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Revision Review Region X SOPs March 1, 2007


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Title: Revision Review Region X SOPs March 1, 2007

Revision Review Region X SOPs March 1, 2007
  • Condell Medical Center
  • EMS System
  • May, 2007
  • Site Code 10-7200E-1207

Prepared by Sharon Hopkins, RN, BSN, EMT-P
  • To familiarize the EMS provider with the changes
    to the March 1, 2007 Region X SOPs in
    preparation for examination
  • Assess patients to be stable or unstable to
    determine if a conservative intervention is
    appropriate (ie medications) or more aggressive
    intervention is needed
  • Clarify interpretation of the SOPs
  • Review Lead II rhythm strips

Region X March 1, 2007 SOPs
  • Some pages have been reformatted
  • reading left to right
  • moving from less critical to more critical
    conditions/situations reading left to right
  • attempted consistency of language through out the
    document (ie low acceptable B/P 100)
  • Most changes in the SOPs were made to reflect
    the updates in the 2005 AHA guideline revisions
  • SOPs must be followed by the EMS provider
    Medical Control can choose to deviate

Table of Contents
  • Reorganized into sections
  • Introduction
  • Cardiac
  • Respiratory
  • Medical
  • Trauma
  • Obstetrics
  • Pediatric
  • Pediatric Considerations
  • Appendices
  • Alphabetized within each section

Introduction to Use of SOPs - pg 1
  • Added statement to allow judgement in decision
  • An alternate order of listed interventions may
    be appropriate based upon patient assessment
  • If EMS is unable to establish communication with
    Medical Control, follow interventions approved in
    the SOPs
  • Clarification of pediatric age
  • under the age of 16
  • this means 15 and under

Routine Medical Care - pg 2
  • Combined with General Patient Care
  • Pain scale is part of vital signs
  • If following the Acute Coronary Syndrome
    protocol, a 12-lead EKG is indicated
  • If a 12-lead is obtained, it needs to be
  • Not every patient that needs to be monitored
    needs to have a 12-lead obtained

Adult IV Conscious Sedation for Intubation - pg 7
  • Age contraindication raised to 16 (consistency)
  • Initial Versed dosage raised to 5 mg IVP
  • If not sedated within 60 seconds (1 min) give
    Versed 2 mg IVP every minute until sedated
  • Following sedation, if needed for agitation, can
    give Versed 1 mg every 5 minutes
  • Total dose of Versed is 15 mg IVP

Adult IV Conscious Sedation for Intubation contd
  • Morphine is given following the start of the
    Versed dose
  • Versed Morphine together potentate effects of
    the drugs enhancing results greater than either
    drug alone
  • Versed relaxes and sedates the patient Versed
    does not affect the level of pain

Secure Airway
  • Term used on all protocol pages when responding
    to the arrested patient
  • Term used to indicate to secure the airway in
    whatever way possible and whatever means
    available at the time
  • You are to accomplish this with minimal
    interruption to CPR
  • Initially using a BVM with or without an
    oropharyngeal or nasopharyngeal airway would
    accomplish the task of securing an airway with
    minimal interruption

Asystole/PEA - pg 8
  • 2 algorithms combined into one
  • A 6th H added to possible causes - hypoglycemia
  • Intubation to be accomplished when time is
    appropriate, not necessarily immediately, and
    with minimal interruption to CPR
  • Atropine administered for asystole and when the
    PEA rate is lt60
  • No transcutaneous pacing for Asystole

Withdrawing Resuscitation Efforts - pg 9
  • Language changed for consistency
  • confirmation of intubation
  • replaced with
  • advanced airway secured

Bradycardia and AV Blocks - pg 11
  • Repeat dosage of Atropine is 0.5 mg
  • when theyre alive, give them 0.5
  • Wide complex bradycardias
    (Type II second degree heart block and third
    degree AV block)
  • begin with TCP first
  • consider sedation (Valium)

Acute Coronary Syndrome - pg 12
  • Note added regarding prior Aspirin intake
  • Aspirin may be withheld if patient reliable
    and states has taken within 24 hours
  • Document what time and what dosage was taken by
    the patient
  • If pain persists after a 2nd dose of
    Nitroglycerin, proceed to Morphine
  • Once you have moved onto Morphine, continue
    Nitroglycerin after consultation with Medical

Transition of Care From AED Trained Personnel To
ALS - pg 14
  • AED users need to follow whatever prompts are
    given by the particular AED unit
  • Older AEDs will prompt for 3 shocks and 1 minute
    of CPR
  • Newly reprogrammed AEDs will prompt for 1 shock
    followed immediately by 2 minutes of CPR before

Supraventricular Tachycardia (Narrow Complex
Tachycardia) - pg 15
  • Diltiazem moved to this page to follow Adenosine
  • When the stock of Diltiazem is exhausted, to be
    replaced with Verapamil
  • Verapamil to be given 5 mg IVP slowly (over 2
  • If no response in 15 minutes, repeat Verapamil 5
    mg slow IVP

Rapid Atrial Flutter/Fibrillation (Narrow Complex
Tachycardia) - pg 16
  • Added note to use Verapamil when Diltiazem is no
    longer available
  • Verapamil can cause hypotension
  • give slowly (over 2 minutes plus)
  • treat hypotension with IV fluid challenge of 200
    ml Normal Saline

Ventricular Fibrillation or Pulseless Ventricular
Tachycardia - pg 17
  • All defibrillation attempts are singular
  • All defibrillation immediately followed by 2
    minutes of CPR prior to rhythm check
  • Antidysrhythmic drugs (choose one)
  • Amiodarone 1st dose 300 mg IVP (diluted)
  • Repeat dosage in 5 minutes Amiodarone 150 mg IVP
  • Lidocaine 1st dose 1.5 mg / kg IVP
  • Repeat dosage in 5 min Lidocaine 0.75 mg/kg

AHA Guideline Revision
  • If arrest is witnessed, begin and perform CPR
    until defibrillator is charged and ready
  • If arrest time lt 4-5 minutes, perform CPR just
    until defibrillator ready
  • If arrest unwitnessed (or time gt4-5 minutes since
    arrest), perform 2 minutes of CPR before stopping
    to defibrillate
  • Immediately after each defibrillation attempt
    resume 2 minutes of CPR
  • After 2 minutes of CPR stop for lt10 seconds for
    rhythm check

Ventricular Tachycardia or Wide Complex
Tachycardia (Patient with a Pulse) - pg 18
  • Amiodarone added as a choice of antidysrhythmic
  • if chosen, dosage of Amiodarone is 150 mg diluted
    in 100 ml D5W IVPB over 10 minutes
  • Mix IV bag, gently rotate bag to mix medication,
    spike IV bag with mini-drip tubing and prime
    tubing, plug in IV tubing to primary line, run
    drip so you can see drops

Acute Pulmonary Edema - pg 19
  • CPAP procedure steps moved to Appendix
  • If the patient is unstable, CPAP provided only on
    orders of Medical Control
  • Remember
  • All interventions (Nitroglycerin, Lasix,
    Morphine, and CPAP) can cause hypotension

Transcutaneous Pacing Protocol - pg 20
  • TCP suggested for symptomatic bradycardia
  • back-up to Atropine failure for narrow complex
  • primary intervention if QRS is wide
  • Second degree type II - Classical
  • Third degree heart block - Complete
  • Valium used for patient comfort

Acute Abdominal Pain/Flank Pain - pg 21
  • Added flank pain to title
  • On this SOP, Medical Control must be contacted
    for any pain medication order
  • Pain management orders often based on your radio
  • be an effective patient liaison
  • if you feel pain management is appropriate and
    you dont receive the order, you need to ask for

Airway Obstruction - Adult - pg 22
  • Follows AHA standards
  • If the obstruction is unrelieved, perform CPR
  • An extra step is taken each time you open the
  • look in the mouth to visualize for an obstruction
  • if one is noted, attempt removal
  • if no obstruction is noted, continue with 2
    breaths and move onto 30 compressions

Adult Allergic Reaction Anaphylactic Shock - pg 23
  • Defined stable and unstable patients
  • Stable hives, itching, rash, GI distress, alert,
    warm dry, B/P gt100
  • Stable with airway involvement alert, warm
    dry, B/P gt100
  • Unstable altered mental status B/P lt 100
  • Defined slow IVP for Benadryl dose - over 2
  • To anaphylaxis added Benadryl 50 mg slow IVP and
    if wheezing, albuterol nebulizer

Allergic Reactions Anaphylaxis
  • For simple reactions without airway involvement,
    Benadryl used (stops release of histamines)
  • For allergic reactions with airway involvement or
    anaphylaxis, start with Epinephrine followed by
  • Epinephrine is life saving
  • Effects are immediate to vasoconstrict blood
    vessels to support circulation
  • Benadryl slowly stops progression of the allergic
    response - stops release of histamines

Altered Mental Status - pg 24
  • Title condensed
  • Added to consider etiology as you are caring for
    the patient
  • may help lead the decision making for treatment

Asthma/COPD with Wheezing - pg 25
  • Added
  • Contact Medical Control to consider use of CPAP
    in a patient has symptoms of COPD

Stroke / Brain Attack - pg 26
  • Added
  • Determine time of onset of symptoms
  • Opportunity to definitively treat a patient with
    an occlusive stroke is a very narrow window of
    time - 3 hours from time of onset
  • To expedite patient intervention, notify Medical
    Control as soon as general impression of a stroke
    is made

Seizures Status Epilepticus - pg 30
  • Changed the order of medications
  • Valium attempted first
  • Dextrose listed 2nd
  • This is a good example of the statement in the
    Introductory to allow for the EMS provider, after
    patient assessment, to use judgement to follow an
    alternate order of listed interventions

Severe Respiratory Febrile Illness - pg 31
  • New SOP
  • Promoting the use of PPE and limiting
    contamination are the goals of this SOP
  • If a patient must wear a
    mask, they are to be given
    a surgical mask
  • The N95 mask is reserved
    for use by the medical team
    and never to be given to
    the patient

N95 mask
Region X Field Triage Criteria for Assessing
Trauma Patients - pg 33
  • Gives guidelines for transporting patient based
  • hemodynamic values (ie serial B/P)
  • stability of vital signs
  • anatomy of injuries
  • mechanism of injury
  • existence of co-morbid factors
  • special circumstances traumatic arrest burns
    gt20 inability to open airway

Transporting The Trauma Patient
  • Unstable trauma patient (adult B/P lt90 x2 or peds
    B/P lt80 x2 or Category I trauma patient (based on
    unstable vital signs /or mechanism or injury)
  • transport to highest level Trauma Center within
    25 minutes
  • you need to be aware of this especially if
    responding mutual aid where this applies
  • CMC departments will go to a Level II trauma
    hospital as no Level I exists within a guaranteed
    response time 24/7 of 25 minutes

Trauma Transports
  • Traumatic arrest
  • Closest Trauma Hospital
  • Unable to secure an airway
  • Closest Emergency Department regardless of
    Trauma status

Amputated and Avulsed Parts - pg 35
  • Care of stump added
  • covered with damp sterile dressing and elastic
    wrap with uniform pressure

Chest Injuries - pg 38
  • New SOP - long standing interventions
  • Authorizes EMS responder to perform bilateral
    chest decompression for a patient with traumatic
  • the mechanism of injury should indicate potential
    or actual traumatic injury to the chest

Heat Emergencies, Adult
  • Defined heat stroke as hot and dry or hot and
    moist skin
  • classic heat stroke is hot and dry
  • exertional heat stroke is hot and moist

Routine Pediatric Care - pg 52
  • New SOP - generic care for all peds patients
  • Reminder that pediatric age is lt16
  • Pediatric assessment triangle (PAT)
  • used to quickly establish level of severity
    identify key physiologic problems
  • assesses ?appearance, ?work of breathing,
    ?circulation to skin
  • obtain this information as you cross the room and
    are approaching the patient

Pediatric Care Guidelines
  • Note
  • Any pediatric drug calculation should never
    exceed the adult drug maximum

Pediatric Respiratory Failure - pg 53
  • Expanded signs symptoms of respiratory distress
  • Distress
  • ? work of breathing, ? respiratory rate, use of
    accessory muscles, nasal flaring, effectively
  • Failure - needs to be bagged!!!
  • exhausted energy reserves, cannot maintain
    adequate oxygenation ventilation, low resp
    rate, ?effort, bradycardia, agitation, lethargy,

Pediatric Altered Level of Consciousness - pg 54
  • Added reference to fluid challenge
  • Administer IV fluid challenge 20 ml/kg

Pediatric Acute Asthma - pg 55
  • Phased approach of care added
  • mild to moderate distress (increased work of
  • severe distress (inadequate oxygenation,
    ventilation, or both)
  • The patient in severe distress (and especially
    the pediatric patient with bradycardia
    respiratory failure) may need to be ventilated
    via a BVM with 100 O2

Pediatric Airway Obstruction - pg 56
  • AHA guideline changes
  • back blow terminology changed to back slaps
  • 5 back slaps and 5 chest thrusts repeated in
    sequence for patients lt 1 year old
  • Unrelieved obstructions handled alike for all
  • Perform steps of CPR
  • Pause before the 2 ventilations to look directly
    into airway attempt removal if object noted

Pediatric Ventricular Fibrillation or Pulseless
Ventricular Tachycardia - pg 57
  • Title change
  • Follows 2005 AHA guidelines
  • CPR- compression rate 100/minute
  • 302 for 1 person CPR all victims
  • 152 CPR for child and infant if 2 person CPR
  • Airway
  • Once intubated, ventilation rate one breath every
    6-8 seconds asynchronous with compressions

Pediatric VF/Pulseless VT contd
  • Amiodarone is alternative antidysrhythmic to
  • 5 mg/kg IVP/IO
  • Repeat dosage thru Medical Control order
  • needs to be diluted due to irritation to vein
  • ETT route discouraged (absorption unreliable) but
    not eliminated
  • IV and IO are preferred routes

Pediatric Asystole, PEA, Pulselsss Idoventricular
Rhythms - pg 58
  • Follows AHA guidelines
  • 6th H to possible causes- hypoglycemia
  • Revised CPR guidelines
  • CPR 302 for 1 and 2 person CPR
  • CPR 152 for 2 person CPR for children and
  • Once intubated, patient is ventilated once every
    6-8 seconds
  • ETT drug route de-emphasized

Pediatric Bradyarrhythmias - pg 59
  • Expanded signs and symptoms of compromise
  • Epinephrine 110,000 - 0.01 mg/kg IVP/IO repeated
    every 3-5 minutes for the duration
  • For persistent bradycardia, contact Medical
    Control for possible order for Atropine
  • Medical Control needs to be contacted for order
    for external pacing

Pediatric Tachycardia with Poor Perfusion - pg 61
  • Under probable ventricular tachycardia column,
    contact Medical Control for possible
    antidysrhythmic order (Amiodarone or Lidocaine)

Pediatric Tachycardia with Adequate Perfusion -
pg 62
  • Under probable ventricular tachycardia column, if
    Amiodarone is chosen, must be diluted and
    administered over 20 minutes
  • Dilute dosage in 100 ml D5W
  • Prime mini-drip tubing
  • Plug piggyback into primary line
  • Run Amiodarone drip to count
    30 minidrips / 10 seconds

Croup/Epiglottitis - pg 64
  • Position of comfort encouraged but transportation
    must be done safely and following current traffic
  • Transport in parent/caregiver arms no longer

SIDS - pg 66
  • Expanded external appearance of SIDS victim
  • cold skin
  • frothy blood tinged fluids around mouth
  • vomit may be present
  • lividity or dark reddish blue mottling on
    dependent side of the body
  • unusual position due to muscle spasms at time of

Burns, Pediatric - pg 67
  • New SOP
  • Formatted following adult Burn SOP
  • Contact Medical Control for pain management
  • Rule of Nines moved to Appendix

Pediatric Toxic Exposures - pg 68
  • Title change
  • For toxic exposures, follow Hazardous Materials

Pediatric Heat Emergencies - pg 69
  • New SOP
  • Follows format of adult heat emergencies
  • During cooling process, if pediatric patient
    begins to shiver, administer Valium to stop the
    shivering (shivering generates energy and heat -
    counterproductive to efforts to lower body
  • Heat stroke can present hot and dry or hot and
    moist (classic or exertional)

Pediatric Allergic Reaction/Anaphylaxis - pg 70
  • Columns headed like adult SOP
  • Allergic Reaction Stable
  • Allergic Reaction Stable with Airway Involvement
  • Anaphylactic Shock
  • Benadryl added to 3 columns
  • Benadryl 1 mg/kg
  • Max at the adult dosage
  • stable - 25 mg maximum
  • stable with airway involvement anaphylaxis -
    50 mg maximum

Glasgow Coma Scale/Revised Trauma Score - pg 76
  • Moved to back of SOPs
  • GCS to be obtained on every EMS call

Calculating Body Surface Burn Percentages - pg 77
  • Includes schematic for adult, child, and infant
  • Includes breakdown of body areas
  • superior and inferior (ie chest abdomen)
  • anterior versus posterior
  • Note Different resources may vary the percentage
    slightly not all award any percentage to perineum

CPR for Infants and Children - pg 78
  • Follows revised 2005 AHA guidelines
  • 1 person CPR
  • 302 for all persons
  • 2 person CPR for adults
  • 302
  • 2 person CPR for infants and children
  • 152
  • Compression rate 100/minute

Pediatric Resuscitation Medication - Cardiac and
Medical - pgs 80, 81
  • Expansion of pediatric weights
  • Provides information of ml (helpful for bedside
    care) and mg (helpful for documentation)
  • Epinephrine 11000
  • On Cardiac page, ETT dosage is shown for arrested
    and critical level patient
  • On Medical page, SQ route is shown for non-arrest
    and stable patients

IV Fluid Challenge
  • Formula for all persons
  • 20 ml / kg
  • All persons need reassessment
  • every 200 ml of fluid administration while the
    fluid challenge is being administered

Region X Approved Drug Information List - pgs
  • Information on individual medications revised
  • Preferred routes in arrest IV/IO ETT
    unpredictable (last resort)
  • Adenosine
  • do not use in setting of WPW history
  • Amiodarone
  • Adult - initial dose in arrest 300 mg repeat
    dosage 150 mg in 5 minutes
  • Adult pediatric dose in patients with pulse -
    must be diluted in 100 ml D5W and run slowly

Region X Approved Drugs contd
  • Benzocaine
  • limit spray to lt 2 seconds
  • Lidocaine
  • Added to indications for suppression of cough
    reflex when used for patient with head injury
    (medical or trauma) requiring conscious sedation
  • Nitroglycerin
  • Added to avoid use if Viagra or Viagra-type drug
    taken within past 24 hours

Region X Approved Drug
  • Verapamil
  • New addition
  • Calcium channel blocker to slow the ventricular
    response of stable SVT or rapid Atrial
    Fibrillation or Atrial Flutter
  • To be used when stock of Diltiazem/Cardizem is no
    longer available
  • Avoid in any wide complex rhythm, in the setting
    of heart block, in severe CHF, in the presence of

Region X Approved Drug
  • Versed
  • Noted increase dosing of Versed used during
    Conscious Sedation
  • 5 mg to start
  • continued at 2 mg every minute til sedated
  • 1 mg every 5 minutes to continue sedation after

Appendix - Needle Decompression, Chest - pg 89
  • Insertion site is 2nd
    intercostal space,
    midclavicu- lar line

Combitube , Dual Lumen Airway Device - pg 91
  • Available alternative to secure an airway for the
    individual department that places it into service
  • Once trained, the EMS
    provider (Basic and
    Paramedic) may use
    the Combitube

Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm (rate 80)?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
Whats This Rhythm?
2 different simultaneous leads
Rhythm Answer Key
  • 1 - Ventricular fibrillation
  • 2 - Ventricular tachycardia
  • 3 - Atrial fibrillation
  • 4 - Second degree Type II - Classical
  • 5 - Sinus Rhythm
  • 6 - Sinus Bradycardia
  • 7 - Atrial fibrillation

Rhythm Answer Key contd
  • 8 - Paced rhythm
  • 9 - Second degree Type I - Wenckebach
  • 10 - PEA
  • 11 - SVT
  • 12 - Third degree heart block - complete