MEDICAL STANDING ORDERS
FOR EMERGENCY MEDICAL TECHNICIANS
Table of Contents
GENERAL GUIDELINES...... 1
ASSESSMENT...... 3
AIRWAY and OXYGEN...... 5
ACUTE MOUNTAIN SICKNESS (AMS)...... 7
ANAPHYLAXIS...... 8
CARDIAC CHEST PAIN...... 9
CARDIAC DYSRHYTHMIAS...... 10
COMA OF UNKNOWN ETIOLOGY/ALTERED MENTAL STATUS...... 11
DETERMINATION OF DEATH and CESSATION OF LIFE SUPPORT...... 12
FRACTURES/DISLOCATIONS...... 13
HEAD TRAUMA...... 14
HYPERTHERMIA...... 15
HYPOGLYCEMIA...... 16
HYPOTHERMIA...... 17
INFECTION PROPHYLAXIS...... 18
INTRAVENOUS THERAPY...... 19
OVERDOSES AND POISONINGS...... 20
PAIN AND NAUSEA CONTROL...... 21
RESPIRATORY DISTRESS...... 22
SEIZURES...... 23
SHOCK...... 24
SPINAL TRAUMA...... 25
Appendices
DRUG LISTING...... 26
SIGN-OFF SHEET...... 27
GENERAL GUIDLINES
1. PATIENT CHARTING:
A. S.O.A.P. charting format is preferred.
B. Documentation of the scene is important:
1. Vehicle accidents: Vehicle or aircraft condition.
2. Trauma: mechanism of injury
3. General Medical: environment
C. Treat every chart as a legal document. It may someday be used in court.
D. If it isn't documented, it hasn't been done.
2. VITAL SIGNS:
A minimum of two (2) sets per patient (time permitting) and one set per hour. If the patient's condition is serious, vital signs should be checked frequently.
3. TEXAS/FOLEY CATHETER:
May be inserted on patients receiving diuretics; those who are unconscious; and those undergoing long, technical evacuations to prevent urination on sleeping bags or other insulation.
4. COMMUNICABLE DISEASES:
A. Protective gloves should be worn by personnel if they are at risk of contacting body fluids of patients.
B. Gloves should be worn at all times when handling bodies.
C. Any suspected exposure to a communicable disease should be reported to the Emergency Services Director.
D. If Corvallis Mountain Rescue Unit (CMRU) members treat patients who are subsequently hospitalized, the receiving hospital should be informed that CMRU personnel did come in contact with said patients. If problems arise later they will be able to contact personnel involved.
E. All equipment exposed to the body fluids of patients should be carefully cleaned according to the manufacturer's instructions. In lieu of those instructions, a solution of 10% bleach or similar disinfectant should be used.
5. MEDICAL PROFESSIONAL AT THE SCENE:
Medical professionals who offer their assistance or wish to take control of patient care should:
A. Identify themselves
B. Preferably show some proof of licensing authority
C. Be treated with professional courtesy
D. Be assisted as needed
E. Be informed that if any patient care goes against the best judgement of the EMT that the physician:
1. Will be solely responsible for said care.
2. Must stay with the patient and accompany them to the hospital.
3. Will sign the patient care document.
6. SCOPE OF PRACTICE:
EMT's should follow these Standing Orders up to the level of their scope of practice.
7. It is understood that there may be times and circumstances when all of the needed equipment and/or personnel may not be available, and modification of these orders may be required.
8. Rescuer safety always comes first.
ASSESSMENT
GENERAL PRINCIPLES
A. Assess the entire patient, not just one body part.
B. Do not let graphic wounds distract you from something life-threatening.
C. You can not learn abnormal until you know normal.
D. The only way to get good at assessment is to practice it.
FOUR METHODS USED
A. Inspection -- looking
B. Palpation -- feeling (be alert to patient response)
C. Auscultation -- listening (not necessarily with a stethoscope)
D. Percussion -- tapping on body organs
PRIMARY SURVEY -- ABC's of Cardio-Pulmonary Resuscitation (CPR)
A -- Airway
B -- Breathing (also Bleeding)
C -- Circulation
ELEMENTS OF THE PRIMARY SURVEY
A. Establish a level of consciousness (LOC) i.e. "Shake and Shout," are they awake, alert, oriented, responsive to what type of stimuli?
B. Airway (includes the chest)
Assume it is compromised until proven otherwise
1. Open Airway
2. Noisy breathing is obstructed breathing
C. Breathing -- look, listen, and feel
D. Circulation
Check for carotid pulse; what is its rate, strength, regularity? Pulses obtained show blood pressures of:
Carotid ==> 60 mm Hg
Femoral ==> 70 mm Hg
Radial ==> 80 mm Hg
IS THERE OBVIOUS BLEEDING?
ELEMENTS OF THE SECONDARY SURVEY
A. Notice the patient positioning. Are they upright trying to breathe? curled up in pain? holding very still guarding an injury? Note skin color, temperature, and moisture.
B. Head
Inspection -- 1. Obvious trauma (Cerebral Spinal Fluid present?)
2. Pupils (Pupils Equal And Reactive To Light -- PEARL)
3. Symmetry
4. Look in mouth for loose teeth, objects, etc.
Palpation -- feel skull, face, and mandible
1. Deformities
2. Crepitus
3. Masses
4. Other trauma (wounds, holes, etc.)
C. Neck
Inspection -- 1. Obvious trauma
2. Trachea
Palpation -- feel muscles of neck. Are they tense and guarding a cervical spine injury?
D. Chest
Inspection -- 1. Obvious trauma
2. Symmetry
Palpation -- Deformities (also equal expansion)
Auscultation -- Are breathing sounds present throughout?
Percussion -- Is there abnormal dullness or tympany?
E. Abdomen
Inspection -- Obvious trauma, distention, etc.
Palpation -- Guarding, rebound tenderness, masses, etc.
Auscultation -- Bowel sounds present, hyper/hypoactive.
F. Pelvis
Inspection -- Obvious trauma, symmetry, etc.
Palpation -- Movement
G. Extremities
Inspection -- Obvious trauma, function (is patient able to use the affected limb?)
Palpation -- (Includes clavicles) Crepitus, swelling, deformity, etc. be sure to note Circulation, Movement, and Sensation (CMS):
Circulation: Distal pulses and capillary refill
Movement: Range of motion
Sensation: Feeling (dermatomes)
AIRWAY and OXYGEN
The following are guidelines for Oxygen therapy and Airway maintenance.
OXYGEN
DEVICE / RATEL/Min / EXAMPLES OF USE
Cannula / 1 - 2 / Chronic Obstructive Pulmonary Disease (COPD)
Cannula / 2 - 4 / Chest pain, moderate shortness of breath (SOB), trauma prophylaxis, pain, etc.
Mask / 4 - 8 / Moderate chest pain, moderate trauma, moderate SOB, minor/moderate hypovolemia, etc.
Non-rebreather
Mask / 10 - 15 / Severe trauma, severe SOB, severe hypovolemia, anaphylaxis, post airway obstruction, smoke inhalation, carbon monoxide poisoning & other toxic gases, etc.
If the patient has COPD and is in severe respiratory distress ie: cyanosis, diaphoresis, decreased LOC, do not withhold Oxygen.
(FR,B, I, P)
SUCTIONING
Appropriate nasal or orotracheal suctioning as patient's condition merits. (FR,B, I , P)
NASOPHARYNGEAL AIRWAY
Use on semiconscious patients or those likely to regain consciousness, excellent for seizure patients. ( (FR,B, I, P)
OROPHARYNGEAL AIRWAYS
All deeply unconscious patients without a gag reflex. ( FR,B, I, P)
COMBI-TUBE (I,P)
Deeply unconscious patients...
More than 70 lbs.
More than 16 years old
no gag reflex
no history of caustic/petro chemical ingestion
no history of esophageal varices etc.
ENDOTRACHEAL TUBES (P)
A) ORAL deeply unconscious patients, cardiac arrest (code99), anaphylaxis, etc.
B) NASAL patients with suspected cervical spine trauma, but without nasal discharge or bleeding, seizure patients (status) in which other measures are unsuccessful, Airway obstruction in which other measures are unsuccessful, etc. Oral or nasal intubation may be required on rapidly deteriorating but awake patients.
C) TACTILE/DIGITAL - deeply unconscious patients in which spinal manipulation is to be avoided or in which other measures are unsuccessful.
PARALYTIC THERAPY – Patients with a Glasgow score of 9 or less may be intubated with the aid of Paralytic drugs using the following sequence. (APPROVED P)
Valium- 5-10mg (0.1 mg/kg) IV if needed
Succinylcholine 1.5 mg/kg IV/ 2mg/kg IM
Vecuronium 10mg (0.1mg/kg) IV if needed
ENDOTRACHEAL SUCTION - as indicated. (P)
NEEDLE CRICOTHYROSTOMY - (P)
(transtracheal catheterization)
Patients with severe/complete airway obstruction due to foreign body, anaphylaxis, trauma, etc.
NEEDLE THORACOSTOMY (P)
Patients with tension pneumothorax, with impending respiratory arrest and/or symptoms of severe shock.
ACUTE MOUNTAIN SICKNESS (AMS)
MILD AMS
Characterized by mild headache, insomnia, anorexia, shortness of breath with exertion, etc...
1. Descend - 200300 meters may be all that is needed.
2. Encourage fluids and nutrition.
3. Tylenol or Aspirin by mouth (PO) for headache. (P)
MODERATE AMS
Characterized by severe headache (not relieved or partially relieved with Tylenol or Aspirin), lassitude, weakness, loss of appetite, nausea, ataxia, SOB with rest, reduced urinary output, etc...
1. Stop Ascent.
2. Descend 300600 meters is usually adequate.
3. Encourage fluids and nutrition.
If unable to descend...
4. Oxygen. (FR,B,I,P)
5. Diamox 125-250 mg po every 12 hours as needed (P)
SEVERE AMS and HIGH ALTITUDE CEREBRAL EDEMA (HACE)
Characterized by headache, ataxia, nausea, vomiting, lassitude, reduced urinary output, etc...
1. Descent - rapid and immediate; do not wait if possible.
2. Oxygen. (FR,B,I,P)
If unable to descend...
3. Decadron 10mg IVP repeat 6mg every 68 hours as needed. (P)
HIGH ALTITUDE PULMONARY EDEMA (HAPE)
Above symptoms usually occur although pure HAPE is possible. Tachypnea, peripheral edema, rales (severe or audible without a stethoscope), copious sputum, cyanosis, etc..
1. Descend - rapid and immediate; do not wait if possible.
2. Oxygen. (FR,B,I,P)
3. Lasix 4080mg IVP. (P)
4. Nifedipine 10 mg SL every 8 hours as needed (P)
ANAPHYLAXIS
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
3. IV large bore, Normal Saline or Lactated Ringers run per patient condition (I, P)
4. If shock is present, follow Shock protocol
5. Epinephrine 1:1,000 0.3cc subcutaneous (SQ) (0.01 mg/kg) (B, I, P)
6. If patient with systolic BP less than 80 mm Hg consider:
Epinephrine 1:10,000 3ml IVP or 0.3cc sublingually in adults (P)
7. If no improvement, repeat Epinephrine 1:1,000 0.2cc SQ every 510 minutes (P)
Also consider in patients with anaphylaxis:
8. Benadryl 2550mg (2mg/kg) slow IVP, IM or PO for hives, itching, swelling repeat every 46 hours as needed. (P)
9. Dexamethasone 1020 mg (0.250.5mg/kg) IVP; repeat 24mg every 4 hours as needed. (P)
CARDIAC CHEST PAIN
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
3. IV (I,P)
- Nitroglycerin (NTG) 0.4mg sublingual (SL) every 5 minutes if systolic BP is greater than 90-100 mm Hg.
(I ,P)
5. If chest pain unrelieved by NTG, lasts longer than 30 minutes, and patient's systolic BP is greater than 90-100 mm Hg:
A. Morphine Sulfate: 2-4mg IVP titrated to affect up to 20 mg. (P)
Caution: NTG, and Morphine may cause orthostatic hypotension. Patients receiving Morphine must be monitored for hypoventilation.
CARDIAC DYSRHYTHMIAS
COMA OF UNKNOWN ETIOLOGY/ALTERED MENTAL STATUS
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor - if dysrhythmia see dysrhythmia section. (I,P)
3. IV large bore - (I,P)
A. Normal Saline at rate per patient's condition.
4. If shock is present, follow Shock protocol.
5. Thiamine 100mg IM/IV if indicated. (P)
6. Dextrose 50% (1/2 gram/kg) IVP. (I, P)
7. Narcan 1.2mg (0.01mg/kg) IVP or IM up to 2.0mg if high suspicion of narcotic overdose exists.
Repeat as needed. (I, P)
DETEMINATION OF DEATH / CESSETION OF LIFE SUPPORT
1. Any trauma patient who is pulseless and apneic may be considered dead.
2. Any patient who exhibits obviously mortal wounds, rigor, lividity, etc. or is pulseless and unresponsive after 30 minutes of Advanced Cardiac Life Support may be considered dead.
- Any hypothermic patient who is Asystolic (monitor), frozen, and who's core temperature is the same as the ambient temperature may be considered dead.
4. Patients who have had prolonged CPR or who would require CPR during technical evacuation may be
considered dead.
- Give hypothermic patients the benefit of doubt. If transport to a medical facility is available it is best to
transport patients with a questionable status.
6. Do Not risk rescuers for patients with little hope of being salvaged.
FRACTURES/DISLOCATIONS
As determined or suspected by pain, swelling, discoloration, deformity, loss of function, bone fragments, etc.
1. Cervical spine precautions if appropriate. (FR,B,I,P)
2. Splint extremities with appropriate and available means. (FR,B,I,P)
3. IV Normal Saline or Lactated Ringers as indicated for fractures with significant blood loss (i.e. usually femur and pelvis). (I,P)
4. For pain control consider local application of cold. Fore more severe pain consider analgesics.
- Check circulation, movement, and sensation before splinting, after splinting, and frequently thereafter.
- Fractures/dislocations with signifcant impairment of circulation may require reduction. This should be done
Only if a prolonged transport time is anticipated.
HEAD TRAUMA
- Airway, Oxygen (FR,B,I,P)
2. C-Spine Precautions (FR,B,I,P)
3. Cardiac Monitor (P)
4. IV large bore Normal Saline or Saline lock. (I,P)
5. If shock is present follow Shock protocol.
6. Consider paralytic therapy in those with a GCS of 9 or less. (P)
HYPERTHERMIA
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
3. IV large bore Normal Saline run per patient's condition. (I,P)
HEAT EXHAUSTION
4. Consider 300500cc fluid challenge of NS or LR to replace fluids and electrolytes; more if patient is hypotensive, tachycardic,or orthostatic. (I,P)
5. If severe shock presents, see shock protocol (avoid MAST).
HEAT STROKE
6. IV as above (I,P)
7. Cool patient - consider wet sheets with good airflow, snow, water, etc...
HYPOGLYCEMIA
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
3. IV large bore – NS or NS lock. (I,P)
4. If patient is conscious may use oral glucose agent. (FR,B,I,P)
5. Dextrose 50% (1/2 gram/kg) IVP; may be repeated if indicated. (I, P)
HYPOTHERMIA
A patient with a rectal temperature of less than 90o F.
1. Airway, Oxygen - remember glottal stimulation may cause V. Fib. (FR,B,I,P)
2. Cardiac Monitor (I,P)
3. Prevent further heat loss. Add heat to groin, neck, axilla, and torso if able. DO NOT warm extremities.
If possible prior to moving patient who is unconscious or rectal temperature less than 90o F consider:
4. IV large bore Lactated Ringers or Normal Saline 300500cc fluid challenge. (I, P)
5. Bretylium (5mg/kg) or Lidocaine (1mg/kg) IVP as prophylaxis to V. Fib. (P)
6. Consider withholding CPR in the apparently pulseless, severely hypothermic patient who has a potentially pulse producing rythmn (i.e. supraventricular or ventricular bradycardias). Compressions may induce V. Fib.
If Ventricular Fibrillation is present:
1. CPR, Airway (FR,B,I,P)
2. Bretylium (5mg/kg) or Lidocaine (1mg/kg) IVP (P)
3. Defibrillate at 200 joules one time only. (P)
If unsuccessful may repeat...
4. Defibrillate at 360 joules one time only. (P)
5. Continue CPR; however keep in mind most ACLS protocols work only after the patient is warmed and may be of no use in the hypothermic patient.
6. Isuprel, Atropine, Dopamine are contraindicated in severely hypothermic patients; DO NOT TREAT BRADYCARDIAS.
INFECTION PROPHYLAXIS
Patients with open: fractures, abdominal wound (evisceration etc.), chest wounds (into pleural cavity, etc.), head wounds (into cranial cavity, etc.), who cannot be readily evacuated.
- Irrigate wounds if possible. Use “clean” or filtered water ( FR,B,I,P)
2. Ancef 250mg1gram IV or IM every 68 hours. (P)
INTRAVENOUS THERAPY
1. IV solutions generally consist of:
A. Balanced salt solutions for volume replacement.
B. Dextrose solutions for medication drips.
- A Saline lock may be substituted at the EMT's discretion. (I,P)
- Consider that many patients in outdoor emergencies are very likely to be dehydrated and hypoglycemic.
Therefore the IV or PO (if not contraindicated) administration of fluids, electrolytes, and glucose may be indcated.
OVERDOSES AND POISONINGS
1. Airway, Oxygen (FR, B, I, P)
2. Cardiac Monitor (P)
3. IV large bore, Normal Saline at rate per patient's condition. ( I, P)
4. If shock is present, follow Shock protocol.
5. Consider contacting poison control and/or receiving hospital.
6. Consider Thiamine, Narcan, and D50 per Coma protocol. ( P )
NARCOTIC OVERDOSE
7. Narcan up to 2.0 mg IVP. Repeat as needed. (P)
PAIN AND NAUSEA CONTROL
PAIN
Patients without potential surgical emergencies (i.e. appendicitis, acute abdomen, etc.) or those withoutCentral Nervous System trauma (i.e. closed head injury, etc.) or those with extremity trauma, chest pain (cardiac), kidney stone etc.
1. Morphine Sulfate 24mg IVP titrate as needed, and/or 515mg IM;
MONITOR RESPIRATIONS. (P)
OR …
2. Toradol 60mg IM or 30mg IV every 6 hours as needed (P)
NAUSEA
5. Phenergan (0.25 - 0.5mg/kg) IM or 1/2 IM dose IV every 4-6 hours as needed. (P)
RESPIRATORY DISTRESS
1. Airway, Oxygen ( FR,B,I,P)
2. Cardiac Monitor (P)
ASTHMA
3. IV Normal Saline or Lactated Ringers TKO (I,P)
4. Nebulized Albuterol 2.5 mg 2 –3 times if needed, may repeat one every 2 hours if needed (I, P)
If severe:
4. Follow anaphylaxis protocol.
PULMONARY EDEMA
- IV Saline lock (I, P)
If systolic BP greater than 90 mm Hg:
7. NTG 0.4mg SL - may repeat if indicated (P)
8. Lasix 2040mg (1mg/kg) IVP may repeat if indicated (P)
- Morphine sulfate 210 mg IVP (P)
SEIZURES
If tonic/clonic movement has lasted longer than 3 minutes or recurrence without an intervening conscious period, airway is jeopardized, or patient has a history of status seizures...
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
3. IV large bore Normal Saline, depending on patient's condition. (I, P)
4. Valium 5mg IVP (0.1mg/kg) may be repeated as needed. MONITOR RESPIRATIONS. (P)
SHOCK
A) Pulse greater than 120bpm with systolic BP less than 90 mm Hg or
B) Orthostatic change of pulse increase 20bpm and/or systolic BP drop 20 mm Hg
C) Cold and clammy skin, patient with feeling of impending doom, decreased Level of Consciousness, restlessness, agitation, or marked thirst.
1. Airway, Oxygen (FR,B,I,P)
2. Cardiac Monitor (P)
If Cardiogenic shock, Post-resuscitation shock, Septic shock:
3. IV Normal Saline TKO (I,P)
4. Consider fluid challenge (200-300cc).
4. Dopamine 25 mcg/kg IV drip, titrated to affect. (P)
Hypovolemic shock, Anaphylaxis, Neurogenic shock:
5. Elevate feet
6. Two or more large bore IVs, run to maintain systolic BP greater than 90mmHg (I,P)
7. MAST
8. Dopamine 25 mcg/kg IV drip, (last resort only), not effective with hypovolemia. (P)
REMEMBER: SEVERE INTERNAL HEMORRHAGE CANNOT BE STABILIZED IN THE FIELD.
In the patient with venous capacitance problems such as neurogenic, septic, or anaphylactic shock, consider fluid challenges of 200500cc before becoming aggressive with fluid therapy.
SPINAL TRAUMA
- Airway, Oxygen - If intubation necessary consider nasal, tactile/digital, or oral with axial traction. (FR,B,I),
(P) intubation
2. Cervical collar, CID, backboard, orthopedic stretcher, KED, etc... (FR,B,I,P)
3. Cardiac Monitor (P)
4. IV Normal Saline, run per patient's condition. (I,P)
If Systolic BP is less than 90 mm Hg:
5. elevate legs
6. IV as above
- MAST - if not immediately needed consider application dry (B,I,P)
- C – SPINE CLEARANCE
Patients who meet the following criteria do not need to have spinal immobilization…
- Fully awake and alert
- Able to localize pain
- Have no deformities of c-spine
- Have no pain on palpation of c-spine
- Have no pain during careful flexion / extension
- Have no pain during careful rotation
Appendix A
DRUG LISTING
Albuterol
Ancef
Aspirin
Benadryl
Decadron
Dexamethasone
Dextrose 50%
Epinephrine 1:1,000
Glucose
Lasix
Narcan
Nitroglycerin
Phenergan
Succinylcholine
Thiamine
Toradol
Tylenol
Valium
Vecuronium
Appendix B
SIGN-OFF SHEET
Approved: ______Date: ______
Jeff Humphery D.O.
Physician Advisor
Date / Name (Printed) / Signature / CertificationNumber Date