• Non-application rules
• Age ≥12
• Normal mental status
• No signs of intoxication
• GCS 15 & A & O x 4
• No acute stress reaction
• No distracting injuries
• No communication barriers (deafness, language, etc.)
• No neurological deficit
• No mid-line spine pain/tenderness on palpation of spinous processes

• Monitor and maintain SpO2 >90%
• If breathing is adequate, high flow O2 by NRB mask
• Do not hyperventilate, EXCEPT for a) Fixed or asymmetric pupils; b) abnormal extension; c) GCS <9 with a further decrease of 2 or more points
• Advanced airway management when needed

• Stabilize impaled objects in place and cover both eyes
• Cover puncture wound with protective devices over both eyes
• Irrigate chemicals or non-penetrating foreign matter from eye with copious amounts of water or normal saline
• Instill Proparacaine into affected eye and repeat every 5 minutes as needed
• Dental avulsions should be placed in an obviously labeled container with saline or cell-culture medium

• Scene safety; remove patient from burn source, including clothing
• Maintain airway and administer oxygen
• In burns over 10% BSA, use dry dressings and insulate patient to prevent hypothermia
• In burns under 10% BSA, use moist dressings
• Initiate IV fluids 0.9% NaCl or Lactated Ringers

• Be sure the scene is safe
• Absorbed poison: Remove clothing and fully decontaminate. If eye(s) involved, irrigate ≥20 minutes
• Inhaled/ingested poison: Administer high-flow O2. Pulse oximetry may be inaccurate
• Ingested poison:
  Contact Poison Control
  Review circumstances with Medical Control and Poison Control
• Envenomations: Immobilize extremity in dependent position; consider ice pack for bee stings

• Obtain glucose reading via glucometer
• Administer high concentration oxygen, and be prepared to assist ventilations if necessary
• Assess patient with Cincinnati Stroke Scale
  • Facial droop (big smile)
  • Pronator drift (extend arms, palms up, eyes closed: one arm drift = positive; both = unclear)
  • Speech (“The sky is blue in Cincinnati”)
• Assess and record the exact time the patient was last known to be normal
• Encourage a family member to be transported with patient
• Keep patient warm; maintain normal body temperature
• Protect any paralyzed or partially paralyzed extremity
• Obtain a 12-lead EKG
• Pre-notify destination Emergency Department as early as possible
• Consider transport to JCAHO-approved stroke center if onset of symptoms to definitive treatment can be within 3 hours (generally within two hours of symptoms to arrival at facility)
• Transport to closest hospital if: a) cardiac arrest; b) unmanageable airway; or c) other medical condition that warrants transport to the closest hospital per protocol
• Per local protocol, initiate fibrinolytic screening and document findings on Stroke checklist

Updated to 2017 KBEMS Protocol

• If generalized seizure activity is present, consider:
• Lorazepam 1-2 mg IV or IM repeated every 5 min to a total of 4 mg

OR

• Diazepam 5 mg IV(then 2.5 mg every 5 minutes to a total of 10 mg
• Midazolam 1-2.5 mg IV/IM/IO repeated every 5 minutes to a total of 5 mg or until seizures are abolished
• Consider Magnesium Sulfate 4 grams IV over 5 minutes in presence of seizure in 3rd trimester of pregnancy

• Systolic BP >90 mmHg, no altered level of mental status, multi-system trauma, or abdominal pain
• Ketorolac 15 mg IVP or 30 mg IM (no repeat); avoid in patients likely to go to OR, NSAID allergy, aspirin sensitive asthma, known peptic ulcer disease, pregnant, or nursing
• Morphine 1-5 mg IV/IM every 10 min, max total 15 mg, titrated to pain and SBP >90 mmHg
• Fentanyl 25-50 mcg slow IV every 5 min, max total 150 mcg
• For hypoventilation from opiate administration by EMS, Naloxone 0.4 mg IV prn

• Assist with normal delivery
• If cord is prolapsed, relieve pressure on cord, elevate hips, keep cord moist, transport
• If buttocks presents first, give oxygen and attempt to open path in birth canal to infant’s mouth w/ sterile gloved fingers.

Transport immediately!

• If massive bleeding or newborn distress, proceed to nearest appropriate hospital

• Proclorperazine 2.5 mg IV or 5 mg IM

OR

• Promethazine (Phenergan) 6.25 mg IV diluted in 10 ml of 0.9% NaCl, which is administered over 2 mins via the furthest port from the vein
• May repeat either medication x1 in 10 mins if symptoms persist
• Ondanestron ((Zofran) 4 mg IV administered over 30 seconds.
• May repeat dose x1 in 30 minutes
• For dystonic reactions caused by EMS administration of prochlorperazine or promethazine administer diphenhydramine 50 mg IV/IM