Guidelines for Care

7/29/2019 Guidelines for Care

1/22

Guidelines for Care

ABDOMINAL TRAUMA

1. Assure ABCs.

2. Oxygen via non-rebreather mask. Consider intubation and hyperventilation

with 100% oxygen for markedly decreased LOC, inability to maintain a

patient airway, or for GCS * 8.

3. Attach cardiac monitor and pulse oximeter.

4. Establish two large bore IVs of lactated Ringer's to maintain systolic

pressure > 90 mmHg.

5. Impaled objects should be stabilized in place.

6. Eviscerations should be covered with saline-soaked gauze. Do not attempt

to push the organs back into the abdomen. Do not inflate the abdominal

section of the PASG / MAST.

7. Rapid transport.

ALCOHOL EMERGENCIES

1. Assure ABCs.




3. Initiate IV of lactated Ringer's TKO.


5. Determine serum glucose level with Glucometer or DextroStix.

6. If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.7. If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.

8. If glucose > 250 mg/dl, go to Hyperglycemia Protocol.

9. If history suspicious for alcoholism, administer 100 mg thiamine IV OR IM.

10. If history of drug abuse, and patient has constricted pupils or respiratory

depression, administer Narcan 1.0-2.0 mg IV.

11. If history of possible Benzodiazepine usage, administer 0.3 mg of Flumazenil

(Romazicon) IVP over 30 seconds. Repeat as needed to a maximum dose

of 1.0 mg.

12. Provide supportive measures.

13. Transport to designated hospital.

ALTERED MENTAL STATUS/COMA

1. Assure ABCs.




3. Initiate IV lactated Ringer's TKO.


5. Determine serum glucose level with Glucometer or DextroStix.a. If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.

b. If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.

c. If glucose > 250 mg/dl, go to Hyperglycemia Protocol.

6. If history suspicious for alcoholism, administer 100 mg thiamine IV OR IM.

7. If history of drug abuse, and patient has constricted pupils or respiratory

depression, administer Narcan 1.0 - 2.0 mg IV.

8. If history of possible Benzodiazepine usage, administer 0.3 mg of Flumazenil

(Romazicon) IVP over 30 seconds. Repeat as needed to a maximum dose

of 1.0 mg.


10. Transport to designated hospital.

AMPUTATIONS

1. Assure ABCs.

2. Control bleeding.

3. Oxygen via non-rebreather mask.

4. Large bore IV of lactated Ringer's solution at appropriate rate to maintain

systolic > 90 mmHg.

5. Treat for shock, if indicated.

6. Rinse amputated part with normal saline to remove loose debris. DO NOT

SCRUB.

7. Wrap amputated part in gauze moistened with saline.8. Place wrapped part in plastic bag and seal. Label with NAME, DATE, and

TIME.

9. Place sealed bag in container filled with water and several ice cubes.

10. Consider Morphine 2-5 mg IVP for pain control. May repeat in 5 minutes up

to a maximum of 10 mg.

11. If partial amputation, place in anatomical position to facilitate the best

vascular status and wrap in bulky dressings. If the vascalarity to the distal

part is compromised, wrap the distil part and apply ice. (Consider placing the

pulse oximeter probe on a finger or toe of the affected extremity to monitor

the vascular status of the injured extremity.)

12. Transport to designated facility.


2/22

ANAPHYLAXIS/ALLERGIC REACTIONS

1. Assure ABCs.





4. IV of lactated Ringer's TKO.

5. If blood pressure normal:a. Consider Benadryl 50 mg IM or slow IV push.

6. If hypotensive (systolic


3/22

BURNS

1. Assure ABCs.

2. Extinguish any flames on patient, remove smoldering clothing (leather), and

any constricting jewelry.

3. Remove from harmful environment and limit injury:

a. CHEMICAL:Flush with water or normal saline. Brush off dry

chemicals.

b. TAR: Cool with water or normal saline (do not attempt to removetar.)

c. ELECTRICAL: Remove from contact with current source if

equipped to do so. (Note any secondary fractures and Exit wounds

caused by current.)

4. If respiratory distress, or airway burns exist, prepare to intubate. Consider

RSI early if respiratory burns are present.

5. If pulseless or apneic, go to Cardiac Arrest Protocol.

6. If additional injuries, go to Trauma Management Protocol.

7. If significant 2 or 3 burns (> 20% BSA):

a. Oxygen via non-rebreather mask

b. Establish two large bore IVs of lactated Ringer's.

c. Administer 4 ml X patient's weight (kg) X % BSA burnedd. Give 1/2 in the first 8 hours post-burn,

e. Give 1/4 in the second 8 hours,

f. Give 1/4 in the third 8 hours.

g. Contact medical control

h. Consider Morphine 2-5 mg IVP. May repeat in five minutes to a

maximum of 15 mg.

8. If altered LOC and/or signs of head injury (consider carbon monoxide

poisoning if closed space burn):

a. Oxygen via non-rebreather mask.

b. Immobilize cervical spine.

c. IV lactated Ringer's TKO.

d. Contact medical control.

9. Transport all significantly burned patients on sterile dry sheets.

10. Consider Foley catheter insertion.

11. Monitor urine output. If output drops to less than 30-60 ml/hour (adults) OR

1.0 ml/kg/hour (pediatric), increase the IV fluids to maintain urine output at

these levels.

12. Consider escharotomy if circumferential burns of the neck, chest, or

extremities are interfering with effective ventilations or circulation.

13. Contact medical control for any questions or problems.

CARDIOGENIC SHOCK

1. Assure ABCs.

2. Oxygen via non-rebreather mask if no history of COPD. If history of COPD,

titrate oxygen delivery to maintain SPO2 > 90%. Consider intubation and

hyperventilation with 100% oxygen for markedly decreased LOC, inability to

maintain a patient airway, or for GCS * 8.

3. Initiate IV lactated Ringer's TKO. If hypotensive, consider 250 mL fluid bolus.

4. Attach cardiac monitor and pulse oximeter.5. Treat dysrhythmias per the appropriate protocol.

6. If signs of severe hypoventilation occur:

a. Assist ventilations with BVM with 100% oxygen.

b. Consider endotracheal intubation.

c. Contact medical control

d. Intubated patients with severe pulmonary congestion may require

PEEP to maintain oxygenation status.

7. Monitor I&O closely.

8. If systolic BP >100 mmHg, consider Dobutamine at 2-20 g/kg/min to

maintain systolic blood pressure > 100 mmHg.

9. If systolic BP 100 mmHg.10. Consider Norepinephrine 0.5 - 30.0 g/min if systolic


4/22

CHEST TRAUMA

1. Assure ABCs.

2. Oxygen via non-rebreather mask. consider intubation and

hyperventilation with 100% oxygen for markedly decreased LOC,

inability to maintain a patient airway, or for GCS * 8.


4. Establish two large bore IVs of lactated Ringer's to maintain systolic

pressure > 90 mmhg.5. If penetrating or sucking chest wound (look for bubbles, listen for air

leaks):

a. Place occlusive dressing during exhalation (tape on 3 sides).

b. Once occluded, monitor for tension pneumothorax.

6. If flail chest (unstable segment that does not expand with the remainder

of the chest on inspiration):

a. If conscious, stabilize flail segment with gauze pad, IV bag, etc.

b. If unconscious, immobilize neck and intubate. ventilate with

100% oxygen by BVM.

c. Re-assess, if tension pneumothorax develops, see #7 below.

7. If tension pneumothorax (unilateral absent breath sounds with or without

tracheal deviation or bilaterally absent breath sounds:a. Perform needle decompression per protocol.

8. Continued inadequate ventilations and decreasing LOC:

a. Rapid secondary survey for additional injuries.

b. Immobilize neck.

c. Control hemorrhage.

d. Intubate with cervical stabilization.

e. Ventilate with 100% oxygen via BVM.

f. Establish second IV lactated Ringer's wide open en route if

signs of shock.

g. Cardiac compressions if pulseless.

9. Impaled objects should be stabilized in place.

10. Treat any dysrhythmias per protocols.

11. Transport.

CHILDBIRTH

1. Assure ABCs.


3. Secondary survey.

4. Obtain pertinent history:

a. Number of pregnancies/deliveries.

b. History of problems with pregnancy (vaginal bleeding, prior

cesarean sections, high blood pressure, premature labor,

premature rupture of membranes.

c. Last menstrual period and due date (if known).

d. Current complaints (onset of labor, timing of contractions, rupture of

membranes, or urge to push.)

e. Past medical history (including medications.)

5. Perineal examination (do not perform internal vaginal examination)

a. Vaginal bleeding or leakage of fluid.

b. Presence of meconium.

c. Crowning during a contraction.

6. Presenting part (head, face, foot, arm, cord.)7. If active labor, and no vaginal bleeding or crowning:

a. Check for fetal heart tones.

b. Transport.

8. If vaginal bleeding with no signs of shock (systolic >90 mmhg):

a. Transport.

b. IV lactated Ringer's at 125 ml/hour.

c. Cardiac monitor.

9. If heavy vaginal bleeding with signs of shock (systolic


5/22

b. Check infant's vital signs (perform CPR or assist ventilations as

necessary.)

c. Clamp cord in two places, six inches from infant, and cut cord

between clamps.

d. Suction, warm, dry, and stimulate infant.

e. Give infant to mother.

f. Massage uterus gently.

g. Do not pull on cord or attempt to deliver placenta.

h. Start IV lactated Ringer's and run at 200 ml/hour.i. Transport.

j. Watch for external bleeding. place fundal pressure if placenta

delivers.

CONGESTIVE HEART FAILURE/PULMONARY EDEMA

1. Assure ABCs.


titrate oxygen delivery to maintain SPO2 > 90%. Consider intubation and


maintain a patient airway, or for GCS * 8.3. Initiate IV lactated Ringer's TKO.


5. If signs of severe hypoventilation:


b. Consider endotracheal intubation.

c. Contact medical control.

6. If history of CHF, and patient exhibiting tachypnea, orthopnea, JVD, edema,

moist breath sounds (rales):

a. Place in seated position (semi-fowler's.)

b. Administer nitroglycerin 1/150 sublingually (if BP >120 systolic.)

c. Administer Lasix 40-80 mg IV.

d. Consider Morphine 2-5 mg every 5 minutes (do not exceed a totalof 10 mg). Carefully monitor blood pressure and respirations.

e. If systolic BP >100 mmhg, consider Dobutamine at 2-20 g/kg/min

to maintain systolic blood pressure >100 mmhg.

f. If systolic BP 100 mmhg.

g. Consider Norepinephrine 0.5 - 30.0 g/min if systolic 90 mmhg (20 ml/kg boluses for children.)

5. Be alert for dysrhythmias.

6. Transport.



6/22

DIABETIC EMERGENCIES/HYPOGLYCEMIA

1. Assure ABCs.


3. Initiate IV lactated Ringer's TKO and draw tube of blood.



a. If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.

b. If glucose > 80 mg/dl and < 250 mg/dl, go to step #6.c. If glucose > 250 mg/dl, go to Hyperglycemia Protocol.

6. If unable to establish IV, give Glucagon 1 mg IM.

7. Transport.

8. Repeat glucose determination in 5 minutes:

a. If glucose remains < 80 mg/dl, and no significant change in

mental status, administer a second 25 gms 50% dextrose IV.



11. Label the pre-treatment blood vial and provide it to the receiving hospital

with the patient.

DIABETIC EMERGENCIES/HYPERGLYCEMIA (KETOACIDOSIS)

1. Assure ABCs.

2. Oxygen via non-rebreather mask. Consider intubation and

hyperventilation with 100% oxygen for markedly decreased LOC,

inability to maintain a patient airway, or for GCS * 8.

3. Initiate IV lactated Ringer's TKO and draw tube of blood.



a. If glucose < 80 mg/dl, go to Hypoglycemia Protocol.


c. If glucose > 250 mg/dl, go to #7.6. Transport.

7. If glucose > 250 mg/dl, and patient exhibiting altered mental status,

Kussmaul respirations, dry skin with poor turgor, and/or ketotic breath:

a. Open lactated Ringer's wide open.

b. Contact medical control for Insulin and bicarb orders.

c. Transport.


9. Consider NG tube placement.

10. Consider thiamine 100 mg IVP.

DIVING EMERGENCIES (DECOMPRESSION SICKNESS)

1. Assure ABCs.

2. Administer oxygen via non-rebreather mask.

3. Place the patient in a supine head-down left lateral decubitus position.

4. Attach monitor and pulse oximeter.

5. Start an IV of lactated Ringer's TKO.

6. Protect against hypothermia and hyperthermia.

7. Monitor closely for complications (pneumothorax, shock, seizures) and treatper standing orders/protocols.

8. Contact medical control if analgesics indicated.

9. Assess vital signs, including temperature, every 10 minutes.

10. Consider transport to a hyperbaric facility. provide hyperbaric personnel with

a detailed history of the dive (depth and duration, timing and onset of

symptoms, complications, and any treatment rendered).

11. Transport at cabin altitude as low as possible or as directed by medical

control or receiving physician.


DYSPNEA

1. Assure ABCs.


titrate oxygen delivery to maintain SPO2 > 90%. consider intubation and







b. Consider endotracheal intubation

c. Contact medical control6. If history of COPD (emphysema/chronic bronchitis):

a. Obtain baseline peak expiratory flow rate (PEFR) while preparing

nebulizer.

b. Administer Albuterol breathing treatment (adult 0.5 ml). Albuterol

can readministered every 10 minutes. discontinue therapy if patient

develops marked tachycardia or chest pain.

c. If patient has received an Albuterol treatment in the last two hours,

consider using Isoetharine (Bronkosol) (adult 0.5 ml) instead of

Albuterol.

d. Ipratropium (Atrovent) (adult 500 g) may added to the initial

nebulizer treatment with Albuterol or Isoetharine.

e. Obtain post-treatment PEFR rate after each treatment.

f. Contact medical control for any questions or problems.


7/22

g. Transport.

7. If history of fever and/or productive cough:

a. Place in position of comfort.

b. Transport.

8. If allergen exposure, edema, rash, and wheezing:

a. Go to Anaphylaxis/Allergic Reaction Protocol

b. Contact medical control

c. Transport.

9. If history of pulmonary embolism:a. Place in position of comfort (preferably with extremities lower than

level of heart)

b. Consider Morphine 2-5 mg IVP for pain. may repeat to a maximum

of 10 mg.

c. Consider Valium 2-5 mg IVP for anxiety.

d. Transport.

10. If history of CHF, and patient exhibiting tachypnea, orthopnea, JVD, edema,

moist breath sounds (rales):

a. Place in seated position (semi-fowler's)

b. Administer Nitroglycerin 1/150 sublingually (if BP >120 mmhg

systolic).

c. Administer Lasix 40-80 mg IV.d. Consider Morphine 2-5 mg every 5 minutes (do not exceed a total

of 10 mg.) carefully monitor blood pressure and respirations.

e. If systolic BP >100 mmhg, consider Dobutamine at 2-20 g/kg/min

to maintain systolic blood pressure > 100 mmhg.

f. If systolic BP 100 mmhg.

g. Consider Norepinephrine 0.5 - 30.0 g/min if systolic


8/22

e. Drug overdose

f. Hypothermia

7. Consider immediate transcutaneous cardiac pacing, if available.

8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. follow

each intravenous drug bolus with 20 milliliters of IV fluid and elevate

extremity. if unable to establish IV access, administer Epinephrine

endotracheally.

9. Administer Atropine 1 mg IV. may repeat every 3-5 minutes up to:

a. 2 mg for patients weighing less than 110 pounds (


9/22

and premature ventricular contractions are malignant:

6 per minute

Multi-focal

Occurring in couplets

Exhibiting "r on t phenomenon"

Exhibiting runs of ventricular tachycardia

then, administer Lidocaine 1.0 - 1.5 mg/kg IV push (reduce dosage by 50% if

patient >70 years of age or has known liver disease).

8. If, after 5 minutes, PVCs persist, repeat Lidocaine at 1/2 the initial dose. if

PVC's suppressed, begin Lidocaine drip at 2 mg/minute. contact medical

control.

9. Consider Procainamide at 30 mg/minute to a maximum of 17 mg/kg if PVCs

persist.

10. If patient at any time becomes pulseless, switch to Pulseless Ventricular

Tachycardia Protocol (or other appropriate protocol).

11. Transport.

DYSRHYTHMIAS (PULSELESS ELECTRICAL ACTIVITY) [PEA]

1. Assure ABCs.

2. Initiate and continue CPR.

3. Intubate at once.

4. Initiate IV of lactated Ringer's wide open.

5. Confirm asystole in more than one lead.

6. Consider possible causes:

a. Hypovolemia

b. Hypoxia

c. Hyperkalemia (increased potassium)

d. Cardiac tamponadee. Pre-existing acidosis

f. Drug overdose

g. Hypothermia

h. Tension pneumothorax

i. Massive pulmonary embolism

j. Massive acute myocardial infarction

7. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. follow


extremity. if unable to establish IV access, administer Epinephrine

endotracheally.

8. If heart rate < 60 per minute, or relative bradycardia, administer Atropine 1

mg IV. may repeat intravenous Atropine every 3-5 minutes up to:a. 2 mg for patients weighing less than 110 pounds (


10/22

6. If patient exhibits any of the following signs or symptoms:

a. Chest pain

b. Shortness of breath

c. Decreased level of consciousness

d. Low blood pressure

e. Shock

f. Pulmonary edema

g. Congestive heart failure

h. Acute MI

consider patient to be unstable.

7. Administer Lidocaine 1.0 - 1.5 mg/kg IV push.

8. Administer Lidocaine 0.50 - 0.75 mg/kg IV push every 5-10 minutes until

ventricular tachycardia abolished or 3.0 mg/kg of the drug has been

administered.

9. Consider Procainamide at 30 mg/minute to a maximum of 17 mg/kg.

10. Consider Bretylium 5 - 10 mg/kg every 8-10 minutes to a maximum of 30

mg/kg.

11. Consider synchronized cardioversion. If time permits, premedicate with

Valium 2-5 mg IVP, Versed 1-2 mg IVP, or Morphine 2-5 mg IVP.12. If patient at any time becomes pulseless, switch to pulseless Ventricular

Tachycardia Protocol (or other appropriate protocol).

13. Transport.

DYSRHYTHMIAS (VENTRICULAR TACHYCARDIA--WITHOUT PULSE)

1. Assure ABCs.

2. Initiate and continue CPR until defibrillator attached.

3. Confirm ventricular fibrillation (VF) or non-perfusing ventricular tachycardia

(VT) on monitor.

4. Defibrillate up to 3 times as needed for persistent VF or VT:a. #1 at 200 joules

b. #2 at 300 joules

c. #3 at 360 joules

5. If VF or VT persists, continue CPR. if patient develops PEA or asystole, go

to appropriate protocol.

6. Intubate.

7. Start an IV of lactated Ringer's TKO.

8. Administer 1 milligram of Epinephrine 1:10,000 every 3-5 minutes IV. Follow


extremity. If unable to establish IV access, administer Epinephrine

endotracheally.

9. Defibrillate at 360 joules within 30-60 seconds following administration ofeach drug.

10. Administer 1.5 mg/kg Lidocaine intravenously. Repeat every 3-5 minutes

until a total of 3 mg/kg has been administered. If unable to establish IV

access, administer Lidocaine endotracheally.

11. Contact medical control.

12. Consider Bretylium 5 mg/kg IV.

13. Consider Sodium Bicarbonate IV.

14. Transport.

ECLAMPSIA

1. Assure ABCs.

2. Oxygen via non-rebreather mask. consider intubation and hyperventilation




4. Establish IV of lactated Ringer's at 125 ml/hr.

5. Valium 5 - 10 mg IVP over 1 minute for seizures.

6. Monitor EKG, vital signs, fetal heart tones, level of consciousness, patellar

reflexes, respiratory rate, oxygenation status every 5 minutes. If patellar

reflexes are absent, shut off the infusion and contact medical controlimmediately.

7. Keep the patient in left lateral recumbent position.

8. Contact medical control for other hypertensive agent orders.

9. Monitor urinary output if possible

10. Evaluate for pulmonary edema. if present, consider Morphine 2-5 mg IVP

over 1-2 minutes and/or Furosemide 20-40 mg IVP over 2-3 minutes.

11. Consider magnesium sulfate if ordered by medical control. begin with a

loading dose of 4 - 6 grams of magnesium sulfate (8 ml of 50% solution) in

100 ml of LR over 30 minutes. After loading dose, start magnesium sulfate

infusion. Place 10 grams of magnesium sulfate (20 ml of 50% solution) in

250 ml of LR and infuse at 50 ml/hr (2 grams/hr). Remember, magnesium

sulfate can cause respiratory depression with cardiovascular collapse.Antidote is calcium chloride IV over 5 minutes.

12. Place NG tube if appropriate.


11/22

ENVIRONMENTAL EMERGENCIES (FROSTBITE)

1. Assure ABCs.


3. Cardiac monitor and pulse oximeter.

4. Check core temperature. if core temperature < 35 c, go to Hypothermia

Protocol.

5. Attend to injured areas:

a. Protect injured areas from pressure, trauma, and friction.

b. Do not rub or break blisters.

c. Do not allow limb to thaw if there is a chance it will re-freeze.

d. Do not allow patient to ambulate once the limb has started to thaw.

e. Maintain core temperature by keeping victim warm with blankets.

f. Warm fluids may be administered orally to conscious patients.

6. Consider using the pulse oximeter probe to detect peripheral perfusion in

affected tissues.

7. Consider Morphine or Nalbuphine for pain control.

8. Transport.

ENVIRONMENTAL EMERGENCIES (HYPERTHERMIA)

1. Assure ABCs.


3. Start two large bore IVs of lactated Ringer's at TKO. bolus as required to

maintain systolic BP >90 mmhg.

4. Attach monitor and pulse oximeter.

5. Assess vital signs, including temperature, every 10 minutes.

6. If history suggestive of heat exhaustion or heat stroke:

a. Remove to cooler environment

b. Cool with ice packs or moist sheets (must have good ambient air

flow)

c. Stop cooling measures when core body temp is 39 c.

7. If seizures are present, and suspected to be heat-related:a. Protect airway with appropriate airway adjuncts.

b. Valium 2-5 mg IV.

8. For hypotension refractory to cooling and fluid boluses, initiate Dopamine

drip and titrate to maintain systolic BP > 90 mmhg.

9. Consider NG tube to low suction.

10. Consider Foley catheter to monitor urine output.

11. Consider Mannitol 0.5 - 1.0 gm/kg for decreased urine output or altered

mental status.

12. Transport.

ENVIRONMENTAL EMERGENCIES (HYPOTHERMIA)

1. Actions for all patients:

a. Remove wet garments

b. Protect against heat-loss and wind-chill

c. Maintain horizontal position

d. Avoid rough movement and excess activity

e. Monitor core temperature

f. Monitor cardiac rhythm

g. Treat major trauma as the first priority and hypothermia as the

second.

2. Assess responsiveness, breathing, and pulse:

a. If pulse/breathing absent, go to #3.

b. If pulse/breathing present, go to #5.

3. If pulse/breathing absent:

a. Start CPR.

b. Defibrillate ventricular fibrillation/ventricular tachycardia up to a total

of 3 shocks (200 j, 300 j, and 360 j)

c. Intubate.

d. Ventilate with warm, humid oxygen.

e. Establish IV of lactated Ringer's and infuse at 150 ml/hour.4. Determine core temperature:

a. If core temperature 30c, then

i. Continue CPR.

ii. Give IV medications based on dysrhythmia (but at longer

intervals.)

iii. Repeat defibrillation for ventricular fibrillation/ventricular

tachycardia as core temperature rises.iv. Transport to hospital.

5. If pulse/breathing present, administer warm, humidified oxygen, and initiate

IV of lactated Ringer's at 150 ml/hour.

6. Determine serum glucose level with Glucometer or DextroStix. If glucose 90%.


4. Establish two large bore IVs of lactated Ringer's at TKO (IV lines will

typically be in place and initiated by transferring facility).

5. Monitor vital signs, ECG, mental status, respiratory and oxygenation status

every 10 minutes.

6. Treat dysrhythmias per the appropriate protocol.

7. Keep the mean arterial pressure (map) between 60-80 mmhg.

8. Do not elevate the head of the bed greater than 30 degrees. Aeromedical

units should communicate with pilot regarding angle of attack during landing

and take-off.9. Frequently reassess patient.

MOTION SICKNESS

1. Assure ABCs.



4. Initiate IV of lactated Ringer's at 125 ml/hr. Give 250 ml fluid bolus if systolic

pressure < 90 mmhg (20 ml/kg for children).

5. Be alert for dysrhythmias.

6. Provide appropriate comfort measures (i.e cool cloth to forehead).

7. If patient nauseated or has recently vomited, administer Phenergan 12.5 -

25.0 mg IVP or IM. Do not repeat more f requently than every 4 hours unless

ordered by medical control.

8. If patient complains of dizziness or motion sickness, consider administering

25 - 50 mg of Dimenhydrinate (Dramamine) IVP over 30 seconds.

9. Monitor ECG, vital signs, pulse oximetry, and level of consciousness.

MULTIPLE TRAUMA

SITUATIONAL GUIDELINES

1. The first paramedic on the scene will become the scene director and others

arriving later will follow his or her lead until a formal incident command

system (ICS) is in place.

2. Try to keep ambulance crews and equipment together to minimize confusion

when several ambulances are present at the scene.

3. Notify dispatch of the need for more help when the estimated number of

injured can be determined.

4. Note any hazards (chemical spills, downed power lines, etc.)

5. Begin rendering emergency care with airway being the first priority, followed

by oxygenation, and hemorrhage control.

6. Begin transporting severely injured, but salvageable, patients first. Dead and

hopelessly dying patients should not be transported until salvageablepatients are removed.

7. In airplane crashes, be sure to leave a marker noting the position of the

patient before removing them from the scene.

8. If more than 6 patients, use start triage system and declare a multiple

casualty incident (see MCI Protocol.)

9. The following are considered "load and go" situations:

a. Airway obstruction that cannot be relieved by mechanical methods

b. Conditions which result in inadequate respirations

c. Large open chest wounds (i.e. sucking chest wounds)

d. Large flail chest

e. Tension pneumothorax

f. Major blunt chest traumag. Traumatic cardiac arrest


14/22

h. Shock

i. Head injury with unconsciousness, unequal pupils, or deteriorating

neurological status.

j. Tender, distended abdomen

k. Bilateral femur fractures

l. Unstable pelvis

m. Development of respiratory difficulty

I f pat ient has u nstable v i ta l s igns:

10. If patient is severely injured, with systolic blood pressure 2 seconds:

a. Airway with cervical spine control

b. Breathing

c. Circulation/perfusion with hemorrhage control

d. Disability determination (AVPU, motor, posturing)

e. Exposure

11. Perform a rapid, abbreviated full-body assessment in order to identify any

major injuries.

12. If extrication required, perform quickly with spinal immobilization.

13. Place PASG and inflate if no contraindications.14. Transport.

15. Start 2 IVs of lactated Ringer's en route and run wide open.

16. Contact medical control en route.

I f the pat ient has stable v i ta l s igns

17. If the patient's systolic pressure is initially and continuously stable, without

significant signs or symptoms of shock, more time may be taken for field

assessment:

a. Airway with cervical spine control.

b. Breathing.

c. Circulation/perfusion with hemorrhage control.d. Disability determination (AVPU, motor, posturing).

e. Exposure.

18. Administer oxygen at 100% via non-rebreather mask.


20. Perform a rapid, full-body assessment in order to identify any major injuries.

21. If extrication required, perform with spinal immobilization.

22. Start an IV of lactated Ringer's en route at 150 ml/hour.

23. Complete splinting and packaging.

24. If head or spinal injury present, see Head Injury/Spinal Injury Protocol.

25. If pelvis or femur fractures present, see Fracture Protocols.

26. If chest trauma present, see Chest Trauma Protocol.

27. Transport.

NAUSEA AND VOMITING

1. Assure ABCs.

2. Oxygen via a nasal cannula at 2 liters per minute unless higher

concentrations warranted by patient condition.

3. Initiate IV of lactated Ringer's at 125 ml/hr.

4. Provide appropriate comfort measures (i.e cool cloth to forehead).

5. If patient nauseated or has recently vomited, administer Phenergan 12.5 -

25.0 mg IVP or IM. do not repeat more frequently than every 4 hours unless

ordered by medical control.

6. If patient actively vomiting, administer 5 - 10 mg of Compazine IVP or IM

(adult patients only)

7. Monitor ECG, vital signs, pulse oximetry, and level of consciousness.

8. Consider intubating patients with altered mental status who are vomiting.

9. Consider NG tube placement for patients with altered mental status and/or

inability to maintain their airway.

NEAR-DROWNING

1. Assure ABCs.

2. Immobilize cervical spine.



5. IV of lactated Ringer's TKO.

6. If apneic:

a. Initiate and maintain mechanical ventilation with 100% oxygen.

b. Endotracheal intubation (with in-line cervical immobilization.)

c. Treat any dysrhythmias per appropriate protocol.

d. Transport and contact medical control en route.

7. If apneic and pulseless:

a. Initiate and maintain mechanical ventilation with 100% oxygen.b. CPR.

c. Endotracheal intubation (with in-line cervical immobilization.)

d. Treat any dysrhythmias per appropriate protocol.

e. Transport and contact medical control en route.

8. If hypotensive:

a. Elevate legs.

b. Administer 250 ml fluid bolus (20 ml/kg for children). Repeat to

maintain systolic BP >90 mmhg. Consider starting a second IV of

lactated Ringer's if multiple boluses required.

c. Transport and contact medical control en route.

d. Initiate Dopamine drip if patient unresponsive to fluid challenge.

begin infusion at 2.0 g/kg/min and titrate to maintain systolic BP>90 mmhg.


15/22

9. Treat dysrhythmias per the appropriate protocol.

10. Consider NG tube at low suction.

11. Start passive re-warming if patient hypothermic.

12. Consider Mannitol 0.5 - 1.0 gram/kg for deteriorating neurological status.

13. Obtain glucometer and administer 25 grams d50w if glucometer


16/22

sulfate can cause respiratory depression with cardiovascular collapse.

Antidote is calcium chloride IV over 5 minutes.

11. Place NG tube if appropriate.


PRE-TERM LABOR

1. Assure ABCs.



4. Establish IV of lactated Ringer's at 125 ml/hr.

5. Consider fluid bolus as initial tocolytic therapy.

6. Position the patient in the left lateral recumbent position.

7. Record frequency, character and duration of contractions, fetal heart tones,

blood pressure, and pulse every 15 minutes.

8. Administer tocolytics as ordered.

9. Transport.

PSYCHIATRIC EMERGENCIES

1. Assure personal safety. Call police.

2. Approach patient only when safe to do so.

3. Talk in an even, reassuring tone.

4. Restrain if suicidal or homicidal or if patient has a life-threatening emergency

(with police assistance only.)

5. Perform primary assessment

6. Perform secondary assessment:

a. Look for medical or traumatic causes for the patient's behavior.

b. Note behavior.

c. Note mental status.

d. Obtain drug/alcohol/medical history/psychiatric history.7. Administer oxygen at 6-10 lpm (if COPD, give 2 lpm via nasal cannula.

8. IV lactated Ringer's TKO.


a. If glucose < 80 mg/dl, administer 25 gms 50% dextrose IV.


10. If history of alcoholism, or alcoholism suspected:

a. Administer Thiamine 100 mg IV or IM.

11. Transport (if restrained, have police accompany patient.)

12. Consider Haldol 2-5 mg IM for sedation.

PULMONARY EMBOLISM

1. Assure ABCs.

2. Oxygen via non-rebreather mask if no history of COPD. if history of COPD,

titrate oxygen delivery to maintain SPO2 > 90%. consider intubation and







b. Consider endotracheal intubation

c. Contact medical control

6. If history suspicious for pulmonary embolism:

a. Place in position of comfort (preferably with extremities lower than

level of heart)

b. Consider Morphine 2-5 mg IVP for pain. may repeat to a maximum

of 10 mg.

c. Consider Valium 2-5 mg IVP for anxiety

d. Transport.

SEIZURES

1. Assure ABCs.



4. If actively seizing, go to #7 below:

5. If not actively seizing:

a. Open airway and suction PRN.

b. Proceed with secondary survey.

c. Obtain history.

d. Apply cardiac monitor and pulse oximeter.6. Determine serum glucose level with Glucometer or DextroStix.

a. If glucose < 80 mg/dl, administer 25 gms 50% Dextrose IV.

7. If actively seizing:

a. Protect patient from injury.

b. Do not attempt to insert tongue blade or oral airway.

c. Suction prn.

d. Nasopharyngeal airway may be useful.

8. If seizures prolonged (>5 minutes):

a. Draw blood tube, if possible.

b. Administer Valium 2-5 mg IV (adults.)

c. Determine serum glucose level. If glucose < 80 mg/dl, administer

25 gms 50% dextrose IV.d. Transport and contact medical control en route.


17/22

9. If recent seizure, and patient is post-ictal:

a. Place in recovery position.

b. Suction prn.

c. Transport.

10. If patient is a child, and actively seizing:

a. Protect patient from injury.

b. Contact medical control.

c. Consider Valium as ordered by medical control.

d. Transport.

SEXUAL ASSAULT

1. Assure ABCs.

2. Reassure patient and provide emotional support.

3. Perform secondary survey.

4. Treat all injuries appropriately, preferably with a relative present.

5. Protect the scene and preserve evidence. Do not allow the patient to bathe,

change clothes, go to the bathroom, or douche.

6. Notify police if not already informed.

7. Transport to hospital which is equipped to perform sexual assault

examinations.

SYNCOPE

1. Assure ABCs.2. Oxygen via non-rebreather mask.3. Initiate IV of lactated Ringer's.4. Cardiac monitor. If dysrhythmia, go to appropriate protocol.5. Obtain vital signs. if BP


18/22

PEDIATRIC EMERGENCIES

1. Remember that children are not small adults. Treatments vary as do drug

dosages and fluid administration rates.

2. Cardiac arrest in children is not a sudden event. it is almost always due to a

respiratory problem which leads to hypoxia, bradycardia, and eventually

asystole. Ventricular fibrillation is a rare event in children. Initial treatment

should be directed at establishment of an airway, administration of

supplemental oxygen, and mechanical ventilation.3. EOAs, EGTAs, PTL airways, and esophageal combitubes should not be

used in children. the preferred method of airway management is

endotracheal intubation. Demand valves should not be used in children

because of the tendency to cause barotrauma.

4. The intraosseous route of fluid and medication administration is available in

children less than 6 years of age.

5. Blood pressure is a late sign of shock in children. Instead, you should

evaluate end-organ perfusion.

Anticipating Cardiopulmonary Arrest

1. All sick children should undergo a rapid cardiopulmonary assessment. Thegoal is to answer the question, "Does this child have pulmonary or

circulatory failure that may lead to cardiopulmonary arrest?" Recognition of

the physiologically unstable infant is made by physical examination alone.

Children who should receive the rapid cardiopulmonary assessment include

those with the following conditions.

a. respiratory rate greater than 60

b. heart rate greater than 180 or less than 80 (under 5 years)

c. heart rate greater than 180 or less than 60 (over 5 years)

d. respiratory distress

e. trauma

f. burns

g. cyanosis

h. altered level of consciousness

i. seizures

j. fever with petechiae (small skin hemorrhages)

Rapid Cardiopulmonary Assessment

The rapid cardiopulmonary assessment is designed to assist you in recognizing

respiratory failure and shock, thus anticipating cardiopulmonary arrest. the rapid

cardiopulmonary assessment follows the basic ABCs of CPR.

Airway Patency

Inspect the airway and ask yourself the following questions.

Is the airway patent?

Is it maintainable with head positioning, suctioning, or airway adjuncts?

Is the airway unmaintainable. if so, what action is required?

(endotracheal intubation, removal of a foreign body, and so on)

Breathing

Evaluation of breathing includes assessment of the following conditions.

1. Respiratory rate. Tachypnea is often the first manifestation of respiratory

distress in infants. An infant breathing at a rapid rate will eventually tire.

Thus, a decreasing respiratory rate is not necessarily a sign of improvement.

A slow respiratory rate in an acutely ill infant or child is an ominous sign.

2. Air entry. The quality of air entry can be assessed by observing for chest

rise, breath sounds, stridor, or wheezing.

3. Respiratory mechanics. Increased work of breathing in the infant and child

is evidenced by nasal flaring and use of the accessory respiratory muscles.

4. Color. Cyanosis is a fairly late sign of respiratory failure and is most

frequently seen in the mucous membranes of the mouth and the nail beds.

Cyanosis of the extremities alone is more likely due to circulatory failure

(shock) than respiratory failure.

Circulation

The cardiovascular assessment consists of the following procedures.

1. Heart rate. Infants develop sinus tachycardia in response to stress. Thus,

any tachycardia in an infant or child requires further evaluation to determine

the cause. Bradycardia in a distressed infant or child may indicate hypoxia

and is an ominous sign of impending cardiac arrest.

2. Blood pressure. Hypotension is a late and often sudden sign of

cardiovascular decompensation. even mild hypotension should be taken

seriously and treated quickly and vigorously, since cardiopulmonary arrest is

imminent.

3. Peripheral circulation. The presence of pulses is a good indicator of the

adequacy of end-organ perfusion. The pulse pressure ( the difference

between the systolic and diastolic blood pressure) narrows as shock

develops. Loss of central pulses is an ominous sign.


19/22

4. End-organ perfusion. The end-organ perfusion is most evident in the skin,

kidneys, and brain. Decreased perfusion of the skin is an early sign of shock.

A capillary refill time of greater than 2 seconds is indicative of low cardiac

output. Impairment of brain perfusion is usually evidenced by a change in

mental status. The child may become confused or lethargic. seizures may

occur. Failure of the child to recognize the parents' faces is often an ominous

sign. Urine output is directly related to kidney perfusion. Normal urine output

is 1-2 ml/kg/hr. urine flow of less than 1 ml/kg/hr is an indicator of poor renal

perfusion.

The rapid cardiopulmonary assessment should be repeated throughout initial

assessment and patient transport. This will help you determine whether the patient's

condition is deteriorating or improving. Any decompensation or change in the patient's

status should be immediately treated.

PEDIATRIC EMERGENCIES:

CARDIAC ARREST (medical)

1. Determine pulselessness and begin CPR.

2. Confirm cardiac rhythm in more than 1 lead.

3. If asystole:

a. Continue CPR

b. Secure airway

c. Hyperventilate with 100% oxygen

d. Obtain IV or IO access.

e. Epinephrine (first dose)

i. IV or IO: 0.01 mg/kg of 1:10,000 solution.

ii. ET: 0.1 mg/kg of 1:1,000 solution.

f. Epinephrine (second and subsequent doses)

i. IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution: repeat every

3-5 minutes.

g. Transport as soon as possible continuing resuscitation en route.

4. If pulseless electrical activity:

a. Identify and treat causes including hypoxemia, acidosis,

hypovolemia, tension pneumothorax, cardiac tamponade, or

profound hypothermia.

b. Continue CPR.

c. Secure airway.

d. Hyperventilate with 100% oxygen.

e. obtain IV or IO access.f. Epinephrine (first dose)

g. IV or IO: 0.01 mg/kg of 1:10,000 solution.

h. ET: 0.1 mg/kg of 1:1,000 solution.

i. Epinephrine (second and subsequent doses)

j. IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution; repeat every 3-5

minutes.

k. Transport as soon as possible continuing resuscitation en route.

5. if ventricular fibrillation/pulseless ventricular tachycardia:

a. Continue CPR.

b. Secure airway.

c. Hyperventilate with 100% oxygen.

d. Obtain IV or IO access.

e. Defibrillate up to 3 times (2 j/kg, 4 j/kg, and 4 j/kg).

f. Epinephrine (first dose)

i. IV or IO: 0.01 mg/kg of 1:10,000 solution.

ii. ET: 0.1 mg/kg of 1:1,000 solution

g. Lidocaine 1 mg/kg IV, IO, or ET.

h. Defibrillate at 4 j/kg 30-60 seconds after medication.

i. Epinephrine (second and subsequent doses)

i. IV, IO, or ET: 0.1 mg/kg of 1:1,000 solution; repeat every

3-5 minutes.

j. Defibrillate at 4 j/kg 30-60 seconds after medication.k. Lidocaine 1 mg/kg up to total dose of 3 mg/kg.

l. Transport as soon as possible continuing resuscitation en route.

CARDIAC ARREST (trauma)

1. If patient is severely injured, and in cardiac arrest:

a. Airway with cervical spine control.

b. Breathing.

c. Circulation/perfusion with hemorrhage control.

d. Disability determination (AVPU, motor, posturing).e. Exposure

2. If extrication required, perform quickly with spinal immobilization.

3. Perform endotracheal intubation with in-line stabilization of cervical spine.

4. Transport immediately and attempt IV or IO en route. give 20 ml/kg fluid

boluses of lactated Ringer's.

5. Contact medical control en route

6. Consider correctable causes:

a. Severe hypoxemia

b. Cardiac tamponade

c. Tension pneumothorax

d. Severe acidosis


20/22

CROUP (LARYNGOTRACHEOBRONCHITIS)

1. Assure ABCs.

2. Administer humidified oxygen via non-rebreather mask.

3. Have equipment ready for endotracheal intubation.

4. Place in position of comfort.

5. Pulse oximetry and cardiac monitor.

6. Defer starting an IV if possible.

7. Contact medical control.

8. Consider Ventolin nebulizer or racemic Epinephrine treatment as ordered by

medical control.

9. Transport. If child to be transported without intubation, have BVM and airway

equipment at the head of the bed. endotracheal intubation equipment should

be open and prepared for immediate use if required.

10. Contact medical control for any questions or problems

11. Severe respiratory distress despite the above measures requires intubation.

Consider intubating with a tube one full size smaller than would normally be

used. Use an uncuffed tube.

12. Consider inserting an NG tube for gastric decompression if intubated.

13. If necessary, restrain the child to protect the ET tube. Agitation may be

treated with Valium 0.1 - 0.3 mg/kg IV (with a maximum dose of 5.0 mg)

Do not examine pharynx as this may cause laryngospasm in cases of epiglottitis.

EPIGLOTTITIS

1. Assure ABCs.

2. Administer humidified oxygen via non-rebreather mask

3. Have equipment ready for endotracheal intubation

4. Place in position of comfort

5. Pulse oximetry and cardiac monitor

6. Defer starting IV if possible

7. Contact medical control

8. Transport. If child to be transported without intubation, have BVM and airway

equipment at the head of the bed. Intubation equipment should be open and

prepared for immediate use if required.

9. Contact medical control for any questions or problems

10. Severe respiratory distress despite the above measures requires intubation.

Consider intubating with a tube one full size smaller than would normally be

used. Use an uncuffed tube.

11. Consider inserting an NG tube for gastric decompression if intubated.

12. If necessary, restrain the child to protect the ET tube. agitation may be

treated with Valium 0.1 - 0.3 mg/kg IV (with a maximum dose of 5 .0 mg)

Do not examine pharynx as this may cause laryngospasm in cases of epiglottitis.

SUDDEN INFANT DEATH SYNDROME (SIDS)

1. Start CPR unless obvious rigor mortis, severe lividity, or early tissue

breakdown.

2. Note the condition of the child and the surroundings in which the child was

found.

3. Obtain a brief medical history from the parents or guardians.

4. Use extreme tact and professionalism.

5. Transport.

6. See Pediatric Cardiac Arrest (medical) Protocol.

7. Contact medical control en route.


21/22

GENERAL GUIDELINES FOR PROTOCOL USAGE

1. The patient history should not be obtained at the expense of the patient.

Life-threatening problems detected during the primary assessment must be

treated first.

2. Cardiac arrest due to trauma is not treated by medical cardiac arrest

protocols. Trauma patients should be transported promptly with CPR, control

of external hemorrhage, cervical spine immobilization, and other indicated

procedures attempted en route.

3. In patients with non-life-threatening emergencies who require IVs, only two

attempts at IV insertion should be attempted in the field. Further attempts

must be approved by medical control.

4. Patient transport, or other needed treatments, must not be delayed for

multiple attempts at endotracheal intubation.

5. Verbally repeat all orders received prior to their initiation.

6. Any patient with a cardiac history, irregular pulse, unstable blood pressure,

dyspnea, or chest pain should be placed on a cardiac monitor.

7. If the patient's condition does not seem to fit a protocol or protocols, always

contact medical control.

NEVER HESITATE TO CONTACT MEDCIAL CONTROL FOR ANY PROBLEM,

QUESTION, OR FOR ADDITIONAL INFORMATION.

SPECIAL CONSIDERATIONS

IV Therapy

1. All trauma patients should receive at least one, and preferably two, IV's of

lactated Ringer's via large bore (14 or 16 gauge) catheters. Trauma patients

with a systolic blood pressure 90 mmHg. Trauma patients with a

systolic blood pressure >90 mmHg should receive fluids at a "to keep open(TKO)" rate or as directed in the applicable protocol.

2. Intraosseous infusion may be performed on pediatric patients up to six years

of age. This procedure should be limited to cardiac arrest and unresponsive

patients after 2 unsuccessful peripheral IV attempts.

3. All pediatric peripheral IVs should be started with a minidrip administration

set.

4. All IV attempts are to be peripheral. The external jugular vein is considered a

peripheral vein. Placement of an intraosseous needle is permitted in children

less than 6 years of age who have a life-threatening emergency where

immediate fluid or medication administration is necessary. Only paramedics

who have obtained the required education in intraosseous needle placement

and who have been approved by the system medical director may place

intraosseous needles. Persons who are designated "Critical Care Transport

Technicians" may place intraosseous needles. This procedure should only

be performed with permission of medical control (except in the case of

pediatric cardiac arrest or pediatric multiple trauma.)

5. Access of indwelling central lines (i.e Hickman Catheters) is permitted only

in patients where peripheral IV attempts have been unsuccessful and the

needs of intended therapy outweigh the risks. Note, many of these catheters

require special access needles. Do not attempt access if special needles are

required unless the patient has access needles available.

6. Each IV bag should be labeled with the following data:

a. Time and date of IV start

b. IV cannula size

c. Initials of paramedic who started the IV.

Endotracheal Intubation

1. Proper endotracheal tube placement must be documented by at least three

different methods. These include:

a. presence of bilateral breath sounds

b. absence of breath sounds over the epigastrium

c. presence of condensation on the inside of the endotracheal tube

d. end-tidal carbon dioxide monitoring

e. use of an endotracheal esophageal detector

f. visualizing the tube passing through the cords

All three verification methods must be documented in the medical record!!

2. Following endotracheal intubation, tube placement should be re-verified

every 5-10 minutes by noting bilateral breath sounds and continuing end-

tidal carbon dioxide readings.

Endotracheal Drug Administration

Only the following four drugs can be administered via an endotracheal tube:

L - Lidocaine

E - Epinephrine

A - Atropine Sulfate

N - NaloxoneNote: Diazepam (Valium) should NOT be administered via an endotracheal tube.

When administering drugs via the endotracheal tube, administer 2.0 - 2.5 times the

IV dose. Also, dilute the drug in enough lactated Ringer's or normal saline to result in

a total volume of at least 10 mL. This will facilitate endotracheal instillation and aid in

increased drug delivery to the respiratory tissues.


22/22

RESUSCITATION CONSIDERATIONS

1. Do Not Resuscitate (DNR) orders should be honored when valid. If a

patient's family presents you with a DNR order written by the patient's

physician, the following procedures should be followed:

a. Contact medical control

b. Provide a brief synopsis of the situation. Be sure to include the

diagnosis which resulted in the DNR order (i.e. cancer).

c. Provide a brief report the patient's current status (vital signs, ECG

tracing)

d. Confirm receipt of written DNR. Be sure to note issuing physician's

name.

e. The medical control physician will determine whether to accept or

deny the DNR order.

f. If the patient is in cardiac arrest upon EMS arrival, initiate BLS

while contacting medical control.

2. Resuscitation should not be attempted in the field in cases of:

a. Rigor mortis

b. Decapitation

c. Decomposition

d. Dependent lividity.e. Obvious massive head or trunk trauma which is incompatible with

life (provided the patient does not have vital signs.)

3. Consider the potential for organ donation. Patients who have sustained

mortal injuries may still warrant emergent care until a determination can be

made whether the patient may be a potential organ or tissue donor.

4. When possible, place the quick look paddles or the ECG leads to confirm

asystole or an agonal rhythm and attach a copy of the strip to the run report.

Orders From Transferring/Receiving Physicians

During interhospital transport, medical crews will be asked to continue treatment

initiated at the transferring hospital. These orders may be written or verbal. Verbal

orders must be written by the medical crew and attached to the record. Ideally, the

transferring physician should sign these orders. If, at any time the Critical Care

Transport Crew questions orders from a referring or receiving physician, on-line

medical control MUST be contacted. Likewise, anytime a transferring or receiving

physician asks the Critical Care Transport crew to carry out medical treatment for

which they have not been trained, or which appears to be in conflict with established

treatment protocols, on-line medical control MUST be contacted before initiating care.

Date post:	14-Apr-2018
Category:	Documents
Upload:	jenny-vi-codeniera
View:	219 times
Download:	0 times

Guidelines for Care

Documents