ABBREVIATION LIST

ALOC Altered Level of Consciousness

ABC’s Airway, Breathing, Circulation
ACLS Advanced Cardiac Life Support
AED Automatic External Defibrillator
AICD Automatic Implantable Cardiac Defibrillator
ALS Advanced Life Support
AMI Acute Myocardial Infarction
AMS Altered Mental Status
AMR American Medical Response
ASA Aspirin
AV Atrial Ventricular
BHPC Base Hospital Physician Contact
BLS Basic Life Support
BP Blood Pressure
bpm Beats Per Minute
BSI Body Substance Isolation
BVM Bag Valve Mask
CaCl Calcium Chloride
CC Chief Complaint
C-spine Cervical Spine
CHF Congestive Heart Failure
COPD Chronic Obstructive Pulmonary Edema
CPR Cardiopulmonary Resuscitation
CVA Cerebral Vascular Accident
D12.5%W Dextrose 12.5% in water
D50%W Dextrose 50% in water
DKA Diabetic Ketoacidosis
DM Diabetes Mellitus
DNR Do Not Resuscitate
ED Emergency Department
EKG Electrocardiogram
EMS Emergency Medical Services
Epi Epinephrine
ET Endotracheal Tube
ETT Endotracheal Tube
gm Gram
GCS Glasgow Coma Scale
HazMat Hazardous Materials
HEENT Head, Eyes, Ears, Nose, Throat
HTN Hypertension
IO Interosseous
IM Intramuscular
ITLS International Trauma Life Support
IV Intravenous
IVP Intravenous Push (IV push prefed)
kg Kilogram
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Abbreviation List 2008
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J Joule
LOC Loss of Consciousness
Max Maximum
mcg Microgram
meds Medication
mEq Milliequivalent
min Minute
mg Milligram
MI Myocardial Infarction
mL Milliliter
MVC Motor Vehicle Collision
NPA Nasopharyngeal Airway
NPO Nothing Per Mouth
NS Normal Saline
NT Nasal Tube
NTG Nitroglycerine
NS Normal Saline
O2 Oxygen
OB Obstetrical
OD Overdose
OPA Oropharyngeal Airway
OPQRST Onset, Provoked, Quality, Region and Radiation, Severity, Time
OTC Over the Counter
PAC Premature Atrial Contraction
PALS Pediatric Advanced Life Support
PEA Pulseless Electrical Activity
PHTLS Prehospital Trauma Life Support
PID Pelvic Inflammatory Disease
PO By Mouth
Pt. Patient
prn As needed
PVC Premature Ventricular Contraction
q Every
QRS Ventricular Conduction Complex
RMC Routine Medical Care
R/O Rule Out
RIVP Rapid Intravenous Push (rapid IV push preferred)
SAD Semi-Automatic Defibrillator
SBP Systolic Blood Pressure
SL Sublingual
SOB Shortness of Breath
SIVP Slow Intravenous Push
STEMI ST Elevation Myocardial Infarction
SVT Supraventricular Tachycardia
TIA Transient Ischemic Attack
TBSA Total Body Surface Area
TCA Tricyclic Antidepressant
TCP Transcutaneous Pacing
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Abbreviation List 2008
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V-Fib Ventricular Fibrillation
V-Tach Ventricular Tachycardia
w/o Without

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Abbreviation List 2008
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 BIBLIOGRAPHY OF STANDARD TEXTS
(Updated January 2009)

Brady Paramedic Care : Principles and Practice, Volume 1-5: Introduction to

Advanced Prehospital Care (2nd Edition) Prentice Hall; 2nd edition (March 7,
2005).

Advanced Cardiac Life Support (ACLS) Manual, American Heart Assocaiton,

2005

2005 American Heart Association Guidelines for Cardiopulmonary Resuscitation

and Emergency Cardiovascular Care. Circulation, 2005;Vol 112, Number 24.

PHTLS: Basic and Advanced Prehospital Trauma Life Support Revised. Fourth
Edition, 2003, Mosby, St. Louis.

Mosby’s Paramedic Textbook (Revised Reprint) Second Edition, 2001, Mosby,

St. Louis.

EMT Prehospital Care, 2004, Mosby, St. Louis.

Pediatric Advanced Life Support Manual (PALS): American Heart Association,

2005

Pediatric Education for Prehospital Professionals (PEPP), Second Edition

(Paperback) American Academy of Pediatrics. Jones and Bartlett Publishers,
Inc.; 2nd edition (June 1, 2005).
 HOW TO USE THESE PROTOCOLS

Introduction
The use or possession of the protocol book does not exempt field personnel from
the responsibility to know the information in the San Mateo Policy and
Procedures Manual. This Protocol Book does not replace the Policy and
Procedures Manual and is provided as a tool for their reference.

Basic Life Support

Each Treatment Protocol section begins with Basic Life Support techniques and
then proceeds to Advanced Life Support techniques. This is done to facilitate
continuity of care between BLS and ALS personnel responding to the same
patient. Start by instituting BLS measures, then proceed to ALS measures as
dictated by your skill level and your patient assessment. Utilize good judgment
and consider additional resources as needed.

Routine Medical Care

A group of standard assessments and treatments, including but not limited to
airway, breathing and circulation, and the use of routine monitoring devices.
Routine Medical Care (RMC) is described in the Primary and Secondary Survey
Sections. RMC is provided to every patient as guided by your assessment of the
scene and the patient’s condition.

Care Outside of Protocol Guidelines

No set of protocols can cover all patient problems. When dealing with a situation
not addressed by a Standard Treatment Protocol, utilize other pre-existing
standard life support guidelines, including PHTLS, ACLS, PALS, and good
medical judgment. We encourage the use of Base Physician contact in such
events.

Universal Precautions
Disease agents may be present in any body substance or fluid, and the presence
of disease agents may or may not be known. Clinically healthy individuals may
carry and be capable of transmitting these agents. Precautions with all patients
shall include routine use of appropriate barrier precautions to prevent skin and
mucous-membrane exposure when contact with blood or other body fluids is
anticipated.

Prehospital personnel who are exposed to potentially infectious materials should

immediately follow the reporting procedures set up by their agency. Notification
should not routinely be made to the EMS Agency or to the San Mateo
Department of Public Health.

Hospital emergency departments have specific requirements for managing

exposure to body substances experienced by prehospital care personnel.
Emergency departments are expected to actively assist prehospital personnel in
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evaluating risk and recommending and/or providing appropriate prophylactic care
when needed. Emergency responders are expected to identify the source
patient to the hospital, and to comply with emergency department procedures
(e.g. Royce log) when reporting potential exposure to infectious materials.

Prophylactic care recommendations for health care workers are found in the
CDC September 30th, 2005 MMWR "Updated U.S. Public Health Service
Guidelines for the Management of Occupational Exposure to HIV and
Recommendations for Postexposure Prophylaxis". Emergency departments are
expected to follow these guidelines when managing prehospital exposure to
potentially infectious substances.

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 SAN MATEO COUNTY
EMS AGENCY
MISSION STATEMENT

Emergency Medical Services (EMS) provides an integrated and coordinated

system of services to ensure appropriate, timely, and respectful emergency
medical care to meet the needs of patients and their families in San Mateo
County.

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 Pediatric Definitions

The definition of a pediatric patient for the purposes of San Mateo County EMS
protocols is age less than 15 years or a length-based weight (per Broselow Tape)
of 36 kg or less. Patients who are known to be less than 15 years of age but
whose weight exceeds 36 kg may still be considered pediatric patients given their
chronological age; however weights will then need to be estimated and adult
dosages should be used.

The following are age classifications of pediatric patients that may assist
prehospital personnel in their assessment and management of pediatric patients.

• Neonate: newborn up to first 28 days of life

• Infant: comprises neonatal period up to 12 months
• Toddler: 1-3 years
• Pre-school: 3-5 years
• School-age: 6-10 years
• Adolescent: 11-14 years

Children with Special Health Care Needs (CSHCN) are children who have any
type of condition that may affect normal growth and development. This may
include physical disability, developmental or learning disability, technologic
dependency, and chronic illness. CSHCN may be any age. It is important to
consider developmental age, rather than chronological age when working with
this population.

General Approach to Caring for the Pediatric Patients

• Allow the parent/caregiver to remain with the patient whenever possible.
• Adolescents may want to be examined without parent/caregiver. Honor
their request if possible and provide them with privacy.
• Obtain history from both older children and adolescents and their
parents/caregivers.
• Approach child slowly and calmly. Observe level of consciousness,
activity level and respiratory rate/effort before touching.
• Compare assessment findings with parents’/caregivers’ description of
normal behavior.
• Be honest with the child and parent/caregiver. Explain all procedures to
older children and adolescents directly.
• Allow child to hold a familiar security object. Use distraction techniques to
assist in gaining cooperation.
• Acknowledge positive behaviors, no matter how small.
• Perform the most distressing components of the assessment last on
infants and younger children.

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Pediatric Age and or Weight Restrictions for Procedures and Protocols

CPR
• Neonatal resuscitation refers to the resuscitation of an infant immediately
after birth
• “Infant” CPR techniques should be utilized for pediatric patients under 1
year of age
• “Child” CPR techniques should be utilized for pediatric patients ages 1-8
years
Endotracheal Intubation
• Contraindicated in pediatric patients unless the following conditions exist:
• Unable to maintain a patent airway
• Unable to provide adequate oxygenation with BVM
Nasotracheal Intubation
• Contraindicated in ages less than 12 years
Pediatric Intraosseous Infusion
• Relatively contraindicated in ages 6 years or more unless patient is in
cardiac arrest or decompensated shock and IV access cannot be rapidly
established.
Needle Cricothyrotomy
• Contraindicated in ages less than 3 years. For pediatric patients less than
36 kg, use a regulator with 20 PSI (if available) or use Bag valve mask
ventilation.
Charcoal
• Contraindicated in ages 2 years or less
Naloxone (Narcan)
• Contraindicated in neonates of known or suspected narcotic-addicted
mothers as it can induce withdrawal reactions
Multi-lumen airway device (Combitube)
• Contraindicated in pediatric patients under 5 feet tall. The entire length of
the Broselow Tape is 5 feet

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 SAN MATEO COUNTY
PRE-HOSPITAL CARE VALUES AND ETHICS STATEMENT

Developed by the Quality Leadership Council

Our Emergency Medical Services community consists of a team of health care

professionals representing many professions including EMT-1’s, paramedics,
firefighters, nurses, physicians, dispatchers, educators and administrators. This
team is composed of all who care for our patients directly or indirectly through the
continuum of the patients’ pre-hospital emergency care. This Statement defines
our vision, code of conduct, and ethical responsibilities and is beneficial in
guiding our practice.

We affirm that:

„ Our purpose is to provide the highest quality of pre-hospital emergency

medical care, including transportation, for the residents and visitors of San
Mateo County.

„ Skilled pre-hospital medical care must be provided with compassion,

respect, and regard for the human dignity to all persons, regardless of
nationality, race, creed, gender, economic status, sexual orientation, age,
nature of illness, or responsiveness to our care.

„ We, as professionals, are accountable and responsible for providing pre-

hospital medical care to the best of our ability and for accurately
documenting such care.

„ Patients who are competent have the right to determine the level of
service and treatment that they shall receive, to either accept or refuse
medical care; and to know the risks and the responsibility resulting from
their decision.

„ We respect the confidential nature of our work and respect the privacy of
our patients and co-workers.

„ We are committed to honesty, integrity, and truthfulness in our

professional relationships with our patients and our colleagues in all
matters pertaining to patient care.

„ We uphold the highest standards of professional conduct when providing

medical care and when interacting with other members of the pre-hospital
community. These standards include maintenance of personal
competence, confidentiality, and mutual respect.

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„ We are responsible for upholding the standards of our profession,
including participating in activities that strengthen the EMS system as well
as benefiting our community.

„ We respect and obey the law and regulations of our profession and do not
participate in any unethical activities. We do not let personal
considerations such as economic gain or convenience influence our level
of patient care.

„ We refrain from conduct and activities that may impair our professional
judgment and our ability to act competently.

„ When differences of opinion or conflicts of interest occur our professional

judgment should always be guided by the ultimate objective, which is
providing the best possible care for our patient.

„ We treat all members of the pre-hospital team with respect. Constructive

comments are welcomed and encouraged. Gossip and other activities that
are potentially destructive to the individual or the team are discouraged.

We affirm the elements of this statement as a measure of our commitment to

excellence in fulfilling our professional obligations to those we serve.

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 PATIENT ASSESSMENT
ROUTINE MEDICAL CARE
PRIMARY AND SECONDARY SURVEY

APPROVED: Gregory Gilbert, EMS Medical Director

Peter D’Souza, Assistant EMS Medical Director
Barbara Pletz, EMS Administrator

DATE: January 2009

The purpose of the primary survey (see page 3 for Secondary Format) is to
identify and immediately correct life-threatening problems.

Scene Size-Up/Global Assessment

• Recognize hazards, ensure safety of scene, and secure a safe area for
treatment
• Apply appropriate universal body substance isolation precautions
• Recognize hazards to patient and yourself and protect from further injury
• Identify number of patients and resources needed
o Call for EMS, fire and police backup
o Initiate Multicasualty Incident Protocol as needed
• Observe position of patient
• Determine mechanism of injury
• Plan strategy to protect evidence at potential crime scene

General Impression:
• Remain global and check for life threatening conditions
• Determine chief complaint or mechanism of injury
• Determine mental status; orientation to person, place, time, and event

Airway:
• Ensure open airway. (see Respiratory Distress Protocol as needed)
• Protect spine from unnecessary movement in patients at risk for spinal injury
• Look for evidence of other upper airway problems and potential obstructions
o Vomitus
o Bleeding
o Loose or missing teeth
o Dentures
o Facial trauma
• Utilize any appropriate adjuncts (OPA or NPA) as indicated to maintain airway

Breathing:
• Look, listen and feel; assess ventilation and oxygenation
• Expose chest and observe chest wall movement if necessary
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• Determine approximate rate and depth; assess character and quality
• Reassess mental status
• Interventions for inadequate ventilation and/or oxygenation:
o Supplementary oxygen
o Bag-Valve Mask
o Intubation (endotracheal or nasal with confirmation of correct placement)
after initial ventilation, if indicated
o Note: Defibrillation should not be delayed for advanced airway procedures
• Assess for other life-threatening respiratory problems and treat as needed

Circulation:
• Check for pulse and begin CPR if necessary
• Note: CPR should be performed until ready for defibrillation
• Control life threatening hemorrhage with direct pressure
• Palpate radial pulse if appropriate
o Determine absence or presence
o Assess general quality (strong/weak)
o Identify rate (slow, normal, or fast)
o Regularity
• Assess skin for signs of hypoperfusion or hypoxia (capillary refill)
• Reassess mental status for signs of hypoperfusion
• Treat hypoperfusion if appropriate

Level of Consciousness and Disabilities:

• Determine need for c-spine stabilization
• Determine Glasgow Coma Scale without delay

Expose, Examine, Evaluate:

• In a situation with suspected life-threatening trauma mechanism, a Rapid
Trauma Assessment should be performed
o Expose and examine head, neck, and extremities
o Treat any newly discovered life-threatening wounds as appropriate
and begin transport in the potentially unstable or critical patient

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 Secondary Survey

The secondary survey is the systematic assessment and complaint-focused,

relevant physical examination of the patient. The secondary survey may be done
concurrently with the patient history and should be performed after:
• The primary survey and initial treatment and stabilization of life-threatening
airway, breathing and circulation difficulties
• Spinal immobilization as needed
• Beginning transport in the potentially unstable or critical patient
• A Rapid Trauma Assessment in the case of significant trauma
• Investigation of the chief complaint and associated complaints, signs or
symptoms
• An initial set of vital signs
o Pulse
o Blood pressure
o Respiration
o Lung sounds
o Cardiac rhythm (if indicated)
o Consider orthostatic vital signs to assess volume status
o Pulse oximetry when indicated
o Assess for pain or discomfort. Use a 0-10 scale to rate and document the
pain

Give initial treatment including oxygen, ventilate if indicated, control hemorrhage

if needed, institute basic wound/fracture care, and establish IV access if
indicated/capable.

The above set of assessment/treatments is referred to in these protocols as

“Routine Medical Care”. This care should be provided to all patients regardless of
presenting complaint. The purpose of the secondary survey is to identify
problems that may not be immediately life or limb threatening but could increase
patient morbidity and mortality. Exposure of the patient for examination may be
reduced or modified as indicated due to environmental factors.

History:
Optimally should be obtained directly from the patient: if language, culture, age-
related, disability barriers or patient condition interferes, consult family members,
significant others, scene bystanders or first responders. Check for advanced
directives, medical alert bracelets and prescription bottles as appropriate. Be
aware of the patient’s environment and issues such as domestic violence, child
or elder abuse or neglect. If you are concerned, bring this to the attention of the
receiving physician or nurse and file the appropriate report.

• Obtain chief complaint

• Allergies
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• Medications
• Past medical history
• Ascertain recent medical history, admission to hospitals, reasons given, etc.
• Mechanism of injury
• See “Information Needed” section of each protocol for history relevant to
specific patient complaints

Head and Face:

• Observe and palpate skull (anterior and posterior) for signs of trauma
(contusions, abrasions, deformity, crepitus, or lacerations)
• Check eyes for: equality and responsiveness of pupils, movement and size of
pupils, foreign bodies, discoloration, contact lenses, prosthetic eyes
• Check nose and ears for foreign bodies, fluid, or blood
• Recheck mouth for potential airway obstructions (swelling, dentures, loose or
avulsed teeth, vomitus, malocclusion, absent gag reflex) and odors, altered
voice or speech patterns, and evidence of dehydration

Neck:
• Observe and palpate for signs of trauma, jugular venous distention, use of
neck muscles for respiration, tracheal shift or deviation, cervical spine
tenderness, stoma, and medical information medallions

Chest:
• Observe and palpate for signs of trauma, implanted devices (AICD or
pacemaker), medication patches, chest wall movement, asymmetry,
retractions and accessory muscle use
• Have a patient take a deep breath if possible and observe and palpate for
signs of discomfort, asymmetry, and air leak from any wounds
• Auscultate breath sounds bilaterally

Abdomen:
• Observe and palpate for signs of trauma, scars, diaphragmatic breathing and
distention
• Palpation should occur in all four quadrants taking special note of tenderness,
masses and rigidity

Pelvis/Genito-urinary:
• Observe and palpate for signs of trauma or asymmetry, incontinence,
priapism, blood at urinary meatus, or presence of any other abnormalities
• Gently palpate lateral pelvic rims and symphysis pubis for tenderness,
crepitus, or instability
• Palpate bilateral femoral pulses when necessary

Shoulders and Upper Extremities:

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• Observe and palpate for signs of trauma, asymmetry, skin color, capillary
refill, edema, medical information bracelets, track marks, and equality of distal
pulses
• Assess sensory and motor function as indicated

Lower Extremities:
• Observe and palpate for signs of trauma, asymmetry, skin color, capillary
refill, track marks, edema, and equality of distal pulses
• Assess sensory and motor function as indicated

Back:
• Observe and palpate for trauma, asymmetry, spinal tenderness, and sacral
edema

Precautions and Comments:

• Observation and palpation can be done while gathering patient’s history
• A systematic approach will enable the rescuer to be rapid and thorough and
not miss subtle findings that may become life-threatening
• Minimize scene time for critical trauma or medical patients; conduct
secondary survey en route to the hospital.
• The Secondary Survey should ONLY be interrupted if the patient experiences
airway, breathing, or circulatory deterioration requiring immediate
intervention. Complete the examination before treating the other identified
problems
• Reassessment of vital signs and other observations may be necessary,
particularly in critical or rapidly changing patients. Changes and trends
observed in the field are essential data to be documented and communicated
to the receiving facility staff
• Prehospital medical personnel (paramedics and EMTs) can assist patient with
self-administration of own medication if appropriate

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