal rings or the tip will arrest against the wall of the airway
(hold-up). This is a good indicator of correct insertion, but is not 100% accurate.
Failure to elicit clicks or hold-up is indicative of esophageal placement. If hold-up
is felt, the bougie should be withdrawn approximately 5cm to avoid the ET tube
impacting against the carina.
9. Pass the ET tube over the proximal end of the bougie and through the glottic
opening, limiting movement of the bougie as much as possible.
10. Hold the ET tube securely in place and remove the bougie.
11. Secure and verify tube placement according to orotracheal intubation procedure.

Revision Date 11/01/2005 356

 Montgomery County Hospital District-EMS EXTERNAL PACING
Standard Delegated Orders –
Procedures PROC 13 Page 357
TOC

Assessment Requirements:

 ABC‘s
 Pulse oximetry
 ECG monitoring

Required Treatments:

 This assumes that the Zoll has already been turned on and is in ―Monitor‖ mode.
 Connect ECG electrodes to patient cable and attach electrodes to patient.
 Remove hair, clean and dry areas over which Multifunction Electrode Pads (aka,
combo-pads) will be placed.
 Connect combo-pads to multi-function Defibrillation/Cardioversion/Pacing Cable
on Zoll.
 Peel off protective covering from combo-pads to expose conductive surface and
position pads on patient according to manufacturers recommended placement
location on outer package
 Rotate selector dial to ―Pacer‖
 Adjust ―Pacer Rate ppm‖ dial to 80 bpm or higher
 Observe oscilloscope for ―Sense‖ marker which should appear on each QRS
complex
 Observe oscilloscope for pacer marker.
 Adjust ―Pacer Output mA‖ until electrical pacer wave is followed immediately by
QRS complex.
 Evaluate for concordance of mechanical pulse with electrical pulse through
multiple methods.
1. Manual evaluate pulse.
2. Evaluate blood pressure
3. Select Wave 2 on Zoll to SpO2 waveform and determine if there is a
corresponding waveform for each paced QRS complex.
 Depressing the ―4:1‖ button will hold four pacer beats to determine underlying
rhythm.
 You can switch to ―Monitor‖, ―Defib‖, and back to ―Pacer‖ and retain the original
pacer settings as long as the Zoll had not been powered off for greater than 5
seconds. When doing this, ALWAYS re-verify pacer settings.

Notes:

 Monitoring should be done through 4 lead cables.

 Defibrillation may be performed as usual while pacing the patient by switching
the selector to ―Defib‖

Revision Date 03/29/2006 357

 Montgomery County Hospital District-EMS HELMET REMOVAL
Standard Delegated Orders –
Procedures PROC 14 Page 358
TOC

General:
In the event that an individual is injured while wearing a protective helmet, the
primary assessment should proceed as always with concern for assessing airway,
breathing and circulation while addressing the potential for cervical spine injury.
 The goal is to appropriately treat the patient in terms of cervical spine
immobilization and manage the patient's airway.

Procedure:
The decision whether to remove a helmet or not to remove a helmet should be based
on the following criteria:

Tight-Fitting Helmets:
1. If the patient is awake and able to protect his/her airway, it is generally preferable
to leave the helmet in place using the helmet to assist with immobilization.
2. If the airway cannot be controlled for any reason with the helmet in place, the
helmet should immediately be removed while maintaining in-line immobilization.
3. If the patient has an altered level of consciousness and/or is unable to protect
his/her airway. The face shield should be immediately removed to allow access
to the airway. If the face shield cannot easily be removed, the helmet should be
removed while maintaining in-line immobilization.

Loose-Fitting Helmets:
1. If the patient is wearing a loose helmet that does not conform closely to his/her
head, the helmet should be removed using in-line immobilization prior to
completing spinal immobilization on the patient.
2. The void behind the Occiput created by the helmet and any other protective
sports equipment should be filled during the spinal immobilization procedure

Considerations:
 When immobilizing patients with the helmet in place, the backboard portion of most
immobilization devices may cause the neck to flex forward when the patient's head
is placed on it. For that reason, head immobilization devices should generally
not be used in these patients. The helmet should rest directly on the backboard
with towel rolls used to provide lateral support to the helmet.
 EMS crews should work closely with team trainers and physicians for organized
team sports. When providing scheduled standbys at sporting events, EMS
personnel should introduce themselves to the sports medicine personnel of the
teams prior to the game.

Revision Date 11/01/2005 358

 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 359
TOC

INTUBATION – OROTRACHEAL

Indications:
Any patient unable to maintain the patency of their airway, requiring mechanical
ventilation and/or PEEP
Patients with possible increasing ICP.

Contraindications:
Presence of gag reflex (consider other appropriate methods of airway management
or PAI)

Equipment:
 Endotracheal tube(s) of appropriate size
 Stylet for ET tubes
 Laryngoscope handle and batteries
 Laryngoscope blades of the appropriate sizes and desired type
 Bag valve mask, complete
 KY Jelly or other lubricant
 Securing device
 Syringe 10 ml
 Suction apparatus
 Stethoscope
 Bulb Check
 End-tidal CO2 detector, or other approved device
 Oxygen

Procedure:
1. Don personal protective equipment (gloves, eye protection, etc.).
2. Manually establish or secure the airway and oxygenate the patient.
3. Chose proper ET tube, (and stylette, if used).
4. Position patient‘s head as appropriate (neutral if c-spine injury suspected,
otherwise ―sniffing‖ position). See ―Making Best Attempt.‖
5. Remove mask and oral airway.
6. Insert laryngoscope blade, moving tongue to the left and lifting epiglottis.
7. Visualize glottis and vocal cords.
8. Visualize tube passing through glottic opening.
9. Advance tube until cuff is just past the cords. STOP advancing.
10. Confirm placement with a Bulb Detector.
11. Check for presence of breath sounds in left and right chest, and absence of
breath sounds in abdomen.
12. If you are unsure of placement, remove tube and hyperventilate patient with
bag-valve mask.

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 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 360
TOC

13. Once proper placement verified inflate cuff with 5 to 10 ml of air and insert
oropharyngeal airway or other bite block.
14. Secure the tube to the patient's head.
15. Apply end-tidal CO2 detector and monitor expired CO2.
16. Reassess airway and breath sounds each time after moving the patient.
17. Consider placing a NG tube to clear stomach contents after the airway is secured
with an ET tube.
18. Consider immobilization of patient‘s head with a c-collar or other device to
maintain tube position.
RECONFIRM tube placement often, ESPECIALLY AFTER moving patient or
manipulating ET tube.

Revision Date 11/01/2005 360

 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 361
TOC

INTUBATION – NASOTRACHAEL

Indications:
 Comatose patients with spontaneous respirations
 Conscious patient with severe hypoxia
 Oral cavity not sufficiently accessible to permit orotracheal intubation
 Wired jaws
 Trismus
 Active seizing

Contraindications:
 Apneic patient
 Facial trauma (blunt or penetrating)
 Penetrating neck wounds
 Nasal or Nasopharyngeal obstruction from deviated septum
 Basilar skull fracture
 Hypertension
 Suspected CVA

Complications:
 Nasal Bleeding
 Tube malposition in the:
- Vallecula
- Pyriform fossa
- Esophagus
 Laryngospasm
 Retropharygeal laceration

Equipment:
 Endotracheal tube
 KY Jelly or other water soluble lubricant
 Securing device
 Syringe 10 ml
 Suction apparatus
 Bag valve mask with oxygen source
 Bulb device
 End-tidal CO2 detector, or other approved device

Procedure:
1. Personal protective equipment including gloves, eye protection and mask.
2. Prepare, position, and oxygenate patient.
3. Chose proper ET tube about 1 mm less than for oral intubation.
4. Lubricate ET tube generously with water-soluble lubricant.

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 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 362
TOC

5. Pass the tube in the largest nostril with the beveled edge against the nasal
septum and perpendicular to the facial plate.
6. Use forward and lateral back and forth rotational motion to advance the tube.
Never force the tube.
7. Pause at the level of the pharynx so gag is minimal and breath sounds are
audible through the tube.
8. Apply firm, gentle cricoid pressure and advance the tube quickly past the vocal
cords during inspiration.
9. Confirm placement with a Bulb device.
10. Check for presence of breath sounds in left and right chest, and absence of
breath sounds in abdomen.
11. If you are unsure of placement, remove tube and hyperventilate patient with
bag-valve mask.
12. Once proper placement is verified inflate cuff with 5 to 10 ml of air.
13. Secure the tube to the patient's head.
14. Apply end tidal carbon dioxide detector and monitor expired CO2.
15. Reassess airway and breath sounds after movement.
16. Consider immobilization of patient‘s head to maintain tube position with c-collar
or other immobilization device. If able, consider placing an NG tube to clear
stomach contents after the airway is secured with an ET tube. Transport
should not be delayed to place an NG tube.

Considerations:
 If the patient is conscious, he or she should receive step by step instructions
before and during the procedure.
 Patient should be positioned either in sitting position or supine to align the mouth,
pharynx and the larynx.
 This is done by placing the patient in sniffing position, and by placing a folded
towel at the base of the patient’s neck.
 However, if the cervical spine injury is suspected, the head and neck
should be maintained in neutral position.

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 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 363
TOC

INTUBATION – DIGITAL

Indication:
Unable to orally or nasally intubate

Contraindications:
Conscious and responsive patient
Patient with intact gag or clenched jaw

Equipment:
 Endotracheal tube
 KY Jelly or other lubricant
 Securing device
 Syringe 10 ml
 Suction apparatus
 Bag valve mask with oxygen source
 Bulb device
 End-tidal CO2 detector, or other approved device

Procedure:
1. Prepare equipment including suction.
2. Ensure patient is well oxygenated by hyperventilation.
3. Don personal protective equipment.
4. Maintain trauma patient in neutral position with manual stabilization throughout
procedure.
5. Insert index and middle finger to palpate and elevate epiglottis.
6. Pass distal end of the ET tube between index and middle finger and advance
tube.
7. Confirm placement with a Bulb device.
8. Check for presence of breath sounds in left and right chest, and absence of
breath sounds in abdomen.
9. If you are unsure of placement, remove tube and hyperventilate patient with
bag-valve mask.
10. Once proper placement verified inflate cuff with 5 to10 ml of air and insert
oropharyngeal airway or other bite block.
11. Secure the tube to the patient's head.
12. Apply end tidal carbon dioxide detector and monitor expired CO2.
13. Reassess airway and breath sounds after movement.
14. Consider placing a NG tube to clear stomach contents after the airway is secured
with an ET tube. DO NOT delay transport to accomplish placement of NG tube.
15. Consider immobilization of patient‘s head with c-collar or other device to maintain
tube position.

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 Montgomery County Hospital District-EMS INTUBATION
Standard Delegated Orders –
Procedures PROC 15 Page 364
TOC

INTUBATION – STOMAL
Indications:
Pre-existing tracheotomy With any of the following:
- Respiratory Arrest
- Hypoventilation

Contraindications:
None when used in the emergency setting

Equipment:
 Endotracheal tube
 KY Jelly or other lubricant
 Securing device
 Syringe 10 ml
 Suction apparatus
 Bag valve mask with oxygen source
 Bulb Check
 Stethoscope
 End-tidal CO2 detector, or other approved device

Procedure:
1. Assemble the equipment while continuing ventilation with BVM.
2. Chose the tube size. (Note: if the stoma is constricted you may need to use a
smaller size tube; 6mm or 7mm)
3. Position patient.
4. Insert the tube through the stoma.
5. Advance the tube until the cuff is just inside the stoma. Insert air into the cuff to
prevent an air leak.
6. Confirm placement with a Bulb device.
7. Check for presence of breath sounds in left and right chest, and absence of
breath
sounds in abdomen.
If you are unsure of placement, remove tube and hyperventilate patient with
BVM device and supplemental oxygen.
8. Once proper placement has been verified inflate cuff with 5 to 10 ml of air.
9. Secure the tube to the patient's neck and head.
10. Apply end-tidal CO2 detector and monitor expired CO2.
11. Reassess airway and breath sounds each time after moving the patient.
12. Consider placing a NG tube to clear stomach contents after the airway is secured
with an ET tube.
13. The ET tube DOES NOT need to be modified in any way.

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CONTINUOUS INTRAVENOUS MEDICATION INFUSION

General:
Any medication that should be administered via IV infusion as indicated by
manufacturer and/or protocol.

Equipment:
 All equipment as noted for intravenous access.
 Medication and IV fluid for infusion (as specified in protocol or Drug Reference).
 18 g syringe needle or needleless adapter.
 60 gtts/ml IV drip chamber and tubing.

Procedure: Continuous Drip

1. Explain the procedure to the patient and inquire for medication allergies.
2. Don appropriate personal protective equipment.
3. Pre-mixed intravenous medications are selected or appropriate dose of medication
is added to intravenous fluid bag. Affix label to fluid container. Shake bag to
distribute medication.
4. Attach 60 gtts/ml drip chamber and tubing. Flush air from tubing and attach 18-ga
needle to end of tubing. Insert tubing into Baxter pump
5. Insert needle into IV injection port (use port closest to patient).
6. Begin medication infusion. Check for patency (indicated by good flow and absence
of infiltration).
7. Once patency is established, set infusion rate on the Baxter pump.
8. Monitor patient and pump during transport for consistency and patency of
IV/medication line.

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ENDOTRACHAEL MEDICATION ADMINISTRATION

General:
Critical patient requiring rapid administration of potentially life-saving medications in
whom vascular access cannot be established in a timely manner and Endotracheal
intubation has been successfully accomplished.

Indications for Administration:

Administration of ET medications as per SDO.
The medications that may be given down the ET tube are:
 Lidocaine
 Epinephrine
 Atropine
 Naloxone (Narcan)

Equipment:
 All equipment as noted in the Endotracheal Intubation Procedure.
 Medications, appropriate syringes, and syringe needles.
 If medication not diluted, 10 ml NS for dilution.

Procedure:
Note: All medications administered via the ET tube are doubled.

1. Endotracheal intubation with confirmation of tube placement.

2. Draw up medication or prepare pre-filled syringe for use.
3. Reconfirm tube placement by auscultation.
4. Hyperventilate patient for 30 seconds.
5. Rapidly inject the medication down the tube in a bolus that is diluted or followed by
normal saline to flush the tube. The total fluid that should be administered in one
bolus is 10 ml maximum.
6. Hyperventilate the patient for at least 30 seconds following medication
administration.

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INTRAMUSCULAR MEDICATION ADMINISTRATION PROCEDURE

General:
 Medications requiring Intramuscular administration.

Equipment:
 Appropriate size syringe
 18 ga syringe needle (to draw up medication)
 20 – 22 ga syringe needle (medication administration)
 Alcohol preps
 Band-Aid

Procedure:
1. Explain procedure to patient and inquire about medication allergies.
2. Medication is prepared in syringe of less than 5 ml with needle 18–22 ga, 1 1/2–2
inches. 0.2 ml of air may be added to syringe.
3. Site is selected and cleansed (deltoid, dorsal gluteal, ventro-gluteal).
4. Spread skin taut, insert needle at 90-degree angle, and aspirate.
5. If no blood appears in syringe, inject medication slowly.
6. Withdraw the needle and massage the site with alcohol prep or 4x4.
7. Dispose of syringe in sharps container.
8. Place a Band-Aid over the injection site

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Standard Delegated Orders –
Procedures PROC 16 Page 368
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INTRAVENOUS MEDICATION ADMINISTRATION

General:
Any patient requiring medications via the intravenous route.
Indications for Administration:
*Prior to any pre-hospital medications being administered All of the following should
be present:
1. Appropriate patient assessment has determined the need for a medication.
2. Patient is interviewed for known allergies and medication history to identify risk of
drug interaction or potentiation.
3. The on-scene In-Charge is familiar with:
 Guidelines for administration
 Actions
 Side-effects
 Drug interactions
 Contraindications
4. Medication is checked for:
 Expiration date
 Clarity

Equipment:
 All equipment and supplies as noted for intravenous access
 Syringe(s) of appropriate size(s) for medication dose
 18 ga syringe needles or Baxter Interlink system
 Alcohol preps

Procedure: IV Bolus
1. Establish vascular access.
2. Explain the procedure to the patient and inquire about medication allergies.
3. Don appropriate personal protective equipment.
4. Medication is prepared in syringe with luer-lock connector or protected-needle. (A
needle to insert into a port should only be used as a last resort.)
5. All air is cleared from syringe and excess medication expelled.
6. Site is cleansed and syringe is inserted into capped port of IV line.
7. Patency of IV is checked by aspirating blood or by monitoring flow with no signs of
infiltration.
8. IV line is clamped or flow is controlled to flush medication, as medication is pushed
into IV port.
9. Time taken to administer medication is specific to medication. Flush IV line to
assure medication administration.
10. Monitor IV catheter site for signs of infiltration.
11. Dispose of syringe in appropriate container.

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 Montgomery County Hospital District-EMS MEDICATION
ADMINISTRATION
Standard Delegated Orders –
Procedures PROC 16 Page 369
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NEBULIZED MEDICATION ADMINISTRATION

Indicated
 Dyspnea with evidence of bronchospasm (wheezes, silence), due to asthma, or
COPD.
 Patient SHOULD be alert and have adequate respiratory effort to inspire mist.

Contraindicated:
 Severely obtunded or unconscious patient.
Note: Nebulized medications have little therapeutic effect when given to patient
with little or no tidal volume.

CHF/Pulmonary Edema
Note: Patients with suspected Pulmonary Edema may be given Nebulized
Albuterol treatments but should not be given Nebulized Atrovent. Consider
Morphine for moderate to severe respiratory distress and/or prior to PAI.

Equipment:
 Medication for Nebulizer
 Oxygen-driven nebulizer
 Oxygen

Procedure:
1. Self-administered by the patient with a metered dose inhaler (MDI), hand-held
nebulizer or nebulized with positive-pressure breathing device such as a bag-valve-
mask or with an in-line device attached to the ET tube.
2. Avoid contamination of equipment. If contamination occurs replace contaminated
equipment prior to use.
3. Medication is measured and introduced into nebulizer and 8 –10 liters of oxygen is
attached to nebulizer.
4. Informs patient of need for treatment. Inquires about medication allergies.
5. Patient is instructed to breathe normally and to hold a deep inspiration every 4 – 5
breaths.
6. Treatment is continued until all medication is gone or is discontinued due to
complication in patient condition.
- Ectopy noted on ECG
- Heart rate increases by more than 20 bpm

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Standard Delegated Orders –
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ORAL MEDICATION ADMINISTRATION

General:
Patient assessment indicates administration of oral medications for optimal patient
care and outcome.
Oral medications currently administered by MCHD are:
 ASA 324 mg
 Oral Glucose
 Nitroglycerin
 Charcoal

Equipment:
 No special equipment required

Procedure:
1. Inquire about medication allergies.
2. Don appropriate personal protective equipment.
3. Prepare medication for administration. Prior to administration check for:
- Expiration Date
- Name of medication being administered to ensure medication chosen is
correct.
4. Obtain permission from patient to administer medication. Advise the patient what to
expect after medication has been administered. (e.g., Nitro may cause headache
but should relieve chest pain, etc.).
5. Provide medications to patient with direction on the administration (i.e.: to be
chewed, swallowed, held under the tongue)

Note: Oral medications Should Not be administered to patients with decreased

and/or altered levels of consciousness.

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RECTAL MEDICATION ADMINISTRATION

Indicated:
Any patient in status seizures requiring medication administration when an IV cannot
be established.
Consider administration of IM Versed BEFORE rectal administration of Valium.

Contraindicated:
 Respiratory insufficiency
 Hypotension

Equipment:
 A # 6–8 fr suction catheter
 Valium
 2–5 ml syringe
 Tape
 Lubricant

Procedure:
1. Carefully restrain patient manually in knee-chest or supine position.
2. Assure airway patency and administer supplemental Oxygen.
3. Don personal protective equipment.
4. Draw up the calculated dose of Valium: 0.4 – 0.6 mg/kg pediatric OR 4 –20 mg
adult.
5. Draw up 5 ml NS in the second syringe.
6. Have assistant hold legs apart.
7. Attach a #6–8 fr suction catheter to the end of a syringe that contains medication to
be administered.
8. Lubricate the tip of the catheter
9. Gently insert catheter into rectum and instill medication.
10. Flush the suction catheter with 5 ml of NS.
11. Optional-withdraw the catheter.
12. If the catheter is withdrawn tape the buttocks closed.
13. Use manual pressure to facilitate drug retention.
14. Monitor patient for respiratory depression, hypotension or any other change in
status.

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SUBCUTANEOUS MEDICATION ADMINISTRATION

General:
Any medication requiring Subcutaneous administration.
SQ injections are not recommended for patients with poor perfusion. (Shock)

Equipment:
 Appropriate size syringe
 18 ga syringe needle (to draw up medication)
 25 ga syringe needle
 Alcohol preps
 Band-Aid

Procedure:
1. Medication is prepared in syringe of 1 ml or less with needle 25–27 ga 1/2–5/8 ―.
2. Explain the procedure to the patient and inquire about medication allergies.
3. A site is selected and cleansed. Use the lateral aspect of the upper arm or leg.
4. Pinch skin up into a fat fold of at least 1‖.
5. Insert needle at 45-degree angle.
6. Aspirate the syringe.
7. If no blood appears in syringe, inject medication slowly.
8. Withdraw the needle and gently massage site with alcohol wipe or 4x4.
9. Dispose of syringe in sharps container.

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 Montgomery County Hospital District-EMS NASOGASTRIC TUBE
INSERTION AND LAVAGE
Standard Delegated Orders –
Procedures PROC 17 Page 373
TOC

Indications:
Nasogastric lavage may be performed on conscious or unconscious patients in any
of the following situations:
1. Patients who have ingested non-caustic poisons or excessive amounts of
medications
2. Cardiac arrest patients for the purpose of alleviating abdominal distention
3. Hyperthermic patients to lower body temperature.

Contraindications:
 Nasogastric lavage should not be performed if the patient is convulsing
 DO NOT delay transport to accomplish this procedure.

Procedure:
1. Explain procedure to patient and question the patient regarding any nasal injuries
or occlusions.
2. Assemble and prepare equipment.
3. Don appropriate personal protective items including eyewear, mask and gloves.
4. Raise head of bed to high fowler‘s position if possible. Support the patient's head
and shoulders with a pillow.
5. Select appropriate catheter size:
- Adults: 12 – 18 fr.
- Pediatric: 8 –12 fr.
6. Measure the tube by placing the tip of the tube on the patient's nose, then extend
the tube to the tip of the ear lobe and then to the end of the xyphoid process.
Use a piece of tape to mark the distance to be inserted or use black markings
found on some tubes.
7. Curve the end of the tube by coiling the first 6 inches tightly around your finger.
8. Lubricate tip with water-soluble jelly or 2% Lidocaine jelly.
9. Tilt patient head forward. Pass the tube through the nose downward but do not
force. Some people have obstructions in nasal passages. If severe resistance is
met, remove the tube, lubricate and try the other nostril.
10. If patient is conscious, have them swallow. Advance the tube with each swallow.
11. After the tube has been inserted halfway, instruct the patient to talk, if there is
any hoarseness or the patient is unable to speak, withdraw the tube and attempt
re-insertion
12. Once tube has been inserted, verify proper placement by injecting 10 – 20 ml of
air through the tube into the stomach while auscultating the stomach just below
the xyphoid process. You should hear a "whooshing" sound of air entering the
stomach.
13. Connect tube to suction use lowest possible setting that is effective.
14. Introduce lavage fluids (Sodium Chloride solution) in 20 – 30 ml portions and
remove the stomach contents. The general rule of thumb is 20 ml in / 20 ml out.
15. Continue this lavaging until returning fluid is clear.

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INSERTION AND LAVAGE
Standard Delegated Orders –
Procedures PROC 17 Page 374
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16. Anchor tube to the patient's nose with tape that has been wrapped around the
tube. Do not allow any pressure to be placed on the patient's nares.
17. Occasionally auscultate placement of tube during transport

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 Montgomery County Hospital District-EMS NITROUS OXIDE
ADMINISTRATION
Standard Delegated Orders –
Procedures PROC 18 Page 375
TOC

General:
Following implementation of the appropriate ALS protocol, this protocol may be
considered for pain management by the In-Charge. The administration of Nitrous Oxide
is done using the self-administration technique (have patient hold the mask and self-
administer the gas).
Indications:
To provide the adult or pediatric patient relief from pain due to any of the following:
 Pain due to fractures/dislocations
 Burns (without airway involvement)
 Significant crushing injuries to limbs
 Abdominal pain (without suspected obstruction)
 Renal colic
 Pain due to cancer
Contraindications:
 Ischemic related Chest pain
 Altered mental status and/or Neurologic deficits
 Head trauma (with or without mental status change)
 ETOH and/or Drug Overdose
 Hypotension
 COPD, Dyspnea
 Airway burns
Procedure:
1. SHOULD BE SELF ADMINISTERED
2. Turn on both oxygen and nitrous cylinders and ensure 50/50 mixture of Nitrous
Oxide and Oxygen.
3. Place the facemask over the patient’s face and have the patient breath in 4 – 5 deep
breaths or until they feel tingling to their face.
4. Once patient is aware of the effects, have patient use the Nitrous Oxide prn. Patient
should continue to inhale gas until relief is obtained.
Considerations:
 An IV or saline lock may be established for use at the discretion of the EMT-P.
 Nitrous Oxide should be the first line of treatment in pain relief unless otherwise
indicated by patient‘s condition.
 Should a titer effect occur in the patient during Nitrous Oxide use, give the patient
high flow oxygen until level of consciousness increases and discontinue use of
Nitrous Oxide.
 Attempts at pain control are not appropriate for patients with closed head injury or
acute abdomen unless cause of pain has a clear etiology e.g. kidney stones.
 Nitrous Oxide should not be used in the patient with a history

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 Montgomery County Hospital District-EMS ORTHOSTATIC VITAL SIGNS
Standard Delegated Orders –
Procedures PROC 19 Page 376
TOC

Indications:
Orthostatic vital signs are serial measurements of blood pressure (B/P) and pulse (P)
that are taken with the patient in the supine, sitting and standing positions to assess
volume depletion. This test is commonly performed on patients who complain of nausea,
vomiting, diarrhea, GI bleed and syncope.

Contraindications:
 None if performed with adequate personnel.

Equipment:
 Blood Pressure cuff
 Stethoscope or
 Electronic Measuring devices

Procedure:
1. Place the B/P cuff on the patient. For consistency the same arm with the same cuff
and location of pulse measurement should be used.
2. Initially, the patient needs to be supine. If the supine position compromises the
patient‘s breathing status or comfort level, assist them to a position that is as flat as
possible. It is recommended that two (2) sets of vital signs be taken in the supine
position, using the second set as the baseline.
3. The second measurement should be taken with the patient in the sitting position.
The patient should be sitting upright, with their legs dangling at the side of the bed or
stretcher.
4. The third measurement should be obtained with the patient in the standing position.
Note: If the patient is unable to stand omit this measurement and utilize readings
obtained in the sitting position.
5. One minute should elapse between measurements.
6. Findings of a decrease of 20 mm hg in systolic pressure, an increase of 10 mm hg
in the diastolic pressure and an increase in heart rate of 20 beats per minute is
significant.

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 Montgomery County Hospital District-EMS PAIN MANAGEMENT
Standard Delegated Orders –
Procedures PROC 20 Page 377
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Indications:
 Patient meeting criteria for pain management

Contraindications:

 Patient that does not meet criteria for pain management.

Equipment:

 Appropriate equipment to monitor heart rate and rhythm, blood pressure and pulse
oximetry.
 Appropriate medication and administration equipment.

Procedure:
 Place patient on all monitors.
 Have advanced airway equipment available, and medications available to treat
adverse reactions.
 Prepare and assemble equipment.
 Prepare patient for appropriate route of administration.
 Use aseptic technique throughout procedure.

Treatment Options

 Cognitive Therapy
 Behavioral Therapy
 Vascular Access
 Nitrous Oxide - self administered 50% Nitrous Oxide / 50% Oxygen pr
 Fentanyl
- Adult: .5 - 1 mcg/kg SLOW
IV/IO, FAST IN prn
Maximum Single Dose 100 mcg
Titrate to 30-50% reduction in pain
May repeat q 5 minutes prn

-Pediatric: 0.5 mcg/kg SLOW IV/IO, FAST IN Use extreme caution

prn with suspicion of
 Morphine - if available
- Adult: 2 – 10 mg IV/IO prn Alcohol or other
- Pediatric: 0.1 – 0.2 mg/kg IV/IO prn intoxicants Ingestion
 Increments of 0.5 mg/kg
 Max single dose 2 mg
 Valium
- Adult: 2 – 10 mg IV/IO
- Pediatric: 0.2 – 0.3 mg/kg IV/IO

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Procedures PROC 20 Page 378
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Special Considerations

 Rule out other possible causes of abdominal pain prior to treating any patient for
kidney stones (see Abdominal Pain protocol)
 Do not administer Fentanyl and Morphine to the same patient
 Beware of synergistic effect of combining Promethazine with Morphine or
Fentanyl, causing profound decreases in level of consciousness, respiration, and
blood pressure
 Nitrous Oxide should be considered for all patients that have no cardiac /
respiratory compromise
 Morphine is the treatment of choice for burns
 Fentanyl is treatment of choice for significant orthopedic injuries
 Fentanyl may be administered to patient‘s that are allergic to Morphine, however
you should remain prepared for a possible allergic reaction
 Intubation equipment and Narcan should be readily available when administering
pain medications
 Pain management should begin as soon as possible in all patients and prior to other
treatments in stable patients

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 Montgomery County Hospital District-EMS PARAPAC VENTILATOR
Standard Delegated Orders –
Procedures PROC 21 Page 379
TOC

Indications:
 Patients in both Respiratory and Cardiac Arrest
 Patients with Profound Hypoxia evidenced by any of the following:
1. Respiratory Arrest
2. Obvious Cyanosis
3. Altered Mental Status
4. Poor air exchange upon auscultation
5. Oxygen Saturation (SpO2) below 90%
Contraindications:
Patients under 15 lbs. or 6.8 kg. lean body weight.
Procedure:
If patient is in respiratory arrest but has a pulse:
1. Attach to and turn on oxygen supply source.
2. Turn on ParaPac (Ventilation ON/OFF switch).
3. Select lowest Pressure Relief of 20cm.
Select 100% Oxygen on Oxygen/Air Mix switch.
1. Ensure proper function by briefly occluding patient valve while watching pressure
gauge to
ensure audible pressure alarm function with relief at desired settings.
2. Attach appropriate sized ventilation mask to ParaPac Patient Valve.
3. Set Tidal Volume to initial setting that most nearly equals 6ml/lb. of patient lean
body weight (10–15 ml/kg.). Adjust as needed within appropriate color coded
range to achieve positive visible chest rise with positive breath sounds upon
auscultation.
4. Set Breaths Per Minute (Ventilatory Rate) at 12–40 BPM. Initial Rate setting can
be adjusted within the appropriate color-coded range as needed to change
minute volumes.
5. Apply facemask to patient with two hands and use either head tilt and/or jaw
thrust to maintain patent airway. Maintain mask seal and monitor inspiratory
pressure on Pressure
6. Gauge. Increase Relief Pressure setting if needed to that which is 10 cmH2O
above the minimum inspiratory pressure required to deliver the full selected Tidal
Volume as determined by cessation of audible alarm, and observation of the
Pressure Gauge.
7. Observe for chest rise and have second rescuer listen to both lungs for air
exchange.
8. A 60cmH2O Pressure Relief setting may be used for Adults and a 40 cmH2O
Pressure Relief setting may be used for Pediatrics after Endotracheal Intubation
has been confirmed. Once intubated, pressure required to deliver full tidal
volume may increase, but should not normally exceed 30 cmH O– 50 cmH O.
If patient is in respiratory and/or cardiac arrest:
1. Attach to and turn on oxygen supply source.
2. Turn on ParaPac (Ventilation ON/OFF switch)

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Standard Delegated Orders –
Procedures PROC 21 Page 380
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3. Select lowest Pressure Relief of 20 cmH O.

4. Select 100% Oxygen on Oxygen/Air Mix switch.
5. Insure proper function by briefly occluding patient valve while watching pressure
gauge to insure audible pressure alarm function with relief at desired settings.
6. Attach appropriate sized ventilation mask to ParaPac Patient Valve.
7. For Adult use set Tidal Volume control to volume that most nearly equals 6ml per
pound of patient lean body weight (10–15 ml/kg.) or 900ml.
8. Set Ventilator Rate at 12 breaths per minute. Insure that Tidal Volume and Rate
selected are color coded in the RED band.
9. For pediatric use, set Tidal Volume control to volume that is 5–6 ml/lb. lean body
weight.
10. Set Rate control at setting whose color code matches that on Tidal Volume (15–
20/minute).
11. Apply facemask to patient with two hands and use either head tilt and/or jaw thrust to
maintain patent airway. Maintain mask seal and monitor inspiratory pressure on
Pressure Gauge.
12. Increase Relief Pressure setting if needed to that which is 10 cmH O above the
minimum inspiratory pressure required to deliver the full selected Tidal Volume as
determined by cessation of audible alarm, and observation of the Pressure Gauge.
13. Observe for chest rise and have second rescuer listen to both lungs for air exchange.
14. Second rescuer finds landmark and performs chest compressions between
ventilations at a ratio of 5 compressions per ventilation (5:1) for Adults and 3:1 ratio
compressions/ventilation for Pediatrics.
15. A 60 cmH O Pressure Relief setting may be used for Adults and a 40 cmH O
Pressure Relief setting may be used for Pediatrics after Endotracheal Intubation has
been confirmed. Once intubated, pressure required to deliver full tidal volume may
increase, but should not normally exceed 30 cmH O – 50 cmH O.
16. In the event of any suspected failure or problem such as failure of the chest to rise or
Audible
Alarm Alert / Trouble Shooting
 Immediately second rescuer listens to both lungs for air exchange.
 If no air exchange re-position head and mask.
 If no air exchange, consider Obstructed Airway Procedures.
 Check Patient Valve for foreign material or blockage.
 Check patient hose connection to Control Box.
 Check Pressure Gauge to observe for function.
 Check all Control Settings (ON/OFF, Pressure Relief, Oxygen, Volume, Rate)
 If unable to resolve the suspected problem promptly (apprx. 30 seconds or less);
 Remove patient hose from ParaPac case,
 Insert Universal 22mm OD mouthpiece into hose,
 Blow into mouthpiece with a slow, full breath.
 By auscultation listen for air exchange while watching for positive visible chest
rise.
 Consider Obstructed Airway procedure or alternative method of ventilation.

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 Montgomery County Hospital District-EMS PATIENT SAFETY RESTRAINT
Standard Delegated Orders –
Procedures PROC 22 Page 381
TOC

This policy shall attempt to establish guidelines to ensure the safety of EMS personnel as
well as patient safety in situations when the patient may be extremely agitated and the
potential for harm to self and/or others may exist.

Pre-hospital Patient Restraints (PPR) should be considered whenever a patient requiring

immediate medical treatment becomes a threat to himself or other emergency personnel.
This should be accomplished with the least amount of force necessary to protect the patient
and emergency personnel.

Law enforcement officers should be requested for assistance on any patient who
requires physical restraints. A blood glucose level should be obtained as soon as it is
safe to do so.

Whenever possible the Alarm communicator should advise responding personnel of

potentially unstable or known unstable scenes and/or situations/locations when a
request for EMS is received. Additionally, responding personnel are to stage for Law
Enforcement personnel and should not enter the location until Law Enforcement
Officers have assessed scene safety

A detailed evaluation of the patient‘s mental status is required prior to initiating Patient
Safety Restraint. Full documentation of all events and patient‘s condition should appear on
the Patient Care Report (PCR) whenever Patient Safety Restraint is utilized.

Agitation or acute behavioral disorders may manifest differently. Always suspect an

organic cause first. Life-threatening organic conditions that may present with behavioral
agitation are subdural hematoma, intracerebral hemorrhage, meningitis, hypertensive crises,
hypoglycemia and drugs (especially atropine and cyclic antidepressants).

 This procedure applies to patients being treated under implied consent and is
not to be used on patients specifically refusing transport.
 A Supervisor consult is required before PPR is attempted. Exceptions would be
imminent threat to EMS personnel by the patient that may pose immediate
physical injury to EMS personnel.
 If EMS personnel have entered a location that becomes unstable and physical
injury is threatened verbally and/or the patient or other parties on scene threaten
physical harm, EMS personnel should physically remove themselves from the
scene and move to a location of safety until Law Enforcement officials arrive. If
necessary EMS personnel should leave medical equipment to accomplish this
task. The safety of EMS personnel comes first.
 In all events, attempts should be made to ―talk the patient down‖ before restraint
is considered. The conversation should be honest and straightforward. EMS
personnel should attempt to have equally open escape routes for both the EMS
providers and the patient.
 Do NOT endanger yourself or other EMS personnel. At All times the safety of the
medical personnel should remain first priority.
 Assess the patient‘s mental status. Determine if the patient has suicidal or
homicidal ideation.

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 Montgomery County Hospital District-EMS PATIENT SAFETY RESTRAINT
Standard Delegated Orders –
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 Use the minimum PPR needed to accomplish necessary patient care and ensure
safe transportation and crew safety. MCHD should never use hard restraints (e.g.
handcuffs, plastic ties, or leathers) to restrain patients.
 Acceptable restraints for EMS personnel include sheets, wristlets, and chest
posey.
 Additional manpower should be requested prior to attempting this procedure. A
minimum of five (5) people should be present to safely apply PPR. Four-Point
restraints (restraining both arms and both legs) are preferred.
 In addition to securing both arms and legs, it may be helpful to tether the hips,
thighs and chest. Tethering the thighs just above the knees prevents kicking
more effectively than restraining the ankles.
 Nothing should be placed over the patients face, head or neck. A surgical mask
may be placed LOOSELY over the patient‘s mouth to prevent spitting on
emergency personnel.
 A c-collar may be applied to limit the mobility of the patient‘s neck, decrease the
patient‘s range of motion to protect from biting as well as prevent injuries to the
patient.
 Restraints SHOULD NEVER be placed in such a way that prevents evaluation of
the patient‘s mental status or interfere with necessary patient care activities.
 Patients in the care of MCHD personnel should never be placed in a prone
position.
 Patients in the care of MCHD personnel should never be sandwiched
between two (2) long spinal boards.
 Patients in the care of MCHD personnel should never be transported with
hands and feet tied behind their backs (hog-tied).
 EMS personnel should monitor circulation and pulses to ensure proper circulation
and prevent further injury to the patient.
 A blood glucose level should be obtained as soon as it is safe to do so.
 Full documentation of all events and patient‘s condition are required on the
Patient Care Report (PCR) whenever Patient Safety Restraints are utilized.
 Continuous ECG, pulse oximetry and blood pressure monitoring (every 5
minutes) are mandatory while being cared for by MCHD personnel.
 All patients restrained by MCHD personnel should receive chemical safety
sedation to prevent further excessive agitation and struggling against
patient safety devices. Continued struggling against safety devices can
lead to hyperkalemia, rhabdomyolsis and cardiac arrest.

The Medical Director and Assistant Director EMS-Clinical Services should be notified
anytime this procedure is initiated. This may be accomplished by alpha pager and should
include patient name and transport destination for follow-up and patient outcome.

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 Montgomery County Hospital District-EMS PATIENT SAFETY SEDATION
Standard Delegated Orders –
Procedures PROC 23 Page 383
TOC

This policy shall attempt to establish guidelines to ensure the safety of EMS personnel as
well as patient safety in situations when the patient may be extremely agitated and the
potential for harm to self and/or others may exist.

General Information
Patient Safety Sedation (PSS) is a last resort for safely calming extremely agitated patients
when physical restraints have proven to be minimally effective and may further compromise
the life, limb or safety of the patient. In all events, attempts should be made to ―talk the
patient down‖ prior to physical and/or patient safety sedation.

Do Not endanger yourself or your crew. At All Times, the safety of all medical and non-
medical personnel will remain first priority.

Whenever Patient Safety Sedation is used, a detailed evaluation of the patient‘s mental
status is required prior to administration. Full documentation of all events and patient‘s
condition should appear on the Patient Care Report (PCR) whenever Patient Safety
Sedation is utilized.

Agitation or acute behavioral disorders may manifest differently. Always suspect an

organic cause first. Life-threatening organic conditions that may present with behavioral
agitation are subdural hematoma, intracerebral hemorrhage, meningitis, hypertensive crises,
hypoglycemia and drugs (especially atropine and cyclic antidepressants).

Law enforcement should be requested for assistance on any patient who requires
physical restraints as well as patient safety sedation. A blood glucose level should be
obtained as soon as it is safe to do so.

Vascular access should be accomplished prior to Patient Safety Sedation if EMS

personnel are able to accomplish with minimum risks to the patient and EMS
personnel. If unable to obtain due to patient agitation, vascular access should be
obtained as soon as possible after Patient Safety Sedation medications have been
administered IM. Fluid therapy for hypotension should be considered to maintain a
systolic blood pressure of > 90 mm Hg.

 Evaluate patient mental status.

 This procedure applies to patients being treated under implied consent and is
not to be used on patients specifically refusing transport.
 A Supervisor consult is required before PSS is attempted. Exceptions would be
imminent threat to EMS personnel by the patient that may pose immediate
physical injury to EMS personnel.
 Have sedative medications prepared for injection. Prepare for possible
hypotension or CNS depression side effects.
 If possible, inquire about medication allergies
 Request Supervisor consult for orders
 After orders are confirmed administer sedative medication
 Versed 2.5 mg SLOW IVP (over 2 minutes) or 2 to 5 mg IM (SBP > 90 mm Hg
OR confirmed radial pulse).
 May repeat IV dose x 2 at 2.5 mg SLOW IVP

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 Montgomery County Hospital District-EMS PATIENT SAFETY SEDATION
Standard Delegated Orders –
Procedures PROC 23 Page 384
TOC

 Additional IM doses require Supervisor contact

 Onset of action for Versed is within 1 to 5 minutes after IVP or 5 to 15
minutes IM.
 Lower doses should be used in the elderly (age > 60), debilitated or poor risk
(respiratory disease, chronic illness) patient.
 Continuous ECG, pulse oximetry and blood pressure monitoring (every 5
minutes) are mandatory during and after administration of Versed.

The Medical Director, Assistant Director EMS-Clinical Services should be notified anytime
this procedure is initiated. This may be accomplished by alpha pager and should include
patient name and transport destination for follow-up and patient outcome.

Revision Date 11/01/2005 384

 Montgomery County Hospital District-EMS PERICARDIOCENTESIS
Standard Delegated Orders –
Procedures PROC 24 Page 385
TOC

General:
 Cardiac tamponade is the hemodynamic result of fluid accumulation within the
potential space that surrounds the heart. This occurs from a specific
condition, such as, pericarditis and or penetrating cardiac injury.
 The pericardium consists of two layers, an outer fibrous layer and an inner serous
layer. The potential space produced by these layers contains approximately 20 ml of
fluid with similar electrolyte and protein profiles to plasma. This potential space can
accumulate approximately 120 ml of additional fluid without any significant
hemodynamic effects.
 Further fluid accumulation can result in marked increases in pericardial pressure
resulting in decreased cardiac output, hypotension, and cardiac arrest. Removing as
little as 30ml may produce dramatic hemodynamic improvement.
Policy:
 Pericardiocentesis is the aspiration of excess fluid that has accumulated within the
pericardial sac surrounding the heart.
 For the purpose of this procedure and MCHD-EMS, pericardiocentesis is utilized
ONLY in the traumatic induced cardiac arrest patient only After other less
invasive procedures have been attempted.
Equipment:
 Defibrillator with monitor
 Pericardiocentesis kit / 16 or 18 gauge cardiac needle (3 ½")
 60 ml luer-lock syringes
 Empty evacuated container, 1000 ml
 Betadine, sterile gloves
 Emergency medications: Atropine, Lidocaine, and Epinephrine
Indications:
For use only in adult patients found in traumatic cardiac arrest, After the following criteria
has been met:
 Airway is secured with Endotracheal Intubation.
 The patient has received approximately 500 ml – 1000 ml of fluid without change.
 The patient has had bilateral chest decompressions performed without change.
Precautions:
Pneumothorax or hemo-pneumo-pericardium may result from leaving needle open to air.

Complications:
 Cardiac perforation / Ventricular puncture
 Laceration of coronary artery
 Pulseless electrical activity
 Pneumothorax
 Liver laceration
Procedure:
1. Ensure that a patent IV and Orotracheal Intubation has been established. (bilateral
IV‘s are preferred with Fluid bolus accomplished)

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 Montgomery County Hospital District-EMS PERICARDIOCENTESIS
Standard Delegated Orders –
Procedures PROC 24 Page 386
TOC

2. Apply cardiac monitor

3. Identify landmarks (costal margin, xyphoid process). See attached
4. Prepare site (attempt to maintain sterility as much as possible).
5. Cleanse site with Providone-iodine (Betadine).
6. Use a 16 or 18 gauge spinal needle (3 ½") attached to a 3-way stopcock and 60 ml
syringe.
7. Insert the needle at the xyphocostal angle approximately 45° to the chest. The
catheter is directed toward the inferior tip of the left scapula.
8. Advance the needle toward the left shoulder while applying a slight negative
pressure on the syringe. The sub-xyphoid technique is the safest approach because
it avoids injury to the coronary arteries.
9. As you advance the needle into the pericardial sac you should feel a slight give.
Begin to aspirate 20 – 30 ml of blood or fluid.
10. After aspirating the fluid withdraw the needle from the chest
11. Assess for any improvement in hemodynamic status. Signs of resolution of
tamponade include:
 Increased response to ACLS therapy
 Improvement in vital signs and hemodynamics
 Absence of JVD.

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 387
TOC

Adult Pharmacologically Assisted Intubation (PAI)

Indication:

 Unable to establish or maintain ability to secure the airway by oral/nasal intubation

 Conditions requiring management and protection the airway.

Contraindications:
 Absolute contraindications to PAI:
- Spontaneous breathing with adequate ventilation and a patent airway.
- Inadequate personnel or other resources to safely carry out procedure
- Prior history or family history of malignant hyperthermia including the following
symptoms (when paralytic agents have been used):
1. Intractable jaw spasms (Trismus)
2. Generalized rigidity
3. Body temperature
4. Tachypnea / Tachycardia

 Relative contraindications to PAI:

- History of pseudocholinesterase deficiency (applies to use of paralytic agents)
- Significant body surface area burns (greater than 24 hours old) (applies to use of
paralytic agents)
- Spinal cord injury (greater than 24 hours old) (applies to use of paralytic agents)
- Crush injuries (greater than 24–48 hours old)
- Consider consult for defasciculating dose of Vecuronium - 1 mg
- Known hyperkalemia
- Neuromuscular diseases such as myasthenia gravis, muscular dystrophy
(applies to use of paralytic agents)
- Concern that intubation might be unsuccessful due to:
1. Major facial or laryngeal trauma
2. Upper airway obstruction
3. Distorted facial or airway anatomy

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 388
TOC

Equipment:

Adequate personnel (2 to perform safely and Bag Valve Mask, complete

correctly) Water-soluble lubricant
Lidocaine 100 mg / 10 ml Tape or tube securing device
Fentanyl 100 g / 2 ml Oral Airway
Etomidate 20 mg / 20 ml Stethoscope
Succinylcholine 20 mg /ml Suction equipment and
Versed 5 mg / 5 ml supplies
Vecuronium 10 mg / 10 ml Oxygen
2 – 3 or 5 ml syringe Surgical airway kit
2 – 5 or 10 ml syringe Monitoring equipment:
Endotracheal tube and stylet - ECG
Laryngoscope handle & blades - Pulse oximeter
Procedure:

1. Prepare:
 Ensure all Equipment is prepared and easily accessible including EtCO
 The patient should already be connected to all monitoring devices including
ECG monitor, pulse oximeter
2. Pre-Oxygenate:
 100% oxygen for 2 minutes.
 DO NOT BVM UNLESS O2 SAT BELOW 90%
BVM ventilation in this circumstance may cause gastric distention and
subsequent aspiration of gastric contents. Gentle BVM ventilation with
cricoid pressure can be utilized as drugs are administered. Do not spend
excessive time trying to raise the saturation of a respiratory patient whose
exacerbation may prevent improved saturation.

3. Pressure:
 Sellicks maneuver should be initiated prior to succinylcholine
 Continued until intubation completed and position confirmed.
 Proceed to step 6 and intubate here if adequate relaxation is
accomplished.
4. Deep Sedation:
- Premedicate – 2 – 3 minute onset
 Administer Lidocaine 100 mg (1 mg/kg)
 Administer Fentanyl 100 g SLOW IV (1 – 2 g/kg)
- Relaxation
 Administer Etomidate: 20 mg IV (0.2 – 0.3 mg/kg)
 Proceed to step 5 and intubate here if adequate relaxation is
accomplished.
- Neuromuscular blockade (if needed)
 Administer Succinylcholine 200 mg IV (1.5 mg/kg)
 Only if intubation cannot be accomplished with medications up to
and including Etomidate

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 389
TOC

Verification of Complete Paralysis

Nerve Stimulator (if available)
Be alert for Jaw muscle spasm or failure to relax as a sign of possible
malignant hyperthermia.
5. Intubate:
 Visualize, Confirm, and Inflate cuff then properly secure
 Maintain Sellick maneuver until cuff up and position confirmed
Verification of Endotracheal Tube Placement
1. Visualization of the ET Tube passing through the glottic opening
2. Auscultation of chest for breath sounds in 4 quadrants
3. Auscultation over epigastrium
4. Improvement and/or maintenance of high O saturation on pulse
oximeter
5. EtCO
6. Bulb Check
7. Clearing and fogging of endotracheal tube during ventilation and
exhalation
6. Maintenance:
 Administer Versed 5 mg (0.1 mg/kg ) SLOW IV For Continued Sedation
7. Consider consult for other medications post intubation for continued
sedation:
 Vecuronium 10 mg IV (0.1 mg/kg) (if prolonged paralysis is indicated)
 Valium 5 – 10 mg IV
 Stadol 1 – 2 mg IV for pain control
 Morphine 2 – 10 mg IV for pain control
 Additional Fentanyl

Failed Intubation
 A maximum of two (2) attempts at tracheal intubation may be attempted within 1
minute.
 If unable to intubate with initial two (2) attempts or if O sat < 80%, initiate BVM
ventilation‘s while maintaining cricoid pressure until O sat > 90%
 In the event that intubation cannot be performed after paralysis, utilize a
combitube. Surgical airway should only be performed when all other adjunct
airways/means have been exhausted.
Precautions:
 PAI should be used with caution in patients who are dependent on their own
upper airway muscle tone or specific positioning to maintain the patency of their
airway (e.g. cases of upper airway obstruction by abscess or abnormal anatomy).
As paralysis occurs and these patients lose their ability to maintain an airway,
BVM ventilation and intubation may not be possible because of obstructions or
distorted anatomy. In these patients, carefully titrated sedation and conscious
intubation may be a more acceptable alternative in securing an airway.
 Cricoid pressure serves a dual function: The posterior movement of the larynx
makes visualization of the vocal cords and tube placement easier, and the gentle

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 390
TOC

pressure occludes the esophagus, preventing passive reflux of stomach contents

into the oropharynx.

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 391
TOC

Pediatric Pharmacologically Assisted Intubation (PAI)

Indication:

 Unable to establish or maintain ability to secure the airway by oral/nasal

intubation
 Conditions requiring management and protection the airway.
 Paralytics for Age > 4 years only

Contraindications:
 Absolute contraindications to PAI:
- Spontaneous breathing with adequate ventilation and a patent airway.
- Inadequate personnel or other resources to safely carry out procedure
- Prior history or family history of malignant hyperthermia including the
following symptoms (when paralytic agents have been used)
1. Intractable jaw spasms (Trismus)
2. Generalized rigidity
3. Body temperature
4. Tachypnea / Tachycardia

 Relative contraindications to PAI:

- History of pseudocholinesterase deficiency (applies to use of paralytic
agents)
- Significant body surface area burns (greater than 24 hours old) (applies to
use of paralytic agents)
- Spinal cord injury (greater than 24 hours old) (applies to use of paralytic
agents
- Crush injuries (greater than 24 hours old)
- Neuromuscular diseases such as myasthenia gravis, muscular dystrophy
(applies to use of paralytic agents)
- Concern that intubation might be unsuccessful due to:
1. Major facial or laryngeal trauma
2. Upper airway obstruction
3. Distorted facial or airway anatomy

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 392
TOC

Equipment:

Adequate personnel (2 to perform safely and Bag Valve Mask, complete

correctly) Water-soluble lubricant
Lidocaine 100 mg / 10 ml Tape or tube securing device
Fentanyl 100 g / 2 ml Oral Airway
Etomidate 20 mg / 20 ml Stethoscope
Succinylcholine 20 mg / 10 ml Suction equipment and
Versed 5 mg / 5 ml supplies
Vecuronium 10 mg / 10 ml Oxygen
2 – 3 or 5cc syringe Surgical airway kit
2 – 5 or 10cc syringe Monitoring equipment:
Endotracheal tube and stylet - ECG
Laryngoscope handle & blades - Pulse oximeter
Procedure:

1. Prepare:
 Ensure all Equipment is prepared and easily accessible including EtCO2.
 The patient should already be connected to all monitoring devices
2. Pre-Oxygenate:
 100% Oxygen for 2 minutes.
 DO NOT BVM UNLESS 02 SAT BELOW 90%
BVM ventilation in this circumstance may cause gastric distention and
subsequent aspiration of gastric contents gentle BVM ventilation with
cricoid pressure can be utilized as drugs are administered.
3. Pressure:
 Sellicks maneuver should be initiated prior to relaxation
 Continued until intubation completed and position confirmed.

4. Deep Sedation:
- Premedicate
 Administer Lidocaine 1 mg/kg IV
 Administer Atropine 0.01 mg/kg IV/IO
(minimum dose 0.1 mg, maximum dose 0.5 mg)
 Administer Fentanyl 2 g/kg SLOW IV
 Administer Versed 0.1 mg/kg IV
- Proceed to step 5 and intubate here if adequate relaxation is
accomplished
- Neuromuscular blockade if needed
 Administer Succinylcholine 1 mg/kg IV (child)
2 mg/kg IV (infant)
- Do not repeat dose
- Only if intubation cannot be accomplished with medications up to and
including Versed.
Verification of Complete Relaxation
Nerve Stimulator (if available)

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 Montgomery County Hospital District-EMS PHARMACOLOGICAL
ASSISTED INTUBATION- PAI
Standard Delegated Orders –
Procedures PROC 25 Page 393
TOC

Be alert for Jaw muscle spasm or failure to relax as a sign of possible

malignant hyperthermia.
5. Intubate:
 Visualize, Confirm, and Inflate cuff then properly secure
 Maintain Sellick maneuver until cuff up and position confirmed
Verification of Endotracheal Tube Placement
1. Visualization of the ET Tube passing through the glottic opening
2. Auscultation of chest for breath sounds in all lung fields
3. Auscultation over epigastrium
4. Improvement and/or maintenance of high O saturation on pulse
oximeter
5. EtCO
6. Bulb Check if > 20 kg or 5 year of age
7. Clearing and fogging of endotracheal tube during ventilation and
exhalation
6. Maintenance:
 Administer Versed 0.2 mg/kg SLOW IV For Continued Sedation

Failed Intubation
 A maximum of two (2) attempts at tracheal intubation may be attempted within 1
minute.
 If unable to intubated with initial two (2) attempts or if O sat > 80%, initiate BVM
ventilation‘s while maintaining cricoid pressure until O sat > 90%
 In the event that intubation cannot be performed after paralysis, assist ventilations
with a BVM.

Precautions:
 PAI should be used with caution in patients who are dependent on their own upper
airway muscle tone or specific positioning to maintain the patency of their airway
(e.g. cases of upper airway obstruction by abscess or abnormal anatomy). As
paralysis occurs and these patients lose their ability to maintain an airway, BVM
ventilation and intubation may not be possible because of obstructions or distorted
anatomy. In these patients, carefully titrated sedation and conscious intubation may
be a more acceptable alternative in securing an airway.
 Cricoid pressure serves a dual function: The posterior movement of the larynx makes
visualization of the vocal cords and tube placement easier, and the gentle pressure
occludes the esophagus, preventing passive reflux of stomach contents into the
oropharynx.

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 Montgomery County Hospital District-EMS POSITIVE END EXPIRATORY
PRESSURE (PEEP)
Standard Delegated Orders –
Procedures PROC 26 Page 394
TOC

Indication:
Any patient with evidence of moderate to severe atelectasis, aspiration or alveolar
infiltrate especially:
 Pulmonary edema
 Near drowning
 Smoke or fume inhalation with severe respiratory distress.

Contraindications:
None

Equipment:
 PEEP valve
 BVM, complete
 Intubation equipment
 ECG monitoring equipment and supplies
 Oxygen

Procedure:
1. ENDOTRACHEALLY INTUBATE THE PATIENT.
2. Attach PEEP valve to end adapter of BVM.
3. Attach BVM to Endotracheal tube in usual manner.
4. Ventilate patient as usual.
5. Observe ECG rhythm and vital signs closely. PEEP may cause dysrhythmias and/or
changes in vitals. Discontinue or decrease PEEP if significant adverse responses
occur.

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 Montgomery County Hospital District-EMS PULSE OXIMETRY
MONITORING
Standard Delegated Orders –
Procedures PROC 27 Page 395
TOC

General:
 The pulse oximeter allows for the assessment of respiratory function by measuring
unsaturated and saturated hemoglobin within the blood. The difference between the
two is the percentage of saturation.
 The percent of hemoglobin saturated with oxygen is referred to as Oxygen
Saturation (SpO2 or O2 Sat)
 A normal SpO2 for healthy individuals is 95–100%.
 A low (93%) or falling SpO2 indicates that the airway or ventilatory status may be
compromised.
Indications:
 Patients with suspected hypoxemia from any etiology.
 Cardiac problems
 Multiple system trauma
 Altered level of consciousness
Precautions:
 The pulse oximeter interprets carboxyhemoglobin (COHb) as saturated hemoglobin
and provides a falsely elevated reading.
 Additionally, high oxygen saturation is not an indicator of sufficient oxygen delivery to
the tissues, as this depends on cardiac output, and the amount of hemoglobin and
level of vasoconstriction present.
 Pulse oximetry readings may be difficult to obtain in states of low perfusion. (Shock )
Procedure:
1. Ensure patency of the airway and manage as indicated.
2. The probe should be applied to a finger or toe.
3. Best probe site in adults is usually the middle fingertip with nail polish removed.
4. Turn the machine on
5. A radial pulse should be taken to evaluate heart rate reading on monitor.
Pediatric Considerations:
 Special probes may be required to obtain readings in pediatric patients.
Special Notes:
 Attempt to obtain and document pulse oximetry readings before and during oxygen
therapy.
 The use of pulse oximetry as a vital sign is encouraged, as the oximeter may be
helpful in detecting hypoxia not evidenced by signs or symptoms.
 Application to pulseless or cold extremities may result in inaccurate determinations of
hemoglobin saturation.
 False readings may be indicated by extremely rapid changing or fluctuating readings.
 Patients with hemoglobin disorders such as carbon monoxide poisoning and anemia
may give artificially high SpO2 readings. Readings in such patients should be
interpreted with extreme caution.
 Excessive probe movement may alter accuracy of reading.
 Optical interference by bright light (direct sunlight, fluorescent and xenon arc
lighting). Cover the sensor.
 Poor waveforms/signals (hypovolemia, hypothermia, profound hypotension, or
vasoconstriction)

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 Montgomery County Hospital District-EMS SPINAL MOTION RESTRICTION
Standard Delegated Orders –
Procedures PROC 28 Page 396
TOC

Indications:
 Complaint of pain or tenderness in the spine or back that is secondary to trauma
 Multiple systems trauma
 Complaints and/or signs of numbness or weakness in an extremity secondary to
trauma
 Patient with Decreased LOC (including patients altered by the influence of drugs and
alcohol) with a high suspicion of trauma.
 Signs of face, head, or neck trauma, (lacerations, contusions, nose bleeds, etc.).
 Any unconscious patient who may be a victim of an accident or fall.

Precautions:
Moving the head into a neutral in-line position is contraindicated if:
 There is pain and/or muscle spasm upon movement.
 Patient holds head angulated (tilted) to the side and is unable to move it.
 The maneuver cannot be safely due to limited space or other conditions. In these
cases the patient should be immobilized in the position in which he/she is found.

Procedure:
1. Ensure adequacy of airway
2. Assess the head and neck for obvious injuries and distended neck veins while
providing manual neutral in-line immobilization for the head and neck.
3. Treat any life threatening conditions
4. Apply an appropriate size cervical collar and continue to manually maintain neutral
in-line immobilization.
5. Secure the patient to a long spine board/short board/K.E.D. The short board and
K.E.D. are for extrication only. The patient should then be placed on a longboard.
6. Ensure that the alignment is maintained while the torso, then the head and the rest of
the body are properly secured. After the patient is properly secured to the spine
board manual immobilization can be released.
7. Treat other injuries
8. Transport

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 Montgomery County Hospital District-EMS SURGICAL AIRWAY
Standard Delegated Orders –
Procedures PROC 29 Page 397
TOC

CRICOTHYROIDOTOMY

Indication
 To provide an emergency airway when other means have failed
 Needle cricothyrotomy/jet ventilation inadequate or prolonged
 Needle cricothyrotomy/jet ventilation impossible or inappropriate
 This is the method of last resort at establishing an airway

Procedure

1) Cricoid pressure shall be applied and maintained continuously.

2) Prepare and assemble all equipment
 #11 or #15 scalpel
 Endotracheal tube
 Stylet or Eschmann Tracheal Tube Introducer
 10 ml syringe
3) The cricothyroid membrane is the preferred site and should be identified by the
attendant performing the skill. If, due to trauma or obstruction at this level, the
cricothyroid membrane is inaccessible, a site two finger-breadths above the
sternoclavicular notch should be identified and utilized.
4) Prepare the site with a Betadine and/or alcohol solution
5) Make a 1.5–2 cm vertical incision through the skin overlying the cricothyroid
membrane.
6) Bluntly dissect the skin and fatty tissue overlying the trachea to visualize the
cricothyroid membrane
7) Make a horizontal incision through the cricothyroid membrane into the trachea.
8) Insert the scalpel handle into the tracheal incision and twist 3–4 times (If a larger
opening is required, a gloved finger can be inserted into the trachea to enlarge the
opening)
9) Form the distal end of the endotracheal tube into the shape of an ―L‖ utilizing the
stylet.
10) Insert the tube within the trachea, remove the stylet, and inflate the cuff.

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 Montgomery County Hospital District-EMS SURGICAL AIRWAY
Standard Delegated Orders –
Procedures PROC 29 Page 398
TOC

QUICKTRACH SURGICAL AIRWAY

Indications:
 Critical patient in whom a patent airway cannot be maintained or established by
oropharyngeal or naso-pharyngeal airway, BVM or Orotracheal Intubation.
 Patient cannot receive adequate respiratory assistance with BVM and supplemental
O2 after a failed PAI attempt.
 Critical patient with severe maxillo-facial-trauma, inflammation or severe swelling of
the airway or other mechanism resulting in a life-threatening airway compromise.

Contraindications:

 An airway obtainable by any other means.

Equipment:

 QuickTrach Surgical Airway Kit

 BVM w/supplemental oxygen
 Ventilator
 Stethoscope

Procedure:
 Prepare and assemble equipment.
 If possible, hyperventilate the patient.
 Disinfect the area of procedure.
 For Non-Traumatic patients hyperextend the neck.
 Locate the cricothyroid membrane.
 Place finger on thyroid cartilage (―Adams apple‖) and
 Move finger down into soft depression between thyroid cartilage and cricoid
cartilage (next firm ―bump‖).
 For trauma or obstruction, site two fingerbreadths above the sternoclavicular
notch should be identified and utilized.
 Perforate tissue at a 90 degree angle with device.
 Aspirate while inserting the device.
 After insertion, change angle of insertion to 45 degrees and advance until stopper
hits the skin.
 Remove the stopper.
 Hold needle in place while advancing the plastic cannula.
 Withdraw needle and advance cannula until the cannula is flush with the skin.
 Secure device with the strap and attach 15 mm connector.
 Ventilate patient w/BVM and supplemental oxygen.
 Apply ventilator for transport.

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Purpose

Termination of advanced life support efforts in the pre-hospital setting applies to situations in
which adult patients experience a non-traumatic cardiac arrest. The decision to implement
the policy may be initiated by the Supervisor or the In-Charge Paramedic on scene in
accordance with the standing orders set forth in this policy by the Montgomery County
Hospital District-E.M.S. Medical Director. All field terminations require Supervisor
consult.

Procedure

Resuscitation efforts should not be terminated in patients meeting the following criteria:
1. The patient whose cardiac arrest may be associated with overdose, toxicologic
agents, hypo/hyperthermia, submersion, electrocution, burns, trauma, airway
obstruction or other sudden external sources.
2. The patient who has persistent ventricular fibrillation or ventricular tachycardia.
3. The patient who has a return of a spontaneous pulse-even a transient pulse.
4. The patient who demonstrates any neurological signs {ie..spontaneous eye opening
or spontaneous movement}.
5. The patient who has suffered cardiac arrest while in the care of MCHD-EMS
personnel.
6. The patient who does not have a secure endotracheal tube in place or a patent IV.

Resuscitation efforts may be terminated in patients meeting the following criteria:

1. The patient should be an adult greater than 18 years of age.

2. The patient should have had a presumed cardiac arrest not associated with sudden
external sources {ie..overdose, toxicoexposure, hypo/hyperthermia, submersion,
electrocution, burns, trauma, airway obstruction}
3. The patient should have been intubated (includes Combitube) successfully with
ResQPOD in place and have had vascular access and standard advanced life
support measures applied throughout the resuscitation.
4. Resuscitative efforts should continue at least 20 minutes after ALS interventions
have begun regardless of previous CPR time and arrest interval.

If the patient remains unresponsive to advanced life support measures and meets the
criteria above, the Supervisor should be contacted before resuscitative efforts are
terminated.

In the event that any family member or responsible party indicates their objection to the
concept of termination of resuscitative efforts, the resuscitation efforts shall continue until
the receiving emergency room physician assumes care.

Once the decision has been made to terminate resuscitative efforts, the EMS crew shall tie
off and knot all established IV lines close to the site and remove the IV fluid bag and any

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other supplies at the code site. The IV catheters and endotracheal tube should remain in
place.

The Supervisor or In-Charge paramedic shall contact the Communications Center for the
notification of code being terminated and to call law enforcement if not already on scene.

At all times MCHD-EMS personnel shall be attentive to the psychological needs of the
―survivors‖ and provide support as needed.

The Attending Medic should contact LifeGift with patient information.

A separate incident form should be completed by the field Supervisor and attached to the
patient‘s chart.

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Standard Delegated Orders –
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Purpose
Termination of advanced life support efforts in the pre-hospital setting applies to situations in
which adult patients experience a traumatic cardiac arrest. The decision to implement the
policy may be initiated by the Supervisor or the In-Charge Paramedic on scene in
accordance with the standing orders set forth in this policy by the Montgomery County
Hospital District-E.M.S. Medical Director. All field terminations require Supervisor
consult.

It is important to remember that Transport is Treatment for the multi-system trauma

patient. This protocol is not intended to delay on scene times of trauma patients. It
specifically addresses those situations when the multi system trauma patient has an
extended extrication time.

Procedure
Resuscitation efforts should not be terminated in patients meeting the following criteria:
1. The patient whose cardiac arrest may be associated with hypo/hyperthermia and
submersion.
2. The patient who has persistent ventricular fibrillation or ventricular tachycardia.
3. The patient who has a return of a spontaneous pulse-even a transient pulse.
4. The patient who demonstrates any neurological signs {ie..spontaneous eye opening
or spontaneous movement}.
5. The patient who does not have a secure Endotracheal tube in place, a patent IV,
bilateral chest decompression and pericardiocentesis.

Resuscitation efforts may be terminated in patients meeting the following criteria:

1. The patient should be an adult greater than 18 years of age.

2. The patient should have been intubated (includes Combitube) successfully.
3. An IV of NS should be established with a bolus of 1000–2000 ml.
4. The patient should have bilateral chest decompression performed.
5. The patient should have pericardiocentesis procedure performed.
6. ECG should show asystole and be verified in two leads.

If the patient remains unresponsive to advanced life support measures and meets the
criteria above, the Supervisor should be contacted before resuscitative efforts are
terminated.

Once the decision has been made to terminate resuscitative efforts, the EMS crew shall tie
off and knot all established IV lines close to the site and remove the IV fluid bag and any
other supplies at the code site. The IV catheters and Endotracheal tube should remain in
place.

The Supervisor or In-Charge paramedic shall contact the Communications Center for the
notification of code being terminated and to call law enforcement if not already on scene.

The Attending Medic should contact LifeGift with patient information

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 Montgomery County Hospital District-EMS VAGAL MANUEVERS
Standard Delegated Orders –
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Indications:
 Narrow Complex Tachycardia

Contraindications:
 None for Valsalva maneuver

Equipment Needed:
 Personal protective equipment
 ECG monitor
 Vascular Access established
 Oxygen
 Emergency medications and equipment should be immediately available.

Procedure:
1. Ensure that patient is on oxygen, has a patent vascular access, and is on a cardiac
monitor.
2. Record the ECG rhythm continuously while performing all Vagal maneuvers.
3. Instruct the patient to cough forcefully several times. If this is ineffective proceed to the
Valsalva maneuver.

Valsalva Maneuver:
1. Have the patient take a deep breath and ―bear down" against a closed glottis, as if
trying to "clear" or "pop" his or her ears. Have the patient perform this for as long as
they can. (Alternative method: Remove plunger from a small syringe and instruct
patient to blow through small end.)
2. If no conversion, repeat the procedure, up to three attempts total.
3. If still no conversion and not contraindicated, proceed with carotid sinus massage.

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Carotid Sinus Massage

Contraindications:
 Presence of carotid bruit
 Unequal carotid pulses
 Patient < 4 years old or >50 years old
 Diagnosis of prior CVA or carotid surgery

Procedure:
1. Place the patient supine or semi-fowler with neck extended. Separately palpate each
carotid artery for pulse quality, and auscultate both for bruits.
2. Tilt patient's head to one side and locate the right carotid sinus adjacent to the carotid
pulse.
3. Using 2–3 fingers, press firmly over carotid sinus toward cervical vertebrae and
massage up and back in a circular motion.

Never massage both carotid arteries at the same time.

1. Discontinue the procedure after any of the following:

 After 20 seconds
 The first indication of conversion
 At first sign of slowing heart rate or heart block.
 If patient experiences dizziness or altered level of consciousness.
2. If no conversion after the first attempt, repeat the procedure once.
3. If still unsuccessful and patient condition warrants, administer an appropriate
pharmacological agent.

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 Montgomery County Hospital District-EMS VASCULAR ACCESS
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TOC

IV THERAPY PROCEDURE

Indications:
Intravenous access shall be obtained when the clinical assessment indicates the
necessity of medication administration, fluid replacement and/or resuscitation.
General Standards:
 Vascular access can be accomplished by a saline lock (see appropriate procedure)
or peripheral venous infusion
 In all pediatric patients receiving intravenous fluids, a buretrol administration set
should be used and delivery of fluids should be monitored.

If non-traumatic / non-shock medical patient:

1. Appropriate size catheter or butterfly needle (usually 16G, 18G or 20G)
2. Microdrop administration set (60gtt/ml)
3. Extension set
4. Normal Saline (0.9% NS)
5. Run at KVO rate (15–30 ml/hour) or rate specified by protocol.
6. Saline Lock:
If trauma patient or shock symptoms present:
1. Large bore catheter when possible (usually 14G or 16G)
 If shock is present use 2 large bore IVs.
2. Standard administration set (10–15gtt/ml) or blood administration set.
3. Blood Tubing:
The use of blood administration tubing is recommended in place of
standard IV sets for patients that may require blood transfusion or
rapid fluid infusion
4. Normal Saline (0.9% NS)
5. Run at rate specified by protocol

Complications:
 Infection
 Air embolism
 Catheter shear
 Hematoma
 Arterial puncture

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Equipment:
 Appropriate size and type IV/IO catheter
 Appropriate administration set
 Providone, Iodine or alcohol preps
 5–10 ml syringe
 IV start kit
 Dressing and tape or commercial securing device ("Venigard", Opsite")
 Blood draw set up
Note: DO NOT risk loss of the IV site to perform a blood draw. Blood can be obtained later
at the receiving facility.

Procedure for Peripheral Cannulation:

1. Don appropriate personal protective gear
2. Explain the need for IV administration and describe what will be done
3. Check the IV solution for expiration date, cloudiness, etc.
4. Spike the bag with the appropriate IV tubing
5. Remove air from IV tubing
6. Place the tourniquet on the extremity
7. Select the site (Preferred IV site for patients in cardiac arrest is the antecubital fossa)
8. Cleanse the skin with Betadine solution or alcohol prep
9. Make puncture while maintaining vein stability
10. Watch for flashback. If you have no blood return and you are in the vein, remove the
needle hub and attach your syringe to assist in aspirating for blood. Once you have a
blood return, advance the catheter as per normal IV technique and attach the IV tubing.
11. Remove the tourniquet
12. Begin IV fluid therapy. Observe the site for redness, edema or other indications of
infiltration.
13. Secure catheter and IV tubing (remember Not to restrict other vascular structures by
applying dressing too tight)
Considerations:
Initiation of vascular access generally should not delay patient transport to the hospital.
Whenever possible:
1. Do not place IV on side of injured arm or chest.
2. Avoid using lower extremities unless last resort.
3. Do not place IV on side of previous mastectomy.
4. Do not place IV on side of stroke or paralysis.
5. Hickman catheters or other indwelling IV access ports should be used only if
unstable patient condition necessitates an IV, and no other access is available.
6. DO NOT USE RENAL SHUNTS.

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EXTERNAL JUGULAR CANNULATION

Indications:
For infusion of fluid or administration of medications in any urgent/critical patient in
whom vascular access cannot be obtained in 3 attempts at other peripheral sites.
EJV cannulation may be considered as first-line vascular access in cardiac arrest or
severe hypovolemic / hypotensive crisis.
1. Don appropriate personal protection gear.
2. Select and prepare equipment. Attach 10 ml syringe to hub of catheter/needle to
assist in identification of placement in patients with low or now cardiac output.
3. Clear air from tubing.
4. Place the patient in a supine, trendelenburg position.
5. Identify external jugular vein.
6. Prepare the site with alcohol or providine/iodine.
7. Place a finger above the clavicle to facilitate filling the vein. (this should also assist
with stabilization of site).
8. Make your puncture midway between the angle of the jaw and the middle of the clavicle
while maintaining vein stability with your finger.
9. Watch for flashback. If you have no blood return and you are in the vein, remove the
needle hub and attach your syringe to assist in aspirating for blood. Once you have a
blood return, advance the catheter as per normal IV technique and attach the IV
solution.
10. DO NOT ALLOW AIR TO ENTER THE CATHETER ONCE IT HAS BEEN
INSERTED. Remember to cover the catheter with gloved finger while preparing to
attach the IV tubing.
11. DO NOT risk loss of vascular access to perform a blood draw.
12. Initiate IV fluid therapy. Observe site for redness, edema or other indications of
infiltration.
13. Secure IV catheter and tubing. A cervical collar may be useful to prevent mobility and
ensure that the catheter does not dislodge.
14. Two attempts are allowed on one side. NEVER attempt cannulation on both
external jugular veins.
15. Consider I/O if all other attempts are unsuccessful.
Complications
 Air embolism
 Pnuemothorax
 Infection
 Catheter shear
 Hematoma
 Arterial puncture
 Fluid overload
Considerations:
 Initiation of vascular access generally should not delay patient transport to the hospital.

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SALINE LOCK

Indications:
Injection locks may be used to secure venous access in any of the following situations:
 The EMS personnel do not anticipate the immediate need for administering IV
medications or IV fluid in the pre-hospital setting at the discretion of the technician.
The saline lock should be flushed periodically in extended transport situations.
 The EMS crew has already secured a patient IV line for medications and fluid but
anticipate a second IV site or "backup" will should be required. (i.e. Acute MI, CVA)
 The patient be receiving IV adenosine. In this situation, personnel should have a
second IV established with large bore catheter of NS.

Equipment:
1. Don appropriate protective gear.
2. Consider Nitrous Oxide prior to attempt (especially in pediatric patients).
3. Explain the procedure. If the patient is a child DO NOT lie regarding the amount of
discomfort involved with the procedure. You may lose all credibility with your patient.
4. Assemble and prepare equipment. Attach all components of injection lock
5. Establish IV with angiocath in usual manner
6. Once needle is removed, attach injection lock to catheter.
7. Flush lock and catheter with 5 ml of normal saline
8. Observe site for redness, edema or other indications of infiltration
9. If patent, secure IV catheter in usual manner

Complications:
 Infection
 Air embolism
 Catheter shear
 Hematoma
 Arterial puncture

Considerations:
Initiation of vascular access generally should not delay patient transport to the hospital.
Whenever possible:
1. Do not place IV or saline lock on side of injured arm or chest.
2. Avoid using lower extremities unless last resort.
3. Do not place IV on side of previous mastectomy.
4. Do not place IV on side of stroke or paralysis.
5. Hickman catheters or other indwelling IV access ports (not renal shunts) should be
used only if unstable patient condition necessitates an IV, and no other access is
available.

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EZ-IO ACCESS DEVICE - ADULT

Indication:
Any adult patient (>45 kg) for who, you are unable to obtain peripheral vascular access
after 2 attempts or 90 seconds and that has one or more of the following:
 Hemodynamic instability
 Respiratory compromise
 Patients requiring EMERGENCY medicinal therapy or volume replacement

May be used without consult in Cardiac Arrest & Post Resuscitation Management

Consult Required for Placement in all other patients

 Any patient that treatment warrants vascular access, but peripheral access has been
unobtainable
 UNDER NO CIRCUMSTANCES should it be used for prophylactic care

Contraindications:
1. Patient‘s weighing less than 45 kg.
2. Any patient that may receive fibrinolytic or thrombolytic therapy; specific to Active MI
and/or Stroke.
3. Hypoglycemic patients needing D50; EXCEPTION ONLY is Cardiac Arrest.
4. Suspected fracture of the associated tibia or femur.
5. Previous orthopedic procedures: i.e., knee replacement
6. Extremity that is compromised by a pre-existing medical condition. i.e. tumor or PVD
7. Overlying skin infection/trauma at placement site
8. Inability to locate the 3 anatomical landmarks for insertion, which are the patella, tibial
tuberosity, and 1 finger width medial of the tibial tuberosity.
9. Excessive tissue over the insertion site.
10. Patient‘s at risk of NO Transport: i.e., Unconscious Hypoglycemic (Diabetic)

Equipment:
 EZ-IO™ Driver
 EZ-IO™ Needle Set
 Provo-iodine, Betadine or Iodine swabs or prep pads
 IV setup and/or optional extension tubing
 10 ml or 20 ml Syringe
 Roller gauze

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Procedure:
i. Don PPE
ii. Determine if EZ-IO™ is indicated and no contraindications are present.
iii. Locate proper site for EZ-IO™ insertion.
a. Feel the front surface of the leg and locate the patella.
b. Locate the tibial tuberosity inferior to the patella.
c. Place 1 finger medial of the tibial tuberosity. Insertion location is 1 finger width medial
of the tibial tuberosity.
iv. Cleanse the insertion site with betadine/iodine or similar prep-pads using accepted aseptic
technique. Remember to work from the inside to the outside in concentric circles.
v. If patient is conscious, inform patient of the EMERGENT need to perform procedure and
that they might feel some discomfort until Lidocaine is administered. Obtain consent from
patient; recall that the patient has the right to refuse.
vi. Consider an anesthetic/analgesic if indicated by medical direction.
vii. Prepare the EZ-IO™ Driver and Needle Set.
a. Open the cartridge and attach the needle set to the driver
b. Remove needle set from the cartridge.
c. Remove the cap from the needle set.
viii. Begin insertion of the EZ-IO™
a. Hold the EZ-IO™ Driver in one hand and stabilize the leg near the insertion site
with the opposite hand.
b. Position the driver at the insertion site at a 90o angle to the bone surface.
c. Power the driver through the skin at the insertion site until it makes contact with
bone.
d. Evaluate the EZ-IO™ needle for the 5 mm mark
ix. Power the EZ-IO™ Driver and continue insertion until the flange (base) of the EZ-IO™
needle set touches the skin OR a sudden lack of resistance is felt, indicating entry into the
marrow cavity.
x. Remove the driver from the needle set.
xi. Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap the
needle set.
xii. Confirm proper EZ-IO™ Catheter tip position by checking for at least 1 of the following:
a. IMMEDIATELY SYRINGE FLUSH with at least 10cc of fluid
b. IO catheter standing at 90o and firmly seated in tibia.
c. Blood at tip of the stylet.
d. A free-flow of fluid through the needle with no evidence of extravasation. DO
NOT ASPIRATE
xiii. Connect IV tubing and begin infusion. An extension set is recommended but not required.
xiv. If site does not flow, consider pressure infusion, reflush and/or rotate needle 180o.
Consider a combination of these procedures and repeat as necessary.
xv. Dress site with roller gauze to prevent accidental dislodgement.
IF PATIENT IS CONSCIOUS FOR PROCEDURE
1. Administer bolus 50 mg (2.5 ml) of Lidocaine 2% SLOW push for local analgesia. This will
probably provide pain relief for up to 1 hour.
2. Consider pain management for additional discomfort/pain associated with infusion.
BY CONSULT ONLY

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EZ-IO ACCESS DEVICE - PEDIATRIC

Indications:
 IO placement is limited to patients under 6 years of age OR
 CRITICALLY ill or injured child in whom vascular access cannot be established
peripherally in 2 attempts within 90 seconds.
 IO placement Should Not be attempted on conscious pediatric patients unless loss of
life or limb could result if treatment is withheld.
 Consider the use of Nitrous Oxide for conscious patients if procedure is deemed
necessary prior to attempting IO procedure for anxiety.

Contraindications:
 History of chronic bone disease
 Osteomyelitis
 Fracture or trauma to site
---Exception: Minor to moderate burns if no other IO site is available.

General:
 Flow rates for all IO‘S are to be at TKO unless otherwise indicated by specific protocol
or Medical Control.

Equipment:
 13 to 18 ga intraossesous needle
 Providine/iodine prep
 10 ml syringe
 Tape
 4 x 4‘s
 3 inch roller gauze
 Complete IV set up, including fluid and tubing

Procedure:
1. Select and prepare equipment. Don personal protective equipment.
2. Expose and stabilize the lower extremity to minimize motion.
3. Identify the proximal tibia and place sandbags or rolled towels under the knee.
4. Insert the needle, one finger's breadth below the tibial tuberosity or slightly medial to
midline, perpendicular to the skin, directed away from the growth plate, and advance to
the periosteum. The bone is penetrated with a slow boring or twisting motion until you
feel a sudden "give" (decrease in resistance) as the needle enters the marrow cavity.
5. Stop advancing the needle.
6. Attempt to confirm marrow placement by removing the stylet and aspirating blood and
bone marrow. (Absence of marrow does not necessarily indicate incorrect placement).
7. If unable to aspirate, attach 10ml syringe with Normal Saline and gently infuse Normal
Saline.
8. Observe for infiltration or SQ tissue swelling. If no swelling noted, proceed. If swelling
is noted select a different site.

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9. Connect the IV tubing

10. Stabilize the entire intraosseous set-up as if to secure an impaled object.

Complications:
 Complications include subperiosteal infusion, osteomyelitis, sepsis, fat embolism, and
bone marrow damage.
 If infiltration occurs (rare), do not reuse the same bone, select another site.

Considerations:
 Initiation of vascular access generally should not delay patient transport to the hospital.

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MED REFERENCE
 Montgomery County Hospital District-EMS ACETAMINOPHEN
Standard Delegated Orders –
Medicine Reference MED 01 Page 414
TOC

(Tylenol, APAP)
Medication
An analgesic / antipyretic that has weak anti-inflammatory activity and no effects on
platelets or bleeding time

Mechanism of Action
Reduces fever by acting directly on the heat regulating center of the hypothalamus.

Indications
Fever of any etiology

Contraindications
Hypersensitivity

Side Effects
Rarely, gastric irritation

Dosage and Administration

ADULT: 650–975 mg PO or PR

PEDIATRIC: 15mg/kg PO or PR

Acetaminophen Dosing
Concentration: 325 mg / 10.15 ml

Weight
Age (lbs) Dose
0–3 mo 6–11 40 mg/ 1.25 ml
6–-11
mo 12–17 80 mg/ 2.5 ml
12–23
mo 18–23 120 mg/ 3.75 ml
2–3 yrs 24–35 160 mg/ 5 ml
4–5 yrs 36–47 240 mg/ 7.5 ml
6–8 yrs 48–59 320 mg/ 10 ml
9–10
yrs 60–71 400 mg/ 12.5 ml
11 yrs 72–95 480 mg/ 15 ml

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Special Considerations
• Doses may be repeated q 4 hrs prn not to exceed 75 mg/kg total per 24-hour
period.
• Do not administer if last administration was < 4 hours ago.
• Hepatic damage begins at overdoses of 150 mg/kg.

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 Montgomery County Hospital District-EMS ACTIVATED CHARCOAL
Standard Delegated Orders –
Medicine Reference MED 02 Page 416
TOC

(Sorbitol)

Medication
Activated charcoal is an absorbent compound suspension with cathartic. Each
milliliter contains 208 mg of activated charcoal and 400 mg Sorbitol.

Mechanism of Action
Activated charcoal is pharmacologically inert and is not absorbed in the
gastrointestinal tract. It adsorbs a variety of organic and inorganic substances. Once
bound by the charcoal in the gut, toxins are inactivated and excreted. Under
appropriate physiologic conditions, activated charcoal absorbs toxins
instantaneously.

Indications
• Only used after the stomach has been evacuated.
• Ingestion of certain poisons or excessive amounts of certain medications.
• Especially useful in Aspirin, Amphetamines, Strychnine, Dilantin, T.C.A. and
Phenobarbital overdoses.

Contraindications
• Should not be administered before, or in conjunction with, Syrup of Ipecac. If
syrup of Ipecac is being used to produce emesis, administration of Actidose
charcoal should be delayed 30 – 60 minutes after the conclusion of emesis.
• Should not be given in cyanide poisoning or corrosive substances.
• Is of no value in poisoning due to methanol, iron tablets, and organophosphates

Side Effects
• Aspiration of charcoal has been reported to produce airway obstruction.
• Gastrointestinal obstruction from charcoal may occur as a consequence of toxin-
induced antiperistaltic effects.

Dosage and Administration

• Prior to administration, shake the container thoroughly for a minimum of 30

seconds. After administration, the container should be thoroughly rinsed with
water and any residue should be administered to the patient to ensure that the
entire dose has been delivered.

ADULTS: 50 – 100 grams May be given PO or NG tube

Special Considerations
• If patient is unconscious or has ingested a substance that may result in LOC,
have patent airway secured before administration of charcoal.

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 Montgomery County Hospital District-EMS ADENOSINE
Standard Delegated Orders –
Medicine Reference MED 03 Page 417
TOC

(Adenocard)
Medication
A naturally occurring endogenous purine nucleoside found in all body cells. It is
primarily formed from the breakdown product of adenosine triphosphate (ATP).
Adenosine slows tachycardias associated with the AV node via modulation of the
autonomic nervous system without causing negative inotropic effects.

Mechanism of Action
• It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease
chronotropic and dromotropic activity.
• Adenocard slows electrical conduction through the A-V node and can interrupt
the re-entry pathways through the A-V node.
• Onset: 5 –10 seconds
• Duration: 10 seconds

Indications
• PSVT
• PSVT associated with Wolff-Parkinson-White Syndrome.
• Diagnostic for stable, wide complex tachycardias of unknown origin.
• Not for the treatment of Atrial Flutter or Fibrillation; however, if mistakenly
administered to patients in these arrhythmias, the decrease in A-V conduction
may unmask atrial activity.

Contraindications
• 2 or 3 A-V block – Except in patients with a artificial pacemaker
• Sick Sinus Syndrome – Except in patients with a artificial pacemaker
• Use with caution in pregnant women.
• Use with caution in patients who are wheezing

Side Effects
• Due to the very short half-life of Adenocard ( 10 sec.), these side effects should
be short lasting.
• May produce short lasting arrhythmias at time of conversion:
• PVC‘s
• PAC‘s
• Sinus Bradycardia / Asystole / IVR
• A-V blocks: Patients who develop high grade block after administration of
• one dose should not be given additional doses.

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Standard Delegated Orders –
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• May produce any of the following:

1. Chest Tightness 5. Headache

2. Shortness of Breath / Dyspnea 6. Vertigo
3. Bronchoconstriction 7. Facial Flushing
4. Lightheadedness 8. Nausea.

Dosage and Administration

• Adenocard should be given as a rapid bolus intravenous injection.
• It should be given as proximal as possible and followed by a rapid fluid flush (at
least 10 ml).

ADULT: Initial: 12 mg RAPID IV/IO (1–2 sec)

Repeat: If 1st dose is unsuccessful, administer 12 mg RAPID IV/IO
- The 12 mg dose may be repeated once if
needed (maximum 24 mg dose).

PEDIATRIC: Initial: 0.1 mg/kg RAPID IV/IO

Repeat: If 1st dose unsuccessful, administer 0.2 mg/kg RAPID IV/IO

Special Considerations
• Treatment of any prolonged adverse effects should be individualized and
directed towards the specific event.
• Due to the antagonistic effect of methylxanthines (caffeine and Theophylline),
larger doses of Adenocard may be necessary in the presence of
methylxanthines.
• Due to the potentiation by dipyridamole (Persantine), smaller doses of
Adenocard may be effective in the presence of dipyridamole.
• Adenocard is not blocked by Atropine.
• Remember the Valsalva maneuver.
• Record 3 lead ECG prior to use of Adenosine
• Rapid injection with a flush of 10–20 ml of saline, into the IV line increases
likelihood of success.

Revision Date 03/29/2006 418

 Montgomery County Hospital District-EMS ASPIRIN
Standard Delegated Orders –
Medicine Reference MED 04 Page 419
TOC

(Acetylsalicylic Acid, ASA)

Medication
Aspirin (Acetylsalicylic acid) is an analgesic, antipyretic, and anti-inflammatory. It
also inhibits platelet aggregation thus making it a beneficial anti-thrombolytic.

Mechanism of Action
Aspirin inhibits the synthesis of thromboxane A2, which induces platelet aggregation,
by inhibiting a metabolic enzyme necessary for its production. Aspirin is rapidly
absorbed from stomach and small bowel.

Indications
• Ischemic chest pain
• Suspected Myocardial Infarction

Contraindications
• Hypersensitivity to salicylates and its derivatives.
• Previous reactions (e.g. asthma, angioneurotic edema, uticaria, rhinitis)
• Current anticoagulant therapy
• Known or suspected active hemorrhage or bleeding tendency.

Side Effects
• Prolonged bleeding time
• Gastric irritation
• N/V

Dosage & Administration

4 tablets (81 mg chewable tablets) PO (Baby Aspirin)

Special Considerations
• ASA should be administered to patients on anticoagulants and regardless of prior
ASA use.

Revision Date 11/01/2005 419

 Montgomery County Hospital District-EMS ATROPINE SULFATE
Standard Delegated Orders –
Medicine Reference MED 05 Page 420
TOC

Medication
Atropine is a naturally occurring autonomic nervous system inhibitor extracted from
the Atropa belladonna plant (deadly nightshade).

Mechanism of Action
• Blocks parasympathetic (vagal) action on the heart.
1. Improves cardiac output by rate of sinus node discharge.
2. conduction through the A-V junction
• By heart rate to normal range, Atropine the chance of ectopic activity in the
ventricles.

Indications
• Sinus Bradycardia when accompanied by PVC‘s, hypotension or other symptoms
of poor perfusion.
• Asystole
• 2 or 3 AVB when accompanied by bradycardia
• Organophosphate poisoning
• In Neurological injuries with a heart rate < 60 and hypotensive.

Contraindications
• Atrial flutter or Atrial fibrillation when there is rapid ventricular response.
• History of glaucoma should be given atropine with caution.

Side Effects
• Blurred vision, Pupillary dilation
• Headache
• Dry mouth, thirst

Dosage & Administration

ADULT:
• Bradycardia: 0.5 – 1 mg IV/IO or 2 mg ET q 5 min
(Max. 0.04 mg/kg)
• Asystole: 1 mg IV/IO or 2 mg ET q 5 min.(Max. of 0.04 mg/kg)
• Organophosphate Poisoning: 2 mg IM or IV/IO q 5 min.

PEDIATRIC:
0.02 mg/kg IV/ET/IO (0.04 mg/kg for ET)
• Minimum single dose 0.1 mg
• Max. single dose 0.5 mg
• May be repeated X 1

Special Considerations
• May precipitate VTach or VFib, use with caution in the AMI setting.
• Doses < 0.5 mg, or a dose given too slowly, may rather than the heart rate.

Revision Date 11/01/2005 420

 Montgomery County Hospital District-EMS BENADRYL
Standard Delegated Orders –
Medicine Reference MED 06 Page 421
TOC

(Diphenhydramine)

Medication
An antihistaminic agent, benadryl is a crystalline powder, freely soluble in water and
alcohol.

Mechanism of Action
Benadryl produces anticholinergic (drying) and sedative effects. Strongly opposes the
action (dilation and leakiness) of histamine on the capillary bed by binding with the
histamine H2 receptor site.
Benadryl blocks histamine effects that are caused by allergic reactions.
It reverses the extrapyramidal side effects of phenothiazines. (Haldol)
Benadryl reduces or prevents motion sickness.

Indications
Anaphylactic shock and severe allergic reaction
Extrapyramidal reactions (Dystonia) caused by the use of phenothiazine
medications.
Motion sickness

Contraindications
Pregnancy
Asthma
Glaucoma Or Prostate Problems
Known alcohol or depressant abuse

Side Effects
Drowsiness, confusion, sedation
Blurred vision
Dry mouth
Dysuria and urinary retention
Wheezing due to thickening of bronchial secretions
Excitability in pediatric patients

Dosage & Administration

ADULTS: 50 mg IV/IM/IO or
25 mg IV / 25 mg IM

PEDIATRIC: 1–2 mg/kg IV/IM/IO (not to exceed 50 mg IV Single dose)

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 Montgomery County Hospital District-EMS BENADRYL
Standard Delegated Orders –
Medicine Reference MED 06 Page 422
TOC

Special Considerations
Benadryl should be used as an adjunct to epinephrine and other standard measures
for the acute symptoms of anaphylaxis.
Antihistamine overdose reactions may vary from central nervous system depression
to stimulation.
Use extreme caution when administering to patients who have ingested alcohol and
other depressant drugs.

Revision Date 11/01/2005 422

 Montgomery County Hospital District-EMS CARDIZEM
Standard Delegated Orders –
Medicine Reference MED 07 Page 423
TOC

(Diltiazem)

Medication
Calcium channel blocker

Mechanism of Action
Cardizem inhibits the influx of Ca+ ions during membrane depolarization of cardiac and
vascular smooth muscle. Cardizem slows the ventricular rate in patients with a rapid
ventricular response during A-Fib or A-Flutter. The therapeutic benefits of Cardizem in
supraventricular tachycardias are related to its ability to slow AV nodal conduction time
and prolong AV nodal refractoriness.

Indications
Narrow-complex tachycardia refractory to Adenosine
A-Fib/A-Flutter with RVR (>150 bpm)

Contraindications
Ventricular tachycardia or any wide QRS of uncertain origin.
Known hypersensitivity
Patient with sick sinus syndrome except in the presence of a functioning ventricular
pacemaker.
Patients with 2nd or 3rd degree AV block.
Any patient who has received IV beta blockers within the last few hours.
Patients with A-Fib or A-Flutter associated with WPW and short PR syndrome.
Contraindicated in newborns.

Side Effects
2nd or 3rd degree AV block
Hypotension
Nausea
Vomiting
Dizziness

Dosage and Administration

• ADULT: Cardizem 10 – 20 mg IV
- Followed by 80 – 90 mg infusion at 5 mg/hr

Special Considerations
Patient may experience burning or itching at the injection site.

Revision Date 05/21/2007 423

 Montgomery County Hospital District-EMS CORDARONE
Standard Delegated Orders –
Medicine Reference MED 08 Page 424
TOC

(Amiodarone Hyrdochloride)

Medication
Cordarone is classified as a Class III anti-arrhythmic but has characteristics of all 4 anti-
arrhythmic classes.

Mechanism of Action
• Cordarone has a rapid onset.
• Acts directly on the cardiac cell membrane by blocking sodium channels.
• Prolongs repolarization and refractory period.
• Increases ventricular fibrillation threshold
• Acts on peripheral smooth muscle to peripheral resistance.

Indications
• Ventricular Fibrillation
• Hemo-dynamically unstable Ventricular Tachycardia
• Narrow Complex Tachycardia

Contraindications
• Use in caution with patients with Hypokalemia and Hypomagnesemia.
• Heart Block or severe Bradycardia

Side Effects
• Hypotension • Watch for QT prolongation
• Bradycardia • May worsen the arrhythmia or precipitate new
• Nausea arrhythmias.

Revision Date 03/29/2006 424

 Montgomery County Hospital District-EMS CORDARONE
Standard Delegated Orders –
Medicine Reference MED 08 Page 425
TOC

Dosage and Administration

ADULT:
• Ventricular Fibrillation: 300 mg IV Bolus
• Ventricular Tachycardia Unstable: 150 mg IV Loading dose
• Ventricular Tachycardia Stable: 150 mg IV Loading dose
• Ventricular Ectopy: 150 mg IV Loading dose
• Post-Resuscitation Management: 1 mg/min IV infusion

Loading Dose
• Mix 150 mg Cordarone into 100 ml NS, infuse over 10 min via infusion pump

Initiating an Infusion:
• Mix 150 mg Cordarone into 100 ml NS, Run infusion at 1 mg/min
• The infusion should be started within 20 min after the resolution of the
arrhythmia.

PEDIATRIC:
• Ventricular Fibrillation 5 mg/kg bolus

Special Considerations

Drugs whose effects may be increased by Cordarone:

• Propranolol - Beta Blocker
• Verapamil - Calcium Channel Blocker
• Diltiazem - Calcium Channel Blocker

Drugs whose effects may increase side effects of Cordarone

• Bretylium - Hypotension
• MS - Hypotension
• Fentanyl - Hypotension and Bradycardia

Other Drug to Drug interactions:

• Dilantin - Decreases serum blood levels of Cordarone.
• Cimetidine - Increases serum blood levels Cordarone.
• Digitalis - Digitalis toxicity

Revision Date 03/29/2006 425

 Montgomery County Hospital District-EMS CALCIUM GLUCONATE
Standard Delegated Orders –
Medicine Reference MED 09 Page 426
TOC

Medication
Calcium Gluconate is a cation electrolyte.

Mechanism of Action
Needed for the maintenance of nervous, muscular, skeletal, enzymatic reactions, normal
cardiac contractility, blood coagulation, and several other physiological activities.

Indications
Magnesium sulfate or Calcium Channel blocker overdose.
May be helpful in relieving specific muscle spasms due to hypocalcemia.
Cardiac Arrest in a renal dialysis patients.
Arrhythmias and /or cardiac toxicity due to hyperkalemia.
May be helpful for relief of pain and muscle spasms due to black widow spider bite.

Contraindications
Calcium Gluconate should be given with extreme caution and in reduced dosage in the
following settings:

Patient‘s taking Digitalis Renal Calculi (Kidney Stones)

Hypercalcemia CHF
VFib Patients with pre-existing renal disease.

Side Effects
Hypercalcemia
N/V and Diarrhea
Lethargy/Drowsiness
Headache
May myocardial irritability in the presence of digitalis.

Dosage & Administration

ADULT: 4.65 mEq/10ml (10% solution) SLOW IV

PEDIATRIC: No Protocol

Special Considerations
Calcium Gluconate is administered intravenously only. It should not be administered
IM or SQ
Cause tissue irritation and necrosis if infiltrated
Precipitates when mixed with sodium bicarbonate.

Revision Date 11/01/2005 426

 Montgomery County Hospital District-EMS DECADRON
Standard Delegated Orders –
Medicine Reference MED 10 Page 427
TOC

(Dexamethasone)

Medication
Decadron, is functionally a corticosteroid medication, is used principally to treat severe
allergic reaction, respiratory distress, and as prophylaxis in patients who already take
steroids, or are dependant on steroids, and are experiencing a stressful event.

Mechanism of Action
Decadron inhibits inflammatory response of tissues due to mechanical, chemical,
infectious, inflammatory, or other causes, preserves the integrity of small blood vessels
in shock states, increase cardiac output, and stabilizes cellular membranes. Decadron is
metabolized by the liver and excreted by the kidney.

Indications
Life threatening shock states
Bronchial asthma and other bronchospastic states unresponsive to conventional
treatment.

Contraindications
Myasthenia Gravis.
Thromboembolic disease.
Renal insufficiency.
Use with caution if the patient has a history of diabetes mellitus

Side Effects
N/V and Diarrhea
CNS depression
Weakness
Aggravation of diabetes mellitus

Dosage & Administration

Dosage should be based on the size of the patient:

ADULT: 10 mg IV/IM/IO

PEDIATRIC: 0.2–0.5 mg/kg IV/IM/IO

Special Considerations
Neurological findings may be affected by the administration of Decadron.
Documentation of neurological status is essential prior to administering Decadron in
that subsequent neurologic evaluation is made more difficult after administration of
the medication.
Sensitive to extremes in temperature so store to protect from freezing or excess
heat.

Revision Date 11/01/2005 427

 Montgomery County Hospital District-EMS DEXTROSE (25%-50%)
Standard Delegated Orders –
Medicine Reference MED 11 Page 428
TOC

Medication
A simple sugar of the monosacharose group, dextrose occurs naturally in plants and in
the body fluids of animals. It is formed in the digestive tract by the action of enzymes on
carbohydrates. It is packaged as a hypertonic dextrose solution.

Mechanism of Action
The administration of Dextrose raises circulating blood sugar levels. It also acts
transiently as a diuretic. Dextrose (glucose) is the main energy source for the body‘s
cells especially the brain.

Onset: IV: 30 – 60 seconds

Indications
Hypoglycemia
Unconsciousness of unknown origin, without S/S of head injury
Seizure of unknown origin, without S/S of head injury

Contraindications
D50% should not be administered to any patient presenting with S/S of central nervous
system pathology.
Intracranial Hemorrhage
Cerebral Edema
ICP

Side Effects
Tissue necrosis due to infiltration
Administration of dextrose may precipitate severe neurologic symptoms in the
alcoholic patient.
Hyperglycemia / hyperosmolality.

Dosage & Administration

It is important that blood be drawn (red & purple tops) prior to the administration of
Dextrose and that a patent vascular access has been established.

ADULT: 25 grams IV (50 ml of D50)

PEDIATRICS: 0.5 g/kg

- > 10kg or 2 years of age: 1 ml/kg of 50%
- < 10kg: 2 ml/kg of 25%

Revision Date 11/01/2005 428

 Montgomery County Hospital District-EMS DEXTROSE (25%-50%)
Standard Delegated Orders –
Medicine Reference MED 11 Page 429
TOC

Special Considerations
Dextrose is a relatively thick solution and is more easily administered through a large
bore catheter.
Administration of dextrose may precipitate severe neurologic symptoms in the
alcoholic patient. Thiamine should be administered prior to Dextrose in patients
presenting with possible alcohol abuse.
If level of consciousness increases, ensure patient eats.

Revision Date 11/01/2005 429

 Montgomery County Hospital District-EMS DOPAMINE HCL
Standard Delegated Orders –
Medicine Reference MED 12 Page 430
TOC

(Intropin)

Medication
A catecholamine synthesized by the adrenal gland, dopamine is the immediate pre-
cursor in the synthesis of norepinephrine.

Mechanism of Action
Dopamine acts as a sympathetic mediator causing an in the force and rate of cardiac
contractions as well as dilatation of renal and mesenteric arteries.
Dopamine exerts an inotropic effect on the myocardium resulting in a cardiac
output. Dopamine usually systolic and pulse pressure with either no effect or a
slight in diastolic pressure.
Dopamine does not significantly myocardial O2 consumption.
Dopamine dilates renal vasculature presumptively by activation of a dopaminergic
receptor, causing an glomerular filtration rate, renal blood flow and sodium
excretion ( urinary output )
Action of this medication is dependent on the dosage level:
1. Low dosages: - effects predominate
(1–2 g/kg/min) - Myocardial contractility
2. Moderate dosages: - Cardiac Output
(2–10 g/kg/min) - Dilation of renal and mesenteric arteries.
3. Mod. high dosages: - B/P
10–20 g/kg/min) - Peripheral vasoconstriction
4. High dosages: - effect reverses dilation of renal and
(> 20 g/kg/min) mesenteric vessels.
- Flow through these vessels.

Indications
Hypotension during non-hypovolemic shock states.
Symptomatic bradycardia when refractory to Atropine and external pacing.

Contraindications
Dopamine should not be administered in the presence of uncorrected tachyar-
rhythmias or VFib.
Serious acute hypertension may develop in patients with pheochromocytoma (a
tumor that produces epinephrine and/or related substances)

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 Montgomery County Hospital District-EMS DOPAMINE HCL
Standard Delegated Orders –
Medicine Reference MED 12 Page 431
TOC

Side Effects
Ectopic Beats, Palpitations, Tachycardia
N/V
Dyspnea
Angina
Headache

Dosage & Administration

ADULT: Administer 5–10 g/kg/min via IV infusion using a microdrip set. Titrating
the infusion to effect on level of consciousness and B/P
If Pre-mix unavailable:
Add 800mg dopamine to 1000ml of NS 0.9%
- Yielding a concentration of 800 g/ml.

Special Considerations
Dopamine contractility of the myocardium and may be detrimental in patients with
severe myocardial ischemia.
Do not mix with sodium bicarbonate since dopamine may be inactivated by alkaline
solutions.
The effects of dopamine may be potentiated by medications such as Parnate,
Marplan, and Nardil.
Serious acute hypertension may develop in patients with pheochromocytoma (a
tumor that produces epinephrine and/or related substances)

Revision Date 11/01/2005 431

 Montgomery County Hospital District-EMS EPINEPHRINE HCL
Standard Delegated Orders –
Medicine Reference MED 13 Page 432
TOC

(Adrenaline)

Medication
Epinephrine is an endogenous (hormone) catecholamine with nonselective 1, 2, and
properties. It is an adrenergic (sympathomimetic) agent and cardiac stimulant; It is
Secreted by the medulla of the adrenal gland.

Mechanism of Action
Epinephrine stimulates alpha-1, beta-1, and beta2-adrenergic receptors in dose-
related fashion. The most prominent actions are on the receptors of the heart,
vasculature, and other smooth muscles.
Rapid injection produces a rapid increase in systolic pressure, ventricular
contractility, and heart rate:
The 1 sympathetic actions of epinephrine causes:
1. Increased rate of sinus node
2. Increased myocardial contractility
3. Increased AV conduction
4. Increased myocardial irritability
The 2 sympathetic action causes bronchodilation and vasodilation.
The effect of epinephrine causes vasoconstriction in the arterioles of the skin,
mucosa, and splanchnic areas to:
1. the perfusion pressure and possibly improving coronary blood flow.
2. Antagonize the effects of histamine.

Indications
Anaphylaxis / Acute allergic reaction
Asthma
The treatment and prophylaxis of cardiac arrest to:
1. Restore electrical activity in asystole
2. Enhance defibrillation potential in VFib
3. Elevate SVR and perfusion pressure during resuscitative efforts.
Bradyarrhythmias resistant to Atropine.

Contraindications
No contraindications in cardiac arrest or anaphylactic shock.
Hypersensitivity (only on pulsing patients)
Hypovolemic shock
Use with caution in:
1. Hypertensive states
2. Ischemic Heart Disease / Coronary insufficiency
3. Obstetrical patient with B/P > 120/80 mmHg
4. In patients receiving Isoproterenol, digitalis, and/or other sympathomimetics.

Revision Date 11/01/2005 432

 Montgomery County Hospital District-EMS EPINEPHRINE HCL
Standard Delegated Orders –
Medicine Reference MED 13 Page 433
TOC

Side Effects
Arrhythmia‘s / Tachycardias B/P
Palpitations / Ectopic beats Anxiety
Precipitation of anginal pain Restlessness / tremors

Dosage & Administration

1:10,000 contains: 0.1 mg/ml

1:1,000 contains: 1 mg/ml

ADULT:
Cardiac Arrest: 1 mg IV/IO / 2 mg ET q 3–5 min.

Allergic Reaction: 0.3 mg SQ (1:1,000)

Anaphylaxis: 0.5 mg IV/IO (1:10,000) - unconscious

0.5 mg SL (1:1,000) - vascular collapse

Bronchospasm: 0.3 mg SQ (1:1,000)

PEDIATRIC:
Cardiac Arrest: 0.01 mg/kg IV/IO (0.1 ml/kg1: 10,000) q 3–5 min.
0.1 mg/kg ET (1:1,000)

Allergic Reaction: 0.01 mg/kg SQ (1:1,000)

Anaphylaxis: 0.01 mg/kg IV/IO (1:10,000)

0.01mg /kg SL (1:1,000)

Bronchospasm: 0.01 mg/kg SQ (1:1,000)

INFUSION:

PEDIATRICS:
To mix Epinephrine infusion:
- 0.6 multiplied by the child‘s weight in kg. This amount (in mg) is then added to
enough IV solution to equal a total volume of 100 ml.
- Infuse at 20 ml/hr via infusion pump until clinical response (increased heart rate
OR blood pressure OR improved systemic perfusion)
- Reduce infusion to 0.1 to 1 mcg/kg/minute with Baxter Pump
- 1 ml/hr equals 1 mcg/kg/minute

Revision Date 11/01/2005 433

 Montgomery County Hospital District-EMS EPINEPHRINE HCL
Standard Delegated Orders –
Medicine Reference MED 13 Page 434
TOC

Special Considerations
In cases of shock, administer epinephrine via the IV route rather than the
subcutaneous route due to the poor perfusion.
MAOI‘s may potentiate the effect of epinephrine.
Beta-adrenergic antagonists may blunt inotropic response.
May be deactivated by alkaline solutions (sodium bicarbonate, Lasix).

Revision Date 11/01/2005 434

 Montgomery County Hospital District-EMS ETOMIDATE
Standard Delegated Orders –
Medicine Reference MED 14 Page 435
TOC

(Amidate)

Medication
Etomidate is a non-barbiturate hypnotic without analgesic properties. In therapeutic
doses, Etomidate has minimal effect on myocardial metabolism, cardiac output, and
peripheral or pulmonary circulation.

Mechanism of Action
Etomidate is a sedative-hypnotic used to induce anesthesia that should last
approximately 3–10 minutes.

Indications
Induction of anesthesia prior to administration of a neuromuscular blockade

Contraindications
None when used as indicated

Side Effects
Hypotension, arrthymias, hypertension
Hyperventilation, hypoventilation, laryngospasm
Myoclonus, tonic movement, eye movements
Nausea/Vomiting

Dosage and Administration

ADULT: 20 mg IV

PEDIATRIC: No protocol

Special Considerations
Use with caution in patients with focal epilepsy
Injection into small veins can cause pain
Myoclonus is reduced by pre-medicating with Valium

Revision Date 11/01/2005 435

 Montgomery County Hospital District-EMS FENTANYL
Standard Delegated Orders –
Medicine Reference MED 15 Page 436
TOC

(Sublimaze)

Medication
A potent synthetic opiate with analgesic properties. In therapeutic doses, Fentanyl has
little effect on hemodynamic compromise, and may be useful in those with borderline
hypotension or heart failure.

Mechanism of Action
Inhibits ascending pain pathways primarily through interaction with opioid receptors
located in the brain, spinal cord and smooth muscle.
Drug alters perception of pain and emotional response to pain.
When administered in high doses it may produce loss of consciousness.

Indications
For control of moderate to severe pain related to:
Musculo-skeletal disorders
Burns
Amputations
Abdominal pain indicative of kidney stones.

Contraindications
Hypersensitivity to drug

Side Effects
Bradycardia
Apnea, Hypoventilation
Headache, Dizziness, Sedation
Nausea/Vomiting, Constipation

Dosage and Administration

ADULT: 0.5 - 1 mcg/kg SLOW IV/IO, FAST IN prn Pain management

Maximum Single Dose 100 mcg
Titrate to 30-50% reduction in pain
May repeat q 5 minutes prn

100 mcg SLOW IV/IO, FAST IN PAI

PEDIATRIC: 0.5 mcg/kg SLOW IV/IO, FAST IN Pain management

2 mcg/kg SLOW IV/IO, FAST IN PAI

Special Considerations
Use with caution in elderly, young or debilitated patients
Use with caution in patients with respiratory or hepatic dysfunction

Revision Date 06/10/2009 436

 Montgomery County Hospital District-EMS FENTANYL
Standard Delegated Orders –
Medicine Reference MED 15 Page 437
TOC

May interfere with neurological assessment in patients with head injury

Not for routine administration for generalized abdominal pain

Revision Date 06/10/2009 437

 Montgomery County Hospital District-EMS GLUCAGON
Standard Delegated Orders –
Medicine Reference MED 16 Page 438
TOC

Medication
A pancreatic hormone-insulin antagonist

Mechanism of Action
Causes breakdown of glycogen to glucose
Inhibits glycogen synthesis
Elevates blood glucose levels
Increases cardiac contractile force
Increases heart rate

Indications
Altered LOC where hypoglycemia is suspected and an IV route is not immediately
available
Beta blocker overdose
Calcium channel blocker overdose

Contraindications
Hypersensitivity to drug
Allergy to proteins

Side Effects
Tachycardia
Hypertension
Nausea/vomiting
Allergic reaction

Dosage & Administration

ADULT: 1 mg IM may repeat in 20 min.

PEDIATRIC: 0.5 mg IM/SQ may repeat in 20 min.

Special Considerations

Revision Date 03/29/2006 438

 Montgomery County Hospital District-EMS IBUPROFEN
Standard Delegated Orders –
Medicine Reference MED 17 Page 439
TOC

(Motrin)

Medication
Nonsteroidal anti-inflammatory drug (NSAID) with significant antipyretic and analgesic
properties.

Mechanism of Action
Blocks prostaglandin synthesis, inhibits platelet aggregation, and prolongs bleeding time,
but does not affect prothrombin or whole blood clotting times.

Indications
Fever

Contraindications
Hypersensitivity to Aspirin or other NSAIDs
Active peptic ulcer disease
Bleeding abnormalities
Severe renal disease
Severe hepatic disease
< 6 months of age

Side Effects
Anxiety, confusion, depression, dizziness, drowsiness, fatigue, insomnia, tremors
CHF, dysrhythmias, HTN, palpitations, peripheral edema, tachycardia
Blurred vision, hearing loss, tinnitus
Constipation, cramps, diarrhea, dry mouth, flatulence, GI hemorrhage, jaundice,
nausea/vomiting, peptic ulcer
Azotemia, hematuria, nephrotoxicity, oliguria
ncreased bleeding time
Pruritus, purpura, rash, sweating

Dosage & Administration

Age Weight (lbs) Dose

6–11 mo 12–17 50 mg/ 2.5ml
12–23 mo 18–23 80 mg/ 4ml
2–3 yrs 24–35 110 mg/ 5.5ml
4–5 yrs 36–47 160 mg/ 8ml
6–8 yrs 48–59 220 mg/ 11ml
9–10 yrs 60–71 270 mg/ 13.5ml
11 yrs 72–95 325 mg/ 16.25ml

Revision Date 11/01/2005 439

 Montgomery County Hospital District-EMS IBUPROFEN
Standard Delegated Orders –
Medicine Reference MED 17 Page 440
TOC

Special Considerations
Patients with history of cardiac decompensation should be observed closely for
evidence of fluid retention and edema.
Monitor for GI distress and signs of GI hemorrhage.
Symptoms of acute toxicity in children are apnea, cyanosis, response only to painful
stimuli, dizziness and nystagmus.

Revision Date 11/01/2005 440

 Montgomery County Hospital District-EMS LABETALOL
Standard Delegated Orders –
Medicine Reference MED 18 Page 441
TOC

(Normadyne, Trandate)

Medication
Labetalol is a competitive alpha -receptor blocker as well as a nonselective beta-
receptor blocker used to lower blood pressure in a hypertensive crisis.

Mechanism of Action
The beta blocking actions on the S.A. node, A.V. node and ventricular muscle cause
negative chronotropic, dromotropic and inotropic effects. The beta blocking actions
cause bronchoconstriction. The alpha blocking actions lead to general vasodilation and
reduced P.V.R. The net C.V. effects are a decrease in B/P without reflex tachycardia or
significant reduction in H.R.

Indications
Systolic B/P >200 or a Diastolic B/P >110 with or without S/S
Hypertensive Crisis (Systolic B/P >200 or a Diastolic B/P >110)

Contraindications
Absolute:
• STEMI precipitated by cocaine use
• Heart block
Relative:
• Heart Rate <60 bpm
• Systolic Blood Pressure <100 mmHg
• Active CHF
• Active Asthma

Side Effects
Postural hypotension Exacerbates bronchospasm
Fever Wheezing, dyspnea
Liver toxicity Fatigue
Exacerbates CHF Depression

Dosage & Administration

ADULT: 10 mg intravenously over 1 to 2 minutes

PEDIATRIC: Not recommended

Special Considerations
Use with extreme caution as severe decreases in B/P can occur.
Increased hypotensive effect with Cimetidine and calcium channel blockers
Labetalol may blunt bronchodilator effects of beta-adrenergic agonists.
Nitroglycerin may augment hypotensive effects.
Decreased effect and possible hypertensive crisis with NSAIDS.

Revision Date 05/21/2007 441

 Montgomery County Hospital District-EMS LABETALOL
Standard Delegated Orders –
Medicine Reference MED 18 Page 442
TOC

There are some situations in which sympathetic stimulation is vital. For example,
patients with severely damaged hearts may depend on the sympathetic drive to
reach adequate ventricular function. This medication could block this drive and
precipitate heart failure.

Revision Date 05/21/2007 442

 Montgomery County Hospital District-EMS LASIX
Standard Delegated Orders –
Medicine Reference MED 19 Page 443
TOC

(Furosemide)

Medication
Lasix is a potent diuretic that inhibits the reabsorption of sodium and chloride in the
proximal tubule and loop of Henle.

Mechanism of Action
Lasix inhibits sodium and chloride reabsorption in the kidneys promoting diuresis.
It is also thought that Lasix causes venous dilation, decreasing venous return.
Lasix is a rapid acting diuretic with peak effects within 15–30 minutes of
administration.

Indications
CHF
Acute cardiogenic pulmonary edema

Contraindications
Anuria (inability to urinate)
Pregnant women (Lasix has been known to cause fetal abnormalities)
Patients presenting with Hypokalemia (low potassium)
- ECG: prominent p waves, diminished t waves, and u waves.
Patients presenting with S/S of hypovolemia, dehydration or other states of severe
electrolyte depletion.

Side Effects
Hypotension Hypochloremia
ECG changes Hypokalemia
Dehydration Hyponatremia
Hyperglycemia

Dosage & Administration

ADULTS: if patient is taking Lasix, give patient‘s total daily dose

if patient is not taking Lasix, administer 40 mg SLOW IV

Special Considerations
Lasix is a potent diuretic that if given in excessive amounts, can lead to a profound
diuresis with water and electrolyte depletion. Potassium loss may occur which may
aggravate arrhythmias.
Because of the potency of this medication, blood pressure should be monitored
carefully.
Digitalis toxicity may be potentiated by the potassium depletion. Watch for
dysrhythmias.

Revision Date 11/01/2005 443

 Montgomery County Hospital District-EMS LIDOCAINE HCL
Standard Delegated Orders –
Medicine Reference MED 20 Page 444
TOC

(Xylocaine)

Medication
Lidocaine is classified as a Class IV antiarrhythmic and a local anesthetic that is used
intravenously to treat certain ventricular arrhythmias.

Mechanism of Action
Lidocaine suppresses dysrhythmias of ectopic ventricular origin and in ischemic tissue
by the automaticity of ventricular pacemaker cells and the conduction system.
Lidocaine elevates ventricular fibrillation threshold. Reduces non-uniformity of
repolarization in the purkinje fibers and altars conduction velocity in these fibers to
abolish re-entrant ventricular dysrhythmias and unidirectional ventricular tachycardia.
Lidocaine has only minimal effects on atrial muscle.

Indications
PVC‘s when they:
1. occur in the context of myocardial ischemia (chest pain)
2. occur > 6/min.
3. occur in salvos (2 or more)
4. fall close to the T wave
5. Multifocal
VFib/ VTach
To prevent the recurrence of VFib or VTach after conversion

Contraindications
Known hypersensitivity to ―amides‖ or ―caine‖ medications.
Sinus bradycardia, 2 or 3 heart block, or Idioventricular rhythm
Wolff-Parkinson-White syndrome (Lidocaine may block aberrant pathway).
Stokes - Adams syndrome (transient heart block with syncope).

Side Effects
May cause a fall in cardiac output and B/P.
May cause seizure-like activity when given in high doses.
May also cause tremors, lethargy, muscle twitching, and/or coma.
Clinical indicators of toxicity: Drowsiness decreased hearing ability, paresthesias,
muscle twitching, seizures, bradycardia or heart block.

Revision Date 11/01/2005 444

 Montgomery County Hospital District-EMS LIDOCAINE HCL
Standard Delegated Orders –
Medicine Reference MED 20 Page 445
TOC

Dosage & Administration

ADULT:
Initial: 1–1.5 mg/kg IV (2–3 mg/kg ET)
Subsequent: 0.5 mg/kg IV (1 – 1.5 mg/kg ET) Max: 3 mg/kg
Adult Infusion: 2 – 4 mg/min.
PEDIATRIC:
1 mg/kg IV (2 mg/kg ET)

Pediatric Lidocaine Preparation: Dosage:

Infusion 100 mg lidocaine in 100 20 µg/kg/min 6 drops/min per 5 kg
Dose: 20 – 50 g/kg/min ml NS 30 µg/kg/min 9 drops/min per 5 kg
40 µg/kg/min 12 drops/min per 5 kg
50 µg/kg/min 15 drops/min per 5 kg

Special Considerations
Reduction of dosage should be considered in patients >70 y/o, patients
presenting with ↓ cardiac output (CHF, shock), or liver disease.

Revision Date 11/01/2005 445

 Montgomery County Hospital District-EMS MAGNESIUM SULFATE
Standard Delegated Orders –
Medicine Reference MED 21 Page 446
TOC

Medication
Magnesium Sulfate is an electrolyte salt solution with C.N.S. depressant-like properties.

Mechanism of Action
Magnesium is a cofactor in numerous enzymatic reactions and is essential for the
function of the sodium-potassium ATPase pump. It acts as a physiological calcium
channel blocker and blocks neuromuscular transmission of acetylcholine. Magnesium is
also a potent peripheral vasodilator and increases the fibrillation threshold.

Indications
Refractory VFib or VTach
Torsade-de-Pointes
Seizures accompanying eclampsia (Toxemia of pregnancy)
Bronchospasm

Contraindications
High degree AV block

Side Effects
Hypotension, circulatory collapse, heart block
Respiratory depression or paralysis
Flaccid paralysis, depressed reflexes
Hypocalcemia
Flushing, sweating, hypothermia

Dosage & Administration

ADULT: 1–2 grams IV/IO

Infusion: Mix 1 gram in 100 ml NS infused via pump over 10 minutes
PEDIATRIC: 25–50 mg/kg IV/IO (max. 2g)

Special Considerations
Side effects are usually from administering too rapidly.
Assess deep tendon reflexes (D.T.R.s) before, during and after administration
If depressed cardiac function, respiration rate below 12/minute or no reflex
activity is noted consider the administration of Calcium Gluconate 500 mg IV (up to 1
gm) until untoward side effects are abolished.

Revision Date 11/01/2005 446

 Montgomery County Hospital District-EMS MORPHINE SULFATE
Standard Delegated Orders –
Medicine Reference MED 22 Page 447
TOC

Medication
A naturally occurring narcotic analgesic derived from the opium poppy, which effects the
CNS and GI tract.

Mechanism of Action
Morphine the patient‘s tolerance for pain and the perception of suffering.
Stimulates the parasympathetic nervous system, which results in decreased
peripheral resistance, increased venous capacitance, venous pooling and decreased
venous return to the heart.
Depresses respiratory, cough and vasomotor center in the medulla.
Stimulates the vomiting center in the medulla.

Indications
Relief of severe pain in adults and children when associated with:
1. Burns
2. Isolated traumatic injuries.
3. Renal Calculi
Pulmonary edema associated with CHF
Chest pain/cardiac ischemia

Contraindications
Known hypersensitivity
Acute abdomen pain (unless verified Renal Calculi)
Multi-systems trauma
Use with extreme caution in patients with pre-existing respiratory depression, acute
hypoxia (asthmatic attack) or patients with COPD.
Use with caution and in reduced dosages in the presence of other CNS depressants.

Side Effects
Sedation Cough reflex.
Hypotension Constriction of pupils.
Respiratory depression / Apnea Dizziness
Orthostatic hypotension Constipation and N/V.

Dosage & Administration

ADULT: 2–10 mg IV/IO or IM May repeat per medical control

PEDIATRIC: 0.1–0.2 mg/kg IV/IO or IM May repeat per medical control

Max. Single dose 2 mg
Max. dose 10 mg

Revision Date 11/01/2005 447

 Montgomery County Hospital District-EMS NARCAN
Standard Delegated Orders –
Medicine Reference MED 23 Page 448
TOC

(Naloxone)

Medication
Narcan is a synthetic opioid antagonist that inhibits the analgesic effects of opiates. It is
used in the management and reversal of overdoses caused by narcotics and synthetic
narcotic agents

Mechanism of Action
Narcan antagonizes the opioid effects by competing for the same receptor sites. Narcan
should reverse stupor, coma, and respiratory depression when administered to patients
who have ingested narcotic drugs. May precipitate withdrawal symptoms in patients
dependent on narcotics. Some frequently used narcotics include:
Heroin Codeine Darvon Stadol
Morphine Demerol Percodan Talwin
Methadone Dilaudid Fentanyl

Indications
Known narcotic overdose
Unconsciousness of unknown etiology

Contraindications
Hypersensitivity
Use with caution in narcotic-dependent patients who may experience
withdrawal syndrome (including neonates of narcotic- dependent mothers)

Side Effects
Nausea
Rapid administration may precipitate projectile vomiting
Severe withdrawal symptoms in the addicted patient

Dosage & Administration

ADULT: 4 – 8 mg SLOW IV, IM, IO FAST IN q 10–15 min if response seen

PEDIATRIC: 0.1 mg/kg SLOW IV, IM, IO FAST IN (Max: 2 mg single dose)

Special Considerations
Since most narcotics have longer duration of action, repeated doses of Narcan may
be required.
The patient who has satisfactorily responded to Narcan should be kept under
continued surveillance and repeated doses should be administered as
necessary since the duration of action of some narcotics exceed that of
narcan.

Revision Date 08/01/2007 448

 Montgomery County Hospital District-EMS NITROGLYCERIN
Standard Delegated Orders –
Medicine Reference MED 24 Page 449
TOC

(Nitrostat, Nitrolingual Spray)

Medication
Nitroglycerin (NTG), an organic nitrate, is a smooth muscle vasodilating agent.

Mechanism of Action
The mechanism by which NTG produces relaxation of smooth muscle is unknown.
Although venous effects predominate, NTG produces, in a dose-related manner, dilation
of both arterial and venous beds.
Dilation of the post capillary vessels, including large veins, promotes peripheral
pooling of blood and venous return to the heart, left ventricular end-diastolic
pressure (preload).
Arteriolar relaxation reduces systemic vascular resistance and arterial pressure
(afterload).
Myocardial O2 consumption or demand is by both the arterial and venous effects
of NTG, creating a more favorable supply-demand ratio.

Indication
Ischemic chest pain
Congestive heart failure

Contraindications
NTG should be used with extreme caution in patients presenting with:
Hypersensitivity
ICP /Head injury
Hypotension
Nitroglycerin, in any form, is not to be administered to patients that have taken
Viagra (Sildenafil citrate) or Levitra (Vardenafil HCl) within the last 24 hours.
Nitroglycerin is not to be administered to patients who have taken Cialis (Tadalafil)
within the last 48 hours.
Fatal hypotension has been reported when Nitroglycerin or other Nitrates are given
to patients who have used Viagra or Levitra in last 24 hours, and in patients who
have used Cialis in the last 48 hours.

Side Effects
Throbbing Headache (means it‘s working) Palpitations
N/V Weakness
Hypotension / Postural Hypotension Vertigo

Dosage & Administration

ADULT: 0.4 mg SL or MDI q 5 min prn. if systolic B.P. is > than 100 mmHg
0.8 mg SL for CHF
PEDIATRIC: Not recommended

Special Considerations
Administer to patients sitting or semi-reclined
Excessive use may lead to the development of tolerance.

Revision Date 03/29/2006 449

 Montgomery County Hospital District-EMS NITROGLYCERIN
Standard Delegated Orders –
Medicine Reference MED 24 Page 450
TOC

B/P should be monitored closely.

Other vasodilators may have additive hypotensive effects (Viagra or similar
medication).
Nitroglycerin decomposes when exposed to light or heat.
Loses potency after prolonged storage. Replace stock every 4 – 6 months - label a
newly opened bottle with the date.

Revision Date 03/29/2006 450

 Montgomery County Hospital District-EMS NITROUS OXIDE
Standard Delegated Orders –
Medicine Reference MED 25 Page 451
TOC

(Nitronox)

Medication
Nitrous oxide is colorless, odorless and tasteless anesthetic gas that, when mixed with
oxygen, acts to relieve pain.

Mechanism of Action
Nitrous oxide is absorbed through the alveoli by inhalation. It depresses the central
nervous system and relieves pain. Inhalation of 20% nitrous oxide has been compared
to 15 mg of Morphine. Nitrogen does not bind with the hemoglobin and is carried in the
plasma. Because of its slow diffusion across membranes, it occupies the gas filled
spaces in the body

Indications
Mild to moderate pain due to any of the following:
Isolated Musculo-Skeletal injuries
Burns
Renal Calculi (Kidney Stones)

Contraindications
Altered mentation
Alcohol or Drug Intoxication
Head injury with altered mental status
COPD
Pneumothorax / Chest injuries

Side Effects
Headache
Dizziness, drowsiness
N/V

Dosage & Administration

ADULT & PEDIATRIC: Self-administered inhalation (50% N2O / 50% O2)

Special Considerations
Use in well ventilated areas.
If side effects occur, discontinue inhalation therapy and apply 100% oxygen for at
least 5 minutes.

Revision Date 11/01/2005 451

 Montgomery County Hospital District-EMS NORMAL SALINE
Standard Delegated Orders –
Medicine Reference MED 26 Page 452
TOC

(0.9% Sodium Chloride - Intravenous Solution)

Medication
Isotonic crystalloid salt solution used for intravenous infusion and intravenous medium.

Mechanism of Action
Expands circulating volume by approximating sodium content of the blood. Sodium
Chloride passes out of the blood stream quite rapidly, especially when normal renal
function and renal blood flow are present.
Each liter provides 154 mEq of sodium and 154 mEq of chloride.

Indications
Used to maintain a patent Intravenous access
Used in hypovolemic and/or dehydration states for any reason.
Used to facilitate the excretion of thick mucous plugs from the lungs.
Used for dilution of medications and/or as a flushing agent for rapid IV medication
administration.
Used as an irrigation solution for eyes and wounds

Contraindications
Use with caution with CHF

Side Effects
Fluid overload / Edema
Electrolyte imbalance
Hypertension

Dosage & Administration

ADULT: TKO for general access, IV fluid bolus 250 – 500 cc for rapid
administration and fluid resuscitation

PEDIATRIC: TKO for general access 20 ml/kg IV or IO, infused rapidly, for fluid
resuscitation

Special Considerations
Reassess and repeat fluid bolus if poor perfusion is observed
Frequently auscultate breath sounds frequently for rales.

Revision Date 11/01/2005 452

 Montgomery County Hospital District-EMS OXYGEN
Standard Delegated Orders –
Medicine Reference MED 27 Page 453
TOC

Medication
An element – utilized as the primary energy source for the development and
maintenance of life. Required by most cellular activities in order to maintain the
homeostasis within the body.

Mechanism of Action
Oxygen is utilized in all cellular activity occurring within the body, such as metabolism.
When cellular functions occur in a hypoxic or anoxic state the cells utilize other sources
of energy, such as fat. This causes an accumulation of harmful by-products (lactic acid)
which may lead to certain death if not corrected.

Indications
At the discretion of the EMS personnel
Treat and prevent hypoxemia
Decrease myocardial work and respiratory effort.
Any major illness or injury.
Saturations below 95%
Saturations below 85% indicate the need for ventilatory assistance and oxygen
therapy.

Contraindications
None for short term emergency use

Side Effects
None for short term emergency use

Dosage & Administration

Pulse oximetry and other clinical indicators should determine therapy.

Nasal cannula: 1 – 6 L.P.M. (provides 24 - 44% oxygen).
Simple mask: 6 –10 L.P.M. (provides 40 - 60% oxygen).
Non-rebreather mask: 10 – 15 L.P.M. (provides >90% oxygen).
Bag-valve-mask: 15 L.P.M. with reservoir (provides >90% oxygen).

Special Considerations
Humidifying oxygen using low flow devices such as nasal cannulas should prevent
drying of nasal and pulmonary mucosa.
Do not withhold oxygen from a COPD patient if he/she needs it. Initially try low flows
via nasal cannula but, if more is needed, supply it and carefully monitor ventilations.

Revision Date 11/01/2005 453

 Montgomery County Hospital District-EMS PHENERGAN
Standard Delegated Orders –
Medicine Reference MED 28 Page 454
TOC

(Promethazine)

Medication
Phenergan is a phenothiazine with sedative, antiemetic, antihistamine and
anticholinergic properties

Mechanism of Action
It competitively blocks histamine (H1) receptors. It does not block the release of
histamine. The central anti-muscurinic actions of antihistamines are probably
responsible for the antiemetic and anti-vertigo effects.
Reducing stimuli to the brainstem reticular system probably causes the C.N.S. sedation.
Additionally, Phenergan potentiates the effects of narcotics.

Indications
Nausea/ Vomiting

Contraindications
Hypersensitivity
Altered Mental Status
Hypotension
Large ingestion of sedatives
Use with caution with asthma patients (thickens mucous).
Use with caution with patients who have a history of Epilepsy (may trigger seizure)

Side Effects
May cause sedation, confusion, or restlessness
Hypotension and hypertension
Extrapyramidal reactions (dystonia)
Urinary retention

Dosage & Administration

ADULT: 12.5 to 25 mg IV/IO/IM

(IV/IO only dilute in 10 ml over 1–-2 minutes.)

PEDIATRICS: 0.5 mg/kg IV/IO/IM, up to 12.5mg

(IV/IO only dilute in 10 ml over 1–2 minutes)

Special Considerations
Extrapyramidal side effects generally responds to Benadryl administration

Revision Date 11/01/2005 454

 Montgomery County Hospital District-EMS PITOCIN
Standard Delegated Orders –
Medicine Reference MED 29 Page 455
TOC

(Oxytocin)

Medication
Pitocin, a naturally occurring hormone produced by the Posterior pituitary gland. It is also
manufactured synthetically. This drug is administered in the prehospital setting to control
postpartum hemorrhage.

Mechanism of Action
Synthetic Pitocin exerts a selective action on uterine smooth that causes several
activities in order to reduce postpartum hemorrhage.
Stimulates rhythmic contractions of the uterus.
Increases the frequency of contractions.
Raises the tone of the uterine musculature.
Constricts uterine blood vessels.

Indications
Postpartum hemorrhage during the 3rd stage of labor following the delivery of the placenta.

Contraindications
Delivery of placenta should be complete prior to pre-hospital setting use.
Presence of a second fetus.
Patients who are hypersensitive to the medication.
Situations where vaginal delivery is contraindicated.
1. Cord presentation or prolapsed
2. Placenta previa
3. Vasa previa

Side Effects

Rarely seen adverse reactions include:

Anaphylactic Reaction N/V
Postpartum Hemorrhage Hypotension or hypertension
Cardiac Arrhythmia / PVC‘s Pelvic hematoma
Tachycardia Uterine rupture
Seizures (from excessive administration)

Dosage & Administration

ADULT: 2–20 mcg/min IV infusion
- Mix 10 Units of Pitocin in 1000 ml of NS and infuse with pump after
delivery of placenta and vaginal hemorrhage is uncontrolled
- Concentration is 1 mU/ml
- Rate is 2 – 20 ml/min via infusion pump
When the fundus becomes firm, decrease infusion to 150 ml/hour.
(May be added to primary IV line, ―piggy-back‖ not required)

Revision Date 11/01/2005 455

 Montgomery County Hospital District-EMS PITOCIN
Standard Delegated Orders –
Medicine Reference MED 29 Page 456
TOC

Special Considerations
Careful monitoring of the patients V/S during administration is essential.
Fundal massage should be considered before using this agent.

Revision Date 11/01/2005 456

 Montgomery County Hospital District-EMS RETAVASE
Standard Delegated Orders –
Medicine Reference MED 30 Page 457
TOC

(Reteplase)

Medication
Fibrinolytic

Mechanism of Action
Catalyzes the cleavage of endogenous plasminogen to generate plasmin; plasmin
degrades the fibrin matrix of an offending thrombus - fibrinolysis

Indications
Management of acute myocardial infarction

Contraindications
Active internal hemorrhage
History of CVA
Recent intracranial or intraspinal surgery or trauma
Intracranial neoplasm, arteriovenous malformation, or aneurysm
Known bleeding diathesis
Severe uncontrolled hypertension

Side Effects
Bleeding
Dysrhythmias

Allergic reaction
Reinfarction
Tamponade
Nausea/Vomiting
Fever
Hypotension

Dosage & Administration

10 units SIV – repeat dose in 30 minutes

Special Considerations
Use the sterile water packaged with the Retavase for reconstitution. This sterile
water has no preservatives.
No other medications should be administered through the same line.

Revision Date 11/01/2005 457

 Montgomery County Hospital District-EMS SODIUM BICARBONATE
Standard Delegated Orders –
Medicine Reference MED 31 Page 458
TOC

Medication
Sodium bicarbonate is a hypertonic solution used as a systemic alkalizer (buffer).
In water, it dissociates to provide sodium (Na+) and bicarbonate (HCO3-) ions.
Sodium is the principal cation of the extracellular fluid and plays a large part in the
therapy of fluid and electrolyte disturbances.
Bicarbonate is a normal constituent of body fluids.

Mechanism of Action
Reacts with hydrogen ions to form water and carbon dioxide and thereby can act to
buffer metabolic acidosis.
It corrects metabolic acidosis by neutralizing excess acid in the blood, helping to
return the blood towards a physiologic pH, in which metabolic processes and
sympathomimetic agents work more efficiently.
Increasing the plasma concentration of bicarbonate causes blood pH to rise.
In tricyclic antidepressant overdose, alkalization of serum pH increases protein
binding of TCA‘s, this significantly lessens the potential for toxicity.
Produces paradoxical acidosis due to the production of carbon dioxide, which is
freely diffusible into myocardial and cerebral cells.

Indications
Cardiac arrest situations with a down time > 10 min and the patient is intubated.
TCA overdose (ECG: QRS complex widening by 50%).
Known preexisting bicarbonate-responsive acidosis

Contraindications
No contraindications when used for indicated life-threatening emergencies
CHF - cannot tolerate a salt load
Metabolic and respiratory alkalosis
Use with caution in the dehydrated patient due to vomiting.(Chloride loss)

Side Effects
Metabolic alkalosis, hypernatremia, hyperkalemia and hyperosmolarity.
Electrolyte imbalance (tetany)
Seizures
Renal Calculi (Kidney stone)

Dosage & Administration

ADULT & PEDIATRIC Initial: 1 mEq/kg IV/IO of an 8.4% solution

Subsequent: 0.5 mEq/kg IV/IO of an 8.4% solution

INFANT (< 1 y/o) Dosage is the same but using a 4.2% solution

Revision Date 11/01/2005 458

 Montgomery County Hospital District-EMS SODIUM BICARBONATE
Standard Delegated Orders –
Medicine Reference MED 31 Page 459
TOC

Special Considerations
Administration should be accompanied by controlled hyperventilation to blow off
excess CO2. Bicarbonate administration produces carbon dioxide, which crosses
cell membranes more rapidly than bicarbonate, potentially worsening intracellular
acidosis.
May precipitate with Epinephrine and in calcium solutions.
May increase edematous or sodium-retaining states.
May worsen congestive heart failure

Revision Date 11/01/2005 459

 Montgomery County Hospital District-EMS SOLUMEDROL
Standard Delegated Orders –
Medicine Reference MED 32 Page 460
TOC

(Methylprednisolone)

Medication
Solumedrol is a synthetic steroid that suppresses acute and chronic inflammation. In
addition, it potentiates vascular smooth muscle relaxation and may alter airway
hyperactivity. A new indication is for reduction of posttraumatic spinal cord edema.

Mechanism of Action
Beta-adrenergic agonists activity (vascular smooth muscle relaxation)
May stabilize cell membranes by decreasing permeability.
Increases blood pressure by increased sodium and water reabsorption. (aldosterone
effect)
Increases blood sugar by stimulating gluconeogenesis.
Increases protein metabolism.
May prevent the release of histamine and excess lactic acid accumulation.
Demonstrable effects are evident in one hour.

Indications
Bronchial asthma and other bronchospastic states unresponsive to conventional
treatment.
Life-threatening shock states to reduce the body's inflammatory response.

Contraindications
Use with caution in patients with GI hemorrhage and diabetes mellitus.
Systemic fungal infection

Side Effects
No acute toxic effects for short-term therapy.
Long term therapy:
1. Hypertension
2. Hyperglycemia / Hypokalemia
3. Fluid and electrolyte shifts
4. Sodium and water retention
5. Aggravation of diabetes mellitus

Revision Date 11/01/2005 460

 Montgomery County Hospital District-EMS SOLUMEDROL
Standard Delegated Orders –
Medicine Reference MED 32 Page 461
TOC

Dosage & Administration

ADULT: 125 mg SLOW IV over 3 minutes.

PEDIATRIC: 2 mg/kg SLOW IV over 3 minutes

Weight Dose Volume

(kg) (mg) (ml)
5 10 0.2
10 20 0.3
15 30 0.5
20 40 0.6
25 50 0.8
30 60 1.0
35 70 1.1
40 80 1.3
45 90 1.4
50 100 1.6
55 110 1.8
60 120 1.9
65 130 2.1

Special Considerations
Hypoglycemic responses to insulin and oral hypoglycemics may be blunted
Oral contraceptives and estrogens drugs may increase effects.
Administer with caution in diabetes mellitus.

Revision Date 11/01/2005 461

 Montgomery County Hospital District-EMS STADOL
Standard Delegated Orders –
Medicine Reference MED 33 Page 462
TOC

(Butorphanol Tartrate)

Medication
Stadol is a synthetic parenteral opiate agonist-antagonist. It is structurally related to
Morphine, but it is more similar in action to Nalbuphine (Nubain). It has both narcotic
agonist and antagonistic properties. It is about 3 to 7 times as potent as morphine and
40 times as potent as Meperidine.

Mechanism of Action
Stadols actions at opiate receptors most closely resemble those of Nalbuphine.
Opiates are believed to exert their effects by stimulating specific opiate receptors,
designated as µ, kappa, and sigma. Mu-receptors are considered the classic
morphine-receptor type, and stimulation at this receptor produces analgesia,
respiratory depression, euphoria, and physical dependence. Stadol mediates
analgesia via stimulation at kappa-receptors.
Administration of a strong antagonist at the kappa-receptor, such as Narcan, would
displace Stadol from the receptor, producing a mild withdrawal.
Because of its lack of stimulation at the µ-receptor, butorphanol is believed to
produce less respiratory depression and pose a lower risk of physical dependence
than morphine.

Indications
Allergies to other analgesics
Moderate to severe pain
Prepartum pain

Contraindications
Hypersensitivity
Head injury

Side Effects
Sedation, HA, Vertigo, Dizziness, Confusion, Nervousness
Palpitations, HTN, Hypotension;
Bradypnea; GI: Vomiting
Blurred Vision, Flushing, Sweating, Hallucinations

Dosage & Administration

ADULT: 1 – 2 mg IV/IO over 3–5mins q every 3–4 hrs PRN

PEDIATRIC: Not Recommended

Special Considerations
Narcan administration may produce typical opioid withdrawal symptoms. Stadol
administration to patients with history of narcotic abuse may cause symptoms of
withdrawal.

Revision Date 11/01/2005 462

 Montgomery County Hospital District-EMS SUCCINYLCHOLINE CHLORIDE
Standard Delegated Orders –
Medicine Reference MED 34 Page 463
TOC

(Anectine)

Medication
A depolarizing neuromuscular blocking agent used specifically to facilitate endotracheal
intubation by paralysis of muscular tone.

Mechanism of Action
Succinylcholine produces complete neuromuscular paralysis by depolarizing the
neuromuscular end plate and preventing repolarization by binding to the receptors for
acetylcholine. In doing so, it produces minute, but visible muscle contractions called
fasciculation‘s. The paralysis following administration is selective, initially involving
consecutively the levator muscles of the face, muscles of the glottis, and finally the
intercostals, diaphragm and all other muscles. In general for therapeutic dosages, the
onset time is 45 seconds and the effects last 5 minutes

Indications
To induce paralysis in order to facilitate endotracheal intubation

Contraindications
Inability to control airway or support ventilations with a BVM.
Malignant Hyperthermia
Penetrating eye injury (Succinylcholine increases intraocular pressure)
Patients at risk for hyperkalemia:
1. Old burns (>7 days or more post burn)
2. Spinal cord injury (> 24 hrs)
3. Severe renal failure

Side Effects
Apnea, Hypoventilation
Malignant Hyperthermia
Hypertension
Arrhythmias
Histamine mediated signs and symptoms
1. Hypotension
2. Bronchoconstriction
3. salivation, intragastric pressure
4. Rash and flushing.
intraocular pressure
Hyperkalemia and exacerbation of hyperkalemia in trauma patients

Revision Date 11/01/2005 463

 Montgomery County Hospital District-EMS SUCCINYLCHOLINE CHLORIDE
Standard Delegated Orders –
Medicine Reference MED 34 Page 464
TOC

Dosage & Administration

ADULT: 100 mg IV/IO

PEDIATRIC: 1 mg/kg IV/IO

Special Considerations
Patients with neuromuscular diseases may be resistant or very sensitive to the
effects of Succinylcholine
All monitors (ECG, B/P cuff, pulse oximeter) and intubating equipment shall be in
place before inducing the patient. Should the intubation be unsuccessful, the patient
should be oxygenated and ventilated prior to any further attempts. Equipment to
perform an emergency needle or surgical cricothyrotomy should be readily
accessible.
Succinylcholine alone has no effect on perception, consciousness or pain.
Administering an analgesic or sedative prior to administering this agent should blunt
this.
Valium may reduce duration of action.
Lidocaine administration, prior to paralytic administration, reduces the rise in I.C.P.
associated with paralytic endotracheal intubation.
Use with caution in patients with any of the following:
1. Personal or familial history of malignant hypertension or hyperthermia
2. Elderly or debilitated patients
3. Severe burns or trauma
4. Degenerative or dystrophic neuromuscular disease, myasthenia gravis
5. Glaucoma, eye surgery and pheochromocytoma.

Revision Date 11/01/2005 464

 Montgomery County Hospital District-EMS TETRACAINE OPHTHALMIC
SOLUTION
Standard Delegated Orders –
Medicine Reference MED 35 Page 465
TOC

Medication
Tetracaine is a local anesthetic agent of the ester linkage type, related to procaine, used
topically and by infiltration.

Mechanism of Action
Tetracaine prevents initiation and transmission of nerve impulses thereby effecting local
anesthesia. Onset of anesthesia usually begins within 30 seconds and lasts a relatively
short period.

Indications
For situations in which a rapid and short acting topical ophthalmic anesthetic is
indicated, Tetracaine may be used. It is most often used in the field treatment of burns
to the eyes.

Contraindications
Known hypersensitivity
Open or Disrupted globe

Side Effects
Transient reactions may occur, and include:
Stinging
Burning
Conjunctival redness

Dosage & Administration

ADULT & PEDIATRIC: 1–2 drops prn in injured eye(s)

Special Considerations
Prolonged use results in diminished duration of anesthesia.
Patients should be advised not to touch or rub the eye(s) until the effect of the
anesthetic has worn off.
On very rare occasions, a severe, immediate, allergic corneal reaction may occur
characterized by acute diffuse epithelial keratitis with filament formation and/or
sloughing of large areas of necrotic epithelium.

Revision Date 11/01/2005 465

 Montgomery County Hospital District-EMS THIAMINE
Standard Delegated Orders –
Medicine Reference MED 36 Page 466
TOC

Medication
A vitamin B complex (B1), that occurs naturally and is produced synthetically. Most
vitamins required by the body are obtained through dietary intake. But certain states,
such as alcoholism and malnutrition, the intake, absorption, and use of Thiamine may be
severely affected. The brain is extremely sensitive to Thiamine deficiency.

Mechanism of Action
Thiamine is essential for the normal metabolism of carbohydrates and fats. Thiamine
combines with ATP to form Thiamine pyrophosphate coenzyme, a necessary component
for carbohydrate metabolism.

Indications
Patients presenting with S/S of alcohol toxicity, Wernicke‘s syndrome or Korsakoff‘s
psychosis.
Unconscious patient of unknown etiology. Thiamine should be administered prior to
D50 and Narcan.

Contraindications
Known hypersensitivity

Side Effects
Hypotension (from rapid injection or large dose)
Diaphoresis
N\V
Weakness
Tingling

Dosage & Administration

ADULT: 100 mg IV/IO or IM
or
50 mg IV/IO and 50 mg IM

PEDIATRIC: 10–25 mg IV/IO or IM

Special Considerations
In alcoholics, Thiamine deficiency causes Wernicke‘s syndrome, an acute and
reversible encephalopathy (brain dysfunction) characterized by:
1. Ataxia (defective muscular coordination)
2. Eye muscle weakness
3. Mental derangements.

A more serious complication of Thiamine deficiency is known as Korsakoff‘s

psychosis, a memory disorder that may be irreversible once it becomes established.
Since Thiamine is utilized in carbohydrate metabolism, these syndromes may be
precipitated by the administration of dextrose to the alcoholic with pre-existing
Thiamine deficiency.

Revision Date 11/01/2005 466

 Montgomery County Hospital District-EMS VALIUM
Standard Delegated Orders –
Medicine Reference MED 37 Page 467
TOC

Medication
A CNS depressant (sedative) derived from benzodiazepine, with muscle-relaxant and
anticonvulsant properties, Valium is used to relieve anxiety and tension and for the
treatment of seizure disorders.

Mechanism of Action
Valium induces calming effects by depressing the limbic system (emotional intensity)
and R.A.S. (level of alertness) thereby alleviating anxiety and inducing amnesia.
Suppresses the spread of seizure activity through the motor cortex of the brain and
elevates seizure threshold.
Relaxes skeletal muscles and has no autonomic actions and does not inhibit
conditioned reflexes.

Indications
Sedation for acute stress anxiety reactions
Acute alcohol withdrawal to relieve acute delirium tremens or agitation.
Status epilepticus and severe, recurrent convulsive seizures
Sedation before cardioversion in conscious patients.
Isolated musculoskeletal injuries.

Contraindications
Alcohol or sedative ingestion prior to administration
Respiratory depression
Shock, coma, or acute alcoholic intoxication with V/S
Caution in pregnancy, especially the 1st trimester

Side Effects
Drowsiness, confusion, stupor, fatigue
Ataxia (shaky movements and unsteady gait)
Transient Hypotension
Respiratory depression

Dosage & Administration

ADULTS: 2 – 10 mg Slow IV/IO (4 – 20 mg PR)

Until desired dose or effect
Lower doses (2 – 5 mg) for elderly / debilitated patients.
PEDIATRICS: 0.2 – 0.3 mg/kg Slow IV/IO (0.4 – 0.6 mg/kg PR)
Until desired dose or effect
Maximum dose 5 mg if patient < 2yrs.
Maximum dose 10 mg if patient > 10yrs.

Revision Date 11/01/2005 467

 Montgomery County Hospital District-EMS VALIUM
Standard Delegated Orders –
Medicine Reference MED 37 Page 468
TOC

Special Considerations
In order to reduce the possibility of venous thrombosis, phlebitis, local irritation,
swelling, and rarely, vascular impairment, Valium should be injected slowly and small
veins, such as those on the dorsum of the hand or wrist, should not be used.
Extreme care should be taken to avoid intra-arterial administration or extravasation.
Valium should not be mixed or diluted with other solutions or medications.
Has a cumulative and potentiating effect with alcohol and other sedative
drugs.
Respiratory depression is generally caused by rapid IV administration.

Revision Date 11/01/2005 468

 Montgomery County Hospital District-EMS VASOPRESSIN
Standard Delegated Orders –
Medicine Reference MED 38 Page 469
TOC

(Pitressin)

Medication
Vasopressin is an antidiuretic hormone naturally produced by your body. Its primary
function in the body is to regulate extracellular fluid volume by affecting renal handling of
water.

Mechanism of Action
 Potent vasoconstrictor
 Increased blood pressure and systemic vascular resistance
 Increases cerebral blood flow to a greater degree than epinephrine
 Improves cerebral oxygenation
 Decreases:
- Cardiac output
- Heart rate
- Left ventricular oxygen consumption
- Myocardial contractility

Indications
 Ventricular fibrillation/Pulseless Ventricular Tachycardia
 PEA
 Asystole

Contraindications
 Bronchospasm
 Epilepsy
 Heart disease
 Kidney disease
 Heart or blood vessel disease

Side Effects
 Abdominal or stomach cramping
 Dizziness
 Nausea and/or vomiting
 Chest pain
 Coma
 Confusion
 Seizures
 Swelling to face, hands, feet or mouth

Dosage and Administration

 Adults: 40 U IV/IO
May repeat once in 20 minutes
 Pediatrics: Not recommended

Special Considerations
 None in cardiac arrest

Revision Date 03/29/2006 469

 Montgomery County Hospital District-EMS VECURONIUM
Standard Delegated Orders –
Medicine Reference MED 39 Page 470
TOC

(Norcuron)

Medication
A non-depolarizing neuromuscular blocking agent

Mechanism of Action
Through competitive inhibition, Vecuronium blocks cholinergic receptors at the motor
end plate initiating a neuromuscular paralysis within 3 minutes that lasts 25–30
minutes.

Indications
To sustain neuromuscular paralysis after a patient has been completely paralyzed to
facilitate intubation.
Provide muscle relaxation during mechanical ventilation.

Contraindications
Hypersensitivity
Patient who is not intubated
Myasthenia gravis

Side Effects
Bradycardia
Apnea, Hypoventilation

Dosage & Administration

ADULT: 10 mg IV/IO

PEDIATRIC: No protocol

Special Considerations
None

Revision Date 11/01/2005 470

 Montgomery County Hospital District-EMS VERSED
Standard Delegated Orders –
Medicine Reference MED 40 Page 471
TOC

(Midazolam)

Medication

Versed is a short acting benzodiazepine with CNS depressant, hypnotic, anticonvulsant

and sedative properties. Versed is 3 – 4 times as potent as Valium on a milligram to
milligram basis.

Mechanism of Action
Used for its rapid onset, Versed acts on GABA receptors producing anesthetic, sedation
and amnesic effects. Respiratory and cardiovascular depression are also associated with
the administration of Versed.

Indications
Status epilepticus and severe, recurrent convulsive seizures
Sedation for acute stress anxiety reactions
Sedation before cardioversion and/or Intubation in conscious patients
Used in conjunction with other medications during emergent intubation situations.
Sedation of previously intubated patient

Contraindications
Hypersensitivity
Pre-existing respiratory depression due to drugs or C.N.S. dysfunction.

Side Effects
Respiratory depression Euphoria
Amnesia Confusion
Mild hypotension Tremor
CNS depression / Drowsiness Slurred Speech
Laryngospasm / Bronchospasm

Dosage and Administration

ADULT: 2 – 5 mg IV/IO/IN (IM if IV/IO unavailable: 4 – 10 mg)

PEDIATRIC: 0.1 – 0.2 mg/kg IV/IO/IM/IN

Special Considerations
Potentiates respiratory depression and sedative effects of other CNS depressants.
Narcotics accentuates hypnotic effect
Generally need 5 mg maximum for conscious sedation
Reversed with flumazenil

Revision Date 08/01/2007 471

 Montgomery County Hospital District-EMS XOPENEX
Standard Delegated Orders –
Medicine Reference MED 41 Page 472
TOC

(Levalbuterol HCL)

Medication
Xopenex (Levalbuterol HCl) is a purified form of racemic albuterol and is a short-acting
beta -adrenergic agonists. Xopenex is used for the treatment and prevention of
bronchospasms.

Mechanism of Action
Xopenex has been shown to promote bronchial smooth muscle relaxation and to
decrease release of pulmonary histamines within the bronchial tree with the net
effect being broncodilation
Onset of action is within 5 minutes and may provide relief of symptoms for 4 to 8
hours.
Xopenex can produce the same desired effects as Albuterol with less than half the
dose, a longer duration of action, and fewer sympathetic side effects seen with other
beta2 -adrenergic agonists.

Indications
For the treatment and prevention of bronchospasms associated with reversible reactive
airway disease:
Bronchospasm
COPD (bronchitis, emphysema)
As well as other conditions that may cause acute narrowing of the airway. (i.e.
Allergic reactions)

Contraindications
Hypersensitivity to Albuterol, Xopenex, or any of its components

Side Effects
Tremors Cough with increase in sputum
Anxiety Hypertension
Nausea / Vomiting LESS COMMON:
Tachycardia Arrhythmias
Headache Palpitations

Dosage and Administration

ADULT: 1.25 mg in 3 ml of NS solution via hand held/face mask nebulizer

PEDIATRIC: 0.63 mg in 3 ml of NS solution via hand held/face mask nebulizer.

 For children < 4 years of age

Special Considerations
Caution should be used in patients with cardiovascular disorders, hypertension,
convulsive disorders, hyperthyroidism, and diabetes

Revision Date 11/01/2005 472

 Montgomery County Hospital District-EMS ZOFRAN
Standard Delegated Orders –
Medicine Reference MED 42 Page 473
TOC

Ondansetron (Zofran)
Medication
Zofran blocks the actions of chemicals in the body that can trigger nausea and vomiting

Mechanism of Action
Blocks the effects of serotonin at 5-HT3–receptor sites (selective antagonist) located in
vagal nerve terminals and the chemoreceptor trigger zone in the CNS.

Indications
Prevention of nausea and vomiting, especially associated with chemotherapy or
radiation therapy

Contraindications and Precautions

Contraindicated in:
Hypersensitivity
Orally disintegrating tablets contain aspartame and should not be used in patients with
phenylketonuria.
Use Cautiously in:
Liver impairment (daily dose not to exceed 8 mg)
Abdominal surgery (may mask ileus)
Pregnancy, lactation, or children 3 yr (safety not established).

Side Effects

Dosage and Administration

ADULT: 8mg oral dissintegrating tablet (ODT) PO
May be repeated every 15 mins
PEDIATRIC: (8kg-30kg) 4mg ODT PO
(>30kg) 8mg ODT PO
May be repeated every 15 mins
Do not attempt to push the Ondansetron (Zofran) ODT Tablets through the foil backing. With
dry hands, PEEL BACK the foil backing of 1 blister and GENTLY remove the tablet.
IMMEDIATELY place the tablet on top of the tongue where it will dissolve in seconds, then
swallow with saliva. Administration with liquid is not necessary.

Revision Date 1/26/09 473

This Page Intentionally Left Blank
APPENDIX
 Montgomery County Hospital District-EMS 12 LEAD GUIDE
Standard Delegated Orders –
Appendix APP 01 Page 476
TOC

12-Lead ECG in Relation to Anatomy of the Heart

Revision Date 1/26/09 476

 Montgomery County Hospital District-EMS 12 LEAD GUIDE
Standard Delegated Orders –
Appendix APP 01 Page 477
TOC

Revision Date 1/26/09 477

 Montgomery County Hospital District-EMS AMBULANCE ACCEPTABLE
ABBREVIATIONS
Standard Delegated Orders –
Appendix APP 02 Page 478
TOC

Below is a list of acceptable abbreviations that may be used for filing Medicare claims. Please
contact our office if additional abbreviations become common in the industry so that we may
update the list.

Abd Abdomen, abdominal DM Diabetes mellitus

ABG Arterial blood gases DOA Dead on arrival

ADM Admission EKG Electrocardiogram

A-fib Atrial fibrillation EOA Esophageal obturator airway

ALS Advanced life support ER Emergency room

ASA Aspirin ETOH Ethanol alcohol

ASHD Arteriosclerotic heart disease FUO Fever of unknown origin

BBB Bundle branch block fx Fracture

bilat. Bilateral GEN General

BLS Basic life support HM Home

BP, B/P Blood pressure Hx History

c/c Chief complaint IM Intramuscular

CHF Congestive heart failure inj, injs Injuries

CNS Central nervous system IV Intravenous

Chronic obstructive pulmonary LOC Loss of consciousness

COPD
disease
MAST Miltary anti-shock trousers
CPR Cardiopulmonary resuscitation
MVA Motor vehicle accident
C-spine Cervical spine
NH Nursing home
CTR Center
NTG Nitroglycerin
CVA Cerebrovascular accident
O2 Oxygen
disch Discharged (from hospital)
OBS Organic brain syndrome

Revision Date 1/26/09 478

 Montgomery County Hospital District-EMS AMBULANCE ACCEPTABLE
ABBREVIATIONS
Standard Delegated Orders –
Appendix APP 02 Page 479
TOC

PVS, Premature ventricular

PVCs contractions

RBBB Right bundle branch blook

RSCH Research

resp. Respiration

SNF Skilled nursing facihty

SOB Shortness of breath

ST Street

THPY Therapy

TIA Transient ischemic attack

TKO To keep open

Tx Treatment

Vfib,V-fib Ventricular fibrillation

VS, V/S Vital signs

Vtach/V-
Ventricular tachycardia
tach

Revision Date 1/26/09 479

 Montgomery County Hospital District-EMS APGAR SCORE
Standard Delegated Orders –
Appendix APP 03 Page 480
TOC

SIGN 0 1 2
Heart Rate Absent Below 100 Over 100
Respiration Absent Slow and irregular Normal crying
(effort)
Muscle Tone Limp Some flexion- Active; good
extremities motion in
extremities

Irritability No Response Crying; some Crying; vigorous

motion

Skin Color Bluish or paleness Pink or typical Pink or typical

newborn color; newborn color;
hands and feet entire body
are blue

Revision Date 1/26/09 480

 Montgomery County Hospital District-EMS CAPNOGRAPHY
Standard Delegated Orders –
Appendix APP 04 Page 481
TOC

Revision Date 1/26/09 481

 Montgomery County Hospital District-EMS CAPNOGRAPHY
Standard Delegated Orders –
Appendix APP 04 Page 482
TOC

Revision Date 1/26/09 482

 Montgomery County Hospital District-EMS CAPNOGRAPHY
Standard Delegated Orders –
Appendix APP 04 Page 483
TOC

Revision Date 1/26/09 483

 Montgomery County Hospital District-EMS CAPNOGRAPHY
Standard Delegated Orders –
Appendix APP 04 Page 484
TOC

Revision Date 1/26/09 484

 Montgomery County Hospital District-EMS CAPNOGRAPHY
Standard Delegated Orders –
Appendix APP 04 Page 485
TOC

Revision Date 1/26/09 485

 Montgomery County Hospital District-EMS GLASCOW COMA SCALE
ADULT AND PEDIATRIC
COMBINED
Standard Delegated Orders –
Appendix APP 05 Page 486
TOC

GLASGOW COMA SCALE (GCS): Adult & Pediatric Combined GCS

Note: Modifications for age appropriate response for infant/young child are typed in
bold print.
EYE OPENING RESPONSE BEST VERBAL RESPONSE BEST MOTOR RESPONSE
4 pts = Open spontaneously 5 pts = Oriented & converses 6 pts = Obeys commands
Appropriate words and Normal spontaneous
phrases movement
Cries appropriately, coos,
babbles
3 pts = To verbal stimuli 4 pts = Disoriented & 5 pts = Localizes pain
To speech, to shout converses Withdraws to touch
Irritable cry
3 pts = Inappropriate words
4 pts = Flexion withdrawal
2 pts = To painful stimuli Inappropriate
Withdraws to pain
crying/screaming
2 pts = Incomprehensible
3 pts = Flexion abnormal
1 pt = No response sounds/words
(decorticate)
Grunts
2 pts = Extension
1 pt = No response (decerebrate)
1 pt = No response
Risk of injury is high with GCS < 14 COMA is defined by GCS = 8

Any patient with a GCS < 9, consider intubation and hyperventilate at 20 to 24 breaths per
minute to reduce cerebral swelling.

Revision Date 1/26/09 486

 Montgomery County Hospital District-EMS INFUSION CALCULATIONS
Standard Delegated Orders –
Appendix APP 06 Page 487
TOC

Drip Rates For IV Tubing

Macro Drip IV Mini Drip IV Tubing

Tubing10gtts/ml 60gtts/ml
Ml/hr gtts/min gtts/min
30 This is TKO 5 30
45 8 45
60 10 60
75 13 75
100 17 100
125 21 -
150 25 -
175 29 -
200 33 -
225 38 -
250 42 -
300 50 -

DOPAMINE Drip Rate

400 mg of Dopamine in 250 cc Solution

5 Mcg 10 Mcg 15 Mcg 20 Mcg

Weight/Kg gtts/min gtts/min gtts/min gtts/min
40 8 16 24 36
50 10 20 30 40
60 12 24 36 48
70 14 28 42 56
80 16 32 48 64
90 18 36 54 72
100 20 40 60 80
110 22 44 66 88
120 24 48 72 96
130 26 52 78 104
140 28 56 84 112
150 30 60 90 120
160 32 64 96 128

Revision Date 1/26/09 487

 Montgomery County Hospital District-EMS INFUSION CALCULATIONS
Standard Delegated Orders –
Appendix APP 06 Page 488
TOC

170 34 68 102 136

180 36 72 108 144
190 38 76 114 152
200 40 80 120 160

LIDOCAINE Drip Rate

For pre-mixed bag of 2 g/500 ml (4mg/ml)

Lidocaine Drip Rate (per mg/min dose)

mg/min ml/hr
1 15
2 30
3 45
4 60

Pediatric Lidocaine Infusion

Dose: 20 – 50 g/kg/min Preparation: Dosage:

100 mg lidocaine in 100 20 µg/kg/min 6 drops/min per 5 kg
ml NS 30 µg/kg/min 9 drops/min per 5 kg
40 µg/kg/min 12 drops/min per 5 kg
50 µg/kg/min 15 drops/min per 5 kg

Revision Date 1/26/09 488

 Montgomery County Hospital District-EMS MALLAMPATI SIGNS
Standard Delegated Orders –
Appendix APP 07 Page 489
TOC

Revision Date 1/26/09 489

 Montgomery County Hospital District-EMS MCHD STROKE SCALE
Standard Delegated Orders –
Appendix APP 08 Page 490
TOC

MCHD-EMS
Stroke Assessment Scale

FACIAL DROOP
BOTH SIDES OF THE FACE MOVE EQUALLY
ONE SIDE OF FACE DOES NOT MOVE AT ALL

ARM DRIFT
BOTH ARMS MOVE EQUALLY OR NOT AT ALL
ONE ARM DRIFTS COMPARED TO THE OTHER

SPEECH
PATIENT USES CORRECT WORDS WITH NO SLURRING
SLURRED OR INAPPROPRIATE WORDS OR MUTE

ATAXIA
FINGER TO NOSE
HEEL TO SHIN

Revision Date 1/26/09 490

 Montgomery County Hospital District-EMS OXYGEN DURATION
Standard Delegated Orders –
Appendix APP 09 Page 491
TOC

Formula for Calculating Oxygen Duration

Gage Pressure-200psi x Cylinder constant =Duration in Min
Flow rate in LPM

Cylinder Endurance
Cylinder Size D E G M H/k
Cylinder Constants 0.16 0.28 2.41 1.56 3.15

Capacity (liters) 300 600 1000 3450 6500

Flow Rate
(liters/min
2 2:30 5:00 8:20 28:45 54:00
4 1:15 2:30 4:10 14:20 27:00
6 0:50 1:40 2:45 9:35 18:00
8 0:35 1:10 2:05 7:10 13:30
10 0:30 1:00 1:40 5:45 11:00
15 0:20 0:40 1:05 3:50 7:15

Endurance times in hours and minutes are approximations based on full tank pressures

O2 Flow Rates and %

O2 Device Flow Rate O2 %
NC 3-6 LPM 25-40%
Simple Face Mask 6-12 LPM 40-60%
NRB mask 10-12 LPM 90-100%
BVM 10_15 LPM 100% c Reservoir

Revision Date 1/26/09 491

 Montgomery County Hospital District-EMS PAIN ASSESSMENT
Standard Delegated Orders –
Appendix APP 10 Page 492
TOC

Assessing Pain

Onset/Origin What were you doing when the pain began? Did your stomach begin to hurt
immediately after you were kicked by the horse (somatic) or several hours later after you
vomited (visceral)? Somatic pain usually comes on abruptly while visceral pain more gradually.

Provokes What makes the pain worse or better? Does your chest hurt each time you take a
breath and move your intercostals muscles (somatic) or is it made worse with exertion and
anxiety (visceral)?

Quality What does the pain feel like? Is it sharp like a stabbing pain (somatic) or dull like a
throbbing ache or pressure (visceral)?

Referred/Region Where does it hurt? Is you pain only in your shoulder you injured, (somatic) or
does the pain radiate from your abdomen into your back (visceral)?

Severity Can you rate your pain on a scale of 1 to 10?

Time How long have you had this pain? Has it been there only since the injury (somatic) or for
many months (neuropathic)?

The Wong-Baker Faces Pain Rating Scale

Designed for children aged 3 years and older, the Wong-Baker Faces Pain Rating Scale is also
helpful for elderly patients who may be cognitively impaired. If offers a visual description for
those who don't have the verbal skills to explain how their symptoms make them feel.

To use this scale, you should explain that each face shows how a person in pain is feeling. That
is, a person may feel happy because he or she has no pain (hurt), or a person may feel sad
because he or she has some or a lot of pain.

Face 0 is very happy because he or she doesn't hurt at all.

Revision Date 1/26/09 492

 Montgomery County Hospital District-EMS PAIN ASSESSMENT
Standard Delegated Orders –
Appendix APP 10 Page 493
TOC

Face 1 hurts just a little bit.

Face 2 hurts a little more.
Face 3 hurts even more.
Face 4 hurts a whole lot.
Face 5 hurts as much as you can imagine, although you don't have to be crying to feel this bad.

You should point to each face using the words to describe the pain intensity. The patient should
then choose the face that best describes how they feel.

Revision Date 1/26/09 493

 Montgomery County Hospital District-EMS RULE OF NINES
Standard Delegated Orders –
Appendix APP 11 Page 494
TOC

Infant

Revision Date 1/26/09 494

 Montgomery County Hospital District-EMS SUBJECT IN CUSTODY RISK
ASSESSMENT SCALE
Standard Delegated Orders –
Appendix APP 12 Page 495
TOC

SUBECT IN CUSTODY RISK ASSESSMENT SCALE (SICRAS)

The Subject in Custody Risk Assessment Scale was developed to provide Law Enforcement,
Corrections, and EMS Personnel with a means to rapidly assess an in-custody subject‘s risk of
sudden death based on known symptoms and risk factors.

Directions:
Begin at the first observed sign or symptom. Add the numbers for each sign or symptom which
applies.

Alcohol Intoxication 1
Acute Alcohol Intoxication (BAC 0.25 or above) 3
History of Alcoholism 2
Cocaine Intoxication 4
Methamphetamine Intoxication 3
Drug Intoxication (other) 2
Bizarre Behavior 2
Aggressive Behavior 2
Shouting 2
Paranoia 3
Violence Against Others 2
Above Normal Physical Strength 3
Sudden Tranquility / Lethargy 2
Moderate Physical Activity 3
Intense Physical Activity 3
Obesity 1
―Big Bellies‖ 2
Hyperthermia 4
Hypotonicity of Skeletal Muscles 4
Antipsychotic Drug Use 2
History of Schizophrenia 2
Male 1
Ineffectiveness of OC Spray 2
Cyanosis of Lips/Nail Beds 5
Confusion – Disorientation 3

A score 16 or above indicates the subject is at extreme risk for sudden in-custody death
syndrome. Immediate medical attention is necessary.

Revision Date 1/26/09 495

 Montgomery County Hospital District-EMS SUBJECT IN CUSTODY RISK
ASSESSMENT SCALE
Standard Delegated Orders –
Appendix APP 12 Page 496
TOC

Score 10 – 16
Subject is at HIGH risk for Subject in Custody Death Syndrome (SICDS). Immediate evaluation
by EMS personnel is necessary. Medical treatment may be warranted. Subject should be
closely monitored

Score 5 – 10
Subject is at MODERATE risk for SICDS. Subject should be reevaluated by another
officer/provider familiar with the SICRAS system and SICDS. Subject should be monitored by
police, corrections, and/or EMS personnel.

Score 0 – 5
Subject is at LOW risk for SICDS based on known risk factors. Personnel should be watchful
for any signs of distress which would preclude the SICRAS score.

The following conditions or circumstances represent serious, or immediate, threats to safety

which necessitate immediate medical treatment or evaluation and supersede the Subject in
Custody Risk Assessment Scale.

Loss of consciousness
Seizure
Anaphylactic shock
Respiratory rate < 6 per minute
Resting heart rate < 40 or > 140
Severe headache
Medical Shock (any cause)
Chest pain
Gagging, gasping, or choking > 4 minutes after OC ingestion
Obvious respiratory distress

The SICRAS and other guidelines presented here cover only conditions and circumstances
known to date. It is impossible for us to cover all circumstances with which personnel may be
faced. An officer should rely on his common sense, experience, and training. A good rule of
thumb is that when conducting an ABCs survey of a subject, any obvious impairment of the
Airway, Breathing, or Circulation requires evaluation by medical personnel. When in doubt,
have it checked out.

Revision Date 1/26/09 496

 Montgomery County Hospital District-EMS TRAUMA SCORES
Standard Delegated Orders –
Appendix APP 13 Page 497
TOC

PEDIATRIC TRAUMA SCORE (PTS): CATEGORY DEFINITIONS

COMPONENT +2 +1 -1 SCORE
Child/adolescent, >20
Size Toddler, 11-20 kg Infant, < 10 kg
kg
Airway Normal Assisted 02, mask, Intubated; ETT,
cannula EOA, Cric
Obtunded; lost Coma;
Consciousness Awake
consciousness unresponsive
Palpable Palpable radial or Palpable femoral Weak or no
pulseSystolic brachial pulse pulse pulses < 50 mm
blood pressure Good peripheral Peripheral pulses, Hg
pulses, perfusion >90 pulses palpable 51-
mm Hg 90 mm Hg
Fracture None seen or none Single closed Fx Open, multiple Fx
suspected anywhere orfracture
suspected
Cutaneous No visible injury Contusion, abrasion; Tissue loss; and
laceration < 7 cm; not GSW/Stab;
through fascia through fascia
Total Score (PTS)

Totals can range from a +12 to a -6 with the range of <8-9 being the critical break point for
transport to a comprehensive pediatric trauma care facility.

Revision Date 1/26/09 497

 Montgomery County Hospital District-EMS TRAUMA SCORES
Standard Delegated Orders –
Appendix APP 13 Page 498
TOC

Adult Revised Trauma Score

GCS: 14 - 15 5
11 - 13 4
8 - 10 3
5-7 2
3-4 1
Respiratory Rate: 10 - 24 / Min. 4
25 - 35 / Min. 3
36 Min. or greater 2
1 - 9 / Min. 1
None 0
Respiratory Expansion: Normal 1
Retractive / None 0
Systolic Blood Pressure: 90 mm Hg or greater 4
70 - 89 mm Hg 3
50 - 69 mm Hg 2
0 - 49 mm Hg 1
No Pulse 0
Capillary Refill: Normal 2
Delayed 1
None 0
Total Trauma Score: 1 - 16

Trauma Score 16 15 14 13 12 11 10 9 8 7 6 5 4 3 2 1
Percentage Survival 99 98 96 93 87 76 60 42 26 15 8 4 2 1 0 0

Revision Date 1/26/09 498

 Montgomery County Hospital District-EMS ZOLL MSERIES QUICK
REFERENCE
Standard Delegated Orders –
Appendix APP 14 Page 499
TOC

Zoll M Series
Quick Reference Guide

To Test Device Recorder Button

Battery Charging System Soft Keys

Sealed Lead Acid Battery Summary Button

Universal Dial Code Markers

Lead Button NIBP Button

Size Button 12-Lead Monitoring

Alarm Suspend Button EtCO2

To Test Device: (Unplug device from wall outlet if plugged in)(back to top)

Plug end of Universal Cable into the black test port that is attached to the cable
Turn the central dial to the red (Defib) area
Press the down arrow until screen reads - 30 Joules Selected
Press the Charge button
Press Shock when lit
"Test OK" should appear on screen.

Battery Charging System (4x4 Charger with AutoTest)(back to top)

Battery Charging System should recondition a battery every time it is dropped in a bay, the
discharge and reload cycling takes approximately 5 hours, so once youput a battery in the
charger; don't expect to be able to use it for 5 hours. You will know a battery is ready when the
Charger light is off and the Battery Ready light is illuminated. If the Fault light is lit, manually hit
the test button and allow that battery to recycle again. If after two manual tests a battery fails,
battery should be taken out of service.

Sealed Lead Acid Battery with "Smart" Chip(back to top)

Expect 1-1.5 hours of monitoring time when using all parameters on this unit. There are
a lot of parameters using power off one battery, so battery management and rotation is
absolutely required.

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A/C Power is also available for use, you may run off A/C power alone, or with a battery
in the unit. The battery should be quick-charged.
Smart Batteries need to be reconfigured after approximately 20-30 on/off cycles. You
should know when the Smart Chip needs to be reconfigured because when you Hit the
top button on the battery, if the RED light comes on, that means the chip needs to be
reconfigured. This is done by putting the battery in the 4x4 charger and manually hitting
the TEST button.

Universal Dial(back to top)

One universal dial is used with all therapies (defibrillation/monitoring/pacing). Turn the dial to the
therapy you wish to use. Additional options should appear at the bottom of the screen. Soft keys
should be used often and the options at the bottom of the screen should change based on
which therapy you are utilizing.

Lead Button(back to top)

Your device has been set to "power up" in Lead II. You may press the Lead button to look at
any lead on screen, you should see what lead you are in on the top right hand of the screen.

Size Button(back to top)

Your device is set to "power up" at 1.0 size. If you wish or need to adjust the size you would do
so by pressing this button until the size you would like is displayed.

Alarm Suspend Button(back to top)

When the monitor is turned on, all alarms should come up suspended. This allows you enough
time to hook up your patient. Once you press the alarm suspend button, you should enable your
alarms. If an alarm goes off, you should hear a loud beeping, check to see what alarm is
blinking, press the Alarm Suspend button, your alarm should be suspended for 15 seconds to
check your patient and make necessary adjustments. If things get crazy and you want to re-
suspend all the alarms permanently, press the Alarm Suspend button for approx. 5 seconds
until you see X's going through all the alarms.

Recorder Button(back to top)

Pressing the Recorder button should print whatever lead you are in and any readings from
parameters in use. You should press the Recorder button again to stop printing. If you just want
to record and store a "moment in time" or noticed change, simply press the Recorder button
quickly twice and a 6 second strip should be stored in your Code Summary.

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Soft Keys(back to top)

There are five soft keys located directly under the screen. As mentioned above, the options will
changed based where the dial is turned. You should mainly be in the "Monitor" section when
using soft keys, here is your "Main Menu" of soft keys in the Monitor section:

Main Menu

 Param: This is to make adjustments per patient on all parameters on

Your device (NIBP, EtCO2 and SpO2). You should use this button a lot
For NIBP and EtCO2.

 Wave 2: This allows you to scroll between what Lead you are in and EtCO2, or
what Lead you are in and SpO2, or back to what Lead you are in.

 ID #: You may enter a Patient Name here. You also have the option to enter a
Patient Name when in the 12-Lead section. This is here for patients you aren't
doing a 12-Lead on, but want to enter their name for the report.

 Alarms: This shows you the default alarms for all parameters, you may make
changes from here or enable/disable certain alarms as necessary per patient.

 12-Lead: This is where you go to get into the 12-Lead Monitoring section.

Summary Button(back to top)

There are three main uses in the Summary section

1. Print Chart option: allow you to print the patient's code summary. You may choose Print
All or Print Range. If Print All is chosen, everything in the device will be printed. If the
Print Range is chosen, you will then be given the option to scroll through events and
start printing from a particular event. This is useful when multiple patient records are
stored in the device, but you don't want to print everything in there, you would then scroll
to the start of the patient you wish to print, then press print and everything from that point
on will be printed.
2. Print Log option: allow you to print an overview of your entire call, every event with the
time. If there are multiple patients stored in the device, you would receive a log of
everything in there, all patients, and all events.
3. NIBP History option: This should provide you with on-screen trending of your blood
pressures. You may choose to print from this field, you would receive trending of all
blood pressures, heart rate, SpO2, and EtCO2 trending.

Since you may not want to store multiple patients in your device, after you have printed
everything you want, hold the Summary button in for 5 seconds until "Erasing Report" is
displayed on screen. You are getting rid of all history of reports in the device.

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Code Markers(back to top)

By pressing the Code Marker button, you should be given options of up to 20 interventions per
section (Monitor/Defib/Pace). These may be entered specific to your protocol. Once you press
the Code Marker button you should see interventions come up on the bottom of the screen
press the soft key that corresponds with that
intervention. Use the "More" soft key to see additional interventions. Once you have marked an
intervention was used, you have date/time stamped it and should get a 6 second strip
associated with that Code Marker in your code summary.

NIBP Button(back to top)

By pressing the NIBP button you may take a single pressure. If you press and HOLD the NIBP
button for 3 seconds, it should automatically start a STAT mode. The cuff should auto inflate to
180, if a pressure is not obtained at 180, the cuff should re-inflate until a pressure is obtained.

In order to make changes per patient and start Stat and Auto intervals, Adjust cuff inflation or
change the Auto interval time, see below:

Start an Auto Interval: Your device has been set to default with a 5 minute Auto Interval.
To start an Auto Interval, select the "Param" soft key from the main menu, NIBP should
be highlighted, hit Enter. Now all soft keys correspond with NIBP.
Stat: Takes as many blood pressures as it can in 5 minutes, up to 10 readings
Auto: Should take a blood pressure every 5 minutes (or whatever you change it to)
Cuff Inflation: To adjust the cuff inflation, you would choose this soft key and
increase/decrease the cuff inflation for the next pressure
Auto Interval: This is where you would go in and change your Auto Interval time (from 5
minutes to whatever you want). Once you make the change, hit Enter, then you should
still have to hit Auto in order to start the Auto Mode.

To take a single pressure in between the Auto interval, you may do so by hitting the NIBP
button, this should take a single pressure, but not change your Auto interval. You may take a
reading anytime after the first 30 seconds of the last pressure.

Troubleshooting NIBP: If you are having difficulty obtaining a pressure, make sure patient is
stabilized, check cuff and hose are connected properly, stabilize the NIBP hose, this often
alleviates any vibrations and helps speed up the reading.

12-Lead Monitoring(back to top)

Press the 12-Lead Button to enter the 12-Lead Monitoring Section.

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For an Interpretive 12-Lead:

Press PT Info, enter Age, press Enter, then enter Sex, press enter, hit Return, then Acquire. (if
you don't press "Enter" while putting in the Age and Sex it should default back to a 41 year-old
Male).

Troubleshooting: If you run into artifact in a few leads or dark lines in some of your leads, try
adjusting the filter on the 12-Lead to reduce this "noise", this is done by hitting "Settings", then
"Filter", highlight 0.5 - 40 Hz, press Enter, then Aquire to get another 12-Lead at that setting.
This should help alleviate most noise. We have your monitor defaulting to 0.5 - 150 Hz because
this
is the most diagnostic view.

EtCO2(back to top)

When not in use, leave unplugged! This should alleviate drainage on the battery and should
keep the device from "talking" to you. Always keep a disposable Adult/Pedi adapter clipped in
ready to go, if you don't and you have it plugged in, it may try to read open air and "talk" to you.
When EtCO2 monitoring is needed, plug in the cable, and allow the sensor to warm up (should
take 15 seconds up to 1 minute) and "Warm up" will be displayed near the top right hand corner
of the screen.

Your monitors are set to default with O2 compensation with EtCO2 monitoring.O2 and NO2
compensation should be entered in order for your reading to not be compromised.

To Change/Add Compensation for O2 or NO2:

From the main menu, hit "Param" soft key, select EtCO2, then Comp, highlight the desired
option (either O2, Nitro, or Both). Again, you should compensate when using more than 60% of
either one. Make sure to hit Enter so your request is accepted. You should see one asterisk* or
two asterisks** depending if you are compensating for one (O2 or NO2) or both (O2 or NO2).

To View your Waveform on screen:

From the Main Menu, hit the Wave 2 button. You may also print your waveform by pressing
Recorder. Press Recorder again to stop printing.

To Check your sensor and cable to make sure they are functioning properly, clip the sensor into
the REF cell (you should see a Zero (0) and REF cell plug on the cable), when in the REF cell,
you should see your EtCO2 reading displayed as 38 mmg (+/- 2) and the waveform (Wave 2
button) should show a straight line across the screen. This means your cable/sensor is
operating properly.

Troubleshooting: If the device "talks" to you and says:

Zero CO2 Adapter?/Check CO2 Adapter alternate = Airway adapter was removed,
occluded or Adapter Zeroing needs to be performed or was performed incorrectly (for

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example if CO2 was present in the adapter during zeroing). Replace/Clean airway
adapter, perform Adapter zeroing.

Use Room Air Adapter: Adapter zeroing started with CO2 in adapter, or the adapter is on
the "REF" or "0" Cell.

To perform a CO2 Adapter zeroing

Hit Param key, then highlight EtCO2, then hit Zero, then highlight Start (this is the default) then
Enter. Watch on screen, you should see when it tells you that the Adapter Zeroing process is
taking place. These are commonly seen messages, all messages are listed in your Operator's
Guide.

Please, Please, Please read your Operator's Guide for specific and more detailed
information on your monitor. The more familiar you are with this device, the faster you
should be able to make life-saving decisions.

Revision Date 1/26/09 504

 Montgomery County Hospital District-EMS EZ IO HUMERAL PLACEMENT
PROVISIONAL PROCEDURE
Standard Delegated Orders –
Appendix APP 15 Page 505
TOC

EZ IO HUMERAL PLACEMENT

Indication:
Any adult patient (>45 kg) for who, you are unable to obtain peripheral vascular access after
2 attempts or 90 seconds and that has one or more of the following:
 Hemodynamic instability
 Respiratory compromise
 Patients requiring EMERGENCY medicinal therapy or volume replacement

May be used without consult in Cardiac Arrest and Post Resuscitation Management

Consult Required for Placement in all other patients

 Any patient that treatment warrants vascular access, but peripheral access has been
unobtainable
 UNDER NO CIRCUMSTANCES should it be used for prophylactic care

Contraindications:
1. Patient‘s weighing less than 45 kg.
2. Any patient that may receive fibrinolytic or thrombolytic therapy; specific to Active MI
and/or Stroke.
3. Hypoglycemic patients needing D50; EXCEPTION ONLY is Cardiac Arrest.
4. Suspected fracture of the associated humorus.
5. Prosthetic devices on the insertion site
6. Extremity that is compromised by a pre-existing medical condition. i.e. tumor or PVD
7. Overlying skin infection/trauma at placement site
8. Inability to locate the 3 anatomical landmarks for insertion
9. Excessive tissue over the insertion site.
10. Patient‘s at risk of NO Transport: i.e., Unconscious Hypoglycemic (Diabetic)

Equipment:
 EZ-IO™ Driver
 EZ-IO™ Needle Set
 Provo-iodine, Betadine or Iodine swabs or prep pads
 IV setup and/or optional extension tubing
 10cc or 20 cc Syringe
 Roller gauze

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PROVISIONAL PROCEDURE
Standard Delegated Orders –
Appendix APP 15 Page 506
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Procedure:

1. Don PPE
2. Determine if EZ-IO™ is indicated and no contraindications are present.
3. Locate proper site for EZ-IO™ insertion.

4. HUMORAL HEAD PLACEMENT

a. Expose shoulder and adduct humerus (arm against supine patient‘s body)
b. PRIMARY TECHNIQUE TO LOCATE INSERTION SITE
Palpate and identify the mid-shaft humerus and continue palpating toward the
proximal aspect of the humeral head. Identify the greater tubercle insertion
site. Pinch the anterior and inferior aspects of the humeral head while
confirming identification of the greater tubercle. This ensures that the midline
of the humerus is identified. Consider alternative means of placement
identification to ensure proper location
c. ALTERNATIVE INSERTION SITE IDENTIFICATION
i. Identify the acromion and the coracoid process by walking your index and
middle finger along the clavicle to the shoulder‘s lateral end.
ii. Identify the greater tubercle insertion site approximately two finger widths
inferior to the coracoid process
d. Once the insertion site has been identified, place the patient‘s forearm on the
patient‘s abdomen, leaving the elbow on the ground or stretcher.
e. DO NOT ATTEMPT INSERTION MEDIAL TO THE GREATER TUBERCLE
AT ANY TIME.
5. Cleanse the insertion site with betadine/iodine or similar prep-pads using
accepted aseptic technique. Remember to work from the inside to the outside in
concentric circles.
6. If patient is conscious, inform patient of the EMERGENT need to perform
procedure and that they might feel some discomfort until Lidocaine is
administered. Obtain consent from patient; recall that the patient has the right to
refuse. You may consider an anesthetic/analgesic if indicated by medical
direction.
7. Prepare the EZ-IO™ Driver and Needle Set.
a. Open the case and remove the driver and needle set cartridge.
DO NOT USE IF SAFETY SEAL IS NOT INTACT
b. Open the cartridge and attach the needle set to the driver
c. Remove needle set from the cartridge.
d. Inspect the Needle Set for protective cap, 5 and 10 mm indices, and if the
needle set is intact
e. Remove the protective cap from the needle set.
8. Begin insertion of the EZ-IO™
a. Hold the EZ-IO™ Driver in one hand and stabilize the leg near the insertion
site with the opposite hand.
b. Position the driver at the insertion site at a 90o angle to the bone surface.

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PROVISIONAL PROCEDURE
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c. Power the driver through the skin at the insertion site until it makes contact
with bone.
d. Evaluate the EZ-IO™ needle for the 5 mm mark
9. Power the EZ-IO™ Driver and continue insertion until the flange (base) of the EZ-
IO™ needle set touches the skin OR a sudden lack of resistance is felt,
indicating entry into the marrow cavity.
10. Remove the driver from the needle set.
11. Remove the stylet from the catheter. DO NOT REPLACE or ATTEMPT to recap
the needle set.
12. Confirm proper EZ-IO™ Catheter tip position by checking for several of the
following:
a. IO catheter standing at 90o and firmly seated.
b. Blood at tip of the stylet.
c. Aspiration of marrow
d. Bolus and flow fluid through the needle with no evidence of extravasation.
13. Connect IV tubing or extension set and begin infusion.
14. Rapid Bolus site with 10 ml of NS to flush medullary space.
15. If site does not flow, consider a rebolus, pressure infusion and/or rotate needle
180o. Repeat this step as necessary.
16. Attach VidaCare wrist band
17. DISPOSE OF SHARPS

Rescue of IO failure:
Patients failing IO access should be rescued by
A) Tibial IO placement
B) Repeated attempts at standard vascular access including peripheral lines if permitted
by operational protocols.
C) Patients failing standard vascular access under rescue attempt ―A‖ may undergo a
second IO placement attempt in the opposite humoral head or tibia.

IF PATIENT IS CONSCIOUS FOR PROCEDURE OR HAS PAIN RESPONSE

1. Administer bolus 50 mg (2.5 ml) of Lidocaine 2% SLOW push for local analgesia.
This shouldprobably provide pain relief for up to 1 hour.
2. CONSULT ONLY: Consider pain management for additional discomfort/pain
associated with infusion

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 Montgomery County Hospital District-EMS POINT OF CARE CARDIAC
MARKER
PROVISIONAL PROCEDURE
Standard Delegated Orders –
Appendix APP 16 Page 508
TOC

Indications:
 Patient(s) meeting criteria or suspicion for Acute Coronary Syndrome who are
transported to Conroe Regional Medical Center or Kingwood Medical Center

Contraindications:

 None

Equipment:

 Point of Care Marker Reagent

 Pipette
 Purple top Blood Tube
 Equipment necessary for routine blood draw

Procedure:
 Don appropriate Personal Protection Equipment
 Draw blood into blood tubes after obtaining vascular access
 Open the Cardiac Marker Reagent and place in a horizontal position
 Remove the cap from the Purple top tube
 Insert pipette into purple top and fill the pipette with blood sample
 Place cap back on purple top tube
 Squeeze cotents of pipette onto Reagent collection site (Inoculate the Reagent)
 Label blood tubes with the following information:
 Date of service
 Time blood was drawn
 Patient‘s name
 Your initials
 Label the Reagent with the following information:
 Patient‘s name
 Time the Reagent was inoculated
 Dispose of contaminated material in appropriate manner
 Complete accompanying documentation form
 Deliver Reagent, blood tubes, and documentation to receiving facility personnel so
they may perform the test and obtain reading

Revision Date 03/29/2006 508

 Montgomery County Hospital District-EMS IMPEDENCE THRESHOLD
DEVICE (ResQPOD®)
Standard Delegated Orders –
Appendix APP 17 Page 509
TOC

Impedance Threshold Device (ResQPOD®)

General:
An Impedance Threshold Device (ResQPOD®) selectively impedes inspiratory gases
from entering the lungs during the decompression phase (upstroke) of CPR. This
generates a greater negative pressure in the thorax, allowing for an enhanced venous
return to the heart. As a result of greater venous return, increased preload is
accomplished, which generates a greater stroke volume during the subsequent
compression phase (downstroke) of CPR, which leads to increased blood flow.

Indication:
Any patient (>10 kg) in cardiac arrest
Contraindications:
 Traumatic Cardiac Arrest
 Patients <10 kg
 Flail Chest
 Uncontrolled hemorrhage
 Patients with a pulse
Procedure:
1. Begin CPR ensuring proper rate and depth, and allowing for complete chest recoil
during the decompression phase of chest compressions
2. Select the airway adjunct (mask, endotracheal tube, Combitube, etc.)
3. Attach Impedance Threshold Device (ResQPOD®) to the airway adjunct used
above.
4. Attach the EtCO2 detector between the ITD and the ventilation source (BVM or
ventilator)
5. If ventilating with a mask (pt is not intubated):
 Do not use the timing assist light
 CPR continues at 30 compressions : 2 ventilations
 Pause compressions to deliver the ventiliations
6. If patient is intubated endotracheally or with a Combitube:
 Deliver a single one-second ventilation with each flash of the timing assist light
 Do not pause compressions to deliver ventilations. Ventilations may be
asynchronous to compressions.
7. Use of this device must be discontinued once ROSC has been achieved, or when
CPR is no longer necessary.

Revision Date 11/25/2008 509

 Montgomery County Hospital District-EMS Metoprolol
Standard Delegated Orders –
Appendix APP 18 Page 510
TOC

Metoprolol
(Lopressor)

Medication
Metoprolol is a Beta1 selective blocker used decrease the automaticity of cardiac
contractions.
Mechanism of Action
Competitively blocks beta-adrenergic receptors in the heart and juxtaglomerular
apparatus, decreasing the influence of the sympathetic nervous system on these tissues
and the excitability of the heart, decreasing cardiac output and heart rate. Thus the
workload and oxygen demand of the heart is reduced. Metoprolol does not produce
coronary vasodilatation but leads to a shift and redistribution of coronary circulation to
the ischemic areas, thereby decreasing the release of renin from the kidney, thus
lowering blood pressure. Additionally, it acts in the CNS to reduce sympathetic outflow
and vasoconstrictor tone.

Indications
Acute Coronary Syndrome
Cardiac Ischemia
STEMI
Contraindications
Absolute:
• Heart Rate <60 bpm
• Systolic Blood Pressure <100 mmHg
• 2nd and 3rd degree heart block
• 1st degree heart block with PR interval > 0.24 sec
• STEMI precipitated by cocaine use
Relative:
• Pregnancy-2nd and 3rd trimester
• Cardiogenic shock
• Active CHF
• Active Asthma
• COPD

Side Effects
Bradycardia Exacerbates bronchospasm
Heart Block Dyspnea
hypotension Dizziness
Exacerbates CHF Fatigue
Headache Depression

Dosage & Administration

ADULT: 5 mg IV/IO q5 min up to 3 doses (15 mg)
PEDIATRIC: Not recommended

Special Considerations
None

Revision Date 05/21/2007 510

 Montgomery County Hospital District-EMS Intranasal Medication
Administration
Standard Delegated Orders –
Appendix APP 19 Page 511
TOC

Indications:
 Medication administration when IV access is not obtainable or undesirable. To
provide an alternative method for needleless medications delivery.

Contraindications:

 Facial trauma
 Epistaxsis
 Nasal congestion or discharge
 Recent nasal surgery
 Recent cocaine use
 Increased mucous production
 NG or NT tube in place
 Any other recognized nasal mucosal abnormality

Procedure:
 Patient should be in a recumbent or supine position. If the patient is sitting,
compress the nares with a gloved finger for 1-2 minutes after administration
 Draw up medication into a 1 ml or 3 ml syringe with luer-lock tip
 Expel any air within the syringe
 Attach the MAD to the syringe and confirm that it is secured firmly to the syringe
 Visually inspect nares and chose the largest nare or the one with the least
obstruction
 Insert syringe with the MAD attached into the nares until resistance is met
(approximately 1.5 cm)
 Timing the respirations, depress plunger rapidly upon patient exhalation but before
inhalation
 Briskly compress the syringe plunger rapidly upon patient exhalation but before
inhalation.
 The MAD is reusable on the same patient, dispose after each patient

Precaution and Comments:

 No more than 1 ml of medication should be administered per nostril
 No more than 0.5 ml of medication should be administered per nostril for children
under 10 years
 May repeat administration q 5 minutes

Revision Date 08/01/2007 511

 Montgomery County Hospital District-EMS Induced Hypothermia
Standard Delegated Orders –
Appendix APP 20 Page 512
TOC

Indications:
 Any nontraumatic and nonhemorrhagic arrest or post arrest patient over the age
of 16 years who is NOT in an awake and alert status with purposeful neurologic
function.
 Post arrest patient with GCS <9
 Initial temperature > 34°C (93.2ºF)
 Patent airway secured with endotracheal tube (preferred) or combitube.
OR
 Any adult nontraumatic and nonhemorrhagic cardiac arrest greater than 5
minutes without previous signs of hypothermia

Contraindications:
 Traumatic arrest
 Cardiac arrest resulting from or associated with hemorrhage
 Pregnant female with obviously gravid uterus
 Patient whose airway is not managed with either an endotracheal tube or
Combitube unless patient does not respond to CPR for greater than five minutes

General Standards:
 Patients will be cooled to a target range of 33°-34°C (91.4°F - 93.2°F)
 Patients develop metabolic alkalosis with cooling. Do not hyperventilate.
 Patent airway secured with endotracheal tube (preferred) or combitube.
 Otherwise, do not induce hypothermia unless patient does not respond to
CPR for greater than five minutes.

Equipment needed:
 1-liter bags of NaCl IV solution at a temperature of 4°C (39°F)
 IV Tubing
 Pressure infusion device
 Ice packs (optional)
 Versed (no consult needed)
 Vecuronium

Procedure:
 Obtain Temperature prior to inducing hypothermia
 Perform and document Neurological Assessment
 Perform 12-Lead
 If Temperature >34°C (93.2°F) and above criteria are met,
 Establish IV/IO infusion using cooled saline
 Infuse 40 ml/kg of cooled saline via pressure infuser while enroute to an
approved facility. Do not delay transport for the purpose of cooling.
 Monitor patient and continue treatment with appropriate SDO

 Control shivering with:

 Versed 0.1 mg/kg IV/IO
 If Versed does not control shivering
Vecuronium 0.1mg/kg IV/IO (max 10 mg)

Revision Date 03/01/2010 512

 Montgomery County Hospital District-EMS Zoll Digital 12 Lead
Transmission
Standard Delegated Orders –
Appendix APP 21 Page 513
TOC

Indications:
 To facilitate delivery of a 12 lead to a receiving hospital or agency

Contraindications:

 None

Procedure:

 Acquire 12 lead according to PROC 01.

 Connect Zoll Serial Cable to monitor and computer

 Verify computer‘s wifi connectivity to mchdmobile

 Start Zoll Data Real Time and Click ―Real Time‖

 Select ―Current Destination‖ and select receiving agency

 On monitor, select ―Interlink‖ and ―Dial Phone#‖

 Wait for computer to receive upload.

 Select 12 Lead(s) and select ―Send Now‖

 Confirm transmission after a couple of minutes

Precaution and Comments:

 Internet connectivity is necessary

 There is no delivery confirmation. Remember to call the receiving agency for

transmission confirmation.

 Preferred method is to transmit from an analog landline.

Revision Date 02/14/2008 513

 Montgomery County Hospital District-EMS IMPLANTABLE VENOUS
ACCESS DEVICE (iVAD)
Standard Delegated Orders –
Appendix APP 22 Page 514
TOC

General:
 This procedure is to be considered a sterile procedure and should always be performed
with the patient or care-giver‘s consent. The iVAD (also refereed to as a Port-A-Cath)
should be accessed prior to departing the scene. At NO TIME should the device be
accessed while the ambulance is in motion, so as to minimize damage to the site.

 This skill is Paramedic Level Skill only.

 The iVAD is a surgically inserted device connected to the subclavian vein and it is
beneath the skin. Access should ALWAYS occur with a Huber needle. The device is
ALWAYS heparinized when not in use.

 The iVAD should only be accessed with a Huber needle. Other needles will damage
and ruin the device.

 Care should be taken to ensure that this procedure is performed in a near sterile
environment. The most aseptic technique precautions should be used.

 An attempt to withdraw should be made and a minimum of 10cc of blood must be

evacuated to remove heparin from the device. If you are unable to obtain a blood return
from the site, attempt to flush and observe for extravasation of fluid. If the site will not
flush DISCONTINUE the access.

Policy:
 Accessing the iVAD may be performed in lieu of peripheral vascular access when the
patient has a medical condition requiring medication or fluid resuscitation therapy.

 This skill is Paramedic Level Skill only.

 The patient or care-giver may request the EMS crew to access the iVAD if circumstance dictate.

 Accessing the device should be performed when the ambulance is not in motion and preferably
prior to departing the scene.

 For the purpose of this procedure and MCHD-EMS, A CONSULT MUST BE

PERFORMED BY ALL PERSONNEL PRIOR TO accessing the iVAD.

Equipment:

 Huber Needle
 Sharpie or indelible marker
 iVAD prep-kit.
 10 cc or 20 cc Syringe
 IV setup with extension tubing and flushed line. DO NOT uncap distal end of IV tubing
until connected to Huber needle tubing.
 Blood tubes as needed.

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ACCESS DEVICE (iVAD)
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Indications:
For use only in patients that have an iVAD that require medical intervention. This is not a
regular and customary vascular access site, when the patient does not require urgent
medical therapy.

Precautions:
Ensure near sterile or most aseptic technique as possible when accessing to minimize the risk
of nosocomial infection.

Complications:
 Flushing of Heparin into patient from iVAD
 Mechanical obstruction resolved by having the patient shrug shoulders or lean forward to
reduce pressure on subclavian vein.
 Embolization of microthrombi. This occurs free flowing IV fluid breaking off microthrombi
at the catheter‘s distal tip. ALWAYS aspirate at least 10ml of fluid from the catheter prior
to flushing with fluid or medication.
 Air embolism. Prime all tubing prior to infusion including needle set.
 Contamination or infection
 Bleeding due to unclamped tubing
 Catheter breakage and kinking. Inspect equipment prior to using for damage or visible
kinks.
 Catheter dislodgement.

Procedure:

1. CONSULT as indicated
2. Obtains consent from patient (if not previously obtained)
3. Gather and assemble equipment.
4. Prime IV tubing, huber needle and attached tubing with saline.
5. Exposes skin and palpates VAD
6. Examines site for infection, redness, swelling, pain or other complications. If these exist,
DO NOT ACCESS SITE. If the site feels to deep or the site is turned or rotated and you
do not feel comfortable accessing it, DO NOT ATTEMPT.
7. Identifies edges of iVAD and center with fingers.
8. Turns patient‘s head away from the insertion site.
9. Dons either sterile gloves or a clean set of examination gloves.
10. Cleanse area with Chloraprep for a minimum of 90 seconds. If Chloraprep is not
available then use provodine-iodine preps working from the center out in a circular
motion. Repeat this a minimum of 3 times with increasingly larger concentric circles.
11. Allow the site to completely dry. DO NOT blot, blow, or wave a hand past to dry site.
These increase the potential for infection.
12. Close clamp on tubing attached to huber needle until ready to aspirate.
13. Stabilize the site with one hand and with the other, insert the needle at a 90o angle
through the skin and septum of device.

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14. Feel resistance of needle touching the back of the port to avoid subcutaneous
placement.
15. Attempt to Aspirate 10 ml of blood to clear heparin and ensure patency of site. WASTE
THIS BLOOD. If you are unable to obtain a blood return from the site have the patient
raise their arm on the side of the iVAD. If blood return is still not obtained,
CONNECT a flushed saline lock and secure site as noted in step 18 and 21.
DO NOT FLUSH OR FLOW FLUID THROUGH THE SITE. LEAVE THE
NEEDLE IN PLACE AND NOTIFY ER STAFF UPON YOUR ARRIVAL, of the
inability to ensure patency of the site by blood return.
16. Aspirates additional blood as needed using vacuutainer luer adapter for laboratory
collection tubes.
17. Connect IV tubing and flush with saline solution to clear blood and establish patency of
line.
18. Secure needle with sterile dressing. Use folded 4x4‘s on either side of needle and cover
with tegaderm provided in access kit or clear tape. Treat the device as if it were an
impaled object.
19. Observe for signs of infiltration.
20. DO NOT ALLOW IV BAG TO RUN EMPTY. IF AIR ENTERS THE DRIP
CHAMBER THIS WILL CAUSE AN AIR EMBOLISM AND CAN KILL THE
PATIENT. TO AVOID THIS, CONSIDER THE FOLLOWING
 Keep IV Bag vertical at all times.
 Ensure that IV bag has fluid.
 Continually monitor flow and ensure that drip chamber is NEVER dry.
 Do not lay IV bag on patient, between their legs, or in such a position that air can
enter the drip chamber.
21. Label edge of tegaderm with the following:
 Date accessed
 Time accessed
 Initials of person accessing
22. Document
 Time of access
 Patency of site
 Site appearance

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 Montgomery County Hospital District-EMS Controlled Substances
Standard Delegated Orders –
Appendix APP 23 Page 517
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Intent

The following policy will define the usage and tracking of all scheduled injectables (controlled
medications) within the MCHD System. The goal of the policy is to ensure chain of custody as well
as documentation of two (2) MCHD EMS employee signatures that all controlled medications are
accounted for at the beginning and end of each shift.

The procedures contained in this document constitute guidelines only. The Clinical Department
cannot anticipate all extraordinary circumstances that may occur during patient care and the
administration of controlled medications. Unusual events should be investigated and addressed on
a case by case basis, reviewed by the Assistant Director of Clinical Services and the Medical
Director to ensure necessary safeguards are in place to maintain the chain of custody required by
Federal and State Rules and Regulations.

Failure at any time to maintain the chain of custody for controlled medications as described in these
guidelines could result in disciplinary action for all involved MCHD-EMS employees up to and
including termination.

General Information
Ideally the controlled medications should be signed for at the beginning of each shift with the ―off-
going‖ and ―on-coming‖ In-Charge EMT-P‘s present. The weekly sign-in sheet should reflect the
number of controlled medications counted with documentation of each of the unique numbers
assigned or a Controlled Substance Usage and Tracking Form to account for any controlled
medications administered during the previous shift that has not been replaced by a Squad medic or
Supervisor. The on-coming Paramedic should sign in the ―on coming‖ space as receiving the
controlled medications and the Paramedic leaving signs as ―off-going‖ to document transfer of
medications. Failure to count and sign for the controlled medications at the beginning of shift may
result in disciplinary action for all In-Charge paramedics involved including but not limited to the
following:

1st offense - written employee action notice

2nd offense - 48 hours off
3rd offense - 96 hours off
4th offense - termination

It is unacceptable for the In Charge paramedic on shift to sign out BEFORE the end of shift (you
should not sign in and out at the same time). Failure to comply may result in disciplinary action.

Late Call and Posting Assignments

In the event that a medic unit is assigned an emergency response or post assignment near the end
of shift before transfer of the controlled medications can be completed as described above or the
oncoming In-Charge EMT-P arrives on the scene of an assigned response and assumes patient
care, the following guidelines should be followed. The In-Charge paramedic should complete the
sign-in sheet as soon as possible after the call is completed with his/her attendant partner as the
witness. Signatures go in the ―on coming‖ signature box to ensure chain of custody and document
the Incident number of the late call or the time the post assignment was assigned in the ―off Going‖

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signature box on the tracking form. This will indicate to the Clinical Department as well as the
Supervisor why the signature is missing and that disciplinary action is unnecessary.

Policy violations will remain on file for a six (6) month period and may be considered in a
promotional process as a disciplinary violation of Clinical Guidelines as described in Controlled
Substances (CG 35)

The on-coming In-Charge EMT-P or a designated ICT/ICE candidate is responsible for carrying the
key for the controlled medications on his/her person at all times during the shift.
When a situation occurs that requires the In-Charge EMT-P to leave work during the shift, the In
Charge and the Attendant should count and sign for the controlled medications before the In
Charge leaves the station. The In Charge will release custody of the controlled medication keys to
the Attendant assigned to the MICU for the remainder of the shift. There may be situations when
the In Charge and attendant cannot count before the In Charge leaves (illness/accident requiring
transport to a medical facility, etc). In these situations the Attendant should contact his Supervisor
and the Supervisor and Attendant should count and sign for the controlled medications. When the
replacement In-Charge arrives at the station to complete the shift the In Charge and Attendant
should count and sign for the controlled medications to ensure the chain of custody is followed and
documented.

Peak and Special Event Units

MCHD employees assigned to a Peak Unit (In-charge and Attendant) or covering a Special Event
(refer to CG 17 in protocols), when a face-to-face exchange of the controlled medications with an
off going crew is not practical, the controlled medications should be counted with their partner and
both employee signatures should be in the ―on coming‖ space. At the end of shift this process
should be repeated as the ―off going‖ crew and the controlled medications should be secured.

In situations where it is unclear who should be responsible for the controlled medication key (both
crew members are in charge paramedics or the MICU is staffed by attendant paramedics for special
events) the employee with the most time at MCHD should be responsible for and carry the
controlled medication key.

Administration and Replacement of Controlled medications

Controlled medications may be administered by MCHD employees who are authorized by protocol
in Clinical Guidelines 11 (Medical Authorization Levels).
Paramedic Students are allowed to administer controlled medications and other medications under
the direction of their Preceptor.
After administration of a controlled medication the Paramedic administering the medication should
complete appropriate fields of the Controlled Substance Usage and Tracking Form. Supervisors
may refuse to replace controlled medications if/when information is missing. Any medications not
administered to a patient should be disposed of at the receiving facility.
Only MCHD employees should witness the disposal of an unused controlled medication and their
name and signature should be documented on the replacement form. If the controlled medication
was administered by a student the preceptor should complete the top portion of the replacement

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form and have his partner witness the waste of controlled medications that were not administered to
the patient.
The completed usage and tracking form should remain with the controlled medications as it
documents why a specific medication is missing and the unique tracking number assigned to the
controlled medication should be documented in the PCR. Contact a Supervisor or Squad Medic for
replacement.
With appropriate documentation, the medic unit may remain in-service with the minimum of one (1)
of each controlled medication while awaiting replacement. An MICU should be placed out of
service anytime all of one (1) controlled medication has been depleted (i.e. all the valium carried on
the unit has been used) and a Supervisor or Squad Medic should be contacted for replacement as
soon as possible.
PIII‘s assigned to a Squad may replace controlled medications to a medic unit after all paperwork
has been documented. A Squad may remain in service even though their controlled medication
supply is depleted. The completed usage and tracking form should remain with the controlled
medications as it documents why a specific medication is missing. They should contact a
Supervisor for replacements as soon as possible.
Expired Controlled medications
All controlled medications should be checked frequently for expiration dates and may be
administered through the end of a month (e.g. expires 6/02), unless the expiration date specifies a
specific date (e.g. 6/01/02). If possible, medications nearing their expiration date should be
administered first in appropriate situations as controlled medications cannot be returned or
exchanged. A supervisor should be contacted for replacement before the medication expires.
Units/stations with expired controlled medications may result in disciplinary action for all MCHD-
EMS Employees who have been responsible for maintaining the chain of custody for the controlled
injectables.
Reverse Controlled medication Disposal for Expired Medications and/or Compromised
Security Seals
To ensure compliance with Federal DEA and State Laws, MCHD will no longer dispose of expired
controlled medications at outlying stations/locations when the Tamper Resistant Seal is intact. The
procedure for replacing expired controlled medications should be as follows:

 Contact your Supervisor and advise them you have controlled medications that are
expired/expiring.

 The expired controlled medications should be exchanged with the Supervisor with
the Tamper Resistant Seal Intact and completed paperwork. The Supervisor will
return the expired controlled medications to the Clinical Department for disposal.

 Controlled medications that are discovered with broken seals should be exchanged
as they are with an unusual occurrence report attached to the Controlled
Substance Usage and Tracking Form describing how you found the controlled
medication. The replacement form and the compromised controlled medication
should be returned to the Clinical Department for disposal.

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End of Document