green book

Non-Traumatic Cardiac Arrest

• Start High Quality CPR

• Call ALS

• Transport after 3 cycles

KEY POINTS

• minimize chest compression interruptions

Severe Bradycardia (Pediatric)

HR < 60

with

Signs of shock OR AMS

• ventilate for 1min

• if hr<60 begin chest compressions and ventilate

• check pulse every 2 mins and if hr>60 ventilate/O2 according to breathing quality

• request als

• transport

obstructed airway (adult/pediatric)

• if patient is conscious and can breathe/cough/speak: encourage patient to cough

• if patient is unconscious and can’t breathe/cough/speak: perform airway maneuvers or cpr (per guidelines)

• ABCs and Vitals

• Airway Management and O2 therapy

• request als

• transport

• perform airway maneuvers enroute

Respiratory Distress (adult)

Protocol is for patients who have persistent respiratory distress despite from other protocols

• ABCs and Vitals

• Use airways adjuncts as needed to administer O2

For Resp. Distress: administer O2 in position of comfort

For Resp. Failure: assist ventilations at rate of 10 breath/min with 02

• assess/treat for overdose as needed

• call ALS

• If persistenet give CPAP

• transport

Respiratory Distress/Failure (Pediatric)

Protocol is for patients who have persistent respiratory distress despite from other protocols

• ABCs and Vitals

• Use airways adjuncts as needed to administer O2

For Resp. Distress: administer O2 in position of comfort

For Resp. Failure: assist ventilations at rate of 20-30 breath/min with 02

• assess/treat for overdose as needed

• call ALS

• transport

CONSIDERATIONS

• do not give oral solutions to patients that unconscious or have head injuries

Altered Mental Status

• secure scene safety

• Abcs/vitals

• Airway

• Administer O2

• Assess/treat for Overdose

• Request ALS

• Get BGL

  • If bgl<60 and patient is awake and able to drink administer oral glucose OR other sugary beverage

• Transport

Anaphylaxis/severe allergic reaction

• ABCs/Vitals

• Airway Management

• Administer O2

• If patient is anaphylactic

  • Assist patient with their own epinephrine

  • If none prescribed ed administer epinephrine by weight/age

    • Age < 9 and weight < 30kg 0.15 mg of epinephrine 

    • Age > 9 or weight > 30kg 0.3 mg of epinephrine 

• Assess for respiratory failure/distress, shock, cardiac arrest

• Request ALS

• transport

• If symptoms continue after 3-5 minutes, administer a second epinephrine (max 2)

• For wheezing, administer 3ml albuterol and 2.5 ml nebulized over 5-15 minutes

  • Repeat as needed (max 3 doses)

CONSIDERATIONS

• Do not delay in transport, administer second dose in bus

Decompression sickness

• ABCs and vital signs

• Airway management

• Administer O2

• Assess and treat for shock as needed

• Transport patient AND fellow divers to hyperbaric chamber IF:

  • Dizziness, chest pain, difficulty breathing, hypoxia, nausea, abdominal pain, muscle pain, dashing or  itching

CONSIDERATIONS

• bring dive computer/dive watch

• If possible obtain

  • Maximum depth

  • Time underwater

  • Bottom time

  • Time ascending

  • Mixture of gasses used

  • Improvement symptoms

  • Air travel or time since last dive

Hyperglycemia

• ABCs and vitals

• Airway and O2

• Assess and treat for shock

• Obtain bgl

  • Request ALS if >300

• Transport

Severe Nausea

• ABCs and vitals

• Airway and O2

• Assess for any specific cause of symptoms and assess

• Do not allow patient to eat or drink

• Place in position of comfort

• Assess and treat for shock

• Place alcohol prep pad under patients nose and allow patient to inhale vapor 

• Transport

Stroke

• ABCs and vitals

• Airway and O2

• Obtain BGL

• For BGL > 60 evaluate with S-LAMS scale

  • Determine scale by interviewing patient, family or bystanders

  • Determine “last known well” and exact time

• For BGL < 60 

  • If neurological symptoms resolve after hypoglycemia treatment transport to hospital

  • If neurological symptoms persist after hypoglycemia treatment and BGL is > 60 evaluate S-LAMS scale

• Transport to nearest  stroke center

CONSIDERATIONS

• if slams score is > 4 deliver to thrombectomy stroke center

Sepsis

Criteria

• If other shocks ruled and has any TWO of these

  • Abnormal vitals

    • Hr>110

    • Resp. > 20

    • SBP < 90

  • Abnormal temperature

  • AMS

• ABCs and vitals

• Airway and O2

• Obtain BGL

• Request ALS

• Transport

CONSIDERATIONS

• blood pressure might be the last thing to drop

Seizures

• protect patient from injury

• ABCs and Vitals

• Perform Airway management with following considerations

  • Position patient to maintain patency

  • Do not place Opa during convulsions

  • Consider use of npa

• Administer O2

• Avoid excessive retraint

• Obtain bgl and treat

• Request ALS for ongoing seizures (5 mins)

• Transport

Overdose

• Assess and secure scene safety 

• ABCs and vitals

• Airway and O2

• If Ams

  • Obtain BGL

  • request ALS

• If OPIOID overdose suspected AND respiratory rate is inadequate

  • ADULT Naloxone 1mg in EACH nostril, repeat after 5 mins

  • PEDIATRIC Naloxone 0.5mg in EACH nostril, repeat after 5 mins

• Assess and treat for shock

• Do not induce vomiting

CONSIDERATIONS

• Document substances, amount, and time

• Bring product/container

• Maximum doses naloxone (2)

• Naloxone Contraindications

  • Cardiopulmonary arrest

  • Active seizure

  • Nasal trauma, obstruction, epistaxis

Poisoning

• assess and secure scene safety

• ABCs and vitals

• Airway and O2

• Assess and treat for shock

• Special considerations

  • Ingestion: don’t induce vomiting

  • Inhalation: remove patient from contaminated environment

  • Absorption: 

    • BSI

    • Remove contaminated clothes

    • Brush off dry agents

    • Irrigate until transport

    • Treat wounds similar to burns with sterile dressing moistened in saline

  • Envenomation

    • Do not attempt to capture animal

    • Insect stings

      • If debris is seen, remove by scraping with credit card

    • Marine

      • Remove bristles with adhesive tape and wipe with alcohol

      • Remove spine

      • Cover with sterile dressing

    • Snakebite

      • Keep site lower than heart

      • Cover in sterile dressing

      • Stabilize and restrict activity

• If AMS

  • request als

  • Obtain BGL

• Obtain SpCO 

• Do not delay transport with envenomation

CONSIDERATIONS

• utilize PPE

• Document substances, amount taken, time duration

• Attempt obtain info from container and bring in transport

Cold Emergencies

• ABCs and Vitals

• Airway and O2

• Move patient to warmer environment

• If patient is conscious get them to drink warm beverage

• Special considerations

  • Localized cold injuries

    • Remove clothing/jewelry

    • Wrap in dry bulky dressing, fingers individually 

  • Generalized hypothermia

    • Assess palpable pulses for one minute

    • Dry patient and remove wet clothing items

    • Place heat packs in patients groin, chest, neck

    • Wrap the patient in dry blankets

• If Ams: obtain BGL and contact als

• Transport

CONSIDERATIONS

• do not break blisters

Heat Emergencies

• ABCs and Vitals

• Airway and O2

• Move patient to a cooler environment

• Remove outer clothing

• Place in recovery position

• Assess and treat for shock

• If conscious provide water

• If Ams: obtain BGL and contact als

• Cool patient rapidly if they have hot flushed dry skin

• Transport

CONSIDERATIONS

• do not aggressively cool as it can cause shivering

• Do not delay transport for cooling

• Patients experiencing shock should be treated rapidly

Strider/Croup

• ABCs and Vitals

• Airway and O2

• Administer blow by O2 3-5 inches from patients face

• Assess and treat for obstructed airway

• Assess and treat for anaphylaxis 

• Assess and treat for respiratory distress/failure, shock

• Request ALS

• Transport

CONSIDERATIONS

• croup/epiglottitis should be suspected

• Avoid agitating child

• Obtain vaccination history from child

GENERAL TRAUMA

• control external bleeding

• Perform spinal injury precautions as needed

• ABCs and vitals

• Airway management and O2 administration 

• For evisceration

  • (Wet then dry then occlusive dressing)

  • Knees SLIGHTLY bent

• For open chest

  • three sided occlusive leaking towards gravity

• For impalement:

  • Unless airway compromise, DO NOT REMOVE

  • Support and secure object with bulky dressing

• Treat extremities

• Stabilize potentially unstable pelvic fracture

• Transport to trauma center

Traumatic cardiac arrest

• begin high quality cpr

• Control any bleeding WITHOUT stopping cpr

• Request ALS

Considerations

• do not interrupt compressions for N/OPA

Amputation

• control external bleeding

• ABCs/vital signs

• Elevate and wrap amputated extremity with moist sterile dressing and cover with dry bandage

• Care for amputated part

  • Wrap in moist sterile dressing

  • Place amputated part in water tight container (plastic bag)

  • Label with patients name and military time of injury

  • Place container on ice, DO NOT FREEZE

Considerations

• do not delay in transport to search for amputated part

Avulsed tooth

• ABCs and vitals

• Hold tooth by crown (not root)

• Rinse tooth with saline before reimplantation, but do not clean off tissue

• Remove clot from socket (suction if needed)

• Reimplant with digital pressure

• Have patient hold in place with gauze while biting

• Transport

Considerations

• Most successful when implanted within 5 minutes

• Do not reimplant if

  • Ams

  • Requires transport in supine position

  • Bone/gingiva are present

  • Immunosupression

• If you cannot reimplant, place in interim storage media with (low fat milk, patients saliva, saline) and keep cool

Bleeding/hemorrhage control

• assess site of injury and control external bleeding

  • Uncontrolled life threatening bleeding from an extremity

    • Place tourniquet 2-3 inches proximally

    • If bleeding continues place second tourniquet proximally

    • If bleeding site is unknown place “high and tight”

  • Uncontrolled life threatening bleeding from an anatomical junction

    • Pack wound with gauze

    • Place pressure and secure

  • Severe external bleeding

    • Apply direct pressure

    • Pack wound and hold pressure

    • If persisting remove dressing and use hemostatic dressing instead

    • Cover with pressure bandage to secure

  • Severe external bleeding from dialysis shunt or fistula

    • Apply digital pressure to bleeding site

    • Cover with a pressure dressing and secure

  • ABCs and vitals

  • Airway and O2

  • Assess for shock

  • Transport

Considerations

• roller gauze may be used in place of hemostatic dressing

• Put time on tourniquet

• If tourniquet was applied improperly and wound is minor, consider re applying

Burns

• stop burning proccess

• ABCs and vitals

• Airway and O2

• Remove smoldering clothing not adhering to skin

• Remove rings bracelets and constricting objects if possible

• Cover wound with dry sterile dressing

• Immediately irrigate burns to the eye with normal saline water

• Assess/treat for smoke inhalation appropriately 

• Maintain body temperature

• If burn covers <10% of body fat, cover in moist sterile dressing

• Transport to burn center

Considerations

• For liquid chemical burns: flush with saline for 20 minutes

• For dry powder: brush off before flushing

• Do not spread contaminant to unaffected areas

• Notify destination hospital to allow for decontamination

• O2 saturation may be falsely elevated in suspected smoke inhalation

• Do not include first degree burns when calculating percent

• Assess for hypothermia

Eye Injuries

• ABCs and Vitals

• Airway and O2

• Do not apply pressure to the globe

• Loosely Bandage both eyes

• For non-penetrating/chemical injury: flush the eyes with normal saline for 20 minutes

• For impaled objects: stabilize with bulky dressing and cover with both eyes

• For avulsed eye:

  • Do not put back in eye

  • Cover with saline moistened sterile dressing

  • Stabilize with a paper cup or similar object

• Assist patient with removal of contact lenses

• Transport

Bone and Joint Injuries

• Control external bleeding

• ABCs and vitals

• Airway and O2

• Assess for shock

• Manually stabilize

• Cover protruding bones/wounds with dry sterile dressing

• Apply cold packs to injury 

• Immobilize

• Assess pms

• Apply manual traction if distal extremity is cyanotic/pulseless/severely deformed

• Immobilize in position of function

• Elevate extremity

• Apply traction splint for mid thigh fracture

• Stabilize pelvic fracture

• Transport

CONSIDERATIONS

• Splinting should not delay transport

Head, Neck, Spine Injuries

• control external bleeding

• ABCs and Vitals

• Airway and O2

• Cover open neck wounds DO NOT WRAP COMPLETELY

• Assess and treat for shock

• Perform spinal motion restriction if mechanism for spinal injury AND

  • AMS non-intox

  • Distracting injury

  • Neck/spine pain, tenderness, deformity

  • Weakness, paralysis, numbness

  • High risk mechanism (Mva, fall >10 feet, 

• Transport

CONSIDERATIONS

• Don’t use NPA if facial/skull fracture

• No cervical collar torso injuries

Carbon Monoxide Poisoning

• ensure scene safety

• Remove patient from contaminated environment 

• ABCs and vitals

• Airway 

• O2 with nonrebreather (even if symptoms resolve)

• assess and treat for shock

• Obtain SpCO level

• Transport to hyperbolic chamber if

  • Asymptomatic SpCO > 25

  • High index of carbon monoxide poisoning (ams, headache, syncope)

  • Pregnant with SpCO > 15

CONSIDERATIONS

• Consider cyanide poisoning if exposed to burning substance in enclosed space

Smoke Inhalation

• ABCs and Vitals

• Airway

• O2 with nonrebreather (even if symptoms resolve)

• Assess and treat for shock

• Treat burns

• Get SpCO level

• Request ALS assistance

• Transport

CONSIDERATIONS

• Consider cyanide poisoning if exposed to burning substance in enclosed space

Cyanide Poisoning

Criteria

• for patients exposed to cyanide

• Class order from medical director needed to operate scene 

• ABCs and Vitals

• Airway

• O2 via non-rebreather

• Assess and treat for shock

• Assess and treat burns

• Request ALS

• Transport

WMD: Nerve Agent Exposure

Criteria

• Class order from medical control needed to use this protocol

• Assign triage tags

• administer NAAK auto injector and 0.5mg auto-injector according to symptom severity and weight

Color	Symptoms	Weight	NAAK	Atropine 0.5mg
Red	Sludge and: ams or respiratory distress	<18kg	1
		18-40kg	2
		>40kg	3
Yellow	Sludge or respiratory distress	<18kg	0	1
		18-40kg	1
		>40kg	2
Green	Asymptomatic

• 1 Administer doses in rapid succession

• For red and yellow to nor delay treatment for decontamination

• For green decontaminate and observe closely

• Monitor patient every 5 minutes

• Administer atropine every 5 minutes if symptoms persist

  • <18kg 0.5 mg

  • 18-40kg 1 mg

  • >40kg 2mg

CONSIDERATIONS

• sludgem

  • Salivation

  • Lacrimation

  • Urination

  • Defection

  • Gastrointestinal upset

  • Emesis

  • Miosis (muscle twitching)

• no more than 3 NAAK units per patient

• Record the units of atropine and NAAK on triage tag

Behavioral Emergencies

• Assess and Secure Scene Safety

• Request PD if patient risks harm to you, others, self

• If safe, verbally de-escalate patient’s condition

• You may physically restraint patient with soft restraints to protect patient and others

• identify and treat underlying medical/traumatic condition that may be causing agitation

• request ALS if chemical restraint is required

• ABCs and Vitals

• Airway and O2

• Obtain BGL, if able to safely

• Transport

CONSIDERATIONS

• do not call for chemical restraint if patient is not struggling against restraints or just for being non compliant

• if patient is handcuffed or in custody PD must accompany unit in compartment if ambulance

• patients should be handcuffed to stretcher not behind back

Acute Coronary Syndrome/Suspected Myocardial Infarction/Chest Pain

• ABCs and Vitals

• Airway and O2

• Place patient in position of comfort

• Administer 324mg Aspirin

• Request ALS

• transport

• if available, assist patient with prescribed Nitroglycerin every 5 mins

  • max dose 3

  • if sbp>120

Disryhtmia

• ABCs and Vitals

• Airway and O2

• Request ALS

• Transport

Obstetrics Emergencies

• ABCs and Vitals

• Airway and O2

• If mother is having contractions check for crowning

• treat appropriately if delivery has begun

• if delivery not imminent place in LEFT lateral recumbent

• Assess and Treat for shock

• Request ALS if delivery imminent or special emergency birth considerations

• for vaginal bleeding

  • place dressings over vagina to estimate blood loss

  • if post partum, massage abdomen over uterus

• transport

CONSIDERATIONS

• consider pre-eclampsia if

  • sbp > 160 or dbp >110

  • headache, edema, visual disturbance

Emergency Child Birth

• ABCs and Vitals

• Airway and O2

• if patient in labor inspect vagina for crowning

• if delivery is not imminent transport

• if delivery imminent, request ALS, and:

  • apply gentle pressure against head to prevent tearing of perineum

    • not to fontanelles, support bony parts

  • as head presents, clear airway of secretions with bulb syringe

    • depress bulb prior to insertion

    • suction mouth first no more than 1.5 inches

    • suction nose no deeper than 0.5 inches

  • Nuchal Cord

    • if loose enough, slip over head

    • if tight, place too clamps and cut between

  • support head and chest after delivered

  • repeat suction as needed before spontaneous breathing

  • gently guide head downward until shoulder appears, deliver other shoulder with gentle upward traction

  • thoroughly but rapidly dry baby with clean dry towel

• delay clamping of umbilical cord for (1) minute for uncomplicated birth, then:

  • place first clamp 8-10 inches from newborn

  • place second clamp 3 inches from first toward mother

  • cut between clamps, if continuous bleeding is seen add another clamp to that end

  • if clamps unavailable, tie with gauze but DO NOT CUT

  • wrap in dry warm towel with foil around newborn

  • cover scalp in warm covering

  • assess and treat mother for shock

  • assess and treat post partum hemorrhage

  • place newborn on mothers chest if safe

  • if miscarriage or stillbirth occurs, bring all fetal material to hospital with mother

  • if viability of fetus is uncertain, begin recussitation

SPECIAL CONSIDERATIONS

• Breech Presentation

  • place mother face up with hips elevated

  • support newborns thorax

  • if head does not deliver immediately:

    • place fingers between face and wall of birth canal to establish air passageway (maintain until delivery)

    • body should be maintained at or below angle of birth canal

    • do not apply traction

• Prolapsed Chord

  • place mother knee to chest

  • encourage mother not to push

  • if cord is not pulsing, insert gloved fingers inti birth canal and push head back 1-2 inches towards cervix until cord begins to pulsate

  • wrap saline-moistened, sterile dressings around cord

  • continuously monitor cord for pulse

  • maintain position for transport

• intact amniotic sac

  • immediately remove sac from around face

• Shoulder Dystocia

  • encourage mother not to push

  • place mother in knee to chest, may require assistance

  • place mother in trendelenburg position or with head lower than legs

  • apply firm steady suprapubic pressure (avoid fundal pressure)

  • if these maneuvers fail, place mother on her hands and knees

  • guide head downward to aid in delivery of upper shoulder

• multiple births

  • deliver accordingly, tie umbilical cords between births

  • clamp and cut cronologically

  • if second birth does not occur within 10 minutes, begin transport

Neonatal Care

Criteria

• Within one hour after birth

Provider Care

• After (1) minute

  • assess respiratory rate and tone and stimulate by rubbing lower back and gently flicking soles of feet

  • ventilate at 40-60 breaths/min with room air if neonate has ANY of the following

    • persistent central cyanosis

    • respiratory rate < 30 breaths/min

    • Heart rate < 100 beats/min

  • get apgar score

• (2) minutes

  • Assess neonates HR and perform the following

    • HR > 100 beats/min and newborn has good respiratory effort, continue care

    • HR is between 60-100 beats/min OR newborn has poor respiratory effort, continue ventilations

    • HR<60 beats/min after 30 seconds of providing ventilations, start compressions with a 3:1 compression to ventilation ratio

• Reassess neonate every (1) minute and perform the following

  • if HR > 60 beats/min, do not perform compressions and continue 40/60 breaths/min ventilations

  • Provide supplemental O2, but not ventilations or compressions, when ALL of the following are present

    • resporatory rate > 30

    • HR > 60

    • no central cyanosis

• after (5) minutes

  • Reassess apgar

• transport while keeping neonate warm

Asthma/COPD/Wheezing

• ABCs and vital signs

• Airway and O2

• Place patient in position of comfort

• Assist with prescribed albuterol

• for patients > 2 years or > 18 months with albuterol use, 1xunit albuterol and 1xunit bromide to nebulizer over 5-15 minutes (max 3 doses)

• Transport

  • initiate transport after starting treatment

  • do no delay to complete med administration

• for patients in severe respiratory distress/respiratory failure and or shock, administer epinephrine as follows:

  • age < 9 and weight < 30 kg

    • A: Epi 0.15 IM injector

    • B: Pediatric Epi IM injector

  • age > 9 or weight > 30 kg

    • A: Epi 0.3 IM injector

    • B: Adult Epi IM injector