Lisbon Fire Department Standard Operating Guidelines and Policies

• 
  Provides route for administration of fluid for volume replacement
  
• 
  Provides route for administration of medication
  

• 
  Requires special equipment and insertion technique
  

• 
  Infiltration of the fluid into the subcutaneous tissue
  
• 
  Extravasation of some medications can cause tissue sloughing
  
• 
  Introduction of bacteria during insertion can cause infection
  
• 
  Fracture of the tibia
  

• 
  Fracture in the leg
  
• 
  Infection/abscess over the administration site
  
• 
  Unacceptable delay in transport of a critically ill or injured individual
  

Note: If using commercial IO device (e.g. sternal), follow manufacturer’s directions.

END

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
				XX

To remove blood or fluid from the pericardial sac

60 ml syringe

Alcohol preps

Personal protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   

2. 
   Confirm the order with medical control.
   
3. 
   Locate the landmark for the subdiaphragmatic approach -- the angle between the xiphoid and the cartilage of the 7th rib to the left of the xiphoid.
   
4. 
   Cleanse the area with alcohol.
   
5. 
   Insert the needle at the landmark at a 45º angle to the thorax in the direction of the patient’s left shoulder.
   
6. 
   Maintain traction on the plunger of the syringe as the needle is advanced to create a vacuum in the barrel of the syringe.
   
7. 
   Stop advancement of the needle when blood/fluid appears in the syringe.
   
8. 
   Withdraw approximately 50 ml blood/fluid.
   
9. 
   Withdraw the needle at the same angle at which it was inserted.
   
10. 
    Save any aspirated material and transport with patient.
    
11. 
    Dispose of contaminated equipment in the appropriate receptacle.
    
12. 
    Report completion and results of the procedure to medical control.
    
13. 
    Reassess the patient’s condition.
    
14. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Hypotension
  
• 
  Tachycardia
  
• 
  Distended neck veins
  
• 
  Narrow pulse pressure
  
• 
  Lack of pulses with CPR
  

• 
  Improved patient color
  
• 
  Loss of jugular vein distention
  
• 
  Increased blood pressure
  
• 
  Obtain pulses with CPR
  
• 
  Blood in syringe does not clot
  

• 
  Damage to the left anterior descending coronary artery
  
• 
  Pneumothorax
  
• 
  Laceration of the myocardium
  

• 
  Any patient with pulses
  
• 
  Severe respiratory distress
  
• 
  Decreased or absent breath sounds on the affected side
  
• 
  Hypotension
  
• 
  Cyanosis
  
• 
  Tracheal deviation away from the affected side
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX (semi-automatic)	XX (semi-automatic)	XX (semi-automatic or manual)	XX (semi-automatic or manual)

To simultaneously depolarize the myocardial cells to terminate ventricular fibrillation or ventricular tachycardia

Electrode jelly or pre-gelled defibrillator pads

Personal protective equipment to prevent exposure to blood/body fluids

Razor for skin preparation

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Monitor the patient’s electrical rhythm.
   
3. 
   Confirm absence of peripheral and central pulses on the patient.
   
4. 
   Confirm interpretation of ventricular fibrillation or pulseless ventricular tachycardia.
   
5. 
   Ascertain that adequate CPR is in progress.
   
6. 
   Standard or pediatric paddles may be used only if the entire surface of the paddle fits tightly against the chest wall.
   
7. 
   Apply electrode jelly to the paddles or place the pre-gelled defibrillator pads on the patient’s chest in the location specified by the device manufacturer (e.g. upper right anterior chest under the clavicle and on the left chest at the 5th intercostal space between the midclavicular and the anterior axillary line vs anterior-posterior placement). For devices with hands-free defibrillation capabilities, apply the patient pads according to the device manufacturer’s recommendations. Chest hair may need to be shaved to assure good skin contact.
   
8. 
   Charge the defibrillator to settings recommended by AHA (monophasic defibrillators). Biphasic defibrillators will measure resistance and deliver the correct energy levels without external setting.
   
9. 
   Start paper recording to document rhythm if available. Information may also be stored electronically in the defibrillator memory.
   
10. 
    If using defibrillator paddles, place paddles on patient’s chest in the standard defibrillation position (step 7). If using hands-free equipment, attach patient pads to defibrillator.
    
11. 
    Reconfirm the patient’s rhythm.
    
12. 
    Assure that all personnel are clear of direct or indirect patient contact.
    
13. 
    Simultaneously depress both defibrillation buttons, holding paddles in place with approximately 25 pounds of pressure on each until the machine discharges. If using hands-free equipment, press the “shock” button(s).
    
14. 
    Begin CPR and continue for 2 minutes.
    
15. 
    Monitor patient’s rhythm and vital signs.
    
16. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Termination of ventricular fibrillation or ventricular tachycardia in the pulseless, apneic patient.
  

• 
  The electrical current causes some injury to the myocardium.
  

• 
  Poor interface between the paddles and the chest wall can cause burns to the skin
  

• 
  Any patient with pulses
  

Note: During the transition phase from the 2000 to the 2005 ACLS standards, EMTs should follow the voice directions of the AED that is being used in the field.

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Obtain information as to the sequence of treatment thus far.
   
3. 
   Assess patient to confirm that the patient is pulseless.
   
4. 
   Assess the Public Access AED that is already on the patient. If it is not working, remove it and apply the EMS unit. If the Public Access AED pads will adapt to your unit, do not remove the original pads.
   
5. 
   If the Public Access AED is working and is in the process of delivering a group of shocks, continue to operate the unit to complete the series.
   
6. 
   If EMS personnel are familiar with the Public Access AED and it seems to be functioning properly, they may continue to use it. If EMS personnel are not familiar with the Public Access AED, it should be removed and the EMS unit applied.
   
7. 
   EMS personnel should start the AED protocol from the beginning, regardless of the number of shocks delivered by public access.
   
8. 
   The data card from the Public Access AED should be left in place in that unit. The information on the card will be needed for QA purposes by the AED owner. If the Public Access AED is transported to the hospital with the patient, it is possible that the information on the unit could be downloaded at that time.
   
9. 
   Return the Public Access AED to the proper owner. They should be reminded to check supplies and battery function prior to placing the unit back in service.
   

State of Wisconsin Standards and Procedures of Practical Skills Manual (July 2008 Rev) is appended and contains step-by-step instructions for AED use. See index for page numbers.

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
			XX (unstable patients only)	XX

To deliver an electrical charge to the myocardium synchronized to the depolarization of the ventricle

Electrode jelly or pre-gelled defibrillator pads

Patient electrodes

Patient cables

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Place electrodes in the standard 3- or 4-lead configuration and attach patient cable.
   
3. 
   Monitor and record the patient’s rhythm.
   
4. 
   Confirm cardioversion order from medical control.
   
5. 
   Explain the procedure to the patient if necessary.
   
6. 
   Obtain medical control order for sedation (Paramedics only) /pain medication if necessary. (See drug profiles 013, 007, 023)
   
7. 
   Apply electrode gel to the paddles or place the defibrillation pads in the standard position recommended by the defibrillator manufacturer. If using hands-free equipment, place the patient pads as recommended by the manufacturer.
   
8. 
   Turn energy selection dial to the setting ordered by medical control.
   
9. 
   Push the synchronizer button on, check for flashing of synchronizer light.
   
10. 
    Check oscilloscope for sensing mark for each QRS, adjust gain as needed.
    
11. 
    Place defibrillator paddles in the standard configuration as recommended by the device manufacturer. If using hands-free equipment, connect the patient pads to the defibrillator.
    
12. 
    Charge the defibrillator.
    
13. 
    Assure that all personnel are clear of direct or indirect patient contact.
    
14. 
    Simultaneously depress both defibrillation buttons, holding paddles in place with approximately 25 pounds of pressure on each until the machine discharges. If using hands-free equipment, push the “shock” button(s).
    
15. 
    Monitor patient’s rhythm and vital signs.
    
16. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

Synchronized cardioversion (cont.)

• 
  Unstable atrial or junctional tachycardia with pulses
  
• 
  Narrow complex tachycardia with pulses which has not responded to adenosine
  
• 
  Unstable ventricular tachycardia with pulses
  
• 
  Wide complex tachycardia with pulses which has not responded to lidocaine, procainamide, adenosine, amiodarone
  

• 
  Electrical depolarization may result in ventricular fibrillation
  

• 
  Patients taking digitalis preparations
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX *	XX	XX	XX

To obtain and transmit a diagnostic quality 12-lead electrocardiogram

Patient cables

ECG electrodes

Razor to prep skin surface

Personal protective equipment to prevent exposure to blood/body fluids
PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Explain the procedure to the patient and gain his/her cooperation/consent.
   
3. 
   Shave chest hair from electrode sites if it will interfere with good skin contact.
   
4. 
   Attach electrodes to the cables from the machine and place the ten electrodes on the patient as follows:
   

V2 = 4^th intercostal space, left sternal border

V3 = Midway between V2 and V4

V4 = Mid clavicular line, fifth intercostal space

V5 = Lateral to V4 at the anterior axillary line

V6 = Lateral to V5 at the midaxillary line

RA = Right arm (anywhere on the right arm or right shoulder)

LA = Left arm (anywhere on the left arm or left shoulder)

RL = Right leg (anywhere on the right leg or right lower abdomen)

LL = Left leg (anywhere on the left leg or leg lower abdomen).

5. 
   Obtain the 12 lead ECG per manufacturer’s directions.
   
6. 
   Detach the leads from the patient. Consider leaving the electrodes in place
   
7. 
   Document procedure and results, including any unusual circumstances and/or difficulties encountered
   

End page 1

• 
  Chest pain of suspected cardiac origin
  
• 
  Patients exhibiting symptoms/signs suggesting cardiac ischemia
  
• 
  Need for an electrical view of all areas of the myocardium
  

• 
  May delay transport
  

• 
  None
  

• 
  Unacceptable delay in care and transport of a critical/unstable cardiac patient
  

GUIDELINE FOR PRACTICAL SKILL

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	May obtain but not interpret	May obtain but not interpret	xx	xx

PURPOSE

EQUIPMENT

PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Explain the procedure to the patient.
   
3. 
   Body hair at the electrode site may need to be removed to assure good skin contact.
   
4. 
   Prepare the skin area where the electrodes will be attached.
   

5. 
   Attach electrodes to the end of the patient cables and adhere to patient skin surface:
   

6. 
   If monitoring is to done with defibrillator pads:
   

7. 
   Turn on the ECG machine and establish the patient’s rhythm.
   
8. 
   If the ECG machine is so equipped, print out the patient’s initial rhythm.
   
9. 
   Continue to monitor as appropriate for the patient’s condition, including recording of any ECG changes.
   
10. 
    Document the procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Provides real time monitoring of the patient’s cardiac rhythm
  

ECG Monitoring (cont.)

Recognize/verbalize disadvantages of ECG monitoring

• 
  May delay transport
  

• 
  None
  

• 
  Unacceptable delay in care and transport of a critical/unstable patient
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
			XX (Unstable patients only)	XX

PURPOSE

EQUIPMENT

PROCEDURE

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Complete initial and focused physical assessment. (see guideline # 103)
   
3. 
   Provide routine medical care. (see guideline # 106)
   
4. 
   Obtain IV access. (see guideline #3002).
   
5. 
   Identify patient as candidate for transcutaneous pacing: Symptomatic bradycardia/heart block (chest pain, dyspnea, altered level of consciousness, hypotension, diaphoresis, congestive heart failure) that is unresponsive to atropine (See drug profile # 005)
   

6. 
   Obtain baseline ECG and vital signs.
   
7. 
   Explain procedure to patient and/or family.
   
8. 
   Consider sedation (paramedics only).
   
9. 
   Clean and dry skin, shave if necessary to obtain good skin contact with electrodes.
   
10. 
    Apply pacing electrodes per manufacturer’s recommendations (usually anterior-posterior).
    
11. 
    Select pacing mode (fixed-rate or demand).
    
12. 
    Set rate, usually between 60 and 80 beats per minute.
    
13. 
    Set milliAmps. Start at minimum for patients with pulses and turn up until capture is achieved.
    
14. 
    Turn pacer on. Monitor patient’s vital signs and adjust settings as necessary.
    
15. 
    Document procedure and results, including any unusual circumstances and/or difficulties encountered.
    

• 
  Indications as noted above
  
• 
  Noninvasive, quick and easy to apply
  

Pacing (cont.)

Recognize/verbalize disadvantages of transcutaneous pacing

• 
  Cardiac muscle must be capable of responding to electrical current
  
• 
  Can cause muscle twitching, pain and hiccoughs when skeletal muscle/diaphragm also contract
  

• 
  Tissue damage from prolonged transcutaneous pacing
  
• 
  Tissue burns in pediatric patients
  
• 
  Change in pacing threshold may necessitate an increase in milliAmps
  

• 
  Open wounds or burns of the chest
  
• 
  Wet environment
  

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
				XX

To provide a route for administration of fluids and medications into the vascular system via an indwelling central catheter

Some central venous catheters may be used for routine fluid and medication needs and others should not: (permission to acces different types of devices may vary between services)

• 
  Dialysis catheters should only be used in “code” and “pre-code” situations when no other peripheral IV access is available.
  
• 
  PICC lines or other single, double, or triple lumen catheters may be used in place of starting another peripheral IV for routine medications and fluids
  
• 
  Implantable central venous catheters (Hickman, Infuse-a-port, etc.) can be used for routine medications and fluids but require special equipment and technique (see below).
  

Normal Saline intravenous solution

Administration set of appropriate size for the volume of fluid to be administered

Extension set

Tape

Alcohol preps

Clear occlusive dressing e.g.Tegaderm (optional)

0.75 inch Huber needle (optional)

Armboard

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Assemble IV bag and tubing using sterile technique and fill the drip chamber and line.
   
3. 
   Explain the procedure to the patient and get his/her consent if appropriate.
   

5. Cleanse area around clamp and cap at end of indwelling device (the utmost care should be taken to maintain sterility of the central line)

6. Remove cap and attach 10 ml sterile syringe

7. Open clamp and withdraw 10 ml of fluid from the indwelling catheter (this may only be possible through large bore dialysis catheters)

8. Clamp indwelling catheter

End page

9. Attach 10 ml syringe with or without extension set filled with sterile saline

10. Open clamp and flush indwelling line with saline. If resistance is met, abort procedure, document situation and notify receiving RN of failed access attempt.

11. Close clamp

12. Attach IV administration set

13. Open clamp on indwelling catheter and set fluid administration rate as ordered

14. Dispose of contaminated equipment in an appropriate receptacle.

15. Document procedure and results, including any unusual circumstances and/or

difficulties encountered.

16. 
    Continue to monitor flow rate and administration site.
    

SPECIAL NOTES

• 
  Many central lines are not high volume infusing lines. If significant fluid resuscitation is needed, consider a new peripheral IV site.
  

1. 
   Wear simple mask and maintain clean technique
   
2. 
   Preload 10cc normal saline syringe to Huber needle and flush air from assemble
   
3. 
   Locate Port on chest wall and determine if it is single or double lumen
   
4. 
   Stabilize port on chest wall
   
5. 
   Thoroughly clean area with Chloraprep in circular expanding motion
   
6. 
   Place Huber needle into center of port at 90 angle to skin until needle stops
   
7. 
   Attempt to aspirate blood tinged fluid to confirm port is operational
   
8. 
   Attempt to gently flush port with prepared 10cc saline syringe. If resistance is met, abort procedure, document situation, and verbally notify receiving RN of failed access attempt.
   
9. 
   If flush successful, pad needle if needed and secure into place with Tegaderm and tape
   
10. 
    Connect properly prepared IV line as above
    

• 
  Provides route for administration of fluid for volume replacement.
  
• 
  Provides route for administration of medication
  
• 
  Does not require inserting a new intracatheter into a vein
  

• 
  Can potentially allow an air embolus if proper procedure is not followed
  

• 
  Air Embolism
  
• 
  Introduction of bacteria with potential for sepsis
  
• 
  Damage to the central line
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
			XX	XX

PURPOSE

INDICATIONS

CONTRAINDICATIONS

EQUIPMENT

PROCEDURE

2. Obtain physician order in all patients who have a pulse.

3. Assemble the IV bag, administration set and extension set using sterile technique and fill the

drip chamber and line.

4. Determine indications.

5. Rule out contraindications.

6. Identify the intraosseous site – anteromedial aspects of the proximal tibia 1-2 cm below the tibial

tuberosity. Cleanse the site with alcohol and Betadine or Chloraprep.

7. Consider administering 1 ml of 2% Lidocaine subcutaneously at the insertion site if the patient is

conscious.

8. Prepare the EZ-IO driver and appropriate needle set.

9. Stabilize the site and insert appropriate needle set through the bone into the marrow canal.

10. Remove the drive from the needle set while stabilizing catheter hub.

11. Remove the stylet from the catheter, place stylet in sharps container.

12. Connect primed extension set.

13. Attach a 10 ml syringe and attempt to aspirate marrow. Liquid resembling blood may appear in

the syringe.

14. Infuse Lidocaine 2% if the patient is conscious:

Adult: 20-40 mg (1-2 ml) of 2% Lidocaine IO bolus over one minute

Pediatric: 0.5 mg/kg of 2% Lidocaine IO bolus. Try to give it enough time to soak into the

marrow.

16. Connect the extension set to the primed line.

17. Open the flow-regulation clamp and observe the site for signs of infiltration.

18. If infiltration (pain and swelling at the site) occurs, discontinue the IO line, repeat the procedure

on the opposite leg.

19. Adjust the flow rate to deliver the ordered volume of fluid.

20. Consider pressure bag or infusion pump.

21. Dress the site.

22. Continue to monitor flow rate and administration site.

23. Dispose of contaminated equipment in an appropriate receptacle.

24. Document procedure and results, including any unusual circumstances and/or difficulties

encountered.

• 
  Never attempt a second IO near the site of a recent attempt
  
• 
  Never reuse an IO needle/catheter
  
• 
  To remove EZ-IO, use a syringe and clockwise rotation with traction. Do not rock or pry on the catheter.
  

• 
  Provides route for administration of fluid for volume replacement
  
• 
  Provides route for administration of medication
  

• 
  Requires special equipment and insertion technique
  

• 
  Infiltration of fluid into the subcutaneous tissue
  
• 
  Extravasation of some medications can cause tissue sloughing
  
• 
  Introduction of bacteria during insertion can cause infection
  
• 
  Fracture of the tibia
  

GUIDELINE FOR PRACTICAL SKILL

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

To simultaneously depolarize the myocardial cells to terminate ventricular fibrillation or ventricular tachycardia

Semi-automatic Monitor-defibrillator

Pre-gelled defibrillator pads

Personal protective equipment to prevent exposure to blood/body fluids

Razor for skin preparation

AED Considerations:
1. Consider ALS (Intermediate or paramedic) backup at dispatch to provide Advanced Cardiac Life Support (ACLS).

2. Preparation for transport of patient should begin immediately as staffing allows.

3. Assuming no ACLS on scene, the patient should be transported when one of the following occurs:

a. The patient regains a pulse.

b. Two (2) shocks are delivered (in addition to shocks delivered by Public Access

Defibrillator (PAD)

c. The patient should be transported as soon as possible if no shock is advised and ALS is not on scene.

4. For adult patients:

a. If no bystander CPR has been started and EMS arrival is greater than 4 minutes from patient

collapse, EMS personnel should provide two (2) minutes of CPR before analyzing rhythm and possible defibrillation attempt.

b. If bystander CPR is being performed upon arrival of EMS, rhythm analysis and possible

defibrillation attempt may be attempted immediately, followed by two (2) minutes of CPR before reanalyzing.

5. For pediatric patients:

a. For unwitnessed cardiac arrest in children one to puberty, perform two (2) minutes of CPR

before using the AED.

b. For witnessed cardiac arrest in children one to puberty, use an AED as soon as it is available.

6. All contact with the patient must be avoided during analysis of rhythm and/or delivery of shock(s).

7. Automated external defibrillation can be used in cardiac arrest in children over the age one to “age of

puberty.” The preferred method is to utilize an AED with pediatric capabilities. If ONLY a standard AED is available, it may be applied with pads placed anterior and posterior

8. 
   For victims eight (8) years of age and older, do not use child pads or pediatric only capability machines.
   
9. 
   Older AEDs can not analyze a rhythm properly when an emergency vehicle is in motion. Per AHA 2005 guidelines, modern AEDs can safely analyze and defibrillate in a moving vehicle.
   

1. Assure scene safety and observe universal precautions (see guideline #107).

2. Consider ALS (intermediate or paramedic) intercept. Consider early transport if ALS is not available.

3. Stop CPR if in progress,

4. Perform initial assessment (Level of consciousness, airway, breathing, circulation).

5. Confirm absence of peripheral and central pulses and absence of breathing on patient.

6. CPR should be in progress while equipment is being prepared.

7. Adult patient: If Public Access Defibrillator (PAD) is utilized prior to your arrival, switch from PAD to your defibrillator.

8. Pediatric patient: IF EMS AED is not pediatric-capable, then continue to use the PAD with pediatric capabilities. If neither the PAD nor the EMS AED is pediatric capable, use the EMS AED with anterior-posterior pad placement.

9. Attach device to patient

a. Attach pads per manufactures’’ directions or

b. Attach the negative electrode to the patient’s right anterior chest wall, slightly inferior to the clavicle at the mid-clavicular line and

c. Attach the positive electrode to the patient’s left lateral chest wall at the mid-axillary line and slightly inferior to the nipple line.

d. Ensure each pad is securely and firmly adhering to the patient.

e. Anterior/posterior pad placement may be used in pediatric patients when the chest wall is too small to place pads in the standard position.

10. Stop CPR

11. Direct everyone to clear the patient.

12. Initiate the rhythm analysis.

13. If AED advised defibrillation.

a. Deliver the shock (be sure everyone is clear of the patient.)

b. Resume CPR for two (2) minutes (30:2 ratio)

i. Consider insertion of an advanced airway. INSERT AIRWAY WHILE DOING

COMPRESSIONS, artificially ventilate with high concentrations of oxygen.

c. Stop CPR.

d. Reanalyze the rhythm and deliver second shock as the machine advises.

e. Resume CPR for two (2) minutes.

f. Contact medical control if two (2) total shocks have been given.

g. Transport promptly.

14. If, after any rhythm analysis, the machine advised no shock:

a. Resume CPR for two (2) minutes.

i. Consider insertion of an advanced airway. INSERT AIRWAY WHILE DOING

COMPRESSIONS, artificially ventilate with high concentrations of oxygen.

b. Stop CPR

c. Continue sequence until machine givens three (3) consecutive messages separated by two (2) minutes of CPR that no shock is advised.

15. Persistent shockable rhythms and no available ALS backup

a. If after a maximum of two (2) shocks on scene, transport patient promptly. If transport is impossible (i.e. ambulance not at scene) continue the sequence of one shock followed by two minutes of CPR for as long as a shockable rhythm persists or until transport becomes possible

b. After initial two (2) shocks, additional shocks may be delivered at the scene or enroute ONLY BY APPROVAL OF ON-LINE MEDICAL CONTROL.
SPECIAL NOTES:

• 
  Time if valuable, Rapid defibrillation with airway placement when necessary must be accomplished as rapidly as possible. Initiate transport early.
  
• 
  If you are transporting a patient who is in or develops cardiac arrest, you must pull over and stop the vehicle to analyze. Use common sense. Do not stop so often that it takes a lengthy period of time to get to the hospital.
  

• 
  If you successfully resuscitated a patient from a shockable rhythm and the patient subsequently reverts back to a shockable rhythm, you may reinstitute the entire protocol without an on-line medical control order. This may be done a third time if necessary. Medical control must be contacted after a third sequence.
  
• 
  Pulse checks should be done carefully for 5-10 seconds. No CPR can be done while the machine is analyzing.
  
• 
  The EMT shall shock one time as necessary, then place the advanced airway according to the airway protocol. After a two-minute period of CPR, one more shock may be given, if indicated. If no conversion, move to the ambulance and begin transport.
  
• 
  The compression rate should be at least 100 per minute. Ventilator rate should be one breath every 6-8 seconds.
  
• 
  Although contact with Medical Control is highly advised to provide more than two initial shocks, if communication with a physician cannot be obtained for some reason, additional shocks as indicated may be given.
  

GUIDELINE FOR PRACTICAL SKILL

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
	XX	XX	XX	XX

Continuous mechanical CPR

Increased blood flow

INDICATIONS:

Cardiac arrest

Auto-Pulse

Single patient use life band

Adjustable cervical collar

Head bed

Carrying tarp

Heavy Zip Strips (To connect to long board)

Personnel protective equipment to prevent exposure to blood/body fluids

1. 
   Assure scene safety and observe universal precautions (see guideline #107).
   
2. 
   Confirm absence of peripheral and central pulses on the patient.
   
3. 
   Remove upper body clothing from patient.
   
4. 
   Begin manual CPR following AHA guidelines, while deploying Auto-Pulse.
   
5. 
   Consider placing patient in appropriate size C-collar.
   
6. 
   Sit patient up and slide Auto-Pulse base behind patient so that patient’s head and shoulders are within designated area. Turn device on.
   
7. 
   Apply chest band over patient’s chest lining up yellow line on band with yellow line on board. Be sure there are no twists and the bands are fully extended. Secure patients head to board with head immobilization device and padding under head
   
8. 
   Hook-and-loop tape (i.e. Velcro®) the chest bands together being sure they are properly aligned. Press the green button. The machine will ask if the patient is properly aligned. If alignment is correct, press the green button again to continue.
   
9. 
   Begin mechanical CPR following AHA guidelines. Once the advanced airway is secured, switch to continuous compressions.
   
10. 
    Confirm pulses with mechanical CPR.
    
11. 
    Transport the patient.
    

End page 1

Auto-pulse (continued)
List advantages of the Auto-Pulse

• 
  Continuous uninterrupted CPR
  
• 
  Increased blood flow
  
• 
  Decreased fatigue of rescuers
  

• 
  Additional weight
  

• 
  Potential Head/Cervical Injury
  
• 
  May cause friction/rubbing sores on the body
  

• 
  Patient less than 18 y/o
  
• 
  Traumatic cardiac arrest
  
• 
  Weight greater than 300lbs
  

The following content will be considered the Guideline/Standard for:

Approved for use by:	EMT	Advanced EMT	EMT-Intermediate	EMT-Paramedic
				xx

• 
  To decrease body temperature between 32 and 34C for patients with ROSC
  
• 
  To improve neurologic outcome in patients with ROSC
  

• 
  Method of maintaining 2 Liters of 0.9% Saline at 4C
  

• 
  Must include all:
  
  • 
    Cardiac arrest does not need to be witnessed
    
  • 
    Patient was in VT, VF, PEA, or Asystole at some time during this cardiac arrest
    
  • 
    Significant Altered Level of Consciousness for example but not limited to :
    
    • 
      Not following commands
      
    • 
      No purposeful movements
      
    • 
      No purposeful response to pain
      
    • 
      No comprehensible speech
      

• 
  Known Surgery within 2 weeks
  
• 
  History of Bleeding disorder (Coumadin, Lovinox, Aspirin, etc.. are not contraindications)
  
• 
  Active bleeding
  
• 
  Currently Pregnant
  
• 
  Age less then 18 y/o
  
• 
  Evidence of Trauma – ie: Trauma as possible cause of arrest
  
• 
  Cardiac instability
  
  • 
    Refractory or recurrent life threatening dysrhythmia
    
• 
  Environmental hypothermia exposure
  
• 
  Obvious pulmonary edema before protocol is started
  
• 
  Other cause of arrest such as; drug overdose, head trauma, hemorrhagic stroke, status epilepticus, infection, etc.
  
• 
  All appropriate hospitals who have cooling protocols are on diversion
  

• 
  Recognize patient with ROSC status post cardiopulmonary arrest
  
• 
  Review and document inclusion and exclusion criteria – Proceed if patient is a candidate
  
• 
  Place endotracheal tube unless a functioning Combi-Tube or King LT is already in place
  
  • 
    If there is any question as to the status of the alternate advanced airway, intubate the patient with an ETT.
    

• 
  Expose the patient
  
  • 
    Undergarments may remain in place
    
  • 
    Consider the location and patient modesty
    
• 
  Apply ice packs to the axilla, neck, and groin – place barrier to prevent freezing of the skin
  
• 
  Administer Midazolam 0.15mg/kg IVP (max 10mg) if BPs is greater than 90 mmHg
  
• 
  Administer 30ml/kg cold saline fluid bolus (max 2 liters)
  
  • 
    Consider using a pressure bag inflated to 300mmHg
    
• 
  Monitor Blood Pressure and vital signs every 2-5 minutes
  
• 
  Administer Dopamine 5-20 mcg/kg/min IV to maintain the systolic blood pressure (BPs greater than 90 mmHg)
  
• 
  If shivering develops, administer Vecuronium 0.1mg/kg IVP
  
  • 
    The use of paralytics is not mandatory for this protocol
    
• 
  Do not hyperventilate
  
  • 
    Hypothermia causes metabolic alkalosis
    
  • 
    Goal ETCO₂ = 40
    
• 
  Do not delay transport to induce hypothermia
  
• 
  Attempt to obtain second IV access point (KVO or capped line)
  
• 
  Patient must be transported to a hospital prepared to receive patients with induced hypothermia
  
• 
  Stop administration of cold saline at any time there is a loss of spontaneous circulation and return to appropriate resuscitation protocol
  
  • 
    If hypothermia protocol is stopped, it should not be restarted in the pre-hospital setting.
    
  • 
    
    

• 
  Improved neurologic outcome in patients who have survived cardiopulmonary arrest and at the time of the protocol initiation have significant neurologic impairment.
  
• 
  Decreased cerebral metabolism
  
• 
  Decrease in free radical production
  
• 
  Suppression of Calcium mediated cell death
  

• 
  Significant fluid bolus may lead to fluid overload
  
• 
  If hypothermia is not continued in the hospital, increased likelihood of poor outcome
  

• 
  Hypothermia induces metabolic alkalosis
  
• 
  Cold saline can induce vasospasm requiring detailed monitoring
  

• 
  See list in protocol