PA BLS Protocols

When the EMS provider believes a protocol is NOT in the best interest of a patient, ________________________.

The provider should contact medical command if possible

All deviations are subject to investigation to determine if they were appropriate

TRUE OR FALSE: Medical command orders may require/permit EMT to exceed their scope of practice

FALSE

EMT is responsible for knowing scope of practice and MUST refuse orders that exceed it

EMTS are not expected to follow a protocol for providing treatment if _______________.

That treatment is contraindicated

NOT considered a deviation from protocol

DOCUMENT

Guidelines

Best care recommendations - not required care

In patient care algorithms, treatments listed in _________________ may be done in any order based on patient presentation, or may be done simultaneously when additional EMS providers are present.

Solid boxes

In patient care algorithms, treatments listed in solid boxes may be done _______________________________.

In any order based on patient presentation, or may be done simultaneously when additional EMS providers are present.

Algorithms generally don't indicate _______________________.

When to package and transport patient

Determined by patient condition and EMS judgement

Unless otherwise stated, pediatric protocols apply to patients ________________________.

≤ 14 years

If a patient's age is unknown, _____________________.

Pediatric protocols apply unless the EMT determines there are signs the patient has reached adolescence

Estimated weight in kg

(Age in years ∙ 3) + 7

Consider ________________ if the patient's condition may alter their ability to make medical decisions.

ALS

Scene size up

1. Scene safe

2. BSI

3. Determine MOI/NOI

4. Determine number of patients

5. Determine need for additional resources (ALS)

If there is a trauma MOI, _________________ during assessment.

Stabilize cervical spine

Primary assessment

1. Form general impression of the patient

2. Determine the chief complaint and/or life threats

3. Determine level of responsiveness

• AVPU

4. Assess airway

• Open airway

• Treat obstructions

5. Assess breathing

• Ventilate as necessary

6. Assess circulation

• Address any serious uncontrolled bleeding

7. Obtain history (SAMPLE & OPQRST)

8. Focused physical exam

9. Treat and transport per protocol

Nausea may be improved by ___________________.

Allowing the patient to sniff an open alcohol wipe

Oxygen should always be provided for patients with _______________________.

1. Shock

2. Shortness of breath or respiratory distress

3. Inhalation injury/toxicity

4. Suspected/known stroke

5. Suspected/known seizure

6. Chest pain

7. Suspected/known trauma

8. Acute change LOC

9. Patient whose condition seems serious

10. Patient who has a priority condition

11. Patient who normally receives oxygen as part of medical treatment

Inhalation injury/toxicity includes, but is not limited to, ____________________.

1. Carbon monoxide poisoning

2. Smoke inhalation

3. Chemical inhalation

Unless there are other complications, apply oxygen only if room air SpO2 is <95%, and titrate oxygen to attain SpO2 in range of 95-99% in patients with ___________________________,

1. ST elevation MI

2. Suspected stroke

3. Post cardiac arrest with ROSC

Unless there are other complications, apply oxygen only if _______________ in patients with ST elevation MI, suspected stroke, or who are post cardiac arrest with ROSC,

Room air SpO2 is <95%

When administering oxygen to patients with ST elevation MI, suspected stroke, or who are post cardiac arrest with ROSC, ______________________.

Titrate oxygen to attain SpO2 in range of 95-99%

Administer oxygen via ____________________ is high concentration oxygen is not required.

Nasal cannula

If high concentration oxygen is required, but the patient will not tolerate a nonrebreather mask, use a ____________________.

Nasal cannula at 4-6 lpm

Administer high concentration oxygen via a _________________________.

Nonrebreather mask

If ventilation is required, oxygen ____________________.

Should be administered via the bag-valve device

If a pediatric patient will not tolerate a nonrebreather or a nasal cannula, ____________________.

Provide blow-by oxygen via oxygen extension tubing

Conditions where ALS should be considered include, but are not limited to, _____________________________.

1. Altered LOC

2. Allergic reaction with any of the following

• Difficulty breathing

• Difficulty swallowing

• Hives within 5 minutes of exposure

• Altered LOC

• Previous known reaction

3. Cardiac symptoms

4. Cardiac arrest

5. Diabetic problem if the patient is

• Not alert

• Having trouble breathing

6. Multi-system trauma

7. Severe single system trauma

8. OBGYN

• 2nd or 3rd semester bleeding or miscarriage

9. Overdose/poisoning

10. Respiratory distress

11. Respiratory arrest

12. Seizures/convulsions

13. Entrapment with injuries

14. Severe blood loss

15. Shock/hypoperfusion

16. Stroke/CVA symptoms

17. Syncope

18. Severe pain anywhere

19. Agitated delirium

• Fighting against restraints without being aware of actions

20. Vital signs outside the normal range

• Patient does not follow commands (GCS ≤ 5)

• Systolic BP <90

• Pulse is < 60, > 120, or irregular

• Respirations are < 10, > 35, or irregular

• SpO2 is < 95% AFTER application of oxygen

Consider ALS if, when evaluating GCS, _________________.

Patient does not follow commands (GCS ≤ 5)

Consider ALS if systolic BP _______________________.

< 90

Consider ALS if pulse ___________________.

ANY of the following

< 60

> 120

Irregular

Consider ALS if respirations are _________________.

ANY of the following

< 10

> 35

Irregular

Consider ALS if SpO2 is _____________________.

< 95% AFTER application of oxygen

Ventilation rate: adults (≥ 15 years)

10 breaths/minute OR one ventilation every 5-6 seconds

Ventilation rate: children (1-14 years)

20 breaths/minute OR one ventilation every 3-5 seconds

Ventilation rate: infants (< 1 year)

25 breaths/minute OR one ventilation every 3-5 seconds

Patients with suspected carbon monoxide poisoning should _________________.

Receive 100% oxygen without regard for pulse oximetry readings

Patients with _______________________ should receive high flow oxygen at all times.

1. Signs and symptoms of severe respiratory distress (air hunger, cyanosis, retractions, etc.)

2. Suspected carbon monoxide poisoning

3. Respiratory distress who are being prepared for air transport

4. Altered level of consciousness (GCS ≤ 13)

5. Suspected severe allergic reaction IF

• Difficulty breathing

• Signs of shock

6. Chest pain/suspected coronary artery syndrome IF

• Difficulty breathing

• Signs of shock

7. Patients with head injury/suspected traumatic brain injury where there is ANY

• Loss of consciousness

• GCS < 15

• Asking repeated questions

• Seizure after head trauma

8. Burn victim IF

• Coughing or short of breath

• Exposure to smoke in a confined space.

• Facial burns

Glucose monitoring may only be completed by an EMT who _________________________.

Has completed the DOH BLS Glucometer training AND has been approved by the EMS agency medical director

When permitted, blood glucose should always be assessed in patients with _____________________.

• Altered LOC

• Stroke symptoms

12-lead electrocardiogram (ECG) monitoring may only be completed by an EMT who _________________________.

Have completed a DOH approved 12-lead ECG course AND has been approved by the EMS agency medical director

If an EMT HAS NOT completed a DOH approved 12-lead ECG course AND has been approved by the EMS agency medical director, ___________________.

1. ECG monitor setup MUST occur ONLY when in the direct presence of an ALS/IALS provider who is functioning on scene with an ALS/IALS agency

2. BLS providers are NOT PERMITTED to apply AED electrodes or other ECG monitors to non-cardiac arrest patients for the purpose of monitoring UNLESS in the direct presence of an ALS/IALS provider who is functioning on scene with an ALS/IALS agency

Patients with ______________________ may be harmed by immobilization to a back board.

Penetrating trauma to the

• Head

• Chest

• Abdomen

• Neck

• Back

Patients with ___________________ do not need to be immobilized on a back board.

Non-traumatic head or neck pain related to movement, position, or heavy lifting.

Epinephrine autoinjector dose: adult

0.3 mg

Epinephrine autoinjector dose: pediatric

0.15 mg

If the patient has severe symptoms of an allergic reaction and has a prescribed epinephrine autoinjector, _________________.

1. Check the autoinjector (five R's)

2. Assist the patient in the administration of a single dose

If the patient has moderate symptoms of an allergic reaction and has a prescribed epinephrine autoinjector, _________________.

Contact medical command

Treatment of a patient with signs/symptoms of a severe allergic reaction

1. Initiate patient contact

2. Consider ALS

3. Administer oxygen. High flow if:

• Difficulty breathing

• Signs of shock

4. Administration of epinephrine

• Assist in adminis

5. Monitor vital signs and reassess patient

6. Contact medical command

7. Transporttration of single dose if prescribed

• If carry and trained, administer a single dose

If a patient has a prescribed epinephrine autoinjector and has a diminished LOC, the EMT _______________________.

May administer the medication rather than assisting in the administration of the medication

Side effects of epinephrine are (COMMON/RARE) __________________________.

Rare

Side effects of epinephrine

• Increased HR

• Nausea

• Dizziness

• Vomiting

• Chest pain

• Anxiety

• Excitability

• Pallor

• Headache

Conditions that produce shortness of breath from wheezing may be improved by __________________________.

Bronchodilators

Conditions generally associated with wheezing

• COPD (emphysema, chronic bronchitis)

• Asthma

• Allergic reaction

• Respiratory infections (pneumonia, acute bronchitis)

Conditions that produce shortness of breath without bronchoconstriction (usually NOT associated with wheezing) that DO NOT respond to bronchodilators are ___________________.

• Congestive heart failure

• Pulmonry embolism

CPAP may only be administered by an EMT who has _________________________.

Completed the DOH BLS CPAP training AND been approved by the agency medical director

Nebulized bronchodilators may only be administered by an EMT who has _________________________.

Completed the DOH BLS Nebulized Bronchodilator training AND been approved by the agency medical director

Contraindications for CPAP

• Altered mental status/cannot follow commands

• ≤ 14 years old (UNLESS appropriately sized pediatric mask available)

• Respiratory rate < 10

• Apnea

• Unable to maintain an open airway

• Chest trauma

• Suspected pneumothorax

• Tracheostomy

• Active vomiting

• Active upper GI bleed

In patients with __________________________, CPAP is an optional treatment.

Respiratory distress/respiratory failure

In cases of respiratory distress/respiratory failure, CPAP may be administered if there are no contraindications and _________________________.

Has AT LEAST TWO of the following AFTER high concentration oxygen:

• Pulse oximetry < 90%

• Respiratory rate > 25

• Use of accessory muscles during respiration

Procedure for treating respiratory distress

1. Patient contact

2. Consider ALS

3. Administer high concentration oxygen

4. Consider CPAP

5. If patient has history of using bronchodilator for asthma/COPD/emphysema AND has shortness of breath, consider:

• Assist patient with prescribed bronchodilator inhaler (MUST be short-acting, rapid onset - contact medical command if unsure) at prescribed dose (one or two inhalations)

• Assist patient with bronchodilator with oxygen driven nebulizer using either albuteral, albuteral and ipratropium, or levalbuteral

6. If assist with administration of bronchodilator, contact medical command.

7. Transport and reassess en route

Dose SVN albuterol

2.5 mg in approximately 3mL solution

Dose SVN albuteral and ipratropium

Albuteral: 3 mg (approximately)

Ipratropium: 500 mcg

Dose SVN levalbuterol

1.25mg in approximately 3mL solution

Procedure for treating chest pain/suspected coronary artery syndrome

1. Initiate patient contact

2. Consider call for ALS

3. Apply oxygen

• High concentration if has (1) trouble breathing or (2) signs of shock

• Nasal cannula and titrate to lowest possible setting to maintain SpO2 in range of 95-99%

4. Optional 12-lead ECG

5. Administer aspirin

• Four 81mg baby aspirin (chewed)

6. If available, assist patient with prescribed nitroglycerin

• No contraindications

• Suspected cardiac origin

• Active chest pain/discomfort

7. Transport

8. Contact medical command if assisted with nitroglycerin (possible additional doses)

Contraindications for nitroglycerin

• Blood pressure is < 100 systolic

• Patient has taken medication for erectile dysfunction or pulmonary hypertension within the last 24-48 hours

•Patient is ≤ 14 years

EMT may assist with the administration of nitroglycerin _____________________ time before contacting medical command.

ONLY one

Examples of medications that create a contraindication for nitroglycerin

• Viagra

• Levitra

• Cialis

• Revatio

If patient was recently confined to a small space, use _____________________.

100% high flow oxygen

In adult patients, indications that chest pain is of possible cardiac origin include:

1. Retrosternal chest heaviness/pressure/pain

2. Radiation of pain to neck, arms or jaw

3. Associated shortness of breath

4. Associated nausea/vomiting

5. Associated sweating

6. Possibly worsened by exertion (ischemia)

7. More likely if patient is over 30 years of age

8. History of known cardiac ischemic disease

9. Patient with history of recent stimulant/cocaine/amphetamine drug use

Chest pain, probably not of cardiac origin, may include __________________________.

Pleuritic chest pain

• Worsens with deep breath or bending/turning

It is less likely that chest pain is of cardiac origin if the patient is __________________.

Less than 30 years of age

Aspirin dose

Four 81 mg baby aspirins (chewed)

The presence of a ______________________ creates reduced or absent pulse pressure.

Ventricle assist device (VAD)

___________________ to confirm a VAD is still working.

Auscultate the VAD over the area of the heart

•A continuous humming sound indicates the

VAD is running

When performing defibrillation on a patient with a VAD, consider ___________________ pad placement.

Anterior-posterior

• Avoid placing the defibrillation pads directly over the VAD device

If the patient has a sucking chest wound, __________________.

Cover wound with occlusive dressing sealed on 3 sides

Release an occlusive dressing if the patient demonstrates _________________________.

Worsened shortness of breath

In the event of intestinal evisceration, ________________________________.

1. DO NOT PUSH VISCERA BACK INTO THE ABDOMEN

2. Cover intestines with a sterile dressing moistened with sterile saline or water

3. Cover the area with an occlusive material (aluminum foil or plastic wrap)

4. Cover the area with a towel or blanket to keep it warm

5. Transport with knees slightly flexed if possible

____________________ is preferred for isolated femur fractures.

Traction splinting

__________________________ are preferred for isolated tibia/fibula fractures.

Padded board splints or other similar devices

If patient is cold, _________________________________.

Use blankets and possibly hot packs at armpits and groin to prevent additional heat loss

Protocol for patients with head injury/suspected traumatic brain injury (TBI)

Hypoglycemia is a blood glucose __________________________.

< 60mg/dL

Procedure for diabetic emergency

1. Initial patient contact

2. Consider ALS

3. Administer high concentration oxygen if altered level of consciousness

Hypoglycemia is suspected if patient has ___________________.

A history of diabetes or takes insulin or oral diabetes

medications

If a hypoglycemia patient can't swallow but still has gag reflex, oral glucose _______________________________.

May be placed between the cheek and gum in small amounts

If a hypoglycemia patient is unable to follow commands or swallow and has a blood glucose < 60 mg/dl, __________________________.

Administer glucagon if available

Dose glucagon (nasal powder spray)

3 mg

Dose glucagon autoinjector: adults and children over five years of age

1 mg

Dose glucagon autoinjector: adults and children under five years of age

0.5 mg

Glasgow coma scale categories

1. Eyes open

2. Motor response

3. Verbal response

Glasgow coma scale: eyes open has a score of _____________________________.

1-4

Glasgow coma scale: eyes open

Spontaneously ................................................ 4

To verbal command ........................................ 3

To pain ............................................................ 2

No Response .................................................. 1

Glasgow coma scale: motor response has a score of _____________________________.

1-6

Glasgow coma scale: motor response

To verbal command:

Obeys .............................................................. 6

Painful Stimulus:

Localizes pain ................................................. 5

Flexion-withdrawal .......................................... 4

Flexion-abnormal (decorticate rigidity) ............ 3

Extension (decerebrate rigidity) ...................... 2

No response .................................................... 1

Glasgow coma scale: verbal response has a score of _____________________________.

1-5

Glasgow coma scale: verbal response

Oriented, converses ........................................ 5

Disoriented, converses.................................... 4

Inappropriate words ........................................ 3

Incomprehensible sounds ............................... 2

No response .................................................... 1

The age of a neonate is ________________________.

Birth to 28 days

The age of an infant is ________________________.

1-12 months

The age of a toddler is ________________________.

1-2 years

The age of a preschooler is ________________________.

3-5 years