These protocols and procedures are to be used as guidelines for operation during prehospital care that require medical direction. Procedures are not considered rigid rules, but rather established standards against which practice can be measured. Treatment protocols are specific orders directing the actions pertaining to techniques and/or medications used by nurses who are required to practice under direct supervision of a physician and under their respective Medical Control authority. Treatment protocols should be initiated without prior direct Medical Control contact, especially when the patient’s condition and / or situation is life threatening. These protocols and procedures are derived from the State of Ohio EMS guidelines. Please note this protocol is subject to continuous review providing members with the most current emergency medical information and updates may be frequent to a high level of care.
The patient history should not be obtained at the expense of the patient. Life‐threatening problems detected during the primary assessment must be treated first and EMS must be notified at the first available opportunity.
In patients with non‐life‐threatening emergencies who require IV’s, only two attempts at IV insertion should be attempted in the field. As a courtesy to the patient and emergency department, attempts should be made to obtain a full set of lab work. A patient IV should not be compromised to obtain a set of lab work.
Patient transport, or other needed treatments, must not be delayed for multiple attempts at endotracheal intubation. Limit to two attempts pre‐hospital.
Verbally repeat all orders received before their initiation.
Any adult medical patient or patients of any age with a cardiac history, irregular pulse, unstable blood pressure, dyspnea, or chest pain, must be placed on a cardiac monitor if available.
Where clinically indicated, obtain a 12‐lead EKG, and transmit to the emergency department. The transmission must include the patient’s name, age, and sex.
When transferring prehospital care, a thorough consult should be performed between caregivers describing initial patient presentation and care rendered to the point of transfer.
If the patient’s condition does not seem to fit a protocol or protocols, contact Online Medical Control for guidance.
All trauma patients with a mechanism or history for multiple system trauma should be transported as soon as possible to the most appropriate facility. EMS scene time should be 10 minutes or less.
Medical patients requiring transport will be transported in the most efficient manner possible considering the medical condition. Advanced life support therapy should be provided at the scene if it would positively impact patient care. Justification for EMS scene times greater than 20 minutes should be documented.
Establish scene safety
Don appropriate PPE
Assess patient using adult or pediatric assessment procedure
Access airway and breathing
Access circulation
Spinal motion restrictions where indicated with special training
Vital signs
Heart rate
Respirations
Blood pressure
Baseline SpO2
Give/increase supplemental O2 as needed with a goal of SpO2 >= 94% unless specified by a specific protocol
Go to appropriate protocol
Consider EMS transport
Universal Patient Care
Move patient to a climate controlled area
Obtain a 12 Lead EKG
Obtain IV access
Give 500 - 1000 ml normal saline or lactated ringers solution
Consider EMS transport
Recommend EMS transport for tachycardia after 1000 ml of fluid
Universal Patient Care
Obtain 12 Lead EKG if patient has a cardiac history or taking a medication known to prolong QT
Consider IV access
Give ondansetron 4 mg IV/IM or ODT
Consider 500 - 1000 ml normal saline or lactated ringers solution
Consider EMS transport
Nurses may furnish any over the counter medications in a dose recommended on the packaging to patients as long as there are no known contraindications to the medications.
Universal Patient Care
Remove patient from the heat source , preferably a climate controlled area
Remove patient clothing
Increase air flow around the patient
Document patient temperature, core temperature is preferred
Heat exhaustion (no AMS)
Apply towels soaked with coldest water available or ice water
Apply ice packs to patient groin, axilla, and posterior neck)
Obtain IV/IO access
Give 20 ml/kg of normal saline or lactated ringers solution, preferably chilled
Heat stroke (AMS) no immersion available
Apply towels soaked with coldest water available or ice water
Apply ice packs to patient groin, axilla, and posterior neck)
Obtain IV/IO access
If hypotensive, give 20 ml/kg of normal saline or lactated ringers solution, preferably chilled
if normotensive, start IV fluids TKO
Heat stroke (AMS) immersion available within reasonable timeframe
Submerge as far up to neck as possible – keep head above water with towel or sheet under arms
Keep immersed for 10 – 20 mins or return of normal mental status OR Core temp < 102F (40C) if purpose made continuous core temp monitoring device available.
Do not interrupt submersion cooling for vomiting, BM, combativeness, or seizures
Obtain IV/IO access
If hypotensive, give 20 ml/kg of normal saline or lactated ringers solution, preferably chilled
if normotensive, start IV fluids TKO
Notify EMS
Obtain blood glucose
Obtain 12 Lead EKG
Universal Patient Care
COPD patient goal SPo2 >=88%
Obtain a 12 Lead EKG
Mild symptoms
Give nebulized aerosol (albuterol or albuterol/ipratropium) or MDI
Moderate/Severe symptoms
Place patient on continuous capnography
Give nebulized aerosol (albuterol or albuterol/ipratropium)
Give methylPREDNISolone 125 mg IV/IO
If poor air exchange after aerosol consider EPINEPHrine 0.3 mg IM q 5 min PRN
Consider EMS transport
Severe distress with stridor
Place patient on continuous capnography
Give nebulized RACEMIC EPINEPHrine 2.25% 0.5 ml mixed with 3 ml normal saline or nebulized EPINEPHrine
Give nebulized aerosol (albuterol or albuterol/ipratropium)
Give methylPREDNISolone 125 mg IV/IO
Consider EPINEPHrine 0.3 mg IM q 5 min PRN
EMS transport
Scene size‐up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by‐stander safety, and patient / caregiver interaction.
Assess need for additional resources.
Initial assessment includes a general impression as well as the status of a patient’s airway, breathing, and circulation.
Assess mental status (e.g., AVPU) and disability (e.g., GCS).
Control major hemorrhage and assess overall priority of patient.
Perform a focused history and physical based on patient’s chief complaint.
Assess need for critical interventions and complete interventions
Perform a complete secondary exam to include a baseline set of vital signs as directed by protocol.
Maintain an on‐going assessment throughout treatment, to include patient response, possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints and conditions.
Scene size‐up, including universal precautions, scene safety, environmental hazards assessment, need for additional resources, by‐stander safety, and patient / caregiver interaction.
Assess patient using the pediatric triangle of ABCs:
Airway and appearance: speech / cry, muscle tone, inter‐activeness, look / gaze, movement of extremities
Work of breathing: absent or abnormal airway sounds, use of accessory muscles, nasal flaring, body positioning
Circulation to skin: pallor, mottling, cyanosis
Establish responsiveness appropriate for age. (AVPU, GCS, etc.)
Color code using weight‐based tape / treatment chart.
Assess disability. (pulse, motor function, sensory function, papillary reaction)
Perform a focused history and physical exam. Remember pediatric patients easily experience hypothermia and thus should not be left uncovered any longer than necessary to perform an exam.
Assess need for critical interventions and complete interventions
Perform a complete secondary exam to include a baseline set of vital signs as directed by protocol (BP >= 3 years of age, cap refill < 3 years of age). Include immunizations, allergies, medications, past medical history, last meal, and events leading up to injury or illness where appropriate.
Maintain an on‐going assessment throughout treatment, to include patient response, possible complications of interventions, need for additional interventions, and assessment of evolving patient complaints and conditions.
Universal precautions. Gloves.
Prepare equipment.
Inspect the IV solution for expiration date, cloudiness, discoloration, leaks, or the presence of particles.
Connect IV tubing to the solution in a sterile manner. Fill the drip chamber half full and then flush the tubing bleeding all air bubbles from the line.
Place a tourniquet around the patient’s extremity to restrict venous flow only.
Select a vein and an appropriate gauge catheter for the vein and the patient’s condition.
Prep the skin with an antiseptic solution.
Insert the needle with the bevel up into the skin in a steady, deliberate motion until the blood flashback is visualized in the catheter.
Advance the catheter into the vein. Never reinsert the needle through the catheter.
Dispose of the needle into the proper container without recapping.
Draw blood samples when appropriate.
Remove the tourniquet and connect the IV tubing or saline lock.
Open the IV to assure free flow of the fluid and then adjust the flow rate as per protocol or as clinically indicated.
Secure IV using appropriate measures to insure stability of the line.
Check for signs of infiltration.
Adjust flow rate.
Document the procedure, time, and result.
IV placement must not delay transport of any critical patient involved in trauma.
Generally, no more than two (2) attempts or more than two minutes should be spent attempting an IV. If unable to initiate IV‐line,
IVs may be started on patients of any age providing there are adequate veins and patient's condition warrants an IV.
Any venous catheter which has already been accessed prior to arrival may be used.
Upper extremity IV sites are preferable to lower extremity sites.
Lower extremity IV sites are relatively contraindicated in patients with vascular disease or diabetes.
In fistula or post‐mastectomy patients, avoid IV, blood draw, injection, or blood pressure in arm on affected side.
Attempt to draw lab work on all patients when the IV is started, unless the draw will compromise the access site, or the patient is in extremis. Label all blood draws with patient name and DOB
Patient has received 3 or more tetanus toxoid
Clean and minor wound
Give tetanus toxoid vaccine if last dose was >= 10 years
Contaminated or dirty wounds
Give tetanus toxoid vaccine if last dose was >= 5 years
Patient has received less than 3 tetanus toxoid
Clean and minor wound
Give tetanus toxoid vaccine
Contaminated or dirty wounds
Give tetanus toxoid vaccine and human tetanus immune globulin