2017 ri statewide ems protocols education modules - section 4

Rhode Island Emergency Medical Services Statewide EMS ProtocolsOctober 2016Rhode Island Department of Health

Trauma - Environmental - Toxicological ProtocolsSection 4

Trauma – Environmental – Toxicological Protocols

General Changes and Additions• This is a new section in the EMS

protocols• This section has 24 protocols


New Protocol Previous ProtocolPrevious

Protocol Section

04.01A Multiple Trauma - Adult 5.1 TraumaTraumatic Emergencies

04.01P Multiple Trauma - Pediatric 5.1 TraumaTraumatic Emergencies

4.02 Head Trauma - Traumatic Brain Injury 5.1 TraumaTraumatic Emergencies

4.03 Spinal Motion Restriction Precautions New – not in previous versions

4.04 External Hemorrhage Control New – not in previous versions

4.05 Extremity and Musculoskeletal Injuries New – not in previous versions

4.06 Traumatic Cardiac Arrest New – not in previous versions

04.07A Thermal - Burn Injury - Adult 5.2 BurnsTraumatic Emergencies

04.07P Thermal - Burn Injury - Pediatric 5.2 BurnsTraumatic Emergencies

4.08 Chemical and Electrical - Burn Injury 5.2 BurnsTraumatic Emergencies

4.09 Crush Injury New – not in previous versions

4.1 Dental Trauma and Emergencies New – not in previous versions

4.11 Ocular Trauma and Emergencies New – not in previous versions


New Protocol Previous ProtocolPrevious

Protocol Section

4.12 Heat Related Illness 3.5 Heat Stroke 3.4 Heat Cramps and Heat Exhaustion

Environmental Emergencies

04.13A Hypothermia and Localized Cold Injury - Adult

3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia


04.13P Hypothermia and Localized Cold Injury - Pediatric

3.1 Cold Exposure - Frostbite 3.2 Cold Exposure - Hypothermia


4.14 Submersion - Near Drowning 3.3 DrowningEnvironmental Emergencies

4.15 Diving Emergencies New – not in previous versions

4.16 Marine Envenomation New – not in previous versions

4.17 Bites - Stings - Envenomation New – not in previous versions04.18A Toxicological Emergencies - General - Adult 3.6 Poisoning and Overdose


04.18P Toxicological Emergencies - General - Pediatric 3.6 Poisoning and Overdose


4.19 Toxicological Emergencies – Nerve Agent or Organophosphate Toxicity New – not in previous versions

4.20 Carbon Monoxide Exposure New – not in previous versions

4.21 Blast Injury - Incident New – not in previous versions

4.22 Radiation Incident New – not in previous versions

4.01 Adult Multiple TraumaProtocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides standing

orders for adult patient with blunt or penetrating trauma.

• This protocol is divided into different levels of care.ALL Providers Levels

• Routine Patient Care• Manage life threatening injuries• Treat as per appropriate protocols• Vented chest seal device• Stabilize impaled Objects• Stabilize pelvis as indicated• Normothermia• Limit on scene time to ≤ 10 min• If indicated (≥45 mins to Trauma Center) follow

HEMS Protocol • Transport to Level 1 Trauma CenterParamedic• Perform needle thoracostomy for suspected

tension pneumothorax

4.01 Pediatric Multiple Trauma

Protocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides standing

orders for pediatric patient with blunt or penetrating trauma.

• This protocol is divided into different levels of care.ALL Provider Levels

• Routine Patient Care• Manage life threatening injuries• Treat as per appropriate protocols• Vented chest seal device over open penetrating

torso injury• Stabilize impaled objects• Stabilize pelvis as indicated• Maintain normothermia• Limit in scene time to ≤ 10 min• If indicated (≥45 mins to Trauma Center) follow

HEMS Protocol • Transport to Level 1 Trauma CenterParamedic• Perform needle thoracostomy for suspected

tension pneumothorax

4.02 Head Trauma - Traumatic Brain Injury (TBI)

Protocol Summary • Previously protocol 5.1 Trauma.• This protocol recognizes and provides

standing orders for adult patient with a history or clinical evidence of blunt or penetrating head trauma. In addition, patients who fell and take anticoagulant/antiplatelet medications.

• This protocol is divided into different levels of care.ALL Providers Levels

• Routine patient care• Baseline neurologic examination • Evaluate for increased intracranial

pressure, manage as indicated per 2.01 Acute Neurologic Event with Evidence of Increased ICP

• Provide airway management• Ventilate • Perform blood glucose analysis if AMS• TransportAdvanced EMT Cardiac and Paramedic• Manage hypotension as per the age

appropriate General Shock and Hypotension Protocol.

4.03 Spinal Motion Restriction Precautions

Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing orders

for patients experiencing a mechanism of injury with risk for spinal injury.

• This protocol is for all levels of care.ALL Providers Levels• If criteria met, apply

spinal motion restriction precautions

• If criteria is not met, use the algorithm

• Apply cervical collar, supine on cot, secure with belts

• Self-extrication allowed• Ambulatory patients may

sit, then lie on cot• Scoop and flexible devices

to move patients• Long spine boards for

extrication and movement• Position patient supine on

cot, secure with belts• Manage as per Patient

Comfort protocol • Immobilize patients with

penetrating trauma only if deficit

Pediatric Patients • TRANSPORT IN PEDIATRIC RESTRAINT SYSTEM• Apply padding to cervical collar • Avoid movement• Move from car seat to stretcher ONLY if criteria are

met

4.04 External Hemorrhage Control

ALL Providers Levels• Routine Patient Care• Apply direct pressure• Liberal use of a tourniquet to achieve

hemostasis• Hemostatic agent dressings and devices

as needed• Use of a junctional tourniquet• If involving a dialysis fistula/shunt, use

digital pressure, if tourniquet application is necessary, apply PROXIMALY as far from the fistula as possible

• Manage as per the age appropriate Hemorrhagic Shock Protocol

Protocol Summary • This is a new protocol. • This protocol recognizes and provides

standing orders for patients with external hemorrhage.

• This protocol is for all levels of care.

4.05 Extremity Trauma and Musculoskeletal Trauma

ALL Provider Levels• Routine Patient Care• Manage as per appropriate protocol• Remove rings, bracelets, other

constricting items• Care for amputated parts• Splint joint above and below possible

fracture• Traction for isolated midshaft femoral

fractures• Splint dislocations and angulated

fractures in place unless distal circulation is compromised

• Binder for pelvic fractures


standing orders for patients with musculoskeletal injury/complaint.

• This protocol is divided into different levels of care.

Paramedics• CEFAZOLIN 2 mg IV/IO for open

fractures/ amputations/grossly contaminated wounds

• CEFAZOLIN is contraindicated if history of PCN or cephalosporin allergy

4.06 Traumatic Cardiac Arrest

ALL Providers Levels• Routine Patient Care• IMMEDIATELY INITIATE CPR• Consider medical etiology• Control external hemorrhage• Binder for suspected pelvic fracture• Transport to Level 1 Trauma Center if

<15 minutes


standing orders for patients in cardiopulmonary arrest with presumed traumatic etiology.


Advanced EMT Cardiac• LACTATED RINGER’s 1L IV/IO Adult• LACTATED RINGER’s 20 ml/kg Pediatric

Paramedic• LACTATED RINGER’s 1L IV/IO Adult• LACTATED RINGER’s 20 ml/kg Pediatric• Perform needle thoracostomy if

suspected tension pneumothorax

4.07 Adult Thermal Burn Injury

ALL Provider Levels• Routine Patient Care• Assess

burn/concomitant injury severity using Rule of Nines.

• Minor burn management

• Serious or critical burns management and transport to Burn Center

Protocol Summary • Previously protocol 5.2 Burn.• This protocol recognizes and provides standing

orders for patients with minor burn, serious burn and critical burn.


Advanced EMT Cardiac• Analgesia, IV for

minor burns• IVFs for serious or

critical burns and transport to Burn CenterParamedic

• Analgesia, IV for minor burns• IVFs, airway management for serious or critical

burns and transport to Burn Center

ALL Providers Levels• Routine Patient Care• Assess

burn/concomitant injury severity using Rule of Nines.

• Minor burn management

• Serious or critical burns transport to Burn Center


orders for pediatric patients with minor burn, serious burn and critical burn injuries.


Advanced EMT Cardiac• Analgesia for minor

burns• Consider IV• IVFs for serious or

critical burnsParamedic• Analgesia for minor burns• Consider IV• IVFs for serious or critical burns• Airway management

4.07 Pediatric Thermal Burn Injury

4.08 Chemical and Electrical Burn Injury

ALL Providers Levels• Routine Patient Care• Assess chemical source, utilize HAZMAT

resources as needed • Assess electrical source• Assess burn/concomitant injury severity• Decontaminate most chemical burns with liquid• Brush off powdered chemicals• Treat Hydrofluoric Acid burns with calcium gel• Remove non-adherent clothing/rings/constricting

items• Manage per the age the appropriate Thermal

Burn Protocol and Trauma related protocols. • Transport to Adult Burn Center


orders for patients with partial or full thickness burn injury resulting from contact with a chemical agent or energized electrical source.


Advanced EMT Cardiac• Initiate cardiac monitoring

Paramedic• Consider IV CALCIUM if hydrofluoric acid and

hypocalcemia.• Consider nebulized CALCIUM if HF inhalation

4.09 Crush Injury

ALL Providers Levels• Routine Patient Care• Manage as per Trauma Protocols/Shock

Protocols/Hypothermia or Localized Cold Injury Protocols

• Remove constricting items• REQUEST ALS response• Analgesia as needed per Patient Comfort Protocol • Transport

Protocol Summary • This is a new protocol. • This protocol recognizes and provides standing

orders for patients with extremity/body crush, entrapped and crushed under heavy load for > 30 min.


Advanced EMT Cardiac• IV NS with SODIUM BICARBONATE during extrication• Manage Cardiac Arrest per appropriate protocol (s)• If ECG suggests hyperkalemia or cardiac arrest occurs,

contact MEDICAL CONTROL for administration of CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO

• Albuterol for suspected hyperkalemiaParamedic• Consider IV NS with SODIUM BICARBONATE during

extrication • Manage Cardiac Arrest per appropriate protocol(s)• ECG suggestive of hyperkalemia or if cardiac arrest

occurs, CALCIUM CHLORIDE 1 gm IV/IO or CALCIUM GLUCONATE 3 gm IV/IO and SODIUM BICARBONATE 50mEq IV/IO

• Albuterol for suspected hyperkalemia

4.10 Dental Trauma and Emergencies

ALL Provider Levels• Routine Patient Care• Consider possible cardiac etiology• Manage bleeding with direct pressure

during multisystem trauma treatment• Control dental related bleeding with

rolled gauze direct pressure• Put avulsed teeth in saline, milk, or

commercial solution. Do NOT scrub or cleanse.

• Provide analgesia as indicated per the Patient Comfort Protocol

• Transport


standing orders for patients with tooth pain or dental injury.


4.11 Ocular Trauma and Emergencies

ALL Providers Levels• Routine Patient Care• Assess visual acuity• Obtain history• Rigid shield over penetrating ocular injuries• Immobilize impaled objects and patch BOTH eyes• Assess EOM for blunt traumatic injuries, elevate

HOB, patch• Moist saline over traumatic enucleation • Irrigate chemical eye injuries with water or

LACTATED RINGER’S


orders for patients with ocular complaint or injury.• This protocol is divided into different levels of care.

Advanced EMT Cardiac• ONDANSETRON for penetrating ocular injuries

Paramedic• ONDANSETRON for penetrating ocular injuries• TETRACAINE or PROPARACAINE for ocular flash

burns or chemical eye injuries• Irrigate with LACTATED RINGER’S utilizing a Morgan

lens• Use pH to guide irrigation

4.12 Heat Related Illness

ALL Provider Levels• Routine Patient Care• Measure body temperature• Begin passive cooling• Oral rehydration for heat cramps• Active cooling for heat exhaustion and

heat stroke• Transport

Protocol Summary • Previously protocols 3.4 Heat Cramps

and Heat Exhaustion and 3.5 Heat Stroke.

• This protocol recognizes and provides standing orders for patients with heat cramps, heat exhaustion and heat stroke.


Advanced EMT Cardiac and Paramedic• IV NS for heat exhaustion and heat

stroke

4.13 Adult Hypothermia and Localized Cold Injury

ALL Providers Levels• Routine Patient Care• Provide airway management• Check pulse 60 seconds if unresponsive• Assess mental status and treat as

indicated• Determine body temperature

• ≥ 34 – 35°C external rewarming• < 34 – 35°C warmed humidified air or

oxygen if available• Avoid refreezing if localized cold

thermal injury

Protocol Summary • Previously protocols 3.1 Cold Exposure

Frost Bite and 3.2 Cold Exposure Hypothermia in Environmental Emergencies.

• This protocol recognizes and provides standing orders for adult patients with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite).


Advanced EMT Cardiac and Paramedic• For patients with a core temperature <

34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 500 ml IV/IO boluses.

4.13 Pediatric Hypothermia and Localized Cold Injury

ALL Providers Levels• Routine Patient Care• Provide airway management• Check pulse for 60 seconds if

unresponsive• Assess mental status and treat as

indicated• Determine body temperature

• ≥ 34 – 35°C external rewarming• < 34 – 35°C warmed humidified air or

oxygen if available• Avoid refreezing localized cold thermal

injury

Protocol Summary • Previously protocol 3.1 Cold Exposure

Frost Bite 3.2 Cold Exposure Hypothermia in Environmental Emergencies.

• This protocol recognizes and provides standing orders for pediatric with core temperature < 35°C (95°F) and patients with cold thermal injury (frostbite).


Advanced EMT Cardiac and Paramedic• For patients with a core temperature <

34°C (93.2°F), administer warm (40-42°C/104-107°F) NORMAL SALINE 20 ml/kg IV/IO boluses

4.14 Submersion – Near Drowning

ALL Providers Levels• Routine Patient Care• Apply Spinal Motion Restriction

Precautions• Manage Cardiac Arrest even after

prolonged immersion in cold water• Manage Hypothermia and Local Cold

Injury as indicated.• Remove wet clothing, dry and warm the

patient.• Provide Airway Management and

Altered Mental Status as indicated.• Manage per the age appropriate

Respiratory Distress Protocol if indicated• Monitor and reassess the patient.• Transport

Protocol Summary • Previously protocol 3.3 Drowning.• This protocol recognizes and provides

standing orders for patients submersed in water regardless of depth.


4.15 Diving Emergencies

ALL Provider Levels• Routine Patient Care• Consult Diver’s Alert

Network (DAN)• Analgesia for ear or sinus

squeeze• Oxygen and

recompression Treatment at HBO Facility for

• Pulmonary Overpressure syndrome

• Arterial gas embolism

• Decompression sickness type I and II

• Nitrogen narcosis


orders for patients with ear squeeze/sinus squeeze, pulmonary overpressure syndrome, arterial gas embolism, decompression sickness type I and II, Nitrogen Narcosis.


Advanced EMT Cardiac and Paramedics• OXYMETAXOLINE or PSEUDOEPHEDRINE for ear or sinus squeeze – Patient

Comfort Protocol• IV NS for decompression sickness type II

4.16 Marine Envenomation

ALL Providers Levels• Routine Patient Care• Manage allergic or anaphylactic

reactions• Regional Center for Poison Control and

Prevention 800-222-1222• Sting Ray, Lionfish or Urchin/Starfish

related injuries• Immobilize injury and object, or remove barb

if small• Jellyfish or Man o’ War related injuries

• Lift away tentacles• Irrigate with vinegar or sea water NOT fresh

water or ice• Treat pain as per the age appropriate

Patient Comfort Protocol


standing orders for patients exposed to marine organisms with intense localized pain, nausea/vomiting, allergic reaction or anaphylactic reaction.


Paramedic• Manage severe muscle spasm with

CALCIUM IV

4.17 Bite - Stings - Envenomation


standing orders for patients with bee or wasp sting, spider, snake, feline, canine, or human bite.


Paramedic• Manage severe muscle spasm with

MIDAZOLAM

ALL Providers Levels• Routine Patient Care• Manage allergic or anaphylactic

reactions• Consider Regional Center for Poison

Control and Prevention 800-222-1222• Spider bites and bee or wasp stings

• Elevate, ice, remove constricting jewelry• Snake bites

• Immobilize, elevate, remove constricting jewelry

• NO ICE• Feline, Canine or Human bites

• Wound care• Immobilize• Contact animal control

4.18 Adult Toxicological Emergencies

ALL Provider Levels• Routine Patient Care• Recognition symptoms

(toxidromes)• OPIOID OVERDOSE

• NALOXONE UNTIL ADEQUATE VENTILATION

• FOLLOW THE RECOVERY COACH ALGORITHM

• CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL

• ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE manage per appropriate protocol

Protocol Summary • Previous protocol 3.6 Poisoning and

Overdose.• This protocol recognizes and provides

standing orders for patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics.


Advanced EMT Cardiac• NALOXONE for Opioid Overdose until

adequate ventilation• SODIUM BICARBONATE for suspected

antidepressant or other sodium channel blocking agent toxicity

• GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity

• HYDROXYCOBALAMIN for suspected Cyanide toxicity

• MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity

• Treat seizures

Paramedic• INTRALIPID or NOREPINEPHRINE for


• GLUCAGON, CALCIUM or INTRALIPID for beta blocker or calcium channel blocker toxicity

• SODIUM THIOSULFATE for Cyanide toxicity

• ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide exposure

• MIDAZOLAM or LORAZEPEM for sympathomimetic/stimulant toxicity

• DIPHENHYDRAMINE for dystonic reactions

• INTRALIPID for lipid-soluble toxicity cardiac arrest / hemodynamic compromise

2.17 Obstetrical Delivery4.18 Pediatric Toxicological Emergencies

ALL Provider Levels• Routine Patient Care• Recognition symptoms

(toxidromes)• OPIOID OVERDOSE

• NALOXONE UNTIL ADEQUATE VENTILATION

• FOLLOW THE RECOVERY COACH ALGORITHM

• CONSIDER CONTACTING THE REGIONAL CENTER FOR POISON CONTROL

• ORGANOPHOSPHATE NERVE AGENT or INSECTISIDE

• DuoDote

Protocol Summary • Previous protocol 3.6 Poisoning

and Overdose.• This protocol recognizes and

provides standing orders for pediatric patients intoxicated with Beta Blockers/Calcium Channel Blockers, Tricyclic Antidepressants/Sodium Channel blocking agents, Opioids, Organophosphates/nerve agents, and anticholinergics.


Advanced EMT Cardiac• NALOXONE for Opioid Overdose until adequate

ventilation• SODIUM BICARBONATE for suspected


• GLUCAGON or CALCIUM for suspected beta blocker or calcium channel blocker toxicity

• HYDROXYCOBALAMIN for suspected Cyanide toxicity

• MIDAZOLAM or LORAZEPAM for suspected sympathomimetic/stimulant toxicity

• Treat seizures

Paramedic• INTRALIPID or NOREPINEPHRINE for antidepressant or other

sodium channel blocking agent toxicity• GLUCAGON, CALCIUM or INTRALIPID for beta blocker or

calcium channel blocker toxicity• SODIUM THIOSULFATE for Cyanide toxicity • ATROPINE / PRALIDOXIME for organophosphate nerve agent

or insecticide exposure• MIDAZOLAM or LORAZEPEM for

sympathomimetic/stimulant toxicity unless < 5kg• DIPHENHYDRAMINE for dystonic reactions unless < 5 kg• INTRALIPID for lipid-soluble toxicity cardiac arrest /

hemodynamic compromise

2.17 Obstetrical Delivery4.19 Nerve Agent or Organophosphate Toxicity

ALL Provider Levels• Routine Patient Care• PPE• DuoDote

• Adult• Pediatric

Protocol Summary • New Protocol • This protocol recognizes and provides standing orders for patient with

suspected or know exposure to a nerve or organophosphate agent with salivation, lacrimation, urination, defecation, GI distress, emesis [SLUDGE], muscle twitching, seizures, respiratory arrest), bradycardia, bronchorrhea, and/or bronchospasm.


Advanced EMT Cardiac• Manage Seizures as per the age appropriate Seizure Protocol

Paramedic• Manage Seizure as per the age appropriate Seizure Protocol• ATROPINE / PRALIDOXIME for organophosphate nerve agent or insecticide

exposure

4.20 Carbon Monoxide

ALL Providers Levels• Routine Patient Care• OXYGEN• Treat as outlined in table


orders for patients involved in fire or in a confined space/poorly ventilated area with potential for the presence of carbon monoxide (combustion of carbon containing fuels or inadequate ventilation of natural gas).


Advanced EMT Cardiac and Paramedic• Cardiac monitoring and multi-lead ECG

4.21 Blast Injury - Incident

ALL Providers Levels• Routine Patient Care• Ensure scene safety.• Determine nature of incident, nature of device,

nature of environment, potential for threat of particalization of hazardous materials and distance from blast.

• Quantify and triage patients per the Multiple Patient Incident Protocol(s) as indicated.

• Manage patient as indicated per age appropriate Trauma and Burn Protocols, Crush Injury Protocol, Radiation Incident Protocol.

• Transport


orders for Blast explosion occurring in an open space (conventional blast) or enclosed/confined space (vehicle, building, bus, train).


4.22 Radiation Incident

ALL Providers Levels• Routine Patient Care• Ensure scene safety.• If the incident involves a blast, also

manage per Blast Incident and Injury Protocol.

• Determine need for additional resources, exposure type, quantification of exposure, quantify and triage patients as per the Multiple Patient Incident Protocol as indicated.

• Flush contact areas with NORMAL SALINE for 15 minutes.

• If present, manage burn injuries as per age appropriate Burn Protocol(s).

• Identify and manage any secondary injuries as per appropriate Trauma Protocols.

• Transport


standing orders for patients with radiation burn or exposure to radiation.


Continue on to RI EMS Protocol Education ModulesSection 5