2025 EPFD New Protocols PDF

An ISO Class 1 Department El Paso Fire Department EMS Treatment Guidelines, Medication formulary, Reference. Fire Chief Jonathan Killings Medical Director Russell Baker  El Paso Fire Department EMS Guidelines EPFD MEDICAL GUIDELINES TABLE OF CONTENTS...

An ISO Class 1 Department El Paso Fire Department EMS Treatment Guidelines, Medication formulary, Reference. Fire Chief Jonathan Killings Medical Director Russell Baker  El Paso Fire Department EMS Guidelines EPFD MEDICAL GUIDELINES TABLE OF CONTENTS SECTION 1: GENERAL GUIDELINES 1. How to use the guidelines 2. General Information 3. Do Not Resuscitate (DNR) 4. Interfacility and Flight Crew Transport 5. Intravenous Access IV 6. Involuntary Transport 7. MCI Patient Distribution 8. Obvious Death On Scene (DOA) 9. Obvious Death on Scene Documentation 10. Pain Guidelines 11. Patient Determination 12. Patient Encounter Documentation 13. Patient Refusal 14. Patient Transport And Telehealth 15. Sexual Assault / Abuse (SSA) 16. Physician on Scene 17. Termination of Resuscitation (“TOR”) 18. Universal Care 19. US Port of Entry / Bridge Transfer SECTION 2. ACLS CARDIAC GUIDELINES 20. ACS / Chest Pain 21. Atrial Fibrillation w/ RVR 22. Asystole / PEA 23. Bradycardia 24. Cardiac Arrest 25. Cardiogenic shock 26. Pit Crew CPR 27. Post ROSC Care 28. Supraventricular Tachycardia 29. V-Fib & Pulseless V-Tach 30. Wide Complex Tachycardia With Pulses 31. Cardiac Reference EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines SECTION 3. ENVIRONMENTAL EMERGENCIES 32. Bites and Envenomation 33. Carbon Monoxide (CO) / Cyanide (CN-) 34. Dehydration 35. Drowning and Near Drowning 36. Hyperthermia 37. Hypothermia 38. Lighting Injury 39. Organophosphate Exposure 40. Rhabdomyolysis SECTION 4. MEDICAL EMERGENCIES GUIDELINES 41. Medical Patient Categorization 42. Abdominal Pain 43. Allergic Reaction 44. Altered Mental Status 45. Back Pain 46. Behavioral emergency 47. Cerebral Vascular Accident 48. Diabetic Emergency 49. Ebola/High Consequence Infectious Disease 50. Epistaxis 51. Eye Pain 52. Fever / Infection 53. Hypertension (HTN) 54. Hypotension 55. Nausea / Vomiting 56. Opioid Overdose 57. Overdose / Toxic Ingestion 58. Seizures 59. Sepsis 60. Syncope SECTION 5. OB/GYN EMERGENCIES 61. Breech Delivery 62. Childbirth Emergency 63. Childbirth / Labor EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 64. Newborn Care 65. Newborn Care Reference 66. Neonatal Resuscitation 67. Neonatal Resuscitation Reference 68. Obstetric Emergency 69. Preeclampsia / Eclampsia 70. Vaginal Bleeding SECTION 6: PALS PEDIATRIC GUIDELINES 71. PALS: Asystole & PEA 72. PALS: Bradycardia 73. PALS: Cardiac Arrest 74. PALS: Supraventricular Tachycardia SVT 75. Pediatric ROSC 76. PALS: V-Fib & Pulseless V-Tach 77. PALS: Wide Complex Rhythm SECTION 7. PEDIATRIC GUIDELINES 78. Pediatric Airway 79. Pediatric Airway Missed 80. Pediatric Allergic Reaction 81. Pediatric Altered Mental Status 82. Pediatric Drowning/Near Drowning 83. Pediatric Head Trauma 84. Pediatric Hypotension 85. Pediatric Nausea/Vomiting & Diarrhea 86. Pediatric Multisystem Trauma 87. Pediatric Respiratory Distress 88. Pediatric ROSC 89. Pediatric Seizure 90. Pediatric Sepsis / Infection 91. Pediatric Reference SECTION 8: AIRWAY GUIDELINES 92. Airway Management 93. COPD Exacerbation 94. Missed Airway 95. Supraglottic Airway Trouble Shooting EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 96. Pulmonary Edema 97. Post Intubation Sedation 98. Post Intubation Transfer Infusions 99. Respiratory Distress 100. Respiratory Infectious Disease SECTION 9: TRAUMA GUIDELINES 101. Burns 102. Burn Reference Information 103. Burn Parkland Reference Chart 104. Crush Injury 105. Epistaxis Traumatic 106. Extremity Trauma 107. Eye (Ocular) Trauma 108. Head Trauma 109. Multisystem Trauma 110. Salt Triage 111. Spinal Motion Restriction (SMR) 112. Taser Removal 113. Tourniquet Conversion 114. Traumatic Arrest 115. Trauma Patient Catagorization SECTION 10. EMS MEDICATION FORMULARY SECTION 11: AUSTERE/ SPECIAL CIRCUMSTANCES ANTIBIOTICS MEDICATIONS SECTION 12: INTERFACILITY TRANSFER MEDICATIONS (IFT) SECTION 13. CLINICAL PROCEDURE GUIDELINE EPFD ABBREVIATIONS AND DEFINITIONS APPENDIX EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines SECTION 1: GENERAL GUIDELINES EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links 1. HOW TO USE THE GUIDELINES Universal Care Cardiac Arrest In digital format the title and guideline links, when clicked, will take you to the information listed. The guidelines begin at a general level and progress through EMT-B to EMT-A to Scope of practice legend. EMT-Paramedic as Basic interventions are in they descend. BLUE, advanced in GREEN and paramedic in RED. When multiple boxes are present the EMS provider may choose to skip procedures or medications and go further down when clinically indicated. Pearls: 1. The guidelines are designed to foster EMS critical thinking and the flowcharts are not absolute requiring every box to be performed. 2. Some sections or boxes of the flow chart may be skipped as the clinical condition warrants. 3. When medications state “may repeat x1, x2 etc.” this indicates you may give that many additional doses. E.g. may repeat x1 = 2 doses total, may repeat x 2 = 3 doses total. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 2. GENERAL INFORMATION Guidelines, Standing Orders, and Medical Control Orders The El Paso Fire Department Emergency Medical Service (EPFD EMS) Medical Care Guidelines are written to direct the care of a broad range of patients with varying medical conditions. Some patients may require care that is different from that specified in the Guidelines or multiple Guidelines simultaneously. These Guidelines are not to be construed as prohibiting the needed flexibility by EPFD EMS personnel or the Medical Control Emergency Physician (MCEP). The EMT in the field is expected to follow these guidelines to the best of their ability, given the individual's situation, unless they receive verbal orders from an online medical control physician (OLMC). The Medical Control Emergency Physician (MCEP) All EPFD EMS Guidelines follow a standard direction format for Basic Life Support (BLS) for First Responders and EMT-Basic personnel and Advanced Life Support (ALS) for Advanced-EMT and Paramedics. The Guideline direction for each level includes the previous level's direction. Personnel may perform only to the level for which they are Locally Certified. Personnel have standing orders to complete, as necessary for optimal patient care, all steps listed in the guideline up to the printed MCEP identifier in a diamond or flow chart arrow. Medical Control must be contacted if further Pre-Hospital treatment, direction, or advice is needed. In Guidelines without a Medical Control reference, the Standing Order may give all treatments, and it is unlikely personnel will receive orders for any other treatments if Medical Control is contacted. Non-Guideline Orders: Unusual cases or circumstances may require orders for treatments not contained in these Guidelines. Non-guideline orders may be requested with justification by field personnel or initiated by the Medical Control Emergency Physician (MCEP). Care ordered by the Medical Control Physician not contained in specific Guidelines ("Non-Guideline Orders") shall: Follow the rules promulgated under: Texas Administrative Code, Title 25, Part 1, Chapter §157 (Emergency Medical Care). Texas Health & Safety Code Chapter 773 (EMS & Trauma Systems). Be within the scope of the EMT's local level of certification as defined by EPFD EMS Medical Guideline (Universal Patient Treatment #18) and Section 10- EPFD EMS Medications. This will be documented in the Medical Control section of the electronic Patient Care Report (ePCR) by EPFD EMS personnel. The medical control section will include the medical control physician number that gives the order and the instructions. The ePCR will then be reviewed by the Medical Director. Guidelines for Contacting Medical Control Physician: Medical Control responsibilities include being available to provide medical advice and treatment orders. The following situations are routine causes for contacting Medical Control. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines When advice, support, or direction is needed regarding appropriate patient management and disposition. The right to call medical Control is never denied. Advanced Life Support requiring Medical Control orders. For patients refusing transport who appear to need medical attention, Medical Control should be called for "Physician Advice to Patient." Physician Bystander accepting responsibility for patient care. (See Guideline #16, Physician on the Scene). For permission to discontinue, a resuscitation has already begun. NOTE: Medical Control must be contacted before discontinuing any ALS treatments that have been initiated (e.g., IV Therapy, ECG Monitoring, Medication Administration, etc.) unless otherwise directed in the guideline. Communications Failure; Authorization for Treatment: If standard radio communications cannot be established between EPFD EMS Personnel and Medical Control, telephone Dispatch at 832-4432 (or any other recorded line) and request a Conference Call to Medical Control at UMC. If EPFD EMS personnel are entirely unable to contact Medical Control for any reason, in that case, they may perform to the limits of their Local Level of Certification by following established written Guidelines under the following orders: The EMT-P is authorized to perform portions of the Guideline, normally requiring online Medical Control permission if the patient needs immediate therapy to prevent imminent death or disability. If actions normally requiring online Medical Control are not urgent, they should be deferred until communications are re- established. The Medical Director and leadership shall review all circumstances in which there is a failure of communication devices or other communication failures. EPFD personnel involved will notify the fire administration immediately after any inability to contact medical control. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 3. DO NOT RESUSCITATE (DNR) Cardiac Arrest Pearls: 1. Guideline applies to all patients; adult and pediatric. 2. The DNR order does not affect your care unless the patient develops Cardiac or Respiratory Arrest. 3. If the patient is not in Cardiac or Respiratory Arrest, Palliative Care (for patient comfort) may be provided per Standard Protocols or as directed by Medical Control. 4. Resuscitation attempts should be initiated until the DNR order, POLST or bracelet/necklace from any state and identification are presented. If a family member or other caregiver has "DURABLE POWER OF ATTORNEY" they should be consulted for instructions on patient care or withholding patient care. 5. If a DNR/POLST is not physically present but family states the patient has one, or all in attendance wish nothing to be done, or family/ power of attorney is in contact via phone, contact MCEP for guidance in honoring family or the patient’s final wishes. 6. Out-of-State DNR Forms, Bracelet or Necklace should be honored, contact MCEP for guidance. 7. DNRs may be revoked at ANY time by the patient, legal guardian, proxy, or qualified relatives. 8. If the patient is in Cardiac or Respiratory Arrest and resuscitation has already been started, and evidence is found of a DNR Order, the resuscitation should be discontinued. 9. The discontinuation of resuscitation measures in the presence of a State-issued Out-of-hospital DNR order does not require a Medical Control Order but does mandate thorough documentation. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 4. INTERFACILITY AND FLIGHT CREW TRANSPORT Pearls: 1. In general, every attempt should be made to deliver the patient to the designated receiving facility. 2. Post-op patients should be transported to the facility where their recent surgery, cardiac catheterization, endoscopy etc. occurred unless other arrangements have been made. 3. If transporting an ill appearing terminal hospice patient, please call the receiving facility prior to departure to ensure they will accept a deceased patient in the event he dies enroute. 4. You do not need to call MCEP to bypass a closer facility during interfacility transfers. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 5. INTRAVENOUS ACCESS IV Pearls: 1. In the cardiac arrest patient, any preexisting dialysis shunt or venous catheter may be utilized if other access is unavailable. 2. When performing intraosseous access with the appropriate adult / pediatric device, you may use Lidocaine 40 mg (4 ml cardiac lidocaine) Adult or 0.5mg/kg Peds IO flush to reduce pain of infusion. 3. Proximal humerus or distal femur are preferred IO sites in cardiac arrest. 4. Upper extremity IV sites are preferable to lower extremity sites in critical patients. 5. Any prehospital fluids or medications approved for IV use may be given through an intraosseous route. 6. All IV rates should be kept at TKO (minimal rate to keep vein open) unless administering fluid bolus or maintenance fluid. 7. Vasoactive drips should be infused through large bore IV catheter in the antecubital or larger vein. 8. In post-mastectomy and dialysis patients with a shunt or fistula, avoid an IV, blood draw, injection, or blood pressures in arm on affected side. 9. In traumatic arrest patients do not delay on scene for IV access. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Behavioral 6. INVOLUNTARY TRANSPORT Pearls: 1. Legally, the only patient who can be transported against his/her will is one who constitutes a danger to him/herself or others or is legally incompetent (minor, mentally disabled, etc.) 2. The pt must have capacity, meaning the ability to use and understand information to make a decision and communicate any decision made. A person lacks capacity if their mind is impaired or disturbed in some way in which they cannot make an informed decision. 3. Have enough personnel to safely secure patient and assure that all personnel are informed of plans and are involved. Adequately restrain the patient as needed. Do not prone the patient and ensure Law Enforcement involvement. 4. At least two EMTs should be always present if the patient is or suspected of being combative. 5. Keep bystanders and onlookers away from the patient as they may agitate the patient. 6. All resuscitative measures to sustain life may be utilized. 7. Transport to an appropriate health care facility. 8. Document all actions, statements, and responses to your questions that support your decision to treat the patient without consent. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 7. MCI PATIENT DISTRIBUTION How to use the MCI distribution guideline: 1. When an MCI is declared, Red Level 1 trauma patients should be distributed to the appropriate and closest trauma centers based on the location in El Paso. 2. Once the first 8 Red Level 1 patients are transported, the distribution starts again until all patients have been allocated. 3. Attempt a staggard distribution; one patient may go to each facility listed, and the subsequent patients may go after the other facilities listed have received a patient. E.g. an MCI in the NE; the first 2 Red patients may go to UMC, DelSol, and THOPE in any order or simultaneously, then the next 2 could go to UMC and then the distribution resets. 4. Patient distribution should proceed to not overload a receiving hospital at any one time. 5. If there are fewer than 8 Red Level 1 trauma patients, Yellow Level 2 and Green Level 3 trauma patients may be transported to the Level 1 and Level 2 trauma facilities. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links TOR 8. OBVIOUS DEATH ON SCENE (DOA) Cardiac Arrest Pearls: 1. Anytime a provider feels the need to have Law Enforcement on scene they should make the request via dispatch. 2. Criteria for withholding resuscitation: unresponsive, apneic, pulseless, unresponsive pupils, and one or more of the following present: a. Rigor mortis and/or dependent lividity b. Decomposition, decapitation, incineration c. Obvious mortal wounds (severe trauma with signs of organ destruction) 3. Patients with suspected traumatic mechanism found pulseless and apneic by EMS providers with no respiratory effort after basic airway maneuvers AND in asystole on ECG (AED with display or ECG monitor). 4. Prolonged drowning/ submersion; > 30 min warm water (>43°F >6°C), >90 min cold water (< 43°F 20 mmHg during resuscitation improves survival prediction at hospital discharge with good neurological outcomes of OHCA patients. If the rise in EtCO2 is sustained without CPR, these patients should be resuscitated and transported. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Overdose Opioid 10. PAIN GUIDELINES Pearls: 1. Pain severity (0-10) is to be recorded pre and post IV/IM/IN/IO medication delivery. 2. Reduce Narcotic dosing by 50% in patients: o > 65 y/o o That have liver disease or cirrhosis. o That have renal failure or are on dialysis (ESRD) and preferentially use Fentanyl. 3. Do not administer Acetaminophen to patient’s w/ history of liver disease or cirrhosis. 4. Do not administer Toradol to patients with kidney disease. 5. Monitor patient closely for over sedation – refer to overdose protocol. 6. Pts receiving opioid and ketamine pain management should have SpO2 and EtCO2 continuously monitored. 7. Ketamine and Morphine/Fentanyl administered together have a proven synergistic and potentiated therapeutic affect with a decrease in the chance of causing hemodynamic instability. 8. Typical starting dose of Fentanyl is 50 mcg and for Morphine 4 mg. 9. Choose Morphine or Fentanyl based on current inventory level. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Involuntary 11. PATIENT DETERMINATION transport General Guidelines 1. This protocol is intended to refer to individual patient contacts. In the event of a multiple party incident, such as a multi- vehicle collision, it is expected that a reasonable effort will be made to identify those parties with acute illness or injuries. 2. Adult patients indicating that they do not wish assistance for themselves or dependent minors in such a multiple party incident do not necessarily require documentation as patients. 3. No protocol can anticipate every scenario and providers must use best judgment. When in doubt as to whether individual is a “patient”, err on the side of caution and perform a full assessment and documentation. 4. If there is doubt, then complete a patient care record and/or refusal as a report (ePCR) may still need to be filled out to document a response per EPFD policy. Decision-Making Capacity (Must meet all criteria) and be documented: Understands nature of illness or injury Not homicidal or suicidal Understands consequences of refusal of care Not gravely disabled or psychotic Not intoxicated with drugs or alcohol Not a danger to self or others No criteria for an involuntary transport (see guideline) EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 12. PATIENT ENCOUNTER DOCUMENTATION EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 13. PATIENT REFUSAL Pearls for EMS criteria for medical decision-making capacity: 1. Pt must have sufficient information from the provider regarding the medical condition and the associated risks to his health and person. 2. Pt must understand that a decision must be made. 3. Pt must understand the risks, burdens, and benefits of all options, including that of doing nothing. 4. Pt must be able to use the information to decide in the setting of his values and belief systems. 5. Pt must be able to communicate his choice to the provider. 6. Pt must be acting without coercion or undue influence, including from family, friends, and providers. 7. It is the responsibility of the EMS provider to identify loss of capacity for medical decision making. It is not the patient’s responsibility to prove they retain such capacity. 8. If the patient has lost capacity and has a legal power of attorney or guardian present, the POA or guardian must have capacity. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 14. PATIENT TRANSPORT AND TELEHEALTH Pearls: 1. Whenever a patient meets the criteria for one of the specialized centers, they will be transported to the closest appropriate facility. 2. When two receiving facilities are equidistant from the scene, the patient’s preference of the two will be honored as the transport destination. 3. Medical Control may be contacted for destination orders when there is a question or problem with transporting the patient to the closest appropriate facility. 4. The objective of the telehealth model is to provide patient-centered care, increase efficiency in our medical services, and encourage appropriate utilization of EMS through treatment in place via telehealth. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links 15. SEXUAL ASSAULT / ABUSE (SSA) Universal Care Pearls: 1. Pursuant to the Texas Family Code (§261.101. Persons Required to Report; Time to Report), EMS personnel have a statutory obligation to report cases of suspected abuse to children (65 y/o), or disabled persons (>18 y/o), within 24 hours of encountering or by the end of shift to the patient/victim to the abuse hotline of Texas protective & Regulatory Services at 1-800-877-5300 or 1-800-252-5400 or make a report to any Law Enforcement Officer. 2. Ensure and maintain patient confidentiality. 3. Mandatory reporting to Law Enforcement of all cases of child, elder, sex abuse, assaults, stabbings, and gunshots. 4. Doing the best for the patient should be the paramount goal of all patient/ provider interactions. 5. Attempt to transport SSA patients to facility with SANE capabilities but under Chapter 323 Health and Safety Code, Emergency Services for Survivors of Sexual Assault, stable patients may opt to be transported to their hospital of choice within catchment. 6. Patients should be advised of the importance of being evaluated at a SSA designated facility for adequate examination as well as preservation of forensic evidence. 7. When transmitting patient report; refer to patient of this nature as SSA or “Code 5”. 8. If parent/caretaker refuses to allow transport, call for Police assistance. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 16. PHYSICIAN ON SCENE A Physician on-scene can be either a help or a hindrance to EMS Providers in providing optimal care for a patient. It is important to be cordial. Let Medical Control mediate and diffuse any disputes. EMS and Medical Control Authority State regulations emphasize authority for you and On-Line Medical Control, in the following paragraphs from Texas Administrative Code Title 22, Part 9, Chapter §197.5, (Authority for Control of Medical Services at the scene of a Medical Emergency). Control at a Medical Emergency Scene shall be the responsibility of the individual in attendance who is most appropriately trained and knowledgeable in providing Pre-Hospital emergency stabilization and transport. When an Advanced Life Support (ALS) Team, under Medical Direction, is requested and dispatched to the scene of an emergency, a Physician/patient relationship is thereby established between the patient and the Physician designated by the EMS system providing Medical Direction (either offline or online). The pre-hospital provider on the scene is responsible for managing the patient and acts as the physician's agent, providing medical directions. Telehealth Practitioner The health professional providing health services or procedures as telemedicine medical service is subject to the standards that apply to providing the same health care service or procedure in an in-person setting. If the Medical Orders of the patient’s Telehealth practitioner or physician conflict with EPFD EMS Guidelines, the Telehealth practitioner shall be placed in communication with Medical Control. Patient’s Private Physician Present The usual site would be at a Physician’s office, nursing home, or patient’s home. If the patient’s private physician is present and assumes responsibility for the patient’s care, the pre-hospital provider should defer to the orders of the physician unless those orders conflict with established guidelines. Request the patient’s private physician to document their orders with a printed name, signature, and DEA or medical license number. These orders will be forwarded to the EPFD EMS Administration for attachment to the patient’s medical record. The physician providing online medical directions shall be notified of the participation of the patient’s private physician. If the Medical Orders of the patient’s Private Physician conflict with EPFD EMS Guidelines, the Private Physician shall be placed in communication with Medical Control. If the Private Physician and Medical Control cannot agree on treatment, the Private Physician must either continue to provide direct patient care and accompany the patient to the hospital or defer all remaining care to Medical Control. The system’s medical director or online medical control shall assume responsibility for directing the activities of EPFD EMS pre-hospital providers at any time when the patient’s private physician is not in attendance. By-Stander Physician Present The usual site would be in a public place (motor vehicle accident, shopping mall, etc.) or a patient’s home where a bystander or neighbor identifies as a Physician. If a Physician is present and has been satisfactorily identified as a Licensed Physician and has expressed willingness to assume responsibility for the patient's care, a Medical Control Physician should be contacted. Medical Control is ultimately responsible for the patient's care unless and/or until the Intervening Physician appropriately assumes the responsibility for the patient. Identification as a Licensed Physician shall include the following: 1. On-scene Physician must verbally state that he/she is an MD or DO currently licensed to practice in Texas. Plus, one of the following: 1. Visual recognition by EMT. 2. Picture ID (Driver’s License) with name confirmed by either On-Line Medical Control or Dispatch. 3. Wallet copy of Medical Licensure. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Medical Control can manage the case exclusively, work with the Intervenor Physician, or allow the Intervenor Physician to assume complete responsibility for the patient. If there is any disagreement between the Intervenor Physician and the On-Line Physician, the Pre-hospital Provider shall be responsible to the On-Line Physician and place the Intervenor Physician in contact with the On-Line Physician. If the Intervenor Physician is authorized to assume responsibility, all orders to the Pre-Hospital Provider by the Intervenor Physician shall also be repeated to Medical Control for record-keeping purposes. The Intervenor Physician must document their intervention on the Patient Care Form or other 8 ½" x 11" paper with the Physician’s printed name, signature, and DEA or Medical license number. These orders will be forwarded to EPFD EMS Administration for attachment to the Patient’s Medical Record. The decision of the Intervenor Physician not to accompany the patient to the hospital shall be made with the approval of the MCEP. Scope of Practice: Fire Department personnel should not deviate from the Authorized Local Scope of Practice and Medical Procedures EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care DOA 17. TERMINATION OF RESUSCITATION (“TOR”) Pearls: 1. If ROSC is obtained ensure ROSC is not transitory (>2 min) prior to transport. 2. Only terminate if safe to do so. Any scene that may place providers in danger if resuscitation efforts were terminated, or place of business/government should be transported. 3. Any setting where the family will not accept termination of resuscitation efforts should be transported. 4. Do not terminate if the patient is in police custody unless the patient meets obvious death criteria. 5. Do not terminate VF/VT. 6. Notify Law Enforcement and cover the deceased with a sheet or other cover. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 18. UNIVERSAL CARE Pearls: 1. Minimum exam for every patient: V/S, mental status/GCS, location of injury or complaint and pain scale. 2. For the dosing of medications or electrical therapy, an adult is defined as >37 Kg. 3. For the dosing of medications or electrical therapy, a pediatric patient is < 37 Kg or defined by the pediatric reference tape. 4. If the patient does not fit on the tape, they are considered adults. 5. Patients should be assessed for a history of motion sickness and may be treated per nausea/vomiting protocol. 6. In critical patients obtain vital signs every 5 min if possible, all others obtain at least every 15 min. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 19. US PORT OF ENTRY / BRIDGE TRANSFER Pearls: 1. Transport the patient in the safest method for your crew and the patient. 2. You may continue all medication drips infusing that are life-sustaining, do not discontinue them unless indicated. 3. You may transport the physician or paramedic in your unit to assist in monitoring and caring for the patient. 4. If the equipment does not fit into your unit, EPFD and CBP may escort the unit to the appropriate hospital. 5. Contact MCEP for assistance if needed. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines SECTION 2. ACLS CARDIAC GUIDELINES EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 20. ACS / CHEST PAIN N/V Pearls: 1. Do not give NTG to pts who have taken erectile dysfunction medications in the past 24 hrs (Cialis, Viagra etc.). 2. If symptoms do not improve after 2 doses of NTG there is no need to continue with a 3rd dose. 3. NTG: SBP must be ≥90 mmHg for administration, if Right sided MI SBP ≥100 mmHg. 4. If 12 lead indicates an inferior wall MI, consider performing a right sided ECG and if ST elevation in RV4 suspect right sided MI. Consider fluid boluses with NTG to maintain RV filling pressure. 5. Right sided MI is not a contraindication to NTG, hypotension 100 however rate related signs and symptoms are uncommon with HR < 150/min in patients with a healthy heart. Consider rate control at lower heart rates if symptomatic. 6. DO NOT administer Metoprolol if SBP is < 90 mmHg or if the patient is < 18 yo. 7. If the rhythm changes treat with the appropriate protocol/ applicable guidelines 8. DO NOT use NTG or narcotic pain relievers for patients in a-fib/flutter as this may precipitate decompensation or cardiac arrest. 9. Administer Metoprolol slowly, infuse over 2 min as it may cause hypotension, be prepared to administer IVF bolus. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care TOR 22. ASYSTOLE / PEA Post ROSC Pearls: 1. Immediate and adequate CPR with timely defibrillation are the keys to success. 2. Do not interrupt compressions for airway placement, ventilation, medication administration. 3. Re-assess airway frequently and after every patient move. 4. Perform cardiac arrest checklist during resuscitation. 5. Patients in cardiac arrest should be managed in the field, all cardiac pts not experiencing arrest require minimum scene time and expeditious transport. 6. Any pt who presents in cardiac arrest from a medical cause will have CPR performed on scene for 20 min. If ROSC is achieved at any time the pt will be transported. 7. If after 20 min the patient remains in cardiac arrest (asystole, PEA 120 ms 2. V1 negative QRS complex 3. V6 positive QRS complex LBBB results in a widened QRS complex and changes the ST segment consistent with ischemia or injury pattern. Therefore, to diagnose an MI in the presence of a LBBB we must use Sgarbossa’s criteria. How to diagnose an MI when a Left Bundle Branch Block (LBBB) is present: Three criteria are included in Sgarbossa's criteria: 1. ST elevation ≥1 mm in a lead with a positive QRS complex (i.e., concordance) - 5 points 2. Concordant ST depression ≥1 mm in lead V1, V2, or V3 - 3 points 3. ST elevation ≥5 mm in a lead with a negative (discordant) QRS complex - 2 points ≥3 points = 90% specificity of STEMI (sensitivity of 36%) 2.1 2.2 2.3 EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines SECTION 3. ENVIRONMENTAL EMERGENCIES EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Pain Control 32. BITES AND ENVENOMATION Allergic Reaction Hypotension Pearls: 1. Bites from humans have a very high risk of infection due to oral bacteria. 2. Carnivore bites are much more likely to become infected and all have risk of Rabies exposure. 3. Cat bites may rapidly progress to infection due to a specific bacterium (Pasteurella multocida) 4. Venomous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin. a. Coral snake bites are rare: very little pain but very toxic. b. It is NOT necessary to take the snake to the ED with the pt, provider safety takes priority. c. Do not use NSAIDS in snake bites due to the increased risks of bleeding. 5. Black Widow spider bites have minimal pain initially but may develop muscular pain and severe abdominal pain (black w/ red hourglass on belly). 6. Brown recluse spider bites are minimally painful to painless. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider w/ fiddle shape on back). 7. Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound. 8. Immunocompromised pts are at an increased risk for infection (DM, chemotherapy, transplant pts) 9. Consider contacting the US/Texas Poison control Center for guidance: 1-800-222-1222 EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Airway 33. CARBON MONOXIDE (CO) / CYANIDE (CN-) Pearls: 1. Mild poisoning: frontal headache, N/V, SOB, dizziness, and confusion 2. Severe poisoning: syncope, coma, or seizure 3. Pregnant patients should be transported to facility with hyperbaric chamber if available. 4. CO is the most common cause of death from fires. CO reversibly binds hemoglobin more avidly than O2 causing functional anemia. 5. Half-life of COHgb: 300 min on RA, 90 min on 100% NRB, 30 min in hyperbaric chamber 6. Hydroxycobalamin (Cyanokit) reverses cyanide (CN-) toxicity which often is a co-exposure during combustion, smoke, and fire exposures. 7. CN toxicity will have normal SpO2 levels, but the patient will demonstrate symptoms of hypoxia and acidosis. 8. Consider CPAP/BPAP in patients with SOB after enclosed space smoke inhalation. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Hyperthermia 34. DEHYDRATION Fever N/V Pearls: 1. Dehydration may present with severe tachycardia mimicking SVT, treat with fluid bolus. 2. Look for skin tenting, dry mucous membranes and an increase HR 20 bpm when going from sitting to standing (positive orthostatic). 3. Healthy adults tolerating PO rarely require IVF and PO rehydration is usually adequate. 4. Pediatric IVF bolus is 20 ml/kg 5. Allow and encourage the patient to drink oral solutions/ fluids if po tolerant. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Hypothermia 35. DROWNING AND NEAR DROWNING Airway Respiratory distress Cardiac Arrest Pearls: 1. Criteria for resuscitation includes suspected arrest from cause other than submersion, pt submersion time less than 30 min from arrival of the first Public Safety entity until the pt is in a position for resuscitative efforts to be initiated. 2. On-scene rescuers should consider conversion from rescue to recovery at 30 or 60 min (water temp dependent) unless the pt is a diver w/ an air source or a pt trapped w/ a potential air source. Final decision for transition from rescue to recovery mode rests w/ on-scene command. 3. Spinal Motion Restriction should be used when a suspected or known traumatic mechanism preceded the drowning. 4. Trauma drowning victims should be transported to a trauma center, atraumatic victims should go to the closest appropriate facility. 5. All victims should be transported for evaluation due to potential for worsening over the next several hours. 6. Drowning is a leading cause of death among would-be rescuers. Allow appropriately trained rescuers to remove victims from areas of danger. (Reach-throw-row-go-tow) 7. With pressure injuries (decompression / barotrauma) consider transport or availability of a hyperbaric chamber. 8. Consider CPAP/BiPAP early if respiratory distress for any age if adequate mask seal can be established. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 36. HYPERTHERMIA Pearls: 1. Extremes of age are more prone to heat emergencies (i.e., young and old) 2. Drugs may contribute to hyperthermia: TCA, phenothiazines, anticholinergics, EtOH, Cocaine, amphetamines, and salicylates. 3. Utilize cold saline for bolus when available. 4. Heat cramps are benign muscle cramping due to dehydration and are not associated with/ an elevated temperature. 5. Heat exhaustion includes dehydration, salt depletion, dizziness, fever, headache, cramping, and N/V. Vital signs include tachycardia, hypotension, and an elevated temperature. 6. Heat stroke: hyperthermia and altered mental status or seizure w/ core temp of > 104°F (40°C) 7. If the patient has heatstroke and a cooling bath is present onsite, cooling for up to 30 minutes prior to transport is acceptable. Delays in cooling lead to adverse patient outcomes. 8. If the patient can be placed in a cooling bag or tarp (see TACO procedure), initiate cooling on scene and transport. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 37. HYPOTHERMIA Pearls: 1. Extremes of age are more susceptible (young & old) 2. 50 yo with a history of HTN. 3. Orthostatic need not be assessed on obvious hypotensive patients. 4. Ischemia bowel, most often seen in the elderly and the chronically ill, carries a very high mortality rate. Patients often have severe abdominal pain, atrial fibrillation, and limited abdominal exam findings. Those suspected of having ischemic bowel should be viewed as critically ill. 5. Avoid PO medications or food/drink in patients with abdominal pain. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 43. ALLERGIC REACTION Pearls: 1. The shorter the onset from exposure to symptoms, the more severe the reaction. 2. Cold pack to bite or sting site may be beneficial for insect bites. 3. Epinephrine should be administered IM to the lateral thigh, deltoid also acceptable. 4. All patients administered epi should receive a 12 lead ECG and be continually monitored. 5. Diphenhydramine may be administered IV, IM or PO if PO diphenhydramine is available. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care CVA 44. ALTERED MENTAL STATUS Seizure Sepsis OD 1. Pearls: 2. Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety. 3. It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after dextrose. 4. Hyperglycemia is treated with IV fluids, patients are volume-depleted; hyperglycemia will begin to improve with hydration. 5. Patients on oral hypoglycemics are at risk for repeat episodes of hypoglycemia, monitor closely and encourage transport. 6. If hypoglycemic patients on insulin or metformin only, have returned to baseline and wish to refuse care make certain that the patient eats and that there is someone to observe them for repeat hypoglycemic episodes. MCEP is not required. 7. D10 can be made by adding 1-amp D50 into 250 ml of fluid creating 1 g / 10ml solution if needed. 8. Consider 100mg Thiamine IV/IM if history of EtOH abuse or malnutrition. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care SMR 45. BACK PAIN Fever/Infection Pain Pearls: 1. Abdominal aneurysms are a concern in patients over the age of 50 y/o. 2. Any new bowel or bladder incontinence is a significant finding which requires immediate medical evaluation. 3. In patients with history of IV drug abuse or pain management injections a spinal epidural abscess should be considered EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care AMS 46. BEHAVIORAL EMERGENCY OD Pearls: 1. Consider your safety first. Physical restraint should be performed/assisted by Law Enforcement when available and only if sufficient resources are present. A minimum of 4 people is necessary. 2. Be sure to consider all possible medical/trauma causes for behavior (low BGL, OD, substance abuse, hypoxia, etc.) 3. Do not overlook the possibility of associated domestic violence or child abuse. 4. All patients who receive either physical or chemical restraints must be continuously observed by ALS personnel. If possible and when safe to do so monitor ECG, EtCO2, SpO2, BGL. Use physical/chemical restraints only if necessary for protection of EMS providers or the patient. 5. Restrained patients should never be placed or transported in a prone position. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care AMS 47. CEREBRAL VASCULAR ACCIDENT Seizure Pearls: 1. Onset of symptoms is defined as the last time the patient was seen symptom free (i.e. awakening with stroke symptoms would be defined as an onset time of the previous night). 2. Whenever possible, a family member should accompany the patient to the hospital to provide a detailed history. 3. The differential listed on the AMS guideline should also be considered. 4. Be alert for airway problems (swallowing difficulty, vomiting) 5. Hypoglycemia can present as a localized neurological deficit, especially in the elderly. 6. Consider other protocols as indicated: AMS, HTN, Seizure. 7. Transport patient head up at 30° 8. EMS ambulances should proceed to a stroke center if the drive time is shorter than waiting for a specialty unit to arrive on the scene. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 48. DIABETIC EMERGENCY Pearls: 1. Oral diabetic medications of the most concern are the sulfonylureas (glipizide, glyburide, glimepiride). 2. Patients must have mental capacity, another adult present and eat to refuse transport. 3. Infection is a common cause of diabetic emergencies both hypo and hyperglycemia. 4. Elderly, pts with multiple comorbidities, heart, liver or renal failure are prone to develop hypoglycemia. 5. Consider 100mg Thiamine IV/IM if history of EtOH abuse or malnutrition. 6. For patients with an insulin pump who are hypoglycemic with associated altered mental status (GCS less than 15): o Stop the pump, disconnect, or remove at insertion site if patient cannot ingest oral glucose or ALS is not available. o Leave the pump connected and running if able to ingest oral glucose or receive ALS interventions. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care 49. EBOLA/HIGH CONSEQUENCE INFECTIOUS DISEASE Pearls: 1. If advanced airway is required utilize am SGA with filter attached to avoid aerosolization, avoid intubation with ETT. 2. Ebola patients should be transported to a healthcare facility prepared to evaluate and manage the patient. 3. Appropriate PPE for Ebola patients includes: face shield, surgical mask, impermeable gown and two pairs of gloves. 4. Limit provider to only essential personnel. 5. Handle all needles and sharps with extreme care, dispose of all sharps in a puncture-proof sealed container. 6. Use a red biohazard bag for any emesis. 7. Supervised Doffing of PPE should be performed at the hospitals designated location. 8. Decontaminate and disinfect the vehicle and equipment while wearing PPE. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Pain 50. EPISTAXIS HTN Trauma Pearls: 1. 90% of bleeding from the nose is anterior, 10% is posterior from a branch of the sphenopalatine artery which will present with profuse bleeding that may be going down the throat potentially causing airway issues. 2. Before pinching or placing packing, you may consider having the patient blow their nose to express clots. 3. Patients often present with significant anxiety. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Pain 51. EYE PAIN N/V Pearls: 1. Normal visual acuity can be present even with severe injury. 2. Remove contact lens when possible. If adherent to globe do not force. Irrigation may assist removal. 3. Any chemical or thermal burns to the face / eyes should raise concern for respiratory insult. 4. Orbital fracture raise concern for globe or nerve injury and need for repeat assessments. 5. Always cover both eyes to prevent further insult. 6. Do NOT remove impaled objects. 7. Suspected globe rupture or compartment syndromes require emergent evaluation. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Hypotension 52. FEVER / INFECTION Sepsis Pearls: 1. Patients with a history of liver failure should not receive acetaminophen. 2. Rehydration with fluids increases the patient’s ability to sweat and improves heat loss. 3. NSAID’s should not be used in the setting of environmental heat emergencies. 4. Consider MCEP for Toradol 30 mg SIVP for fever plus pain or discomfort and associated N/V EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Chest pain 53. HYPERTENSION (HTN) Preeclampsia Pearls: 1. Hypertension can be defined as a systolic blood pressure of > 140 mmHg (MAP >135 is more accurate). 2. Consider possible causes of hypertension and treat appropriate protocol: Preeclampsia, Aortic dissection, Acute pulmonary edema, AMI, CVA, Urinary obstruction, Pain, Stress, Anxiety, Sympathomimetics, Withdrawal 3. Hypertension is often a sign of an underlying condition that needs to be addressed and is secondary to this condition being present. 4. Patients should always have adequate pain control. 5. Place in position of comfort unless otherwise contraindicated. 6. Do not treat benign hypertension. 7. If patient is pregnant, consider pre-eclampsia. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Trauma 54. HYPOTENSION Sepsis Pearls: 1. Hypotension can be defined as a systolic blood pressure of 120 bpm. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 56. OPIOID OVERDOSE AMS Pearls: 1. The essential feature of opioid overdose requiring EMS intervention is respiratory depression or apnea, managed by ventilation followed by naloxone. 2. Legally prescribed opioids are also manufactured as an adhesive patch for transdermal absorption, and if found, should be removed from the skin. 3. Critical resuscitation (opening and/or maintaining the airway, provision of oxygen, ensuring adequate circulation) should be performed prior to naloxone administration. 4. The administration of the initial dose or subsequent doses of Narcan can be incrementally titrated until respiratory depression is reversed. 5. The clinical opioid reversal effect of naloxone is limited and may end within an hour whereas opioids often have a duration of 4 hours or longer. 6. Methadone can produce QT prolongation and torsades and tramadol can produce seizures. 7. Patients with opioid overdose from fentanyl or fentanyl analogs may rapidly exhibit chest wall rigidity and require positive end expiratory pressure (PEEP), in addition to multiple and/or larger doses of naloxone, to achieve adequate ventilation. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Behavioral 57. OVERDOSE / TOXIC INGESTION AMS Airway Pearls: 1. Do not rely on patient history of ingestion especially in suicide attempts. 2. Tricyclic antidepressant (TCA): 5 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert to death. (e.g. Nortriptyline, amitriptyline, Imipramine, etc.) 3. Depressants: decreased HR, BP, temperature, respirations, non-specific pupils. 4. Stimulants: increased HR, BP, temperature, dilated pupils, diaphoretic, seizure. 5. Anticholinergic: increased HR & temperature, dilated pupils, dry, mental status changes. (e.g. diphenhyamine) 6. Cardiac Meds: dysrhythmias (usually bradycardia), hypotension and AMS. 7. Solvents: N/V and AMS 8. Insecticides: variable HR (↑↓), increased secretions, N/V, diarrhea, pinpoint pupils. 9. Consider contacting Poison Control for guidance. 1-800-222-1222 10. DECON of Haz-Mat patients should be performed by trained personnel prior to initial patient contact or transport. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care 58. SEIZURES AMS Airway Eclampsia Pearls: 1. Status epilepticus is defined as 2 or more successive sz w/o a period of consciousness or recovery, or a seizure lasting >5 min. This is a true emergency requiring rapid airway control, treatment, and transport. 2. Complex (generalized/grand mal) seizures are associated w/ loss of consciousness incontinence, and tongue trauma. 3. Simple (petit mal/focal) effect only a part of the body and are not usually associated w/ LOC. 4. Jacksonian seizures are seizures which start as a focal seizure and become generalized. 5. Assess possibility of occult trauma and/or substance abuse. 6. Be prepared to assist ventilations especially if high dose Midazolam is used. 7. For any seizure in a pregnant or recently post-partum pt (2 months), follow the OB Emergencies Protocol 8. Initial seizure treatment medications should be given IM or IN do not attempt IV in an actively seizing patient. 9. Atraumatic postictal states in patients with epilepsy or seizure disorder do not need code 3 transport. 10. May use Lorazepam 2 mg IV/IM when a Midazolam shortage exists. 11. Consider eclampsia if the patient is pregnant. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Guideline Links Universal Care AMS 59. SEPSIS Fever/Infection Pearls: 1. Septic shock: hypotension (SBP 1000 mL or >500mL w/ signs & symptoms. The perineum should be checked for bleeding from vaginal tears. Bleeding should be controlled by direct pressure over the laceration. 7. The most common cause of postpartum hemorrhage is uterine atony due to prolonged labor or multiple gestations. 8. Determining imminent birth may include: regular contractions lasting 45-60 seconds at 1-2 minute intervals; crowning, urge to bear down/ push or the urge to have a bowel movement. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  Guideline Links El Paso Fire Department EMS Guidelines Universal Care Neonatal Resus 64. NEWBORN CARE Pearls: 1. Non vigorous infant as evidenced by poor muscle tone, poor/absent respiration, and heart rate 180 mmHg and/or diastolic blood pressure >110 mmHg) Concomitant use of another parenteral GP IIb IIIa inhibitor Acute pericarditis DRUG INTERACTION In combination with heparin and aspirin, it has been associated with an increase in bleeding, compared to heparin and aspirin alone. ADMINISTRATION Requires an infusion pump AGGRASTAT should be administered intravenously, at an initial rate of 0.4 mg/kg/min for 30 minutes and then continued at 0.1 mg/kg/min. For patients with severe renal insufficiency (creatinine clearance 180, or diastolic BP > 110) Active internal bleeding History of CVA (within 2 months) Recent brain, or spinal surgery (within 2 months) Recent trauma DRUG INTERACTION Additive effect on bleeding with other anticoagulants, ASA, NSAID. ADMINISTRATION NOTE: Doses vary per physician direction Follow physician’s orders SPECIAL NOTES Monitor all puncture sites (e.g., catheters, incisions, etc.) during therapy, and subsequent heparin administration. Avoid new puncture sites or injections. When administering to the patient with AMI, (the most likely to receive this medication), watch the ECG closely for reperfusion dysrhythmias. Allergic reactions and anaphylaxis can occur when administering this medication. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines FIBRINOLYTICS (Reteplase - Retavase®) SCOPE OF PRACTICE EMT-Paramedic - Medication for administration during patient transport. Second dose only. CLASS OF DRUG Thrombolytic PHARMACOLOGIC ACTION Reteplase binds to fibrin rich clots via the fibronectin finger-like domain and the Kringle 2 domain. The protease domain then cleaves the Arg/Val bond in plasminogen to form plasmin. Plasmin in turn degrades the fibrin matrix of the thrombus, thereby exerting its thrombolytic action. INDICATIONS Myocardial Infarction CONTRAINDICATIONS Hypersensitivity Recent surgery (within 10 days) GI/GU bleeding Uncontrolled hypertension (SBP > 180, or DBP > 110) Active internal bleeding History of CVA (within 2 months) Recent brain, or spinal surgery (within 2 months) Recent trauma DRUG INTERACTION Additive effect on bleeding with other anticoagulants, ASA, NSAID. ADMINISTRATION Follow physician’s orders SPECIAL NOTES Monitor all puncture sites (e.g., catheters, incisions, etc.) during therapy, and subsequent heparin administration. Avoid new puncture sites or injections. When administering to the patient with AMI, (the most likely to receive this medication), watch the ECG closely for reperfusion dysrhythmias. Allergic reactions, and anaphylaxis can occur when administering this medication. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines TOPICAL OPHTHALMIC ANESTHETIC (Proparacaine® - Ophthaine®, Alacaine ®) SCOPE OF PRACTICE EMT-Paramedic CLASS OF DRUG Topical/local ophthalmic anesthetic PHARMACOLOGIC ACTION After topical application to the eye, local anesthetics penetrate to sensory nerve endings in the corneal tissue. These medications block both the initiation and conduction of nerve impulses by decreasing the neuronal membrane's permeability to sodium ions. This reversibly stabilizes the membrane and inhibits depolarization, resulting in the failure of a propagated action potential and subsequent conduction blockade. INDICATIONS Ocular pain relief prior to irrigation of the eyes CONTRAINDICATIONS Hypersensitivity Known or suspected trauma that may have produced intraocular injury. DRUG INTERACTION None ADMINISTRATION 1 - 2 drops of 0.5% solution in each eye. May repeat one time at 15 minutes SPECIAL NOTES Assess visual acuity as soon as possible. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines VACCINES DPT (Diptheria, Tetanus (Acellular), Pertussis), TT (Tetanus Toxoid), DT (Diptheria, Tetanus) DTP/DTaP Hepatitis B Vaccine (RECOMBIVAX HB®, ENGERIX-B®) Hepatitis A Vaccine (HAVRIX®, VAQTA®) Measles, Mumps, Rubella (MMR) Poliovirus Vaccine - live, Orimune (OPV) Poliomyelitis Vaccine, Inactivated, IPV, Salk Pneumococcal Vaccine (PNEUMOVAX®) SARS-CoV2 Vaccine Varicella (chicken pox) vaccine SCOPE OF PRACTICE EMT-Basic, EMT- Advanced and EMT-Paramedic Administration of Immunizations, Vaccines, Biologicals, and TB skin testing is authorized under the following circumstances: In the event of a disaster or emergency, the EMS Medical Director or Chief Medical Officer of the Department of Health or similar state agency may temporarily authorize the administration of pharmaceuticals or tests. Administration of Immunizations, Vaccines, Biologicals, and TB skin testing is authorized under the following circumstances: To the general public as part of a Department of Health initiative or emergency response, utilizing Department of Health protocols. The administration of immunizations is to be under the supervision of a physician, nurse, or other authorized health provider. Administer vaccines to EMS and public safety personnel TB skin tests may be applied and interpreted if the licensed provider has successfully completed required Department of Health training. In the event of a disaster or emergency, the State EMS Medical Director or Chief Medical Officer of the Department of Health may temporarily authorize the administration of pharmaceuticals or tests not listed above ADMINISTRATION Follow physician’s orders EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines VASOPRESSOR AGENTS VASOPRESSIN (Pitressin®) SCOPE OF PRACTICE EMT-Paramedic CLASS OF DRUG Hormone (antidiuretic) PHARMACOLOGIC ACTION Vasopressin acts on three different receptors, vasopressin receptor V1a (which initiates vasoconstriction, liver gluconeogenesis, platelet aggregation and release of factor VIII), vasopressin receptor V1b (which mediates corticotrophin secretion from the pituitary) and vasopressin receptor V2 which controls free water reabsorption in the renal medullar. The binding of vasopressin to the V2 receptor activates adenylate cyclase which causes the release of aquaporin 2 channels into the cells lining the renal medullar duct. This allows water to be reabsorbed down an osmotic gradient, so the urine is more concentrated. INDICATIONS Useful in hemodynamic support in vasodilatory shock (e.g., septic shock) CONTRAINDICATIONS Chronic renal failure Known hypersensitivity to beef or pork proteins. DRUG INTERACTION Vasopressor effect may be increased by concurrent administration of ganglionic blocking agents. ADMINISTRATION Adult: One time only dose: 40 units IV/IO SPECIAL NOTES Potent vasoconstrictor. Increased peripheral vascular resistance may provoke cardiac ischemia and angina. Do not use in responsive patients with coronary artery disease. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines DOBUTAMINE (Dobutrex®) SCOPE OF PRACTICE EMT-Paramedic CLASS OF DRUG Sympathomimetic, beta-agonist PHARMACOLOGIC ACTION Dobutamine directly stimulates beta-1 receptors of the heart to increase myocardial contractility and stroke volume, resulting in increased cardiac output. INDICATIONS Primary indication is cardiogenic shock, with pulmonary edema. CONTRAINDICATIONS None when indicated. Use cautiously in AMI and atrial fibrillation. DRUG INTERACTION Synergistic effect with sodium nitroprusside Reduced effects with Beta-adrenergic blocker Hypertensive crisis with tricyclic antidepressants ADMINISTRATION Adult: 2 - 20 mcg/kg/min (mix 1 ampule (250 mg) in 250 ml of D5W - resulting in a concentration of 1mg/ml = 1000 mcg/ml) Pediatric: 1.0 mcg/kg per minute (6 x body weight (kg) equals milligrams to add to D5W to create a total volume of 100ml). Infuse at 1mL/h. SPECIAL NOTES Dobutamine should be titrated to effect. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines NOREPINEPHRINE (Levophed®) SCOPE OF PRACTICE EMT-Paramedic CLASS OF DRUG Alpha/beta adrenergic agonist PHARMACOLOGIC ACTION Strong beta-1 and alpha-adrenergic effects and moderate beta-2 effects, increase cardiac output and heart rate, decrease renal perfusion and peripheral vascular resistance, and cause variable BP effects. INDICATIONS Pressor agent for the management of shock CONTRAINDICATIONS: Hypersensitivity Hypotension due to blood volume deficit, Peripheral vascular thrombosis (except for lifesaving procedures) DRUG INTERACTION Cyclopropane or halothane anesthesia, cardiac glycosides, doxapram, and cocaine may increase myocardial irritability. MAO inhibitors, methyldopa, doxapram, and tricyclic antidepressants may produce severe hypertension. Alpha-adrenergic blockers may negate effects. Beta-adrenergic blockers may exaggerate hypertension and block cardiac simulation. Ergot alkaloids or oxytocin may result in enhanced vasoconstriction. ADMINISTRATION 4 mcg/min IV/IO infusion, may increase by 2 mcg/min q 5 mins up to a max dose of 10 mcg/min. SPECIAL NOTES Use with an infusion pump only. Incompatible with alkaline solutions, aminophylline, barbiturates, phenytoin WARNING: Norepinephrine is a vesicant and can cause severe tissue damage if extravasation occurs. Do not use in the same IV line as alkaline solutions as these may deactivate it. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines SECTION 13. CLINICAL PROCEDURE GUIDELINE 12 Lead ECG Automated External Defibrillator AED Alternative Venous Access Auto-injector Delivered Medication Blood Glucose Assessment Cardiac Pacing Cardioversion Childbirth Contact Precautions CPAP/BiPap (Continuous Positive Airway Pressure Ventilation) CPR (cardiopulmonary resuscitation) Cricoid Pressure Decontamination Determination of Capacity End Tidal CO2 Monitoring: EZ Cap End Tidal CO2 Monitoring Wave Form: Capnography Extraglottic/Supraglottic Airway (EGA/SGA) – I-gel / King Airway Extremity IV External Jugular Access Flex Guide ETT Introducer (Gum-elastic Bougie) Gastric Tube Insertion Hyperthermia Heat Stroke Treatment IO Insertion: EZ-IO Insulin Pump Intramuscular Injections Intraosseous Infusion Los Angeles Pre-hospital Stroke Scale (LAPSS) and Los Angeles Motor Scale (LAMS) MIST Report Nasal Drug Delivery Device Nebulized Medication Orotracheal Intubation Orthostatic Blood Pressure Measurement Patient Assessment Pelvic Binder (SAM Sling®) Physical Restraints Pleural Decompression Pulse Oximetry Pressure Infusion Bag Rectal Medication Administration Respiratory Precautions REVERT Maneuver/ modified Valsalva (for SVT conversion) Safe Injection Practices Spinal Motion Restriction/Extrication using a backboard Splinting Standard BSI Precautions Stoma and Tracheostomy Care Suctioning-Advanced Taser® Probe Removal Tourniquet (TQ) Application Vagus Nerve Stimulator (VNS) Vasopressor Drips Ventilator Guidelines Wound Care and Wound Packing EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines 12 Lead ECG Clinical Indications: Any patient > 35 years old with the following: Suspected cardiac patient Includes pain between navel and jaw Pressure, discomfort, tightness or heartburn CHF Electrical injuries Syncope Weakness New onset stroke symptoms Difficulty breathing Suspected overdose Any patient at any age with a cardiac history or when patients have overdosed on medications or elicit substances with a cardiac effect. Procedure: Any provider: Expose chest and prep as necessary. Modesty of the patient should be respected. Apply chest leads and extremity leads using the following landmarks: 1. RA -Right arm 2. LA -Left arm 3. RL -Right leg 4. LL -Left leg 5. V1 -4th intercostal space at right sternal border 6. V2 -4th intercostal space at left sternal border 7. V3 -Directly between V2 and V4 8. V4 -5th intercostal space at midclavicular line 9. V5 -Level with V4 at left anterior axillary line 10. V6 -Level with V5 at left midaxillary line To view the Right side of the heart use V4R The most useful lead is V4R, which is obtained by placing the V4 electrode in the 5th right intercostal space in the mid- clavicular line. See Diagram. ST elevation in V4R has a sensitivity of 88%, specificity of 78% and diagnostic accuracy of 83% in the diagnosis of RV MI. Paramedic: 1. Prepare ECG monitor and connect patient cable with electrodes. 2. Enter the patient age into the 12-lead ECG device. 3. Instruct patient to remain still. 4. Press the appropriate button to acquire the 12 Lead ECG. 5. For patients with cardiac complaint, keep all leads connected at all times practical to allow automatic ST-segment monitoring to proceed. 6. Monitor the patient while continuing with the treatment protocol. 7. Document the procedure, time, and results on/with the patient care report (PCR). EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Automated External Defibrillator AED Clinical Indications: Patients in cardiac arrest (pulseless, non-breathing) Contraindications: None Notes/Precautions: Age < 8 years, use Pediatric Pads, if available If AED Pads touch due to patient size, use an Anterior-Posterior pad placement Procedure: 1. If multiple rescuers available, one rescuer should provide uninterrupted chest compressions while the AED is being prepared for use. 2. Apply defibrillator pads per manufacturer recommendations. Use alternate placement when implanted devices (pacemakers, AICDs) occupy preferred pad positions. 3. Remove any medication patches on the chest and wipe off any residue. 4. Turn on AED and follow prompts. 5. If using the cardiac monitor device (Zoll-X®, LP12/15®) place the device into AED mode. 6. Keep interruption of CPR as brief as possible. 7. If shock advised, state “clear” and visualize that no one including yourself, is in contact with the patient then press the shock button 8. Immediately return to chest compressions. 9. If no shock advised, immediately return to chest compressions. 10. Allow AED to analyze when prompted (approximately 2 minutes). Perform pulse check at this time. 11. Repeat steps 6 through 8. 12. Keep interruption of CPR compressions as brief as possible. Adequate CPR is a key to successful resuscitation 13. If pulse returns: See post resuscitation protocol. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Alternative Venous Access Clinical Indications: Venous access when IV and/or IO access is unsuccessful AND intravenous fluids or medications are needed AND a peripheral IV cannot be established AND exhibit 1 or more of the following: 1. Cardiac or peri-arrest state 2. An altered mental status (GCS of 40kg Site of Access Specific Guidelines Humerus Palpate the greater tubercle by letting it sink into the palm of your hand. Insert needle at a 45° angle as if aiming towars the opposite hip. Distal femur Straighten and center the leg within the anterior plane. Insert the needle 1-2 cm proximal to the patella, and 1 cm medially. Proximal tibia Insert the needle 1-2 cm inferior and medial to the tibial tuberosity in the flat portion of the tibia. Distal tibia Insert the needle 2 cm proximal to the medial malleolus in the flat portion of the tibia. Education: EZ:IO Insertion tutorial EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Insulin Pump Clinical Indications Patient that is hypoglycemic with altered mentation and an insulin pump in place Contraindications None Notes/Precautions: Care is directed at treating hypoglycemia first, then stopping administration of insulin Procedure 1. Refer to appropriate PPE procedure. 2. Turn off insulin pump, if possible. 3. If no one familiar with the device is available to assist, disconnect pump from patient, completely remove the dressing, thereby removing the subcutaneous needle 4. Transport patient to hospital. 5. If patient is refusing transport against medical advice (AMA): 6. Encourage the patient to eat 7. Ensure the patient is with a competent person to observe the patient and assure they eat 8. Instruct them to follow-up with their physician 9. Instruct them to call back if symptoms return EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Intramuscular Injections Clinical Indications: When the rate of absorption needs to be slower and/or prolonged in action When other administration routes are unsuccessful, unavailable or indicated by protocol Contraindications: None Notes/Precautions: Appropriate equipment Needles size and length 5/8 to 1 inch for deltoid, 1 to1.5 inch for larger muscles 25 gauge for aqueous medications, 21 gauge for oily or thicker medications 3 or 5 ml syringe Chlorohexadine or alcohol wipe and Band-aids Appropriate injection sites Posterior deltoid for injections of 1 mL or less in adults Vastus Lateralis for injections of 2 mL or less in children and adults Ventrogluteal site for injections of 2 to 5 mL in adults or 2 mL or less in children Procedure: 1. Prepare equipment. 2. Check label, date, and appearance of medication. 3. Five “R’s”: Right patient / Right medication / Right dose / Right route / Right time. 4. Locate appropriate injection site. Deltoid: 1. Identify the bony portion of the shoulder where the clavicle and scapula meet [the acromioclavicular joint (AC)] 2. Measure 3 to 4 fingers-width down the arm from AC joint 3. Slide one to two fingers-width posteriorly on the arm Vastus lateralis sites: 1. Located on the anterior and lateral aspects of the thigh 2. Divide the area into thirds between the greater trochanter of the femur and the lateral femoral condyle 3. Injection is given into the middle third Ventrogluteal site: 1. Place heel of palm on the patient’s greater trochanter of the femur 2. Place index finger on the anterior superior iliac spine and spread other fingers posteriorly 3. Injection is given in the V formed between the index finger and the second finger 4. Using a circular motion from selected site outward, cleanse site with Chlorohexadine betadine or alcohol. 5. With one hand, stretch or flatten the skin overlying the selected site. This will allow for smoother entry of the needle. 6. In the other hand, hold syringe like a dart and quickly thrust the needle into the tissue and muscle at a 90-degree angle. 7. Aspirate for frank blood. If frank blood is present remove and utilize deferent location. 8. Slowly inject medication. 9. After all medication is injected, quickly withdraw syringe and dispose of in an approved container. 10. Gently massage over the injection site to increase absorption and medication distribution. 11. Apply firm pressure and place band-aid over site. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Intraosseous Infusion Clinical Indications: Alternate to Intraosseous Infusion when unavailable As the initial means of circulatory access in cardiac arrest Patient where rapid vascular access is unavailable by other means in the following conditions: Multisystem trauma with severe hypovolemia Severe dehydration with vascular collapse and/or loss of consciousness Respiratory failure or respiratory arrest After 3 unsuccessful venous access attempts & patient is unstable Contraindications: Fracture proximal to proposed intraosseous site History of Osteogenesis Imperfecta Current or recent infection at proposed Intraosseous site Previous Intraosseous insertion within 24 hours or joint replacement at or above the selected site Procedure: Landmark for insertion as follows: 1. Proximal Tibia: Identify anteromedial aspect of the proximal tibia palpated just below the inferior border of the patella. Insertion site is 1-2 cm (2 finger widths) below this on the flat surface of the tibia 2. Distal Tibia: (reserved for > 12 years of age) 3. Identify the anteromedial aspect of the distal tibia (2 cm proximal to the medial malleolus) 4. Prep the selected insertion site with Chlorohexadine or alcohol. 5. Hold the Intraosseous needle at 90° angle aimed away from the nearest joint. 6. Using firm pressure and a rotating or twisting motion, penetrate the cortex until a pop or give is felt indicating a loss of resistance. Do not advance the needle further. 7. Remove the stylette and place in approved sharps container. 8. Attach a syringe filled with at least 5 mL of NS and aspirate to confirm placement. Inject 5 mL of NS to clear the needle while observing for infiltration. 9. Attach IV tubing and adjust flow rate as desired. A pressure bag may be used to enhance flow where appropriate. 10. Stabilize and secure the needle. 11. If the patient experiences pain with infusion or medication administration, lidocaine may be instilled in the IO catheter line. Discontinue fluid/medication administration prior to administering lidocaine and wait 15 seconds prior to restarting. 12. Lidocaine dosing as follows may be repeated once if pain persists: 13. Adult: 40 mg (2 mL of 2% solution) 14. Pediatric: 0.5mg/kg (0.025mL/Kg of 2% solution) 15. When administering medications via the IO route delivery should be followed with a 10mL flush of NS. 16. Document the procedure, time and result on the patient care report. EPFD Chief J. Killings Medical Director Dr. R. Baker Released 01/01/2025  El Paso Fire Department EMS Guidelines Los Angeles Pre-hospital Stroke Scale (LAPSS) and Los Angeles Motor Scale (LAMS) Clinical Indications: Assessment of patient exhibiting signs and symptoms associated with stroke Contraindications: Unconscious patients unable to participate in the stroke scale Procedure: Initiate assessment and treatment of the suspected stroke patients in accordance with the Stroke protocol. Ascertain the last time the patient was seen normal to establish the time of onset. Perform Pre-Hospital Stroke Screen (LAPSS). Pre-hospital stroke screening criteria: Patient is ≥45 years of age Has no history of seizure/epilepsy Symptom is a new onset and duration is < 24 hours Patient is ambulatory prior to event (Not bedbound) Blood glucose is between 60-400 mg/dL. 1. Have the patient smile or show their teeth. Look for asymmetry 2. Assess for arm drift/weakness by asking the patient (while sitting upright or standing) to close their eyes and extend their arms, palms up and hold it for 10 seconds. Look for asymmetric pronation (palm turning towards the ground) or drift (one arm drops compared to the other) 3. Ask the patient to grab your fingers or hands with both hands and squeeze looking for incorrect unilateral weakness. 4. If all screening criteria are met proceed to exam for stroke activation. 5. Whenever possible identify a family member or historian to accompany the patient to the hospital. 6. If the LAPSS is positive as outlined complete the LAMS score. 7. Patients who have a positive LAMS with ≥4 should be preferentially transported to a Comprehensive Strok