Tools
Protocol Flow Diagrams
The core EMT decision sequences, one diagram at a time.
Primary Assessment Sequence
Scene size-up: BSI, scene safety, MOI/NOI, number of patients
↓
Form general impression (age, sex, distress level, obvious life threats)
↓
Level of consciousness — AVPU: Alert, responds to Verbal, responds to Painful, Unresponsive
↓
Trauma with life-threatening external bleeding?
Yes — spurting or pooling
Control it first: tourniquet for a life-threatening extremity bleed, pressure or packing otherwise
↓ then airway
No
Go straight to the airway
↓ continue
Catastrophic bleeding comes before the airway in trauma — the X in X-ABC. A patient can exsanguinate from a femoral artery faster than an obstructed airway will kill them. For a medical patient, the airway is still first.
Airway patent?
No
Open airway (manual maneuver, suction, adjunct as needed)
↓ then breathing
Yes
Proceed to breathing
↓ continue
Breathing adequate? (rate, depth, effort)
No
Assist ventilations, high-flow oxygen
↓ then circulation
Yes
Proceed to circulation
↓ continue
Circulation: pulse, remaining bleeding, skin signs
Bleeding still uncontrolled
Escalate: packing, hemostatic dressing, or tourniquet
↓ then priority
Perfusion adequate
Proceed to the priority decision
↓ continue
Significant MOI, unstable finding, or altered mental status?
Yes
Rapid head-to-toe exam, high transport priority
↓ reassess
No
Focused exam on the chief complaint, then history and vitals
↓ reassess
Ongoing reassessment — every 5 minutes if unstable, every 15 if stable
Adult & Child Foreign Body Airway Obstruction (1 year and over)
Signs of choking — can the patient cough, speak or cry?
Yes — mild / partial
Encourage forceful coughing. Do not do anything else. Stay with them and watch for it becoming severe
No — severe / complete
5 back blows between the shoulder blades, then 5 abdominal thrusts — repeat the cycle
↓ continue
A cough moves more air than any thrust you can deliver. Intervening on a patient who is still coughing effectively can turn a partial obstruction into a complete one.
2025 AHA change. Back blows now come first, for adults as well as children — this used to be abdominal thrusts alone. In a cohort of 709 choking patients, back blows relieved more obstructions, with fewer injuries, than thrusts. If you cannot get your arms around the abdomen — late pregnancy, or significant obesity — give 5 chest thrusts in place of the abdominal thrusts.
Result of the cycle?
Object expelled
Reassess airway and breathing, monitor, transport for evaluation
Patient becomes unresponsive
Lower to the ground and begin CPR — look in the mouth before each set of breaths and remove an object only if you can see it
Infant Foreign Body Airway Obstruction (under 1 year)
Infant choking — can they cry, cough or make any sound?
Yes — mild / partial
Let them cough. Do not intervene. Keep them calm and watch closely
No — severe / complete
5 back blows between the shoulder blades, head lower than the chest
↓ continue
No abdominal thrusts under 1 year. An infant’s liver is large for the abdomen and extends below the rib margin, where the ribs do not protect it, so abdominal thrusts can tear it.
2025 AHA change. The chest thrusts are delivered with the heel of one hand, not two fingers. Two fingers did not reliably reach the depth needed, and the technique was dropped for infant compressions as well.
Turn the infant over, 5 chest thrusts — heel of one hand on the lower sternum
↓
Object out?
No, still responsive
Repeat 5 back blows and 5 chest thrusts until it clears or the infant goes unresponsive
Infant becomes unresponsive
Begin CPR — look in the mouth before each set of breaths, and remove an object only if you can see it. Never sweep blindly
Anaphylaxis Recognition & Management
Allergic reaction after a likely exposure — is it anaphylaxis?
Anaphylaxis needs more than one body system, or hypotension after a known allergen. Skin findings alone — hives, flushing, itching — are an allergic reaction, not anaphylaxis, however dramatic they look.
Skin only — hives, itching, flushing
Allergic reaction, not anaphylaxis. Supportive care, transport, and reassess often — it can progress
Skin plus airway, breathing or circulation — or hypotension alone after a known allergen
Anaphylaxis: stridor, hoarseness, tongue or throat swelling, wheeze, vomiting, dizziness, hypotension
↓ treat now
Epinephrine into the lateral thigh — the patient’s own auto-injector or your own supply, per standing orders or medical direction
↓
Call for ALS and start moving to the ambulance now — do not wait to see whether it works
↓
High-flow oxygen, supine with legs raised if hypotensive, sitting up if breathing is the problem
↓
Improving?
No, after about 5 minutes
Repeat epinephrine per protocol, continue support, transport emergency traffic
Yes
Keep transporting and keep watching — a biphasic reaction can return hours later, so this patient goes to hospital regardless
Stroke Assessment & Transport Decision
Sudden neurological symptoms — perform a stroke screen (BE-FAST or Cincinnati)
↓
Screen positive? (balance, eyes, facial droop, arm drift, speech)
No, but suspicion remains
Transport and monitor anyway — symptoms evolve, and a negative screen does not rule it out
↓ still check glucose
Yes
Establish the time last known well — this decides what treatment is still possible
↓ continue
Check blood glucose — result?
Low
Can the patient swallow safely and protect their own airway?
↓ see below
High
Treat as a stroke and transport. Hyperglycemia can mimic a stroke and worsens its outcome, but there is nothing an EMT gives for it in the field
Normal
Treat as a stroke — high-priority transport to a stroke-capable facility, minimal scene time, alert the hospital with the last-known-well time
Swallows safely
Oral glucose, then reassess — hypoglycemia is the classic stroke mimic and may resolve the findings entirely
Cannot swallow safely
Nothing by mouth. Protect the airway, request ALS for IV dextrose or IM glucagon, and transport
Spinal Motion Restriction Decision
After the 2018 joint position statement of ACEP, the ACS Committee on Trauma and NAEMSP. Your protocol decides the details.
Blunt trauma with a mechanism that could involve the spine
↓
Can the patient give a reliable exam? Not if any of: altered mental status (GCS below 15) or intoxication; a distracting injury or circumstance (long-bone fracture, degloving or crush injury, large burn, emotional distress); a communication barrier (language, age, developmental level, hearing)
No
Spinal motion restriction indicated
Yes
Assess the spine directly
↓ continue
Midline neck or back pain or tenderness, or a deformity of the spine?
Present
Spinal motion restriction indicated
Absent
Check the extremities
↓ continue
Focal neurologic signs or symptoms: numbness, tingling or weakness?
Present
Spinal motion restriction indicated
Absent
Spinal motion restriction generally not required — continue monitoring
Age 65 and over: older adults break their necks from smaller forces, often a ground-level fall, and many protocols (and the Canadian C-Spine Rule) treat age 65+ as high risk even with a normal exam. Keep a lower threshold and follow yours.
Penetrating trauma: restrict motion only when there is a new neurologic deficit; it should never delay transport. What restriction means: a cervical collar and keeping the patient still on the stretcher. A long board is an extrication tool, not a transport device.
Adult BLS / CPR Sequence (no advanced airway)
Scene safe, BSI taken
↓
Check responsiveness
↓
Check breathing & pulse together (≤10 sec)
No pulse
Begin CPR
30:2, 100–120/min, 2–2.4 in. deep, full recoil
↓ continue
Pulse, not breathing
Rescue breaths, 1 every 6 seconds. Recheck the pulse every 2 minutes — start CPR if it is lost
Attach the AED as soon as it arrives, analyze, shock if advised
↓
Resume compressions immediately after the shock, or immediately if no shock is advised
↓
Switch compressors every 2 minutes, at the AED’s rhythm check
↓
Continue until ROSC, handoff to higher care, or you are physically unable to continue
The AED prompting a re-analysis is a pause in the cycle, not a reason to stop resuscitating. Every two minutes it asks you to stand clear, it analyzes, and compressions resume either way.
Shock Recognition & General Management
Assess perfusion: skin color, temperature and moisture; pulse rate and quality; mental status; cap refill
↓
Treat the cause you can treat — control severe bleeding first of all
↓
Oxygen titrated to 94–98%, keep the patient warm, supine unless injuries dictate otherwise
↓
Compensated or decompensated?
Compensated — tachycardic, anxious, still mentating, BP holding
Prompt transport. Reassess vitals every 5 minutes: the blood pressure holds until it suddenly does not, and catching that moment is the whole point of reassessing
Decompensated — hypotensive, altered, weak or absent peripheral pulses
Load and go. Request ALS intercept, assist ventilation if breathing is inadequate, and do the rest of the assessment en route
The management above the fork is the same either way, which is why it sits above the fork. What changes is urgency: a decompensated patient has already spent the reserve the compensated one is still using.
START Triage (adult, multi-casualty incident)
Can the patient walk?
Yes
MINOR (green) — direct them to the treatment area
No
Assess breathing
↓ continue
Breathing?
No — reposition the airway once
Breathing now?
↓ see below
Yes
Respiratory rate over 30?
↓ see below
Still not breathing after repositioning
DECEASED (black)
Breathing only after repositioning
IMMEDIATE (red)
Rate over 30
IMMEDIATE (red)
Rate 30 or under — check perfusion: radial pulse present, or cap refill under 2 seconds?
No radial pulse, or refill over 2 seconds
IMMEDIATE (red)
Perfusion adequate
Can they follow simple commands?
↓ see below
START has four categories: Minor, Delayed, Immediate and Deceased. There is no Expectant tag in START — that belongs to SALT, below. Under START a patient who is breathing is never tagged black.
SALT Triage
SALT — Sort, Assess, Lifesaving interventions, Treatment/Transport — is the other system taught nationally, and the one that has an Expectant category. It differs from START in two ways that matter: it sorts by voice command before touching anyone, and it allows a handful of interventions during triage rather than after it.
STEP 1 — SORT, by voice, from where you stand
Walks when asked
Assess third
↓ to step 2
Waves or makes a purposeful movement
Assess second
↓ to step 2
Still, or has an obvious life threat
Assess first
↓ to step 2
STEP 2 — LIFESAVING INTERVENTIONS, done now, during triage: control major hemorrhage; open the airway (two rescue breaths for a child); chest decompression and auto-injector antidotes where in scope
↓
STEP 3 — ASSESS and assign
Not breathing after the airway is opened
DEAD
Injuries incompatible with survival given the resources you actually have
EXPECTANT — reassess if resources improve
Obeys commands, has a peripheral pulse, not in respiratory distress, major bleeding controlled — but injuries are not minor
DELAYED
Any of those missing
IMMEDIATE
Injuries are minor
MINIMAL
Expectant is not a synonym for dead, and it is not permanent. It means this patient cannot be saved with what is on scene right now — and if more crews arrive, the category is meant to be revisited.