Protocols

Facilitate appropriate initial assessment and management of any EMS patient as required by EMTALA and link to appropriate specific guidelines as dictated by the findings within the Universal Care guideline.

Definition of a patient

A patient is anyone:

-with a complaint which suggests potential for medical, traumatic, or psychiatric illness, who requests or whom another individual in direct contact with them requests evaluation for such a complaint on their behalf,

-with obvious evidence of medical, traumatic, or psychiatric illness, who has experienced an acute event that could reasonably lead to medical, traumatic, or psychiatric illness,

-in a circumstance that could reasonably lead to medical, traumatic, or psychiatric illness.

This definition is to be applied in the broadest sense. If there is any question, the individual should be considered a patient and treated accordingly. Medical assist (i.e. fall out of wheelchair, etc) are considered patients.

Assessment

Pediatric Pearls:

Signs & Symptoms:

Differential:

Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Always start with

uninjured areas first to build trust

Location
Onset
Precipitating Event(s)
Quality
Radiation
Severity
Time/Duration
Aggravating/Alleviating
Associated Symptoms
Prior history of same/similar

Vascular
Infectious/Inflammatory
Trauma/Toxins
Autoimmune
Metabolic
Idiopathic
Neoplastic
Congenital

Never lie to a child

Clinical Management Options

EMT-B

Demonstrate professionalism and courtesy; Scene/Crew Safety/PPE; with appropriate equipment and medications to the patient side
Use closed looped communication and crew resource management with all on scene providers
Perform an initial assessment and physical exam
Obtain a full set of vital signs: Mental status, BP, pulse rate, respiratory rate, and body temperature
Obtain blood glucose level as appropriate
Orthostatic vital signs if appropriate for patient condition
Oxygen as needed to maintain SpO2 92 – 96% or as indicated by signs of hypoxia
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations
Identify need for ALS transportation or rapid transportation for critically ill patients and time critical diagnosis

Paramedic

IV / IO access as appropriate for patient condition
Medication administration as indicated
Advanced airway management as indicated
Place and monitor EtCO2 as indicated
Acquisition and interpretation of 12 lead ECG and/or 4 lead ECG

Consult Online Medical Control as Needed

Rules

Medical Control should be contacted in the following order:
- WashU EMS line
- Receiving Hospital
- Barnes Hospital
Try to state the question first in a med control phone call. It can set up the conversation to be more successful
- Ie. I’m calling for a medication request vs. I’m calling for advice
Use feedback communication both in medical control requests and on scene.
Refer to drug formulary charts for all medication dosing for both adults and pediatric patients.
Minimum exam for all patients includes vital signs, mental status including GCS, location of injury or complaint, and pain scale.
Maintain all appropriate medications and procedures that have been initiated at the referral agency or institution.
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‌Patient Refusals
Patient Care Goals
Ensure that the patient has full understanding of the risks and benefits of refusing transport and to document that the patient’s understanding/capacity. Competency is generally a legal status of a person’s ability to make decisions.
Clinical Management Options
EMT-B

Paramedic
- Demonstrate professionalism and courtesy; Scene/Crew Safety/PPE; with appropriate equipment and medications to the patient side
- Use closed loop communication and crew resource management with all on scene providers
- Perform an initial assessment and physical exam
- Obtain vital signs: BP, pulse rate, and respiratory rate
- Obtain blood glucose level as appropriate
- 12 lead/4 lead acquisition as appropriate
- Oxygen as needed to maintain SpO2 92 – 96% or as indicated by signs of hypoxia
- Perform medication cross check for all medication administrations
- Identify need for ALS transportation or rapid transportation for critically ill patients and time critical diagnosis
- IV / IO access as appropriate for patient condition
- Medication administration as indicated
- Advanced airway management as indicated
- Place and monitor EtCO2 as indicated
- Acquisition and interpretation of 12 lead ECG and/or 4 lead ECG
- Complete Refusal and Capacity Checklists
Consult Online Medical Control as Needed
Pearls
BLS can write a refusal after an ALS assessment. Work with your ALS partners to discuss risks and benefits and document these in our chart.
Lift assists require a refusal. Most lift assists are because the patient fell or are now too weak to move. Evaluate and document evidence of injury if patients fell. Evaluate and document patients for causes of weakness if the patient cannot get out of a chair/bed (especially if the patient can typically get up/walk).
AOx4 does not mean the patient has capacity. Many intoxicated patients can state the name and year but do not fully understand the risks of refusals. Documentation of the patient’s reasoning is essential to prove the patient’s capacity.
Pediatric patients cannot consent for transport (or refuse if there is a concern for injury). It is critical that the guardian be contacted. If the guardian cannot be reached, contact medical control to discuss the case.
Document why the patient is refusing transport.
Document if family is present, record their names in the chart as well.
Document the patient’s plan of care (ie. Going to the doctor tomorrow, self-transport, etc.)
If a patient refuses vital signs, medical control should be contacted to discuss the case. It is important to document any vital signs you can observe (respiratory rate, skin signs, mental status).
Medical Translators should be used if the patient does not speak English.

Contact Medical Control for high-risk refusals or if they do not meet the checklist below; it will reduce your own liability and risk

Adult Refusal of Care and/or Treatment Checklist

Patient is not suicidal or homicidal
Patient demonstrates capacity based on capacity checklist
Patient is informed and understands evaluation is incomplete
Solutions to obstacles have been sought
Patient instructed to seek medical attention
Patient instructed to call back at any time
Above documented fully in ePCR

Pediatric Refusal of Care and/or Treatment Checklist

Vital signs are normal for age; must be documented
Patient has normal mental status for age
Patient is not suicidal or homicidal
No obvious injury or distress
Parent/Guardian has capacity, understands the risks of refusal
Parent/Guardian has the ability to care for the patient at home (has meds for child, etc)
No concern for abuse in the home
Patient instructed to call back at any time
Above documented fully in ePCR
Medical control has been contacted

Capacity Checklist

Patient is able to express in their own words:

 An understanding of the nature of their illness, and

 An understanding of the risks of refusal including death, and

 An understanding of alternatives to EMS treatment and/or transport, and

 Provide rationale for refusal and debate this rationale.

A patient with any of the following MAY lack decision-making capacity and should be carefully assessed for their ability to perform the above. These are considered high-risk refusals. All high- risk refusals must be discussed with medical control.

If any question exists about their capacity, then contact

Medical Control.

Orientation to person, place, or time that differs from baseline;
History of drug and/or alcohol ingestion with appreciable impairment such as slurred speech or unsteady gait;
Head injury with positive loss of consciousness, amnesia, repetitive questioning;
Medical condition such as hypovolemia, hypoxia, metabolic emergencies (eg. diabetic episode), hypothermia, hyperthermia, etc.;

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‌Abdominal Pain

Patient Care Goals

Identify life-threatening causes of abdominal pain and improve patient comfort.

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:

DKA often presents with abdominal pain, nausea, and vomiting.
Intussusception (episodic pain episodes)
Appendicitis
Consider necrotizing enterocolitis or volvulus in an infant
Bilious vomiting in babies is bad

Pain
Nausea
Vomiting
Diarrhea
Dysuria
Constipation
Vaginal bleeding / discharge
Pregnancy
Fever
Abdominal distension

Pneumonia or P.E.
Cholecystitis
Hepatitis or Pancreatitis
Gastroenteritis
Peptic Ulcer Disease
Myocardial Infarction or CHF
Kidney Stone
Aortic Aneurysms (AAA)
Appendicitis
Bladder/Prostate Disorder/infection
Pelvic – Pregnancy, Ectopic, STI, PID, Ovarian Cyst, Ovarian torsion
Diverticulitis
Bowel Obstruction
Testicular torsion

Clinical Management Options

EMT-B

Paramedic

Place in position of comfort
Keep the patient NPO
Oxygen target SpO2 92% – 96%
Have the patients sniff alcohol swabs as needed for nausea
12 lead/4 lead acquisition as appropriate
Perform medication cross check for all medication administrations

IV / IO access as appropriate for patient condition
IV fluid with Isotonic Crystalloid as needed for dehydration.
Pain Management as needed (Pain Management) with morphine, fentanyl, droperidol, or ketamine
- Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
- Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
- Droperidol 2.5mg IV/IM (adults only)
- Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Antiemetics as needed (Nausea and Vomiting) with ondansetron or droperidol
- Ondansetron
  - Adult 4mg PO/IV/IM
  - Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
- Droperidol 2.5mg IV/IM adults only
Consider 12 lead ECG and/or 4 lead ECG acquisition and interpretation

Contact Medical Control as needed

Pearls

Using a stethoscope to listen to the abdomen in all quadrants with gentle pressure may allow you to examen the abdomen in patients who are anxious about the exam.
Consider cardiac causes of epigastric abdominal pain in patients older than 40 years old.
Abdominal pain in women of childbearing age should be suspected pregnant until proven otherwise.
Abdominal pain and hypotension in women of childbearing age should suspect ruptured ectopic pregnancy until proven otherwise.
Consider testicular pathology in males as testicular injury can present as abdominal pain.
The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50 Y/O.
Sudden abdominal pain in patients over 50 Y/O and hypotension should suspect ruptured AAA.
Orthostatic vital signs do not need to be assessed on obviously hypotensive patients.
Mesenteric ischemia presents with severe pain with limited exam findings. Risk factors include age > 60, atrial fibrillation, CHF, and atherosclerosis.
For all female patients ask about last menstrual period.
Consider ovarian/testicular torsion in patients with sudden onset of unilateral low abdominal pain.
Intermittent abdominal pain/cramping in young children is classic for intussusception.

‌Abuse/Maltreatment and Human Trafficking

Patient Care Goals

Recognize when patients are being mistreated either through coercion, direct harm, or omission of care. Remove the patient from harm while preserving the evidence as much as possible. Document history and exam thoroughly.

Clinical Management Options

EMT-B

Paramedic

Demonstrate professionalism and courtesy
Perform an initial assessment and physical exam- document findings thoroughly
Wound treatment as appropriate
12 lead/4 lead ECG acquisition as appropriate
Perform medication cross check for all medication administrations

12 lead/4 lead ECG acquisition and interpretation as appropriate
Chemical sedation administration as appropriate

Consult Online Medical Control as Needed

Pearls

EMS are mandatory reporters in any case where there is concern for child and elder abuse. Always report your concerns to the hospital and/or law enforcement.
- Elder abuse is considered anyone who is 60 years old or older who is dependent on someone for their care
Transport pediatric patients with concern for non-accidental trauma to level 1 pediatric trauma center.
Consider abuse/maltreatment in BRUE cases
You may find patterned bruising, bruising of multiple ages, age-inappropriate behavior, evidence of medical neglect, frequent calls for UTI/genitourinary complaints, evidence of malnourishment

Human trafficking is common in Saint Louis. Signs may include but not limited to: tattoos, padlocks on interior doors, additional security.

Human Trafficking Children’s Division for MO is 800-392-3738;

National Human Trafficking Hotline is 1-888-373-7888

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‌Agitated/Behavioral Emergencies

Patient Care Goals

Provision of care while maintaining safety for the patient, EMS personnel, and others.

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:
	agitation, confusion

Use approved reference document

Anxiety,

Refer to Altered Mental Status

for medication dosing, electrical therapy, and equipment sizes.

change, hallucinations

/ overdose

Parents may know what de-escalation techniques have worked in the past

Affect
Delusional thoughts, bizarre behavior
Expression of suicidal homicidal thoughts
Tachycardia, diaphoresis, tachypnea
Struggles violently despite appropriate restraints
Combative / violent
Very “hot” to touch

Hypoglycemia
Hypoxia
Alcohol intoxication
Illicit drug use
Medication effect
Withdrawal syndromes
Bipolar (manic-depressive)
Schizophrenia, anxiety disorders, etc.
Hypertensive emergency
Seizure / Postictal
Domestic Violence or Abuse

Patient Care Goals

EMT-B

Paramedic

Oxygen, target SpO2 92 – 96%
Check a blood glucose
Basic Airway Management as needed
Physical restraint if needed and use Restraint Checklist
- Never transport a restrained patient in a prone position on a stretcher
Cooling measures if needed
Perform medication cross check for all medication administrations

Vascular access as appropriate for patient condition
Fluid therapy as needed with Isotonic Crystalloid, preferred cold if excited delirium
Cardiac monitor and 12 ECG
Consider sedation for agitated patients; document a pre-sedation RASS and a RASS after medications have been provided
- RASS +3/+4 Ketamine is preferred if available
  - Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
  - Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
- RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
  - 5-10mg IM (adults only)
  - 5mg IV (adults only)
- RASS +1 Midazolam is preferred
  - Adults: 5-10mg IM
  - Adults: 5mg IV adults
  - Pediatric: 0.1mg IV max dose of 5mg
  - Pediatric: 0.2mg IM/IN max dose of 10mg
- Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
- Alternative agents if none of the above are available
  - Haloperidol

Adults: 5mg IM/IV
Pediatrics: 2mg IM/IV (not for kids younger than 3 or less than 15kg)

Lorazepam
- Adults: 2-4mg IVIM
- Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)

If the patient is suspected of excited delirium and suffers cardiac arrest, then consider a fluid bolus and Sodium Bicarbonate early

Consult Medical Control as needed

Richmond Agitation Sedation Score (RASS)
+4	Combative	Overly combative or violent and an immediate danger to provider
+3	Very Agitated	Aggressive, non-combative or pulls on or removes tube(s) or catheter(s)
+2	Agitated	Frequent, non-purposeful movement or patient/ventilation desynchrony
+1	Restless	Anxious or apprehensive, movements not aggressive or vigorous
0	Alert and Calm	Spontaneously pays attention to provider
-1	Drowsy	Not fully alert but sustains more than 10 seconds wake, with eye opening in response to verbal command
-2	Light Sedation	Awakens briefly for less than 10 seconds with eye contact or verbal command
-3	Moderate Sedation	Any movement, except eye contact, in response to command
-4	Unarousable	No response to voice or physical stimulation

Restraints Checklist

contraindicated.

sensation in all extremities.

sedation, Continuous monitoring, Neurovascular status evaluation

All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical

Pearls

Consider your safety first. Physical restraint should be performed / assisted by Law Enforcement when available.
Be sure to consider all possible medical and/or trauma causes for behavior.
All patients who receive either physical or chemical restraint must be continuously observed by ALS personnel on scene or immediately upon their arrival.
Any transported patient who is handcuffed or restrained by Law Enforcement should be accompanied by an officer whenever possible and if not, then law enforcement must be immediately available.
Restrained patients must never be maintained or transported in a prone position.
SAVE Mnemonic for De-Escalation:
- Support – “Let’s work together…”
- Acknowledge – “I see this has been hard for you…”
- Validate – “I would probably be reacting the same way if I was in your shoes…”
- Emotion naming – “You seem upset…”
Excited Delirium (EXD) is interchangeable with Excited Delirium Syndrome (ExDS) and Agitated Delirium (AgDS) and all refer to a condition where the patient continues to struggle violently despite appropriate restraint that results from a combination of delirium, psychomotor agitation, anxiety, hallucinations, speech disturbances, disorientation, violent and bizarre behavior, insensitivity to pain, elevated body temperature, and superhuman strength. Therefore, underlying etiologies of EXD/ExDS/AgDS must be considered:
- Metabolic / Endocrine – hypoxia, electrolyte abnormalities, hepatic encephalopathy, hypercarbia, hyper/hypoglycemia, thyrotoxicosis, uremia
- Neurologic – dementia, head injury, encephalitis, post-ictal state/seizure
- Psychiatric – acute psychosis, mania, medication stoppage, personality disorder, schizophrenia
- Infectious/Inflammatory – autoimmune encephalitis, herpes encephalitis, meningitis, sepsis
- Toxicologic – alcohol, amphetamines, cocaine, neuroleptic malignant syndrome, PCP, polypharmacy, serotonin syndrome, synthetic cannabinoids, synthetic cathinones
Cold isotonic crystalloid boluses 30 ml/kg with temperature > 104 F up to 2 liters in adults.
Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants).
Droperidol can cause dystonic reactions such as akathisia (restlessness and need to move) or torticollis. The treatment for both of these side effects is IV/IM Benadryl.
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‌Allergic Reaction/Anaphylaxis
Patient Care Goals
Identify anaphylaxis (life-threatening allergic reactions) quickly to prevent cardiorespiratory collapse. Anaphylaxis is defined as two or more of the following symptoms: skin (hives/itching), GI symptoms (nausea/vomiting/diarrhea), respiratory symptoms (chest tightness/wheezing/shortness of breath), swelling (tongue/face/lips), difficulty swallowing, hypotension. Early epinephrine should be considered for anyone with signs of anaphylaxis, or anyone with concern for anaphylaxis with hypotension and/or facial swelling.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:

Obstruction
- Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
- Do not hesitate to give epinephrine for anaphylaxis
- Edema / Voice Changes
- Stridor
- Itching or Hives
- Coughing / Wheezing or Respiratory Distress
- Chest or Throat Constriction / Tightness
- Difficulty Swallowing
- Hypotension or Shock
- Vomiting / Diarrhea
- Urticaria (rash only)
- Anaphylaxis (systemic effect)
- Shock (vascular effect)
- Angioedema (drug induced)
- Aspiration / Airway
- Vasovagal event
- CHF
- Asthma or COPD
- Anxiety
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Cold pack to inset bite or sting site and remove bee stinger if present.
- Basic airway management as needed
- Acquisition of 12 lead/4 lead as appropriate
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- IM Epinephrine, up to 3 additional doses q5 minutes as needed for continued symptoms
  - Adult: 0.3 mg IM 1;1000 (1mg/mL)
  - Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg)
  - NOTE: IM vs. IV dosing is VERY different
- Consider Albuterol 2.5mg/3mL for wheezing, chest tightness, shortness of breath
  - Adult: 5mg nebulized
  - Pediatric: 2.5 mg nebulized
- Consider nebulized epinephrine for stridor/other signs of upper airway obstruction
  - 2mg (of 1mg/ml) for a total of 2ml mixed with 1ml normal saline
- Consider CPAP, if refractory to Albuterol
- Diphenhydramine for Allergic Reaction or Dystonia
  - Adult: 50mg IV/IM
  - Pediatric: 1mg/kg IV/IM (max dose 50 mg)
- IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
- Consider Dexamethasone
  - Adult: 10mg PO/IV/IM
- Pediatric 0.6 mg/kg PO/IV/IM (max 10mg)
- Consider Push dose Epinephrine IV/IO for hypotension
  - Adult: 20mcg IV (10 mcg/mL 1:100,000)
  - Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
  - NOTE: IM vs IV dosing and concentration are VERY different
- Monitor ETCO2 in patients with respiratory distress
- Consider acquisition/interpretation of 12 lead/4 lead ECG
Consult Medical Control as needed
Pearls
Epinephrine is the single most important intervention in this setting and has small risk for high benefit.
Epinephrine IM vs. IV dosing errors are common, please double/triple check prior to administering.
Hives + vomiting is anaphylaxis and should be treated with epinephrine
Skin symptoms (hives) may be missing in up to 40% of patients
Continuous reassessment for lack of improvement or rebound reaction with need for additional epinephrine.
Lungs should be assessed between each dose of Albuterol prior to additional nebulizers.
Any patient with respiratory symptoms or extensive reaction should receive IV/IO or IM Diphenhydramine.
The shorter the onset from exposure to symptoms, the worse the reaction.

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‌Altered Mental Status (AMS)/Behavioral

Patient Care Goals

Identify treatable causes of altered mental status.

Assessment

Pediatric Pearls:

Signs & Symptoms:

Differential:

AMS is ominous in peds
Use volume control device for Dextrose infusions
Upper limit BGL is 200
Ask about how formula is being mixed in formula fed babies
Consider head trauma, non-accidental trauma

Decreased mental status
Changes in baseline mental status.
Bizarre behavior
Hypoglycemia (cool, diaphoretic skin)
Hyperglycemia (warm & dry skin, fruity

breath, Kussmaul’s respira tions, signs of dehydration)

Hypo/Hyperglycemia
Post-ictal
Hypoxia
Brain trauma
Meningitis
CNS (Stroke, Tumor, Seizure, Infection)
Cardiac (MI, CHF)
Infection
Thyroid (hyper or hypo)
Shock (septic, metabolic, traumatic)
Toxicological / Carbon Monoxide / Cyanide
Acidosis / Alkalosis
Heat Stroke
or Hypothermia
Electrolyte abnormality

Patient Care Goals

EMT-B

Oxygen, target SpO2 92 – 96%
Blood Glucose Level Assessment
- Oral glucose of appropriate
Basic Airway Management as needed
Acquisition of 12 lead/4 lead as appropriate
Perform medication cross check for all medication administrations

Paramedic

Vascular access as appropriate for patient condition
Dextrose if hypoglycemia and not eligible for oral glucose
- Adult: 25g (D10W in 250 ml infusion) titrate to effect
- Pediatric 30 days or older: 5ml/kg of 25g/250ml
- Pediatric 0-29 days: 1ml/kg of 25g/250ml

Stroke Screening
Monitor ETCO2
12 lead/4 lead acquisition and interpretation as appropriate
Consider sedation for agitated patients; document a pre-sedation RASS and a RASS after medications have been provided
- RASS +3/+4 Ketamine is preferred if available
  - Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
  - Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
- RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
  - 5-10mg IM (adults only)
  - 5mg IV (adults only)
- RASS +1 Midazolam is preferred
  - Adults: 5-10mg IM
  - Adults: 5mg IV adults
  - Pediatric: 0.1mg IV max dose 5mg
  - Pediatric:0.2mg IM/IN max dose of 10mg
- Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
- Alternative agents if none of the above are available
  - Haloperidol
    - Adults: 5mg IM/IV
    - Pediatric: 2mg IM/IV (not for kids younger than 3 or less than 15kg)
  - Lorazepam
    - Adults: 2-4mg IVIM
    - Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
Advance Airway Management as Needed

Consult Online Medical Control as Needed

Restraints Checklist

All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
contraindicated.
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
sensation in all extremities.
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical sedation, Continuous monitoring, Neurovascular status evaluation

Pearls

Be aware of AMS as presenting sign of an environmental toxin or Haz-Mat exposure and protect personal safety.
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or oral glucose.
Do not let alcohol confuse your clinical practice as alcoholics frequently develop hypoglycemia and metabolic illness.
Poor perfusion can cause altered mental status
Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants).
‌Back Pain
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Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Back pain without trauma is concerning in the pediatric patient
- Weakness
- Numbness
- Fever
- Difficulty urinating/controlling bowel movement
- Hematuria (renal stone)
- Herniated disk
- Cauda equina
- Muscle strain
- Renal stone
- Aortic aneurysm
- Aortic dissection
- Osteomyelitis
Patient Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Check movement/sensation in extremities
- Perform Pain Management procedures
- Acquisition of 12 lead/4 lead as appropriate
- Perform medication cross check for all medication administrations
- Vascular access as appropriate for patient condition
- Consider acquisition/interpretation of 12 lead/4 lead ECG
- Consider additional pain management with morphine, fentanyl, or ketamine
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Online Medical Control as Needed
Pearls
Tearing back pain that radiates to several locations can be signs of aortic dissection. Consider blood pressures in both arms.
Abdominal aneurysms may present as flank/back pain and are a concern in patients over the age of 50.
Any new bowel or bladder incontinence is a significant finding and may indicate a spinal cord compression which requires immediate medical evaluation.
In patients with history of IV drug abuse or pain management injections, an epidural abscess should be considered.
Pulsatile abdominal mass with back pain can be an abdominal aneurysm.
Hematuria and back pain can be signs of renal stones
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‌Bronchospasm
Patient Care Goals
Alleviate respiratory distress due to bronchospasm. Deliver appropriate therapy by differentiating other causes of respiratory distress.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Wheezing in <2yo is often bronchiolitis and not asthma (unless they have a diagnosis of asthma).
- Work of breathing is important. Pediatric patients will not start to desaturate until they are in respiratory failure
- Shortness of breath
- Pursed lip breathing
- Decreased ability to speak
- Increased respiratory rate and effort
- Wheezing, rhonchi, rales, stridor
- Use of accessory muscles
- Fever, cough
- Tachycardia
- Anxious appearance
- Shark-wave appearance on ETCO2
- Asthma / COPD (Emphysema, Bronchitis)
- Anaphylaxis
- Aspiration
- Pleural effusion
- Pneumonia
- Pulmonary embolus
- Pneumothorax
- Cardiac (MI or CHF)
- Pericardial tamponade
- Hyperventilation
- Inhaled toxin (CO, etc.)
- Croup / Epiglottitis
- Congenital heart disease
- Trauma
- Hydrocarbon ingestion
Patient Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Blood Glucose Level Assessment
- Basic Airway Management as needed
- Acquisition of 12 lead/4 lead as appropriate
- Perform medication cross check for all medication administrations
- Vascular access as appropriate for patient condition
- Monitor and interpretation of 12 lead/4 lead ECG & EtCO2
- If wheezing (non-cardiac), consider Albuterol with Ipratropium
  - Albuterol
    - Adult: 5mg
    - Pediatrics: 2.5mg
  - Ipratropium
    - 0.5mg (adults and pediatrics)
- Dexamethasone
  - Adult: 10mg PO/IV/IM
  - Pediatric: 0.6 mg/kg PO/IV/IM (max 10mg)
- Consider early CPAP with PEEP in distressed patients
- For severe bronchospasm, consider Magnesium Sulfate and/or IM epinephrine
  - Magnesium
    - Adult: 2g infusion over 10 minutes
    - Pediatric: 50mg/kg, max dose 2g infusion over 10 minutes
  - Epinephrine
    - Adult: 0.3 mg IM 1;1000 (1mg/mL)
      - Use caution in patient’s who are 65yo and older
- Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg)
- Advance Airway Management as Needed
Consult Online Medical Control as Needed
Pearls
EtCO2 and SpO2 must be monitored continuously if either are abnormal or decline in patient’s
mental status/condition.
Normalization of ETCO2 can mean improvement of the patient OR failure to compensate with impending death. Monitor the ETCO2 wave and mental status of the patient closely.
Consider other reasons for respiratory distress such as pneumothorax or CHF (CHF can also wheeze, consider the entire patient history and exam).
A silent chest in respiratory distress is a sign for pre-respiratory arrest.
Chronic COPD may have elevated CO2 at baseline. Patient respiratory status must be reassessed after each nebulizer or medication administration to determine need for additional dosing.
Chronic COPD may have lower O2 at baseline and have increased mortality with hyper- oxygenation. The O2 goal is above 90% (not 100%).
Children less than 2yo are likely bronchiolitis, not asthma. Suctioning and oxygen is the first line treatment for bronchiolitis.
A history of intubations and ICU stay can be a poor prognostic sign in some patients.
Consider early CPAP in patients with respiratory distress.
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‌Chest pain/Coronary Syndrome/STEMI
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:

Myocardial infarction
- Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
- Avoid ASA and nitroglycerin in pediatric patients
- Pain, discomfort, or pressure between navel and jaw
- “Heart racing”, “palpitations”, or “heart too slow”
- CHF signs or symptoms
- Syncope
- Severe weakness if > 45 years old
- Difficulty breathing
- Angina vs
- Pericarditis
- Pulmonary embolism
- Asthma / COPD
- Aortic Dissection
- Pneumothorax
- Aortic dissection
- GI reflux / Hiatal hernia / PUD
- Esophageal spasm
- Chest wall injury or pain
- Pleuritic pain
- Overdose (sympathomimetic)
Patient Care Goals
EMT-B

Paramedic
100mcg)
- Oxygen, target SpO2 92 – 96%
- Perform bilateral blood pressures, if difference between R & L arm SBP is > 20mmHg then consider aortic dissection and withhold Aspirin and Nitroglycerin
- Acquire a 12-lead EKG
- Perform medication cross check for all medication administrations
- Aspirin
  - 324 mg PO
- Basic Airway Management as needed
- Vascular access
- Isotonic Crystalloid PRN if hypotensive titrated to SBP > 100 mmHg or MAP > 65
- Within 5 minutes of patient contact, 4 lead and 12 lead ECG placement and acquisition
- Nitroglycerin if SBP > 100 mmHg
  - 0.4mg (400mcg) SL every 5 minutes PRN up to 3 doses
  - 5-50 mcg/minute infusion
  - Caution with inferior STEMI
  - Contraindicated if use of erectile dysfunction drugs within the last 24-48 hours
- Monitor and interpretation of ECG & EtCO2
- Additional Pain Management if needed with morphine or fentanyl
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below
- EKG faxed to destination hospital if STEMI
Consult Online Medical Control as Needed
Pearls
12 lead EKG should be obtained within 5 minutes of first patient contact
Aspirin should be given to ALL patients suspected of having ACS/STEMI and this should be documented. If it was not administered it should be documented why it was not administered (i.e. administered prior to arrival).
The ONLY contraindications to aspirin administration is history of anaphylaxis to aspirin (and not simply mild allergy or intolerance) or active GI bleed.
Diabetics, females, and geriatric patients can have atypical pain, or generalized complaints. Consider cardiac causes for nausea, vomiting, and weakness.
Do not administer Nitroglycerin in any patient who used Viagra (sildenafil) or Levitra (vardenafil) in the past 24 hours or Cialis (tadalafil) in the past 48 hours or other PDE erectile dysfunction medications due to potential severe hypotension.
In patients with suspicious story but unremarkable initial EKG due serial EKG’s every 5 minutes.
Avoid hyperoxemia, as it can lead to increased cardiac damage.
If patient has STEMI, or is going directly to cardiac cath, attempt to establish a second IV but do not delay transport. Transport providers need to minimize scene time to < 15 minutes whenever possible.
STEMI Criteria:
- A STEMI/ACO Alert should be called when a patient is currently symptomatic for an acute coronary syndrome event and has new or presumably new ST segment changes:
  - All Patients: Elevation > 1 mm in two anatomically contiguous leads (Except V2 & V3 in males)
  - Males: V2 and V3 need 2 mm or more elevation to be concerning for STEMI/ACO
  - Isolated ST segment depressions in V1-V4 (Posterior Myocardial Infarction)
  - Any positive findings for Sgarbossa criteria in LBBB or Ventricular Paced patients
  - ST Segment elevation in aVL and ST segment depression in III (High Lateral MI)
- Use modified Sgarbossa criteria for LBBB or Ventricular Paced patients
  - Concordant ST elevation >1 mm in leads with a positive QRS complex
  - Concordant ST depression >1 mm in V1-V3
  - ST Elevation at the J-point, relative to QRS onset, is at least 1 mm AND has an amplitude at least 25% of the preceding S-wave

Lead placement posterior EKG

Lead placement right sided EKG

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‌CHF/Pulmonary edema

Assessment

Pediatric Pearls:

Signs & Symptoms:

Differential:

Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Pediatric hypotension is defined as SBP < 70 +

(age in years x 2) mmHg

Bilateral rales
Jugular vein distention
Pinky, frothy sputum
Peripheral edema
Diaphoresis
Hypoperfusion
Hypotension
Chest pain
Respiratory distress
Apprehension/anxiety
Orthopnea

Myocardial infarction
Congestive heart failure
Pulmonary embolus
Pericardial tamponade
Pleural effusion
Pneumonia
Asthma
Anaphylaxis
Aspiration
COPD
Toxic exposure

Patient Care Goals

EMT-B

Oxygen, target SpO2 92 – 96%
Position of comfort
Basic airway management
Acquire a 12-lead EKG
Perform medication cross check for all medication administrations
Aspirin if suspected ACS Chest Pain
- 324mg PO

Paramedic

Vascular access
Consider CPAP with PEEP (5-20 cm H2O) with rales/rhonchi indicating wet lung sounds
Nitroglycerin q 5 minutes if SBP > 100 mmHg
- SBP 100 – 149 mmHg: 0.4 mg SL
- SBP 150 – 199 mmHg: 0.8 mg SL
- SBP 200 or greater: 1.2 mg SL
4 lead and 12 lead ECG placement and acquisition
Monitoring and interpretation of ECG, waveform EtCO2
Advanced Airway as needed

Consult Online Medical Control as Needed

Pearls

Avoid Nitroglycerin in any patient who has used Viagra or Levitra in the past 24 hours or Cialis in the past 48 hours or other PDE erectile dysfunction medications due to potential severe hypotension.
Careful monitoring of level of consciousness, BP, and respiratory status with above interventions is essential.
Consider myocardial infarction in all these patients. If suspected give Aspirin.
Allow the patient to be in their position of comfort to maximize their breathing effort.
Patient BP may drop with CPAP, if CPAP is necessary for oxygenation/ventilation, may move to add pressor.
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‌End-of Life/Hospice
Patient Care Goals
To provide relief from pain and other distressing symptoms. To assist the family and loved ones in understanding the dying process, normalizing the death process, and providing support. To allow patients to remain comfortable in their home when possible.
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Call medical direction for assistance with pediatric hospice patients
- None
- None
Patient Care Goals
EMT-B

Paramedic
100mcg)
- Offer comfort measures: fan, bedding, food/drink, etc.
- Contact hospice or palliative care provider for medical control orders
- Perform medication cross check for all medication administrations
- Treat pain with hospice plan/home meds or use follow Pain Management COG
- Treat nausea and vomiting
  - Ondansetron
    - Adult: 4mg PO/IV/IM
    - Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
  - Droperidol 2.5mg IV/IM adults only
- Treat agitation/anxiety with hospice plan/home meds or use:
  - Midazolam
    - Adults: 5-10mg IM/IN
    - Adults: 5mg IV adults
    - Pediatric: 0.2mg IM/IN, max dose of 10mg
    - Pediatric: 0.1mg IV max dose of 5mg
  - Lorazepam
    - Adults: 2-4mg IVIM
    - Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)
  - Droperidol
    - Adults: 2.5mg IV, 5-10mg IM
- Opioids can help with respiratory distress
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below
Consult Online Medical Control as Needed
Pearls
Careful and thorough assessments should be performed to identify complaints not related to the illness for which the patient is receiving hospice or palliative care.
Care should be delivered with the utmost patience and compassion.
Families often call because they do not understand the dying process. Normalizing the dying process can be helpful for families.
Patient’s can sometimes appear to be short of breath. Pain medications such as fentanyl can
help reduce this discomfort.
Consider non-medication options as well (ie. A fan blowing on a patient’s face can help reduce
air hunger).
‌Glucose Emergencies
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Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Newborn hypoglycemia is below 40 mg/dL
- Can only use D10 for infants (not D50)
- If there is a concern for DKA, consider 20cc/kg fluid bolus
- Altered Mental Status
- Seizure
- Reported low blood sugar prior to arrival
- Shakiness
- Stroke-like deficits
- Sweating
- Lethargy
- Difficulty Breathing
- Kussmaul respirations
- Infections / Sepsis
- Medication under/overdose
- Liver failure
- Stroke
- Seizure
- Cancer
- Electrolyte abnormalities
- Alcoholism
Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- BGL Assessment, if BGL < 60 and intact gag reflex then Oral Glucose
  - Consider removing the insulin pump if present. Please bring the insulin pump if present
- Basic Airway Management as needed
- Perform medication cross check for all medication administrations
- Vascular access
- If BGL < 60 then Dextrose Infusion or oral glucose titrated to patient condition and response
  - Adult: 250ml of D10 IV (25g)
  - Pediatric 30 days or older: 5ml/kg of 25g/250ml
  - Pediatric 0-29 days: 1ml/kg of 25g/250ml
- If no IV access and unresponsive give IO Dextrose
- If BGL > 300 (adults)/> 200 (pediatrics) or signs of dehydration, give an IV fluid bolus
- ECG Monitoring
- Monitor for hyperkalemia changes and treat with Calcium , Albuterol, and Sodium Bicarbonate if present
  - Calcium Chloride
    - Adult: 1000mg (1g) IV
    - Pediatric: 20mg/kg (max 1000mg) IV
  - Albuterol
    - Adult: 5mg
    - Pediatrics: 2.5mg
  - Sodium Bicarbonate
    - Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
- Monitor EtCO2 if BGL > 550 mg/dl
  - If EtCO2 < 21 mmHg, Advise ED of Diabetic Ketoacidosis
  - If using mechanical ventilation, ensure high minute volume
Consult Online Medical Control as Needed
Pearls
Hyperglycemia
- New onset diabetic ketoacidosis in pediatric patients commonly presents with nausea, vomiting, abdominal pain, and/or urinary frequency
- Consider causes for hyperglycemia by thinking about the 3 I’s:
  - Insulin – this refers to any medication changes for insulin or oral medications including poor compliance or malfunctioning insulin pump
  - Ischemia – this refers to hyperglycemia sometimes being an indication of physiologic stress in a patient and can be a clue to myocardial ischemia in particular
  - Infection – underlying infection can cause derangements in glucose control
Hypoglycemia
- Consider contribution of oral diabetic medications to hypoglycemia
- If possible, have family/patient turn off insulin pumps
- Consider potential for intentional overdose of hypoglycemic agents
- Avoid overshoot hyperglycemia when correcting hypoglycemia. Administer Dextrose– containing IV fluids in small doses until either mental status improves or a maximum field dose is achieved
  Hypoglycemia Treatment-In-Place
  Checklist
  - Has a known history of diabetes
  - Repeat glucose is greater than 80mg/dL
  - Patient takes insulin for glucose control (no oral hypogylcemics as oral hypoglycemics are long acting)
  - There is a clear and reversible cause for the hypoglycemia (ie. Missed a meal)
  - There was no medication error (too much long-acting insulin should be transported)
  - Patient’s mental status has returned to baseline
  - Patient is able to obtain and eat a carbohydrate meal (needs to be immediately available, take at least a few bites)
  - Someone can stay with the patient for the next several hours and monitor the patient
  - Patient is willing and would prefer to stay at home for home treatment
  ‌Hyperkalemia
  page break
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  - Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
  - Bradycardia
  - Crush syndrome
  - DKA
  - Cardiac arrest
  - Missed dialysis
  - Decreased PO/urine output
  - Peaked T-waves
  - Widening QRS complexes (later finding)
  - Sine wave (pre-arrest finding on monitor)
  - Arrhythmia
  - Acute kidney injury
  - Fluid overload
  Care Goals
  EMT-B
  
  Paramedic
  - Oxygen, target SpO2 92 – 96%
  - BGL Assessment
  - Basic Airway Management as needed
  - 4-lead/12-lead acquisition
  - Perform medication cross check for all medication administrations
  - Vascular access
  - ECG Monitoring
  - 4-lead/12-lead acquisition and interpretation
  - Monitor for T-wave changes and treat with Calcium , Albuterol , and Sodium Bicarbonate if present
    - Calcium Chloride
      - Adult: 1000mg (1g) IV
      - Pediatric: 20mg/kg (max 1000mg) IV
    - Albuterol
      - Adult: 5mg
      - Pediatrics: 2.5mg
    - Sodium Bicarbonate
      - Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
  Consult Online Medical Control as Needed
  Pearls
Hyperkalemia should be suspected in patients with concern for crush injuries, DKA, or kidney injury.
Give calcium first as this helps protect the heart from the impact of hyperkalemia. The albuterol and sodium bicarb are used to reduce the amount of potassium in the blood stream.
Consider in patients who have had recent failure to thrive (decreased PO intake can lead to kidney injury and potassium imbalances)
Hyperkalemia can have a wide range of EKG changes. The most classic EKG changes are below.
‌LVAD
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
these patients.
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for
- Cardiovascular compromise
- Cardiac arrest
- Medical or injury-related event not involving the cardiovascular system or VAD malfunction
- Infection
- Stroke/TIA
- Bleeding
- Arrhythmias
- Cardiac tamponade
- CHF
- Aortic insufficiency
- LV thrombus
Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Basic Airway Management as needed
- 4-lead/12-lead acquisition
- Perform medication cross check for all medication administrations
- Bring batteries/equipment with the patient
- Assess for Pump Malfunction and contact VAD coordinator
  - BJH LVAD Nurse Coordinator: 314-454-7687
  - If Pump not working and in cardiac arrest, start CPR
- Vascular access
- 12 lead ECG
- Consider IV Crystalloid Fluid Bolus if the patient appears dehydrated/history consistent with fluid loss
  - May also be indicated by “low flow” alarm
- Consider push dose Epinephrine for signs of poor perfusion that is not improved with IV fluid boluses
  - Adult: 20mcg IV (1:100,000 which is 10mcg/ml)
  - Pediatric: 10mcg IV (1:100,000 which is 10mcg/ml)
  - IV and IM dosing and concentration are very different!
Consult Online Medical Control as Needed
Pearls
Transport patients to the hospital that placed the LVAD
“Flow” on LVAD display is typically 4-6L/min (much like natural cardiac output)
- Flows less than this (patient usually knows their normal flow rate) indicates hypovolemia so consider IVF
- “low flow” alarm indicates hypovolemia and should receive IVF bolus
- Flow around or less than 0.5L/min indicates cardiac arrest
Patients with LVADS can have medical issues NOT related to the LVAD (such as the stomach flu).
Take a thorough history and physical, treat the cause
- Low volume should be given volume
- Avoid volume and move straight to push-dose pressors if the patient has a history and exam related to elevated volume
Patients should go to the center that placed the VAD in them whenever possible.
You do not need to disconnect the controller or batteries to:
- Defibrillate or cardiovert
- Acquire a 12-lead EKG
Automatic non-invasive cuff blood pressures may be difficult to obtain due to the narrow pulse pressure created by the continuous flow pump.
Flow though many VAD devices is not pulsatile, and patients may not have a palpable pulse or accurate pulse oximetry.
The blood pressure, if measurable, may not be an accurate measure of perfusion.
Ventricular fibrillation, ventricular tachycardia, or asystole/PEA may be the patient’s “normal” underlying rhythm. Evaluate clinical condition and provide care in consultation with VAD coordinator.
- Do not shock Vtach/Vfib if the patient appears well-perfused
The patient’s travel bag should always accompany them with back-up controller and spare batteries
If feasible, bring the patient’s power module, cable, and display module to the hospital.
All patients should carry a spare pump controller with them.
The most common causes for VAD alarms are “low flow” alarms (secondary to hypovolemia)
or low batteries/battery failures.
Although automatic non-invasive blood pressure cuffs are often ineffective in measuring systolic and diastolic pressure, if they do obtain a measurement, the MAP is usually accurate.
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‌Nausea-Vomiting
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- No Zofran in patients who are less than 1 year old
- Projective vomiting/green vomiting in less than 2 months old is abnormal
- Tachycardia is first sign of dehydration
- Ask about urine output
- Fever
- Pain
- Constipation
- Diarrhea
- Anorexia
- Hematemesis
- Bilious emesis
- CNS (Increased ICP, headache, stroke, CNS lesions, Trauma, or hemorrhage)
- Vestibular
- AMI
- Small bowel obstruction
- Drugs (NSAIDS, antibiotics, narcotics, chemotherapy)
- GI or GU disorders
- Uremia
- Gynecologic disease (Ovarian Cyst / PID)
- Infections (pneumonia, influenza)
- Electrolyte abnormalities
- Food or Toxin induced
- Pregnancy
Care Goals
EMT-B
- Oxygen, target SpO2 92 – 96%
- Basic Airway Management as needed
- Orthostatic vital sign assessment if appropriate
- Allow patient to inhale isopropyl (rubbing) alcohol for aromatherapy to treat nausea
- 4-lead/12-lead acquisition as appropriate
- Perform medication cross check for all medication administrations
Paramedic
- Consider vascular access
- 12 lead ECG acquisition and interpretation adults>50
- Consider Ondansetron or Droperidol
  - Ondansetron
    - Adult: 4mg PO/IV/IM
    - Pediatric: 0.1mg/kg (max 4mg) PO/IV/IM
  - Droperidol 2.5mg IV/IM adults only
- Consider IV fluid with Isotonic Crystalloid as needed for dehydration
  - Reduce the amount of IV fluids if there is a history of CHF
Consult Online Medical Control as Needed
Pearls
Assess number of times of emesis
Appearance of emesis: bloody, coffee ground, bilious – green bile – solids and liquid or just liquid
Heart rate: One of the first clinical signs of dehydration, usually increased heart rate, tachycardia increases as dehydration becomes more severe, very unlikely to be significantly dehydrated if heart rate is close to normal.
Consider small bowel obstructions in patients who have abdominal distension with nausea and vomiting.
Remember to consider exposures and ingestions in some populations
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‌Pain Management
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Uses faces scale in younger patients
- Consider IN meds for kids without an IV.
- Severity (Pain scale)
- Quality
- Radiation
- Relation to movement
- Respirations
- Reproducible
- Increased upon palpation
- Per the specific protocol
- Musculoskeletal
- Visceral (abdominal)
- Cardiac
- Pleural / Respiratory
- Neurogenic
- Kidney stone
Care Goals
EMT-B
- Bleeding control
- Oxygen, target SpO2 to 92-96%
- Pain scale assessment 0-10, Wong-Baker faces for pediatrics, FLACC for infants
- Splinting/bandaging needed
- Ice pack as needed
- Perform medication cross check for all medication administrations
Paramedic
- Consider vascular access
- Isotonic Crystalloid as needed
- Consider medications for pain control
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
- Monitor ECG and ETCO2 if fentanyl was provided
Consult Online Medical Control as Needed
Pearls
Pain severity is a vital sign to be recorded pre and post pain intervention, especially medications.
Vital signs should be obtained pre and 5-minutes post all medications.
Monitor patient closely for over sedation, refer to Overdose COG if needed
Be cautious with pain medications in patients with head injury
Do not administer Acetaminophen to patients with history of liver disease or known to have consumed large amounts of ETOH.
Fentanyl should be reserved for acute pain.
Controlled substances are discouraged for non-traumatic back pain.
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‌Seizures
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Assess for VP shunt
- Febrile seizures occur between 6 months and 5 years
- Consider a broad differential including ingestion non-accidental trauma for seizures
- Altered mental status
- Sleepiness
- Incontinence
- Observed seizure activity
- Evidence of trauma
- Unconscious
- Fever
- Seizure activity
- Tongue trauma
- Rash
- Nuchal rigidity
- CNS/Head trauma
- Tumor
- Metabolic, Hepatic, or Renal failure
- Electrolyte abnormality (Na, Ca, Mg, K)
- Medication non- compliance
- Infection / Fever
- Alcohol withdrawal
- Eclampsia
- Stroke
- Hyperthermia
- Hypoglycemia
Care Goals
EMT-B

Paramedic
- Oxygen, Target SPO2 92-96%
- Blood glucose level
- BLS airway management
- For any seizure in a pregnant or recently post-partum patient, consider eclampsia and consult the OB Emergencies guidelines
- Examine mental status, HEENT, heart, lungs, extremities, and neuro
- Perform medication cross check for all medication administrations
- Stroke Assessment
- Vascular access
- Consider Isotonic Crystalloid
- Monitor ECG and ETCO2
- Midazolam or Lorazepam if the patient is actively seizing or has a seizure in your presence
  - Preference for IM/IN over IV for first dose if IV not already established
  - Midazolam
    - Adults: 5-10mg IM/IN
    - Adults: 5mg IV adults
    - Pediatric: 0.2mg IM/IN, max dose of 10mg,
    - Pediatric: 0.1mg IV max dose of 5mg
- Lorazepam
  - Adults: 2-4mg IVIM
  - Pediatrics 0.1 mg/kg IV/IM (max dose 4mg)
- Consider advanced airway
Consult Online Medical Control as Needed
Pearls
Status epilepticus is defined as two or more successive seizures or a continuous seizure lasting 5 minutes without a period of consciousness or recovery. This is a true emergency requiring rapid airway control, treatment, and transport.
Seizures can be grand mal, focal, or staring spell.
Grand mal seizure (generalized) is associated with loss of consciousness, incontinence, and tongue trauma.
Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness.
Jacksonian seizures are seizures which start as focal seizure then become generalized.
Avoiding hypoxemia is extremely important.
Be prepared to assist ventilations, especially if Midazolam is used.
Assess possibility of occult trauma and substance abuse.
Addressing the ABCs and verifying blood glucose is more important than stopping the seizure.
Hypoglycemia is the 2nd most common cause of seizure.
Consider acquiring a 12-lead EKG following cessation of seizure in patients without a history of seizure to determine possible cardiac cause
In an infant, a seizure may be the only evidence of a closed head injury.
The presence of fever with seizure in children less than 6 months old and greater than 6 yo is not consistent with a simple febrile seizure, and should prompt evaluation for meningitis, encephalitis or other cause
Seizure in a patient with a history of VP shunt may be shunt malfunction. Needs to go to the hospital where they are followed for their shunt
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‌Shock/Hypotension (medical)
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Initial NS bolus is 20cc/kg
- Restlessness, confusion, weakness
- Syncope
- Tachycardia
- Diaphoresis
- Pale, cool, clammy skin
- Delayed capillary refill
- Coffee-ground emesis
- Tarry stools
- Infection/Sepsis
- Dehydration
- Vomiting
- Diarrhea
- Congenital heart disease
- Medication or Toxin
- Anaphylaxis
- Cardiogenic shock
- Pericardial effusion
- Hemorrhagic shock
Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 to 92-96%
- Blood glucose assessment
- Keep the patient warm
- Acquire 4-lead/12-lead as appropriate
- Perform medication cross check for all medication administrations
- Vascular access
- Monitor ECG and ETCO2
- Acquisition and interpretation of 4-lead/12-lead
- These fluid boluses are for volume depletion – NOT for active bleeding.
  - Pediatric: Isotonic Crystalloid bolus 20 ml/kg may repeat 10 ml/kg bolus x 2 PRN
  - Adult non-cardiac: Isotonic Crystalloid 500-1000 ml bolus, may repeat up to 2 liters
  - Adult Cardiac: Isotonic Crystalloid 250-500 ml bolus, may repeat up to 1 liter
- Push Dose Epinephrine for hypotension not improved with fluid bolus
  - Adult: 20mcg IV (10 mcg/mL 1:100,000)
  - Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
  - NOTE: IM vs IV dosing and concentration are VERY different
Consult Online Medical Control as Needed
Pearls
Adult hypotension can be defined as a systolic blood pressure of < 90 mmHg or MAP < 60 and signs or symptoms of hypoperfusion – altered mental status, increased respirations, tachycardia, poor pulses, skin changes.
ETCO2 is often low in shock. ETCO2 <25mmHg is concerning
Consider all possible causes of shock and treat per appropriate protocols
Patients should always have adequate intravascular fluid volume prior to the use of vasopressors-> give fluid if you believe they do not have enough intravascular fluid volume.
MAP calculation = [(2 x diastolic) + systolic] divided by 3
Aggressive Isotonic Crystalloid administration should be avoided in patients in whom hemorrhage is suspected.
Note that intubating hypotensive patients can cause them to reduce their blood pressure further and cause sudden cardiac arrest. It is appropriate to resuscitate with fluids prior to obtaining an advanced airway when possible.
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‌Sickle Cell Pain Crisis
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Pain
- Shortness of breath
- Tachycardia
- Diaphoresis
- Hypoxia
- Fever
- New stroke-like symptoms
- Priapism
- LUQ abdominal pain
- Shock
- Infection/Sepsis
- Dehydration
- Acute chest
- Splenic sequestration
- Osteomyelitis
- Meningitis
Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 to 92-96%
- Pain scale assessment 0-10, Wong-Baker faces for pediatrics, FLACC for infants
- Ice pack as needed
- Perform medication cross check for all medication administrations
- Consider vascular access
- Isotonic Crystalloid as needed
- Consider medications for pain control
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
- Monitor ECG and ETCO2 if fentanyl, morphine, or ketamine was provided
Consult Online Medical Control as Needed
Pearls
Patients with chest pain, fever, tachycardia, and/or shortness of breath may be suffering from acute chest syndrome. Pediatric patients need to go to a children’s hospital as these patients may need antibiotics and admission.
Patients with LUQ abdominal pain, hypotension may be suffering from splenic sequestration. Follow the shock protocols.
Patients with sickle cell often have severe pain. It is reasonable to treat this pain en route .
‌Stroke/TIA
page break
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Altered mental status
- Weak / Paralysis
- Blindness or other sensory loss
- Aphasia / Dysarthria
- Syncope
- Vertigo / Dizziness
- Vomiting
- Headache
- Seizures
- Respiratory pattern change
- Hyper/hypotension
- Altered mental status
- Transient Ischemic Attack (TIA)
- Seizure
- Hypoglycemia
- Hypoxia / Hypercarbia
- Stroke
- Thrombotic / Embolic (85%)
- Hemorrhagic (15%)
- Tumor
- Trauma
- Atypical migraine
Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 to 92-96%
- Blood Glucose Level
- Basic Airway Management
- Perform an extended Cincinnati Stroke Scale followed by a LAMS score to look for large vessel occlusion
- Acquisition of 4-lead/12-lead ECG
- Perform medication cross check for all medication administrations
- Vascular access
- Isotonic Crystalloid if hypotensive
- Acquisition and interpretation of 4-lead/12-lead
- Transport immediately to nearest stroke center if stroke suspected and symptoms less than 24 hours old (scene time less than 15 minutes)
Consult Online Medical Control as Needed
Pearls
Stroke patients are transported per Regional TCD Plan.
Onset of symptoms or “last known well/normal” is defined as the last time the patient was seen symptom free; example: Awakening with stroke symptoms would be defined as an onset time of the previous night when the patient went to bed symptom free.
Whenever possible, a family member should accompany the patient to the hospital to provide a detailed history or provide the hospital with the name and contact information of someone who can.
The differential list on the Altered Mental Status guideline should be considered.
Be alert for airway problems (swallowing difficulty, vomiting).
Hypoglycemia can present as a localized neurological deficit, especially in the elderly.

Blood samples for performing glucose analysis should be obtained through a finger-stick (heel for infants). Venous blood samples may produce artificially high glucose values and should be avoided.

Expanded Cincinnati Pre-hospital Stroke Screen (eCPSS)
Test	Finding
Balance: Have the patient walk in a line with eyes closed
	Uncoordinated/ ”Drunk”/ Stumbling gait
Eyes: Assess for Partial/Total Vision loss in each eye as well as double vision
	double vision
Facial Droop: Have the patient smile or show their teeth.
	move as well as the other side.
Arm Drift: Patient closes eyes and extends both arms straight out, palms up, and for 10 seconds.	both arms and held steady.
	to lift one arm.
Abnormal Speech: Have the patient say: “You cannot teach an old dog new tricks.”	no slurring.
	wrong words, or is unable to speak.

Normal – Coordinated walking

Abnormal –
Abnormal – unable to do a finger-to-nose

Normal – No vision loss or double vision. Blurry vision is considered normal

Abnormal – Any amount of vision loss or

Normal – both sides of face move equally

Abnormal – one side of the face does not

Normal – both arms move the same or

Abnormal – one arm drifts downward or the palm turns towards the ground (pronator drift*) when compared with the other or unable

Normal – patient uses correct words with

Abnormal – patient slurs words, uses the

*Pronator drift is when the forearm will pronate, and arm will drift downwards.

Large Vessel Occlusion (LVO) Stroke Screening

LA Motor Scale (LAMS)
Face	0	Both sides move normally
Face	1	One side is weak or flaccid
Arm	0	Both sides move normally
	1	One side is weak
	2	One side is flaccid/does not move

Grip	0	Both hands grip normally
	1	One hand is weak
	2	One side is flaccid/does not move
Total	0 – 5	Score of 4 or 5 = LVO

LVO suspected patient must be transported to a MO DHSS Level 1 Stroke Center

Transport

Group 1: (Thrombectomy Candidates)
- LAMS ≥4 & Estimated hospital arrival from last known well (LKW) < 24 hours
- Transport to the closest Level 1 bypassing Level 2 stroke center if difference is less than 20 extra minutes of transportation time.
- Use of emergency lights and sirens is strongly recommended if safe.
- If more than 20 extra minutes of transportation time is predicted, transport to closest Level 2 stroke center
- Notify stroke center that patient is a “Group 1 – Thrombectomy Candidate”
- LevelIStrokeCenters.pdf (mo.gov)
Group 2: (Thrombolysis Candidates)
- LAMS ≤3 & estimated hospital arrival from last known well (LKW) < 24 hours
- Transport to the closest Level 1 or Level 2 stroke center.
- Use of emergency lights and sirens is strongly recommended if safe.
- Process shall take into consideration time for transport, patient condition, and treatment window, with the goal to secure the appropriate treatment for the patient within the treatment window.
- LevelIIStrokeCenters.pdf (mo.gov)
Group 3: (Out of the therapeutic window)
- Suspected CVA > 24 hours from LKW
- Transport to stroke center (Level 1-4) in a non-emergent manner
- LevelIIIStrokeCenters.pdf (mo.gov)
Patients presenting with worst headache of life, loss of consciousness associated with headache or neck stiffness, coma or evidence of very severe stroke (i.e.: mute and unable move arm and leg at all) should be transported to Level 1 stroke center
‌Syncope
page break
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
- Syncope with activity is concerning
- Loss of consciousness with recovery
- Lightheadedness, dizziness
- Palpitations, slow or rapid pulse
- Pulse irregularity
- Decreased blood pressure
- Vasovagal
- Hypotension / Hypoperfusion
- Arrhythmia
- Pulmonary embolism
- Micturition / Defecation syncope
- Stroke
- Hypoglycemia
- Seizure
- Toxicological
- Medication effect (hypotension)
- Aoristic Stenosis / Vascular Disease
Care Goals
EMT-B

Paramedic
- Oxygen titrated and PRN
- Blood glucose level
- Basic airway management
- Assess for injury
- Orthostatic vital sign assessment if appropriate
- Acquisition of 4-lead/12-lead ECG
- Perform medication cross check for all medication administrations
- Consider vascular access
- Isotonic Crystalloid as needed for low-volume states, hypotension
- Acquisition/Interpretation of 4-lead/12-lead ECG
Consult Online Medical Control as Needed
Pearls .
Assess for signs and symptoms of trauma if associated or questionable fall with syncope.
Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as a possible cause of syncope.
More than 25% of geriatric syncope is cardiac dysrhythmia based.
Anyone > 65 years old should have continuous cardiac monitoring.
Syncope in the young during activity (passing out while running) is concerning
Syncope without a prodrome (i.e. feeling lightheaded) is also concerning

page break

‌Resuscitation Protocols Airway‌‌

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:

Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
Avoid intubation of the pediatric patient when possible. OPA/NPA is preferred.
Children compensate well initially but decompensate quickly with little warning.
Most pediatric cardiac arrests are due to respiratory compromise.

Percentage of Glottic Opening
Neck mobility
Beard may prevent mask seal.
Facial trauma/instability
Foreign material in airway
Swelling/Edema
Respiratory effort
Thyromental distance

Airway obstruction
Pulmonary edema
COPD/Asthma
Stroke
Drug overdose
Cardiac arrest
Head injury
Anaphylaxis

Clinical Management Options

EMT-B

BLS Foreign Body Airway Obstruction evaluation / removal
Place NPA and/or OPA and ventilate with BVM.
Oxygen, including passive apneic oxygenation 25 LPM with NC
SpO2 monitor
SGA if patient can tolerate an OPA.
Place gastric tube through SGA if possible
Perform medication cross check for all medication administrations

Paramedic

IV / IO access as appropriate for patientcondition
4-lead and 12-lead ECG acquisition and interpretation
Direct laryngoscopy Foreign Body Airway Obstruction evaluation / removal
PEEP Valve: 5 – 20 cm H2O
All advance airway procedures will include passive apneic oxygenation where possible.
Use Airway Management Checklist – Determines PACE (Primary, Alternate, Contingency, Emergency) Plan
Push dose Epinephrine for refractory hypotension prior to sedation
- Adult: 20mcg IV (10 mcg/mL 1:100,000)
- Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
Sedation before Airway Placement
- Ketamine
  - Adult: 200mg slow IV push
  - Pediatric: 2mg/kg slow IV push (max dose 200mg)
- Etomidate
  - Adult and pediatric 0.3mg/kg IV
Video laryngoscopy for intubation (Preferred)
Direct laryngoscopy intubation with Gum Bougie
Nasal/Oral Gastric tube when possible
Continuous EtCO2 is mandatory for all intubations.
Post intubation medications for pain/sedation, Goal of RASS -2:

Ketamine
- Adult: 100mg slow IV push every 2 minutes PRN
- Pediatrics: 1mg/kg (max 100mg per dose) slow IV push every 2 minutes PRN
Fentanyl
- Adult and pediatric 1mcg/kg IV (rounded to the nearest 12.5mg)

Nasal/Oral Gastric tube when possible
Consider Tracheostomy Tube change for patients in distress/unable to ventilate
Difficult airway and “Can’t Oxygenate/Can’t Ventilate/No EtCO2”, Cricothyroidotomy as indicated
- Surgical – 8 years and above
- Needle – Under 8 years

‌Medical Cardiac Arrest

NOTE: FOR NEONATES PLEASE REFER TO PEDIATRIC PROTOCOL NEONATAL RESUSCITATION

FOR NON-NEONATAL PEDIATRIC ARREST REFER TO THIS PROTOCOL

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:
Treating patients on scene for 20 minutes can have improved ROSC rates and survival Avoid intubation of the	STEMI Syncope Seizure Decreased in ETCO2	Hypovolemia Hypoxia Acidosis Hypoglycemia Hyperkalemia Hypothermia Tension pneumothorax Tamponade Toxins Thrombosis (PE, STEMI)
pediatric patient when
possible. OPA/NPA is
preferred. Children compensate well
initially but decompensate
quickly with little warning. Most pediatric cardiac
arrests are due to
respiratory
compromise/hypoxia Transport pediatric arrests
to a level 1 pediatric center

Clinical Management Options

EMT-B

Assess for unresponsiveness, absence of normal breathing, and pulselessness
Assess for obvious death criteria
Begin Pit Crew CPR procedure with Engine until relieved by CHEMS arrival.
BLS Airway Management and BVM with Oxygen as available
Passive oxygenation with nasal cannula/nonrebreather at 25 LPM
Consider airway management with Igel
Place on monitor
For sustained Vtach/Vfib arrest (after the third shock), add a second set of pads to the patient to change the vector of defibrillation
- Do not let the pads touch as it can cause damage to the machines
Perform medication cross check for all medication administrations

Paramedic

Vascular access
Epinephrine for three doses every 5 minutes
- Adult: 1mg IV
- Pediatrics: 0.01mg/kg (max 1mg) IV
- Epinephrine count restarts after a ROSC event
Amiodarone or lidocaine if ventricular fibrillation/tachycardia (VF/VT)
- Amiodarone
  - Adult: 300mg IV 1st dose, 150mg 2nd dose (4 minutes after 1st)
  - Pediatrics: 5mg/kg IV (max adult doses 300mg 1st dose, 150mg 2nd dose 4 minutes after 1st)
- Lidocaine
  - Adult: 100mg IV every 4 minutes (max total dose 3mg/kg)
  - Pediatrics: 1mg/kg IV (max dose 100mg) every 4 minutes (max total dose 3mg/kg)
Fluid bolus with Isotonic Crystalloid as needed
Monitor ETCO2 & ECG
Narrow PEA QRS < 0.12 seconds:
- Consider mechanical causes – Cardiac tamponade, Tension pneumo, Mechanical hyperinflation, PE, Hypovolemia, Acute MI, heart failure
Wide PEA QRS > 0.12 seconds or Asystole:
- Consider metabolic causes – Tricyclic OD, Severe hyperkalemia, Acidosis, Calcium Channel Blocker OD, Acute MI, heart failure.
If awake/awareness during CPR, treat per RASS score.

Consult Online Medical Control as Needed

Pearls

To be successful in adult or pediatric arrests, a cause must be identified and corrected.
Respiratory arrest is a common cause of pediatric cardiac arrest. Unlike adults, early oxygenation and ventilation is critical.
- Assess for airway obstruction if difficult to ventilate
Patients who are greater than 20 weeks pregnant should be transported immediately for consideration of perimortem C-section
In most cases, manage pediatric airways by basic interventions.
Effective CPR is critical: 1) Push hard and fast at appropriate rate 2) Ensure full chest recoil 3) Minimize interruptions in CPR. Pause CPR< 10 seconds only.
Effective CPR and prompt Defibrillation are the keys to successful resuscitation.
Prolonged cardiac arrests may lead to tired providers and decreased compression quality. Ensure compressor rotation, summon additional resources as needed, and ensure provider “rest and rehab” during and post-event.
For pediatrics use volume control device for Dextrose and Fluid infusions
Always quickly confirm asystole in more than one lead.
Trouble shoot for Equipment settings/ problems
Reassess and document airway continuously after every move and at transfer of patient care.
Initiate continuous ETCO2 as soon as practicable.
Calcium and sodium bicarbonate should be given early if hyperkalemia is suspected (renal failure, dialysis). There is no indication for these medications in most cardiac arrests without suspected hyperkalemia or overdose.
Adult treatment priorities: uninterrupted compressions, defibrillation, ventilation, then IV/IO and airway management if needed.
Polymorphic VT (Torsades) may benefit from Magnesium Sulfate.
Prior to any external shocks, providers should verify that defibrillation pads are well adhered to the patient and that they do not touch.
Both lidocaine and amiodarone can be effective for Vtach/Vfib arrests. There is no benefit for amiodarone over lidocaine. Amiodarone can be continued if started by another team. Do not give amiodarone in patients who are pregnant.
‌Cardiac Arrest Algorithm
‌Pit Crew CPR
If Engine/Ladder Arrives First
- Ensure 360o access around patient and consider moving patient before initiating CPR.
- The crew will always maintain a triangular configuration around the patient and occupy positions 1, 2, and 3.
- A member of the crew will occupy position number 1. This crewmember will check for a pulse (10 seconds or less) and if the patient is in cardiac arrest, they will immediately begin High Quality chest compressions at a rate of 110 per minute. The goal is 220 compressions in two mins. There will be a 10:1 ratio of compressions to ventilations once the BVM is ready. They will switch off compressions with provider 2.
- The second crewmember on the pumper will occupy position 2, apply defibrillation pads, and operate the AED/Monitor. Ensure compressions continue during AED charging and immediately resume compressions after shock without pulse check or rhythm analysis.
- The final provider will move to position three on arrival and place an I-gel airway on all patients. Compressions should not be stopped to secure the airway. The paramedic will then ventilate the patient after every 10th compression in a manner that is asynchronous with
  chest compressions. Provider 3 can assess for sufficient chest compressions by performing a pulse check (carotid/brachial).
- The crewmembers in positions 1 and 2 will take turns doing 2 minutes of compressions (110 compressions per minute).
- During Provider 1’s rest cycle, they can consider IV/IO access and initiate drug therapy.
  This can be deferred until more help arrives.
  When the Ambulance Arrives after the Engine/Ladder
When the ambulance arrives, one paramedic will assume position 4 and obtain vascular access. An intraosseous line in the proximal humerus is preferred unless there are any contraindications, followed by IV and then tibial IO. This medic will then oversee giving medications. They can also obtain
history from the family, contact the hospital, or go for equipment if necessary.
The other paramedic on the ambulance will assume position 5 and exchange the AED for the monitor. The goal is to ensure continuous waveform capnography, monitor CPR feedback to correct chest compressions, and defibrillate as needed during pulse checks.
Approximately 15 seconds prior to rhythm check, the monitor should be precharged. If a shockable rhythm is noted, an immediate shock should be delivered. After the shock or if no shock is advised and charged is dumped, the provider (1 or 2) coming off a rest cycle will do 2 minutes of chest compressions.
A carotid pulse needs to be identified during compressions to assist in pulse checks.

Provider 5 will also determine the intubation plan for the patient. If needed, they will convert the I-gel airway to an endotracheal tube. This will be in a controlled fashion with a full intubation setup. Compressions will not be stopped for the intubation attempt. This step can be deferred until after AutoPulse/LUCAS is placed on patient.

Adult Cardiac Arrest A!gorithm

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Epinephrine

ASAP

If no signs of return of spontaneous Girculation (RQCS), go to 10
If ROCS, go to Post-Cardiac Arrest Care checklist

Pediatric Cardiac Arrest Algorithm

CPR Quality

(100-120/min) and allow complete chest recoil

2 minutes, or sooner if fatigued

Shock Energy for Defibrillation

Drug Therapy

0.01 mg/kg (0.1 mUkg of the

Repeat every 3-5 minutes.

If no IV/10 access, may give endotracheal dose: 0.1 mg/kg (0.1 mUkg of the 1 mg/ml concentration).

3 total doses for refractory VF/pulseless VT

lidocaine IV/10 dose: Initial: 1 mg/kg loading dose

Advanced Airway

Reversible Causes

Push hard ( 113 of anteroposterior diameter of chest) and fast
Minimize interruptions in compressions
Change compressor every
If no advanced airway, 15:2 compression-ventilation ratio
If advanced airway, provide continuous compressions and give a breath every 2-3 seconds

First shock 2 J/kg
Second shock 4 J/kg
Subsequent shocks 4 J/kg, maximum 10 J/kg or adult dose

Epinephrine IV/10 dose:

1. mg/ml concentration). Max dose 1mg.
  - Amiodarone IV/10 dose: 5 mg/kg bolus during cardiac arrest. May repeat up to

Endotracheal intubation or supraglottic advanced airway
Waveform capnography or capnometry to confirm and monitor ET tube placement

Hypovolemia
Hypoxia
Hydrogen ion (acidosis)
Hypoglycemia
Hypo-/hyperkalemia
Hypothermia
Tension pneumothorax
Tamponade, cardiac
Toxins
Thrombosis, pulmonary
Thrombosis, coronary

‌ROSC

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:

Stabilize on scene post- ROSC for 10 minutes to optimize the patient

Increased in ETCO2
Return of pulses

Continue to address specific differentials associated with original dysrhythmia.

Clinical Management Options

EMT-B

Paramedic

Continue Oxygenation, target SpO2 92% – 96%
Use Post Resuscitation Checklist below as indicated
Wait 10 minutes prior to transport to help optimize the patient prior to transport
Acquisition of 4-lead/12-lead EKG
Perform medication cross check for all medication administrations

Vascular access
Obtain and monitor 12-lead EKG at 8 minutes
Monitor ETCO2, especially during movement
Acquisition/interpretation of 4-lead/12-lead EKG
Fentanyl as needed for comfort
- 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
Push-dose epinephrine as needed for hypotension
- Adult: 20mcg IV (10 mcg/mL 1:100,000)
- Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
- NOTE: IM vs IV dosing and concentration are VERY different

Consult Online Medical Control as Needed Pearls

(VF/pVT1Asystole/PE!A)
Reassess airway frequently and with every patient move.
Take the time to optimize the patient prior to transport: secure all lines, consider IV access, obtain an EKG, prepare push-dose epinephrine, optimize ETCO2. Patients often re-arrest when transporting to the ambulance. Optimizing the patient prior to transport can reduce this risk.
It is ideal to wait 8 minutes after ROSC for the EKG. The EKG obtained immediately after the cardiac arrest is abnormal and can hide a STEMI. As many cardiac arrests are from STEMI, it is ideal to get a good EKG to assess for a STEMI.
Do not hyperventilate as this is associated with worse outcomes.

Post Resuscitation / ROSC Checklist

Reassess patient and obtain vital signs

Airway confirmed continuously and with each move

Oxygen target 92-96%, use mechanical ventilator as soon as possible.

Continuous EtCO2 (goal 40-50 mmHg) and ECG monitoring

Wait 8 minutes before 12-lead ECG, if STEMI then transmit 12-lead ASAP for early notification

Ketamine / Fentanyl if no hypotension (advanced airway only)

If saline infused, 30 ml/kg, max 2 L

Controlled ventilation < 12 bpm

Adequate personnel for transport

If loss of ROSC, then go to appropriate guideline

‌Termination of Resuscitation

Medical Arrest Termination of Resuscitation Checklist

Medical Arrest: Termination of Resuscitation (> 30 minutes of downtime) Checklist:

Adequate CPR has been administered
ETCO2 is less than 20
PEA rate is less than 40
Airway managed with ET, Igel, cric
IV/IO access has been achieved
Rhythm appropriate medications and treatment administered
Identified reversible causes have been addressed
Failure to establish sustained ROSC at any time
Failure to establish recurring/persistent v-fib
Arrest not due to suspected hypothermia
Providers agree with decision to cease efforts
If all present, may terminate without contacting medical control, otherwise discuss case with

medical control

‌DNR/Advance Directives

Standard:

In the event any provider of the EMS System is presented with a completed Out of Hospital Do Not Resuscitate (OOH-DNR) form and/or OOH-DNR ID device, the provider shall withhold CPR and the listed therapies in the event of cardiac arrest. The form and device may be from any (US) State.

Purpose:

To honor the terminal wishes of the patient and to prevent the initiation of unwanted resuscitation.

If you are unsure whether the patient meets criteria, then resuscitate.

Exceptions:

The provider shall begin resuscitation efforts until such time as a physician or On-Line Medical Control (OLMC) directs otherwise when:
1. The patient is known to be pregnant.
2. If there are any indications of unnatural or suspicious circumstances.
3. If the Provider is unsure of the existence or validity of the DNR.
4. An advanced directive does not imply that a patient refused supportive or palliative care.

Application:

When confronted with a cardiac arrest patient, one of the following conditions must be present to honor the DNR request and withhold CPR and ALS therapy:
1. Out-of-Hospital Do Not Resuscitate (OOH-DNR) or OOH-DNR ID device, original or copy.
2. Valid original or copy of OOH-DNR written order or OOH-DNR ID device from any US state.
3. A licensed physician on scene or in contact by telephone orders that no resuscitation efforts are to take place.
A DNR request may be overridden by:
1. The patient or person who executed the order destroying or directing someone in their presence to destroy the form and/or remove the identification device.
2. The patient or person who executed the order telling EMS providers or attending physician that it is their intent to revoke the order.
3. The attending physician or physician’s designee if present at the time of
  revocation records in the patient’s medical rector the time, date, and place of the revocation and enters “VOID” on each page of the OOH-DNR.
In the event here is a question regarding whether to honor or not honor an OOH-DNR or Advanced Directive, then initiate resuscitation and contact OLMC.

‌Bradycardia with a pulse

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:

Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
Pediatric pads should be used in children < 25kg
If bradycardia is not corrected rapidly and the patient appears poorly perfused, start CPR.

HR < 60 min with hypotension
Acute altered LOC
CHF
Seizure, syncope, or shock secondary to bradycardia.
Altered LOC
Shock / Hypotension
Syncope

Sick sinus syndrome
Heart block
Respiratory distress
Hyperkalemia
Respiratory obstruction
Beta blocker / Digoxin
/Calcium Channel Blocker overdose
Organophosphate
Hypovolemia
Hypothermia
Hypoxia
Infection / Sepsis
Medication or Toxin
Trauma
Acute MI

Clinical Management Options

EMT-B

Oxygen PRN titrated to SpO2 92%-96%
Basic airway management
If pediatric and HR < 60 with poor perfusion despite oxygenation & ventilation, begin Pit Crew CPR
Acquisition of 4-lead/12-lead EKG
Perform medication cross check for all medication administrations

Paramedic

Vascular access
Acquistion/interpretation of 4-lead/12-lead EKG
Place pads on the patient
Monitor ETCO2
Consider fluid bolus
Provide atropine or push dose epinephrine for bradycardia with hypotension
- Atropine
  - Adult: 1mg IV every 3 minutes (max dose 3mg)
  - Pediatric: 0.02mg/kg IV (minimum dose 0.1mg max dose 0.5mg) every 3 minutes (max dose 3mg)
- Epinephrine
  - Adult: 20mcg IV (10 mcg/mL 1:100,000)
  - Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
  - NOTE: IM vs IV dosing and concentration are VERY different
Provide transcutaneous pacing for hypotensive patients who do not improve with atropine or epinephrine
- Provide sedation if transcutaneous pacing with midazolam, lorazepam, or ketamine
  - Midazolam
    - Adults: 5mg IV adults

Pediatric: 0.1mg IV max dose of 5mg

Lorazepam
- Adults: 2-4mg IV
- Pediatric: 0.1 mg/kg IV (max dose 4mg)
Ketamine
- Adults and Pediatric: 1mg/kg IV (max dose 100mg)

Consider hyperkalemia and if suspected treat with calcium, sodium bicarbonate, albuterol
- Calcium Chloride
  - Adult: 1000mg (1g) IV
  - Pediatric: 20mg/kg (max 1000mg) IV
- Albuterol
  - Adult: 5mg
  - Pediatrics: 2.5mg
- Sodium Bicarbonate
  - Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP

Consult Online Medical Control as Needed

Pearls

The use of lidocaine or amiodarone in heart block can worsen bradycardia and lead to asystole and death.
Treatment of bradycardia is based on the presence of symptoms. If asymptomatic, monitor only.
The use of Atropine for bradycardia in the presence of an MI may worsen ischemia.
Consider treatable causes for bradycardia (Beta blocker OD, Calcium channel blocker OD, etc.) –
treat appropriately.
If wide complex bradycardia, consider hyperkalemia.
‌Tachyarrhythmia Narrow Complex
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
used in children < 25 Kg.
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
- Pediatric pads should be
- QRS < 0.12 sec
- Pale or Cyanosis
- Diaphoresis
- Tachypnea
- Vomiting
- Hypotension
- Altered Level of Consciousness
- Pulmonary Congestion
- Syncope
- Underlying accessory pathway (WPW, LGL)
- Tachyarrhythmia
  - SVT
  - AF
- Myocardial infarction
- Electrolyte imbalance
- Exertion, pain, emotional stress
- Fever
- Hypoxia or Anemia
- Hypovolemia
- Drug effect / Overdose
>180 in children
- Consider SVT with HR
- Consider SVT with HR > 220 in infants
- Hyperthyroidism
- Pulmonary embolus
- Alcohol withdrawal
Clinical Management Options
EMT-B

Paramedic
effective
- Oxygen PRN titrated to SpO2 92%-96%
- Basic airway management
- Acquisition of 4-lead/12-lead EKG
- Perform medication cross check for all medication administrations
- Vascular access
- Acquisition/interpretation of 4-lead/12-lead
- Monitor ETCO2
- Vascular access
- Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65
- For stable SVT
  - Have the patient perform vagal maneuvers
    - “Modified valsava maneuver” in adults has been shown to be almost 50%
    - Ice to the face in infants can be effective
  - Consider adenosine (monitor EKG during adenosine use)
    - Adult: 6mg rapid IVP, may repeat with 12mg rapid IVP
    - Pediatric: 0.1mg/kg rapid IVP (max dose of 6 mg), may repeat with 0.2mg/kg rapid IVP (max dose of 12mg)
  - If the patient becomes unstable, perform a synchronized cardioversion
    - Adult: 50-100 J
    - Pediatric Synchronized Cardioversion 0.5-1.0 j/kg, repeat as needed at 2 j/kg
  - Obtain a new EKG after cardioversion (whether with medication or electricity)
- For stable afib/aflutter
  - Consider Magnesium (may cause hypotension so use with caution)
    - Adult: 2g slow IVP
    - Pediatric: 50mg/kg slow IVP (max dose 2g)
  - If the patient becomes unstable, perform synchronized cardioversion
    - Adult: maximum joules
    - Pediatric: 0.5-1.0 j/kg, repeat as needed at 2 j/kg
- Consider sedation (if time allows) prior to cardioversion of SVT/afib/aflutter with midazolam, lorazepam, ketamine, or etomidate
  - Midazolam
    - Adults: 5mg IV adults
    - Pediatric: 0.1mg IV max dose of 5mg
  - Lorazepam
    - Adults: 2-4mg IV
    - Pediatric: 0.1 mg/kg IV (max dose 4mg)
- Ketamine
  - Adults and Pediatric: 1mg/kg IV (max dose 100mg)
- Etomidate
  - Adults and pediatric: 0.1 mg/kg (max dose 20mg)
- For sinus tachycardia, treat the underlying cause of sinus tachycardia
Consult Online Medical Control as Needed
Pearls
- Sinus tachycardia may be misinterpreted as SVT or A-fib. Sinus tach >150 (adult) or >180 (pediatric) may be seen in the septic patient.
  - Obtaining a full EKG can help determine the underlying rhythm
- Use caution in patient currently on antihypertensive medication.
- Adenosine may not be effective in identifiable atrial flutter / fibrillation but is not harmful.
- Cardioverting afib/aflutter can potentially cause a stroke. Do not attempt to cardiovert stable afib/aflutter.
- Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
- Continuous pulse oximetry is required for all atrial fibrillation patients.
- Narrow complex tachycardia in setting of alcohol withdrawal should be treated aggressively with midazolam. If SVT is “exquisitely regular”, any heart rate variability should lead you to consider sinus tachycardia or atrial fibrillation.
- Consider a change of vector of initial cardioversion is unsuccessful to anterior/posterior pad placement.
  ‌Tachycardia with a pulse wide complex
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  used in children <25 Kg.
  - Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
  - Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
  - Pediatric pads should be
  - QRS > 0.12 sec
  - Ventricular tachycardia on ECG (runs or sustained)
  - Conscious, rapid pulse
  - Chest pain
  - Shortness of breath
  - Dizziness
  - Rate usually 150-180 bpm for sustained V-tach
  - Artifact / Device failure
  - Cardiac history
  - Endocrine / Electrolyte
  - Hyperkalemia
  - Drugs / Toxic exposure
  - Pulmonary disease
  - Tricyclic OD
  EMT-B
  
  Paramedic
  - Oxygen PRN titrated to SpO2 92%-96%
  - Basic airway management
  - Acquisition of 4-lead/12-lead EKG
  - Perform medication cross check for all medication administrations
  - Vascular access
  - Acquisition/interpretation of 4-lead/12-lead
  - Monitor ETCO2
  - Vascular access
  - Isotonic Crystalloid PRN titrated to SBP > 100 mmHg or MAP > 65
  - If stable, administer amiodarone or lidocaine
    - Amiodarone
      - Adult: 150mg IV over 10 minutes
      - Pediatric: 5mg/kg IV over 10 minutes (max dose 150mg)
    - Lidocaine
      - Adult: 100mg IV every 4 minutes (max total dose 3mg/kg)
      - Pediatrics: 1mg/kg IV (max dose 100mg) every 4 minutes (max total dose 3mg/kg)
  - Unstable Wide complex tachycardia, cardiovert
    - Adults: Synchronize cardioversion at 100J
    - Pediatric Cardioversion: 1J/kg then repeat at 2J/kg as needed
    - 12 lead ECG post conversion
  - Consider sedation (if time allows) prior to cardioversion of SVT/afib/aflutter with midazolam, lorazepam , ketamine , or etomidate
  - Midazolam
    - Adults: 5mg IV adults
    - Pediatric: 0.1mg IV max dose of 5mg
  - Lorazepam
    - Adults: 2-4mg IV
    - Pediatric: 0.1 mg/kg IV (max dose 4mg)
  - Ketamine
    - Adults and Pediatric: 1mg/kg IV (max dose 100mg)
  - Etomidate
    - Adults and pediatric: 0.1 mg/kg IV (max dose 20mg)
  - If Torsades, give Magnesium
  - If Tricyclic OD, consider Sodium Bicarbonate early
    - Adult and pediatric: 1mEq/kg IVP (max dose 50 mEq)
  - If Hyperkalemia, Calcium, Sodium Bicarbonate, and Albuterol
    - Calcium Chloride
      - Adult: 1000mg (1g) IV
      - Pediatric: 20mg/kg (max 1000mg) IV
    - Albuterol
      - Adult: 5mg
      - Pediatrics: 2.5mg
    - Sodium Bicarbonate
      - Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
  Consult Online Medical Control as Needed
  Pearls
- For witnessed / monitor ventricular tachycardia, try having patient cough while preparing other therapies.
- Wide complex between 100 – 140 beats/min, consider Hyperkalemia.
- Consider a change of vector if initial Cardioversion is unsuccessful to anterior/posterior pad placement.
  ‌Tracheostomy care
- Patient Care Goals:

The overall goal is to avoid hypoxia. All efforts must be exerted to avoid hypoxia. Any repeated attempts to cannulate the trachea must be accompanied by oxygenation efforts to avoid any hypoxic events. Techniques include high-flow oxygen over the stoma accompanied by BVM with oxygen over mouth/nose or combinations thereof to deliver oxygen throughout the procedure if the changeout attempt is not initially successful

Assessment

Pediatric Pearls:

Signs & Symptoms:

Differential:

All children with tracheostomies should have a “go bag” with emergency equipment to

manage tracheostomy

Respiratory distress
Shortness of breath
Secretions from trach

Tracheostomy dislodgement
Trach obstruction
Pneumonia

Transport patient with “go bag”

Upper respiratory infection
Sepsis

Care Goals

EMT-B

Oxygen titrated and PRN
Suction tracheostomy if c/f obstruction
BVM tracheostomy if indicated
If tracheostomy dislodged BVM over nose and mouth (ineffective if previous laryngectomy) or stoma
Basic airway management
Acquisition of 4-lead/12-lead ECG as indicated
Perform medication cross check for all medication administrations

Paramedic

Suction and BVM tracheostomy if indicated
If unable to relieve tracheostomy obstruction or tracheostomy is dislodged it will need to be emergently replaced (procedure details below)
Consider vascular access
Isotonic Crystalloid as needed for low-volume states, hypotension
Acquisition/Interpretation of 4-lead/12-lead ECG

Consult Online Medical Control as Needed

Procedure:

Have all airway equipment prepared for standard airway management, including equipment for orotracheal intubation and failed airway.
Have airway device (endotracheal tube or tracheostomy tube) of the same size as the tracheostomy tube currently in place as well as 0.5 size smaller available (e.g., if the patient has a #6.0 Shiley, then have a 6.0 and a 5.5 tube).
Lubricate the replacement tube(s) and check the cuff.
Remove the tracheostomy tube from mechanical ventilation devices and use a bag-valve apparatus to preoxygenate the patient as much as possible.
Once all equipment is in place, remove devices securing the tracheostomy tube, including sutures and/or supporting bandages.
If applicable, deflate the cuff on the tube. If unable to aspirate air with a syringe, cut the balloon off to allow the cuff to lose pressure.
Remove the tracheostomy tube.
Insert the replacement tube. Confirm placement via standard measures.
If there is any difficultly placing the tube, re-attempt procedure with the smaller tube size.
If difficulty is still encountered, use standard airway procedures such as oral bag-valve mask or endotracheal intubation. More difficulty with tube changing can be anticipated for tracheostomy sites
that are immature – i.e., less than two weeks old. Great caution should be exercised in attempts to change immature tracheotomy sites.

Document procedure, confirmation, patient response, and any complications in the ePCR

Pearls .

DO NOT replace if it was placed 14 days or less ago (risk of creating a false tract)
Always talk to family and/or caregivers as they have specific knowledge and skill
Important to ask if patient has undergone laryngectomy. This does not allow mouth/nasal ventilation by covering stoma nor will there be ability to orotracheally intubate
Use patient’s equipment if available and functioning properly. Estimate suction catheter size by
doubling the inner tracheostomy tube diameter and rounding down
Suction depth: Ask family / caregiver. No more than 3 to 6 cm typically. Instill 2 – 3 mL of NS before suctioning. Do not suction more than 10 seconds each attempt and pre-oxygenate before and between attempts
DO NOT force suction catheter. If unable to pass, then tracheostomy tube should be changed
Always deflate tracheal tube cuff before removal (if there is a cuff balloon, not all trachs are cuffed). Continual pulse oximetry and EtCO2 monitoring if available
DOPE: Displaced tracheostomy tube / ETT, Obstructed tracheostomy tube / ETT, Pneumothorax and Equipment failure
If trouble is encountered with the trach change, then avoid hypoxia by continuing to deliver oxygen via BVM over mouth/nose or over the stoma while continuing to troubleshoot and attempt smaller trach tube or other techniques to secure the airway
Some trachs have cuffs some don’t
Some trachs have an inner cannula which can be removed and cleaned
To reiterate:The overall goal is to avoid hypoxia. All efforts must be exerted to avoid hypoxia. Any repeated attempts to cannulate the trachea must be accompanied by oxygenation efforts to avoid any hypoxic events. Techniques include high-flow oxygen over the stoma accompanied by BVM with oxygen over mouth/nose or combinations thereof to deliver oxygen throughout the procedure if the changeout attempt is not initially successful
‌Withholding resuscitation
1. Signs of obvious death:
  1. Rigor mortis and/or dependent lividity
  2. Decomposition
  3. Decapitation
  4. Incineration
  5. Obviously mortal wounds resulted from severe trauma with obvious signs of organ destruction.
2. Patient submersion great than 20 minutes from the time the patient was witnessed going underwater or from arrival of first public safety entity until the patient is in a position for effective resuscitative efforts to begin.
3. Fetal death with a fetus < 20 weeks by best age determination available at scene; consider products of conception and does not require time of death. Fetal death < 20 weeks may be documented on mother’s ePCR. If > 20 weeks, then create a separate ePCR.
4. Valid DNR
5. Injuries Incompatible with life
  ‌Trauma Protocols Trauma Management‌
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  - Hypotension: (SBP < 70+ 2x Age in years)
  - Massive Hemorrhage
  - Airway
  - Respirations (decompression)
  - Circulation (IV, TXA)
  - Hypothermia / Head injury
  - Pain
  - Wound Care
  - Splinting
  - AMS
  - Respiratory failure
  - Foreign body airway obstruction
  - Hypovolemia
  - Trauma
  - Tension pneumothorax
  - Hypothermia
  - Toxins or Overdose
  - Hypoglycemia
  - Acidosis
  - Acute MI or PE
  - Stroke
  Clinical Management Options
  EMT-B
  
  Paramedic
  - Control external hemorrhage and apply tourniquet(s) as necessary, including junctional tourniquets if needed and available.
  - Wound packing (junctional/extremity) with pressure dressing as appropriate and apply hemostatic gauze if available
  - BLS airway management
  - Place occlusive dressing/chest seal over penetrating torso trauma between supraclavicular areas to umbilicus
  - Evaluate the need for spinal motion restriction
  - Assess GCS score
  - Keep patient supine and warm
  - Administer Oxygen via NRB to all serious trauma patients.
  - Bandage/splint injuries as appropriate for patient condition
  - Acquisition of 4-lead/12-lead EKG if indicated
  - Perform medication cross check for all medication administrations
  - Needle Decompression of the chest as indicated
  - Avoid hypoxia, hypotension, and hyperventilation with significant head injuries
    - These are the killer H-bombs of head injuries
  - If clear evidence of brain herniation, then MILDLY hyperventilate the patient 20-24 breaths per minute. Then titrate ventilation rate to Adult & Pediatric ETCO2 30-35 mmHg,
    - Otherwise aim for 35-45 mmHg if patient has a traumatic brain injury WITHOUT clear signs of herniation.
  - Vascular access
  - For hemorrhagic shock, Calcium Chloride
  - If Hypotensive, IV Crystalloid in 250 mL increments until MAP > 65 or SBP > 90 or until patient mentation improves
  - Pain Management Guideline as needed with morphine , fentanyl , or ketamine
    - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
    - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
    - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
  - 12-lead acquisition and interpretation as indicated
  - ETCO2 assessment
  - Consider Simple Thoracostomy if concern for chest trauma and patient peri-arrest
  - Advance airway management as needed
  - If Adult Neurogenic Shock (as indicated by cervical spine injury, paralysis, hypotension with inappropriately low heart rate/bradycardia) – push-dose epinephrine until MAP > 65
    - 10mcg IV (1:100,000 or 10mcg/ml solution)
  Contact Medical Control as needed
  Pearls
Consider Chest Decompression with signs of shock and diminished/absent breath sounds. If patient arrests or is peri-arrest, then immediately perform bilateral finger thoracostomies.
See East Central EMS Regional Trauma Guidelines for criteria when declaring trauma alert.
Minimize Scene time. If patient meets Trauma Alert criteria, then interventions should be performed enroute.
Severe bleeding from an extremity not rapidly controlled by direct pressure may necessitate the application of a tourniquet.
Permissive hypotension (target fluid resuscitation to MAP 55-65) should be used in the absence of traumatic brain injury, pregnancy, hypertensive history, and age < 45 years old. If traumatic brain injury is suspected, maintain Adult SBP > 90 mmHg.
- Hypotension, hypoxia, and hyperventilation are independent predictors of morbidity and mortality in patients with traumatic brain injuries
  - These are known as the killer H-bombs
Hypotension is devastating to neurologic injury and should be aggressively treated.
MAP calculation [(2 x diastolic) + systolic] divided by 3
Peripheral neurovascular status should be document on all extremity injuries and before and after splinting procedures. Same for neuro status before and after extrication, and before/after transport.
With traumatic amputations, time is critical. Transport and notify medical control immediately, so that the appropriate destination can be determined.
Hip dislocations and knee and elbow fracture / dislocations have a high incidence of neuro- vascular compromise. Document pulse, motor, and sensation.
Urgently transport any injury with vascular compromise.
Blood loss may be concealed or not apparent with extremity injuries.
If evidence of brain herniation (blown pupil, Cushing’s reflex, rapid decline in GCS, or bradycardia) and in absence of capnometer, MILDLY hyperventilate the patient 20 – 24 breaths per minute. If available titrate to: Adult and Pediatric ETCO2 30 – 35 mmHg. ETCO2 < 30 is associated with poor neurologic outcomes.
Increased intracranial pressure (ICP) may cause hypertension and bradycardia with altered breathing (Cushing’s Response).
Consider Altered Mental Status guideline.
The most important item to monitor and document is a change in the level of consciousness and GCS.
Avoid nasal airways in patient’s with significant facial trauma
Consider Restraints if necessary, for patient’s and/or personnel’s protection per the Restraining
Procedure.
For dental trauma, collect teeth and place them in a cup of normal saline. Avoid touching the root of the tooth as much as possible.
Local Level 1 traumas centers
- Barnes-Jewish Hospital, St. Louis Children’s Hospital
- Mercy Hospital
- SLU Hospital, Cardinal Glennon Children’s Hospital

Local Level 2 trauma centers

Mercy Hospital, South

GCS Score Adult

Eyes Open	Best Verbal	Best Motor
4 – Eyes Open	5 – Oriented	6 – Obeys Commands
3 – To Voice	4 – Confused	5 – Localizes Pain
2 – To Pain	3 – Inappropriate	4 – Withdraws from Pain
1 – None	2 – Incomprehensible	3 – Pain-Flexion
	1 – None	2 – Pain-Extended
		1 – None

GCS Score Pediatric

Spinal Motion Restriction

Spinal motion restriction can be accomplished by securing the patient to the stretcher. Do not transport patients on rigid long boards unless the clinical situation warrants long board use. C-collars should be placed for the following:

Patient complains of midline neck or spine pain
Any midline neck or spinal tenderness with palpation
Any abnormal mental status (including extreme agitation)
Focal or neurologic deficit
Any evidence of alcohol or drug intoxication
Another severe or painful distracting injury is present
A communication barrier that prevents accurate assessment
If none of the above apply, patient may be managed without a cervical collar

Do not place a C-collar if the patient has a penetrating injury to the neck as it can delay identification of injury and potentially compromise the airway.

‌Trauma Procedure Needle Decompression

Clinical Indications:

Patients with suspected tension pneumothorax as evidenced by:
1. Hypotension of SBP < 90, clinical signs of hypoperfusion, and at least one of the following:
  1. Jugular vein distention
  2. Absent or decreased breath sounds on the affect side.
  3. Hyper-resonance to percussion on the affected side
  4. Increased resistance when ventilating a patient.
  5. Tracheal deviation away from the side of injury, which is a late sign.
  6. Patient in traumatic arrest with chest or abdominal trauma in whom resuscitation is indicated. These patients may require bilateral chest decompression even in the absence of the signs above.
  7. Asthma patient in Cardiac Arrest, perform bilateral decompression.

Contraindications:

None in the emergency setting.
Procedure:
1. Administer high flow oxygen.
2. Prepare equipment and don appropriate PPE.
3. Identify and prep the site:
  1. Lateral placement at the fourth or fifth intercostal space in the mid-axillary line.
  2. Locate the second intercostal space in the mid-clavicular line.
4. Prepare the site with Alcohol.
5. Insert the appropriate catheter perpendicular to the chest wall over the top of the inferior rib.
6. Advance the needle-catheter assembly through the parietal pleura until a pop is felt and air or blood exists the catheter. Advance only the catheter until the hub is in contact with the chest wall.
7. Remove the needle leaving the plastic catheter in place.
8. Secure the catheter hub to the chest wall.
9. A 60cc syringe may be used to aspirate air to confirm access.
10. Consider placing a one-way valve or creating a flutter valve from the finger of an exam glove. This sho]uld not delay the pleural decompression procedure.
‌Trauma Procedure Finger Thoracostomy
Clinical Indications:
1. Traumatic cardiac arrest with known or suspected injury to the chest/abdomen.
2. Hemodynamically unstable patient with clinical presentation of a tension pneumothorax/hemothorax.
Contraindications:
1. Definitive loss of pulse for > 10 minutes prior to arrival of first unit.
2. May consider the procedure if PEA is present at a rate > 60
3. Any patient that has adequate cardiac output.
4. Injuries incompatible with life.
5. Any pediatric patient that appears too small for utilization of simple thoracostomy.
Preparation for Use:
1. Don appropriate PPE
2. Ensure all equipment is readily available: Scalpel, Curved Kelly Forceps, Chlorhexidine Sponge, Permanent Marker, Chest Seals
3. Ventilation, oxygenation, and IV access should be performed by other crew members and not delay thoracostomy.
Procedure (link to video):
1. Ensure patient is in the supine position and begin on the side most likely to be affected
  by a tension pneumothorax. Abduct the patient’s arm on the same side of the procedure.
2. Identify lateral chest wall site directly over 5th or 6th rib between anterior axillary and midaxillary lines.
3. Cleanse the site with Alcohol
4. Using a scalpel, make a 1–2-inch incision directly over the 5th or 6th rib, between the anterior axillary line and midaxillary line.
5. It is important not to extend or make incisions in or through penetrating wounds when at all possible.
6. Use scalpel for skin only, there after use blunt dissection to pass through the intercostal muscles.
7. Utilizing curved forceps, penetrate the thoracic cavity over the rib making sure to control the depth by grasping the forceps near the curved portion while inserting.
8. Following penetration into the thoracic cavity and with the tips of the forceps, open the forceps maintaining control of the depth and withdraw to create an adequate opening sufficient to place your finger in the chest.
9. Insert finger into pleural space. Ensure the lung is palpated and, if possible, feel caudally for the diaphragm.
10. Allow the soft tissues to fall back over the wound to act as a flutter valve.
11. Repeat the procedure on the opposite side.
  Post Procedure:
  1. If ROSC, then place an occlusive dressing over the wound (Pediatric defib pad, vent chest seal, etc).
  2. If no ROSC, then prior to pronouncement circle simple thoracostomy site and/or other incisions made by EMS. Label each with “EMS” to aid in identification for postmortem examination.
  3. If evidence of tension pneumothorax occurs, including cardiac arrest following ROSC, then remove occlusive dressing(s) and re-insert finger to relieve tension.
‌Burn
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
2) mmHg
for adults and children

thickness (2°) – blistering and painful
thickness (3°) – painless and charred or leathery skin
- Pediatric hypotension is defined as SBP < 70 + (age in years x
- Rule of 9’s is different
- Rapid heat loss from burns is common
- Burns, pain, swelling
- Dizziness
- Loss of consciousness
- Hypotension / shock
- Airway compromise / distress, singed facial or nasal hair, hoarseness / wheezing / stridor
- Superficial (1°) – red and painful
- Partial
- Full
- Chemical
- Thermal
- Electrical
- Radiation
Clinical Management Options
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Basic Airway Management as needed
- Remove rings, bracelets, or other constricting items
- If thermal burn: < 10% body surface area, then cool down the wound with Isotonic Crystalloid or sterile water
- If thermal burn: After cooling cover burn with a dry sheet or dressings
- If chemical burn: Remove clothing or expose area, brush off any dry chemicals or powder, then flush area with large amount of water or Isotonic Crystalloid
- Establish BSA, location(s), and type of burn
- Perform medication cross check for all medication administrations
- Partial/Full Thickness burn area > 10% BSA then:
  - Isotonic solution infusion
    - 1L NS for adults
    - 20cc/kg for children
  - Pain Management Guideline with morphine, fentanyl, or ketamine
    - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
    - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
    - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
  - Continuous ETCO2 and ECG monitoring
- If airway burn: Nebulized Epinephrine for Respiratory Distress and prepare to secure the airway with intubation
  - Adult: 2mg nebulized (1mg/ml) mixed with 1ml normal saline
  - Pediatric: 1mg nebulized (1mg/ml) mixed with 4ml normal saline
- Cricothyrotomy if significant airway edema and unable to intubate
- Calcium Chloride for hydrofluoric acid burns with unstable vital signs, such as hypotension, tachy/bradycardia, ectopic beats, and/or ECG changes
  - Adult: 1000mg IV
  - Pediatric: 20mg/kg IV (max dose 1000mg)
Consult Online Medical Control as Needed
Pearls
- Consider nebulized epinephrine for respiratory distress early in airway burns when horsed/muffled voice, stridor, etc. are presenting. It can cause bronchodilation and reduce the airway edema.
- Evaluate BSA: Use chart or use palm side of patient’s hand = 1% BSA
- Critical Burns:
  - >20% body surface area (BSA) age 10-50.
  - >10% BSA age < 10 or > 50.
  - 3° burns >5% BSA.
  - 2° and 3° burns to face, eyes, hands or feet or genitalia; electrical burns; respiratory burns; deep chemical burns.
  - Burns with extremes of age or chronic disease; and burns with associated major traumatic injury.
- Non-critical burns (< 5% BSA 2nd and 3rd) not complicated by airway compromise or trauma do not require transport to a trauma center.
- Potential CO exposure should be treated with 100% oxygen.
- Potential Cyanide (CN) exposure should be treated with hydroxycobalamin (Cyanokit).
- Circumferential burns to extremities are dangerous due to potential vascular compromise 2° to soft tissue swelling.
- Burn patients are prone to hypothermia – Never apply ice or cool burns that involve >10% body surface area.
- Do not overlook the possibility of multiple system trauma or child abuse with burn injuries.
- Hydrofluoric acid burns of 3% BSA may be fatal and may have little to no external signs
  - Causes massive electrolyte derangements: hypocalcemia, hyperkalemia, and hypomagnesemia resulting in cardiac arrest
    ‌Crush Injury
    Assessment
    Pediatric Pearls:
    Signs & Symptoms:
    Differential:
    2) mmHg
    - Pediatric hypotension is defined as SBP < 70 + (age in years x
    - Compartment Syndrome
      - Pain on passive stretch
      - Paresthesia
      - Paralysis
      - Pallor
      - Pulselessness
    - Hypoperfusion
    - Hypotension
    - Altered Mental Status
    - Skin irritant exposure
    - Dust concentrations in airway
    - Hypo/Hyperthermia
    - Hyperkalemia
    - Dehydration
    - Additional trauma
    EMT-B
    
    Paramedic
    - Oxygen, target SpO2 92 – 96%
    - Treatment in a confined space should be performed only by appropriately trained personnel.
    - Air quality monitoring should be conducted and documented prior to entry into confined space. Continuous air quality monitoring must be maintained once contact is made with victim and when any rescuer is in a confined space. Document air quality measurement at patient location on PCR.
    - Remove rings, bracelets, and other constricting items
    - N95 mask PRN for dust environment
    - Acquisition of 4-lead/12-lead ECG as appropriate
    - Perform medication cross check for all medication administrations
    - If amputation is being considered, contact WUEMS for physician response.
    - Vascular access x 2
    - Bolus Isotonic Crystalloid 20cc/kg for max of 1 liter followed by a continuous drip.
    - Continuous ETCO2 and ECG monitoring once practical.
    - If goes into cardiac arrest, then treat for hyperkalemia with both Calcium Chloride and Sodium Bicarbonate in conjunction with cardiac arrest guidelines.
      - Calcium Chloride
        Adult: 1000mg (1g) IV
        Pediatric: 20mg/kg (max 1000mg) IV
      - Sodium Bicarbonate
        Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
    - Consider a sodium bicarbonate drip if prolonged extrication
    - Add 1 amp bicarb to a 250cc bag of D10. Infuse of 1 hour. Check glucose every 30 minutes if the patient is diabetic or the history is unknown.
    - If MAP > 65 and no respiratory failure, then Morphine, Fentanyl , or Ketamine for refractory pain
      - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
      - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
      - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
    - If MAP < 65 and/or respiratory failure, then Ketamine for pain
      - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
    - Push Calcium Chloride and Sodium Bicarbonate immediately prior to released. Start nebulized Albuterol prior to release of the patient.
      - Calcium Chloride
        Adult: 1000mg (1g) IV
        Pediatric: 20mg/kg (max 1000mg) IV
      - Albuterol
        Adult: 5mg
        Pediatrics: 2.5mg
      - Sodium Bicarbonate
        Adult and Pediatric: 1mEq/kg (max 50 mEq) IVP
    Consult Online Medical Control as Needed
    Pearls
- Refer to drug formulary charts for all medication dosing for both adults and pediatric patients.
- Hydration should begin prior to extrication whenever possible. Large volume resuscitation prior to removal of the crush object and extrication is critical to preventing secondary renal failure and death.
- Crush injury is usually seen with compression of 4-6 hours but may occur in as little as 20 min.
- If possible, monitor patient for signs of compartment syndrome.
- Crush injury victims can 3rd space > 12L in the first 48 hours.
- Elderly patients should be monitored closely for volume overload but do NOT withhold fluids unless clinical signs/symptoms of volume overload.
- The larger the mass crushed (i.e., more limbs) the greater the likelihood of severe rhabdomyolysis and renal failure, which has high risk for hyperkalemia.
- Crush injury may cause profound electrolyte disturbances resulting in dysrhythmias. Monitor as soon as practically possible.
- Do not overlook treatment of additional injuries, airway compromise, hypothermia/ hyperthermia.
- ETCO2 if multiple doses of Narcotic Medication administered or if the patient is altered.
  ‌Drowning/Submersion
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  observation
  - Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
  - Airway and ventilation is a priority
  - Consider transport to pediatric trauma hospital as these patients may need admission for
  - Unresponsive
  - Mental status changes
  - Decreased or absent vital signs
  - Vomiting
  - Coughing
  - Trauma
  - Pre-existing medical problem
  - Pressure injury (diving)
  - Barotrauma
  - Decompression sickness
  - Duration of immersion
  - Temperature of water
  Clinical Management Options
  EMT-B
  
  Paramedic
  - Scene safety & decontaminate patient as needed
  - Evaluate for Cardiac Arrest
  - Oxygen, Target SpO2: 92-94%
  - BLS airway management as needed
  - Evaluate for spinal motion restriction if neuro deficits present
  - Keep patient warm
  - Acquisition of 4-lead/12-lead ECG as appropriate
  - Perform medication cross check for all medication administrations
  - If conscious and with wheezing, Albuterol & Ipratropium Bromide nebulizer
    - Albuterol
      - Adult: 5mg
      - Pediatrics: 2.5mg
    - Ipratropium
      - 0.5mg (adults and pediatrics)
  - If conscious and with rales/rhonchi, CPAP
  - Vascular access
  - Evaluate and interpret ECG and EtCO2
  - Advance airway maneuvers and management as needed
  Consult Online Medical Control as Needed
  Pearls
- Do not attempt a water rescue unless trained.
- Criteria for resuscitation includes:
- Suspected arrest from cause other than submersion
- Patient submersion time less than 20 minutes from witness of person going underwater or from arrival of the first Public Safety entity until the patient is in a position for resuscitative efforts to be initiated.
- On- scene rescuers should consider conversion from rescue to recovery at 20 minutes unless the patient is a diver with an air source, or a patient trapped with a potential air source.
- Final decision for transition from rescue to recovery mode rests with on-scene command.
- Spinal motion restriction should be used when a suspected or known traumatic mechanism preceded the drowning.
- All victims should be transported for evaluation due to potential for worsening over the next several hours.
- Drowning is a leading cause of death among would-be rescuers. Allow appropriately trained rescuers to remove victims from areas of danger.
- With pressure injuries (decompression / barotrauma), if possible, transport dive computer and/or dive logs with patient.
- Consider CPAP early if respiratory distress for any age if adequate mask seal can be established and patient alert.
- Assess water temperature (< 10◦ C / < 50◦ F) defines cold water.
  ‌Lift Assist/Fall
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  - Pediatric hypotension is defined as SBP < 70 + (age in years x 2) mmHg
  - Assess for non-accidental trauma
  - Pain
  - Dizziness
  - Weakness
  - Syncope
  - Difficulty Breathing
  - Altered Mental Status
  - Inability to ambulate
  - Mechanical Fall
  - Stroke
  - Sepsis
  - Electrolyte Abnormality
  - Acute Coronary Syndrome
  - Unmet Healthcare Needs
  - Seizures
  - MI
  Clinical Management Options
  EMT-B
  
  Paramedic
  - Scene safety & decontaminate patient as needed
  - Oxygen, target SpO2 92 – 96%
  - Complete and document a full set of vitals
  - Basic Airway Management as needed
  - General Trauma Assessment
  - Blood glucose level
  - Acquisition of 4-lead/12-lead ECG as appropriate
  - Perform medication cross check for all medication administrations
  - Consider vascular access
  - Consider evaluating EKG, ETCO2
  Consult Online Medical Control as Needed
  Pearls
- Patients that refuse transport to the hospital should be able to ambulate/move at the same ability as prior to the fall/lift-assist.
  - This should be documented as a refusal
- Evaluate and document the reason for the fall. Specifically ask about weakness, lightheadedness, pain prior to falling.
- Ambulation around the scene for multiple feet can help find signs of a stroke or back/hip/femur fracture.
- Consider contacting the patient’s primary care doctor to speak with the physician or leave a voicemail stating that the patient is unable to get off the ground on their own.
- Consider contacting MO Department of Health and Senior Services if there is any amount of concern for elder abuse or the patient is living in a dangerous environment.
- Attempt to remove any tripping hazards in the living environment and perform a fall-risk assessment.
  Home Assessment-home checklist
  ‌High Threat Considerations/Active Shooter Scenario/Care Under Fire
  Definitions
- Hot Zone/Direct Threat Zone: an area within the inner perimeter where active threat and active hazards exists.
- Warm Zone/Indirect Threat Zone: an area within the inner perimeter where security and safety measures are in place. This zone may have potential hazards, but no active danger exists.
- Cold Zone: Normal EMS Operations
  Patient Care Goals
- Assess the scene
- Mitigating further harm
- Accomplish goal with minimal additional injuries
  Assessment, Treatment, and Interventions
- Hot Zone/Direct Threat care considerations:
- Look for cover
- Defer in depth medical interventions if engaged in ongoing direct threat (e.g., active shooter, unstable building collapse, improvised explosive device, hazardous material threat)
- Threat mitigation techniques will minimize risk to patients and providers
- Triage should be deferred to a later phase of care
- Prioritization for extraction is based on resources available and the situation
- Minimal interventions are warranted
- Encourage patients to provide self-first aid or instruct aid from uninjured bystanders
- Consider hemorrhage control:
  - Tourniquet application is the primary “medical” intervention to be considered in
Hot Zone/Direct Threat
- Consider instructing patient to apply direct pressure to the wound if no tourniquet available (or application is not feasible)
- Consider quickly placing or directing patient to be placed in position to protect airway, if not immediately moving patient
- Warm Zone/Indirect Threat care considerations:
  - Maintain situational awareness
  - Ensure safety of both responders and patients by rendering equipment and environment safe (firearms, vehicle ignition)
  - Conduct primary survey, per the Trauma Management guideline, and initiate appropriate life-saving interventions:
    - Hemorrhage Control:
      - Tourniquet
      - Wound packing if feasible
    - Needle Decompression
  - Do not delay patient extraction and evacuation for non-life-saving interventions
  - Consider establishing a casualty collection point if multiple patients are encountered
  - Unless in a fixed casualty collection point, triage in this phase of care should be limited to the following categories:
    - Uninjured and/or capable of self-extraction
    - Deceased/expectant
    - All others
      ‌Traumatic Arrest
      Assessment
      Pediatric Pearls:
      Signs & Symptoms:
      Differential:
      tools. Intubation may
      
      not be the best option
      
      for these patients.
      
      be used in children < 25
      
      Kg.
      
      cause hypoxia leading
      
      to bradycardia
      - Focus on rapid and early BLS airway and ventilation
      - Traumatic Mechanism
      - Apnea
      - Pulseless
      - PEA
      - Medical Cardiac Arrest
      - Exsanguination
      - Tension Pneumothorax
      - Pelvic fracture(s)
      - Hypoventilation
      - Hypovolemia
      - Hemorrhage
      - Toxins
      - Tamponade
      - Pediatric pads should
      - Traumatic airway can
      Clinical Management Options
      EMT-B
      
      Paramedic
      - Assess for obvious signs of death and withhold resuscitation if present (see pearls)
      - Place tourniquets prior to or concurrent with CPR for major hemorrhagic injuries as indicated.
      - Perform Pit Crew CPR for Trauma with basic airway management until Paramedic arrives, and then pause CPR as necessary for correctable traumatic causes of death.
      - Acquisition of 4-lead/12-lead ECG as appropriate
      - Perform medication cross check for all medication administrations
      - Bilateral finger thoracostomy for any torso trauma
      - Consider non-transport if no ROSC or signs of life
      - Consider advanced airway management
      - 4-lead ECG and EtCO2 placement/interpretation
      - Vascular access with Isotonic Crystalloid bolus until ROSC or up to 1 liter
      - Pull all extremities out to anatomical length/position.
      - Calcium Chloride
        Adult: 1000mg (1g) IV
        Pediatric: 20mg/kg (max 1000mg) IV
      - Consider medical etiology if low mechanism
      Consult Online Medical Control as Needed
      Pearls
- Emphasis is to be placed on correcting traumatic causes of death (hemorrhage control, application of pelvic binder/closing open pelvic fractures with a sheet, ventilation, decompression of the chest, reduction of grossly deformed extremities, volume resuscitation, etc.) prior to or concurrent with initiating CPR.
- LUCAS device is contraindicated in traumatic arrests
- Chest decompression should not be delayed for any other medical procedure or intervention to be accomplished, including CPR.
- CPR should be paused during Simple Thoracostomy (Simple Thoracostomy procedure under Trauma Management section) to minimize risk of provider injury.
- There is no indication for using the Lucas device for chest compressions in a traumatic cardiac arrest. However, if it has already been placed, it can be continued during transportation.
- Traumatic arrest patients with short downtime and proximity to an appropriate trauma facility can be considered for transport after reasonable lifesaving interventions are first performed.
- In multi-patient events, traumatic arrests should not receive intervention until there are sufficient responders present to meet the needs of the living patients.
  - Except for lightning strikes, then perform reverse triage by giving higher priority to cardiac/respiratory arrests.
- Obvious signs of traumatic death include:
  - Rigor mortis or dependent lividity
  - the patient is apneic, pulseless, and without other signs of life upon EMS arrival including, but not limited to spontaneous movement, EKG activity, or pupillary response
  - Injuries incompatible with life (such as massive crush injury, complete exsanguination, severe displacement of brain matter)
  - Decapitation: the complete severing of the head from the remainder of the patient’s
    body
  - Transection of the torso: the body is completely cut across below the shoulders and above the hips through all major organs and vessels. The spinal column may or may not be severed
  - Incineration: 90% of body surface area with full thickness burns as exhibited by ash rather than clothing and complete absence of body hair with charred skin
    Finger Thoracostomy
    Clinical Indications:
    1. Traumatic cardiac arrest with known or suspected injury to the chest/abdomen.
    2. Hemodynamically unstable patient with clinical presentation of a tension pneumothorax/hemothorax.
      Contraindications:
      1. Definitive loss of pulse for > 10 minutes prior to arrival of first unit.
      2. May consider the procedure if PEA is present at a rate > 60
      3. Any patient that has adequate cardiac output.
      4. Injuries incompatible with life.
      5. Any pediatric patient that appears too small for utilization of simple thoracostomy.
      Preparation for Use:
      1. Don appropriate PPE
      2. Ensure all equipment is readily available: Scalpel, Curved Kelly Forceps, Chlorhexidine Sponge, Permanent Marker, Chest Seals
      3. Ventilation, oxygenation, and IV access should be performed by other crew members and not delay thoracostomy.
      Procedure (link to video):
Ensure patient is in the supine position and begin on the side most likely to be affected
by a tension pneumothorax. Abduct the patient’s arm on the same side of the procedure.
Identify lateral chest wall site directly over 5th or 6th rib between anterior axillary and midaxillary lines.
Cleanse the site with Alcohol
Using a scalpel, make a 1–2-inch incision directly over the 5th or 6th rib, between the anterior axillary line and midaxillary line.
It is important not to extend or make incisions in or through penetrating wounds when at all possible.
Use scalpel for skin only, there after use blunt dissection to pass through the intercostal muscles.
Utilizing curved forceps, penetrate the thoracic cavity over the rib making sure to control the depth by grasping the forceps near the curved portion while inserting.
Following penetration into the thoracic cavity and with the tips of the forceps, open the forceps maintaining control of the depth and withdraw to create an adequate opening sufficient to place your finger in the chest.
Insert finger into pleural space. Ensure the lung is palpated and, if possible, feel caudally for the diaphragm.
Allow the soft tissues to fall back over the wound to act as a flutter valve.
Repeat the procedure on the opposite side.

Post Procedure:

If ROSC, then place an occlusive dressing over the wound (Pediatric defib pad, vent chest seal, etc).
If no ROSC, then prior to pronouncement circle simple thoracostomy site and/or other incisions made by EMS. Label each with “EMS” to aid in identification for postmortem examination.
If evidence of tension pneumothorax occurs, including cardiac arrest following ROSC, then remove occlusive dressing(s) and re-insert finger to relieve tension.

‌Toxicology Protocols Poisoning/Overdose‌

Assessment
Pediatric Pearls:	Signs & Symptoms:	Differential:
Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg Consider calling poison control early	Altered mental status Nausea/vomiting/diarrhea Pupil changes Tachycardia/bradycardia Tachypnea/bradypnea/apnea Seizures Burns Hyperthermia Hypertension/hypotension	Sepsis Suicidal ideation Heat illness Cold illness DKA Stroke Hypoglycemia Post-ictal

Patient Care Goals

EMT-B

Place in position of comfort
Oxygen target SpO2 92% – 96%

Obtain blood glucose level
Consider contacting poison control at 1-800-222-1222
Obtain 12 lead/4 lead as indicated
Perform medication cross check for all medication administrations

Paramedic

IV / IO access as appropriate for patient condition
IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
Monitor ETCO2 in patients with respiratory distress/failure
Acquisition and interpretation of 12 lead/4 lead
Provide antidotes when available
Consider Push dose Epinephrine IV/IO for hypotension
- Adult: 20mcg IV (10 mcg/mL 1:100,000)
- Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
- NOTE: IM vs IV dosing and concentration are VERY different

Consult Medical Control as needed

Pearls

Frequent re-evaluations are required as patients can deteriorate rapidly.
Identify amount and timing of any ingestions when possible.
Take pill bottles if available.
Reduce the risk of exposure to you and those around you and perform rapid decontamination on scene if necessary.
Consider contacting poison control early to guide treatment options
Provide antidotes early when possible
‌Acetylcholinesterase Inhibitors (Carbamates, Nerve Agents, Organophosphates) Exposure
Symptoms-DUMBELS
Diarrhea
Urination
Miosis/Muscle weakness
Bronchospasm/Bronchorrhea/Bradycardia (the killer B’s)
Emesis
Lacrimation
Salivation/Sweating
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Remove the patient from exposure, remove clothing if contaminated
- Obtain 12 lead/4 lead as indicated
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- Acquisition and interpretation of 12 lead/4 lead
- Atropine and pralidoxime (not available)
  - May require multiple doses of atropine for respiratory symptoms
  - Atropine
    - Adult: 2mg IV/IM every 3 minutes until symptoms resolve (secretions dry out)
    - Pediatrics: 0.02mg/kg (minimum 0.1mg, maximum 0.5mg per dose) every 3 minutes until symptoms resolve (secretions dry out)
Consult Medical Control as needed
Pearls
Be aware of the environment, particularly closed spaces
Decontaminate the patient prior to transport to avoid contaminating providers
‌Airway/Respiratory Irritants
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:

/dyspnea

laryngospasm and

laryngeal edema

cardiogenic)
- Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
- Consider early airway management
- Unusual odor /smell
- Tearing or itchy eyes
- Burning sensation and burns to the nose, pharynx and respiratory tract
- Sneezing
- General excitation
- Cough
- Chest tightness
- Nausea
- Shortness of breath
- Asthma/COPD
- CHF
- FB
- Tracheitis
- Bronchiolitis
- Wheezing
- Stridor
- Dyspnea on exertion
- Dizziness Upper
- Change in voice
- Airway obstruction include
- Pulmonary edema (non-
- Seizures
- Cardiopulmonary arrest
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Provide humidified air
  - 10cc normal saline nebulized
- Obtain 12 lead/4 lead as indicated
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- Acquisition and interpretation of 12 lead/4 lead as indicated
- Consider albuterol for patients with wheezing
  - Adult: 5mg nebulized
  - Pediatric: 2.5 mg nebulized
- Consider early advanced airway options in patients with stridor, drooling, etc
Consult Medical Control as needed
Pearls
Inhalation of a variety of gases, mists, fumes, aerosols, or dusts may cause irritation or injury to the airways, pharynx, lung, asphyxiation, or other systemic effects
Inhaled airway/respiratory irritant agents will interact with the mucus membranes, upper and lower airways based on solubility, concentration, particle size, and duration of exposure
The less soluble and smaller the particle size of the agent the deeper it will travel into the airway and respiratory systems the inhaled toxic agent will go before reacting with adjoining tissues thus causing a greater delay in symptom onset
Smell can help identify toxin
- Fresh mowed hay= phosgene
- Rotten Eggs= Hydrogen Sulfide
  ‌Beta-Blocker Overdose
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  - Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
  - Bradycardia
  - Hypotension
  - Altered mental status
  - Weakness
  - Shortness of breath
  - Possible seizures
  - Sepsis
  - Hypoxia
  - Hypoglycemia
  - Hear block
  - Sick sinus syndrome
  Patient Care Goals
  EMT-B
  - Place in position of comfort
  - Oxygen target SpO2 92% – 96%
  Paramedic
  - Check blood glucose level, especially in the pediatric patient
  - Obtain 12 lead/4 lead as indicated
  - Perform medication cross check for all medication administrations
  - IV / IO access as appropriate for patient condition
  - Acquisition/interpretation of 12 lead/4 lead ECG
  - Consider atropine sulfate for symptomatic bradycardia
    - Adult: Atropine 0.5 mg IV every 5 minutes to maximum of 3 mg
    - Pediatric: Atropine 0.02 mg/kg (0.1 minimum – 0.5 mg maximum per dose) every 5 minutes, maximum total dose 3 mg
  - Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia
  - For symptomatic patients consider Calcium:
    - Adult: 1000mg (1g) slow IVP
    - Pediatric: 20mg/kg (max 1000mg) slow IVP
  - Consider push dose epinephrine after adequate fluid resuscitation and calcium for the hypotensive patient
    - Adult: 20mcg IV (10 mcg/mL 1:100,000)
    - Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
    - NOTE: IM vs IV dosing and concentration are VERY different
  - Consider transcutaneous pacing if refractory to initial pharmacologic interventions
  Consult Medical Control as needed
  ‌Calcium Channel Blocker Overdose
  Assessment
  Pediatric Pearls:
  Signs & Symptoms:
  Differential:
  - Fluids and medications titrated to maintain SBP > 70 + (age x 2) mmHg
  - Bradycardia
  - Hypotension
  - Decreased AV Nodal conduction
  - Cardiogenic shock
  - Hyperglycemia
  - seizures
  - Sepsis
  - Hypoxia
  - Hypoglycemia
  Patient Care Goals
  EMT-B
  
  Paramedic
  - Place in position of comfort
  - Oxygen target SpO2 92% – 96%
  - Check blood glucose level
  - Obtain 12 lead/4 lead as indicated
  - Perform medication cross check for all medication administrations
  - IV / IO access as appropriate for patient condition
  - Acquisition/interpretation of 12 lead/4 lead ECG
  - Consider atropine sulfate for symptomatic bradycardia
    - Adult: Atropine 0.5 mg IV every 5 minutes to maximum of 3 mg
    - Pediatric: Atropine 0.02 mg/kg (0.1 minimum – 0.5 mg maximum per dose) every 5 minutes, maximum total dose 3 mg
  - Consider fluid challenge (20 mL/kg) for hypotension with associated bradycardia
  - For symptomatic patients consider Calcium:
    - Adult: 1000mg (1g) slow IVP
    - Pediatric: 20mg/kg (max 1000mg) slow IVP
  - Consider push dose epinephrine after adequate fluid resuscitation and calcium for the hypotensive patient
    - Adult: 20mcg IV (10 mcg/mL 1:100,000)
    - Pediatric: 10mcg IV (10 mcg/mL 1:100,000)
    - NOTE: IM vs IV dosing and concentration are VERY different
  - Consider transcutaneous pacing if refractory to initial pharmacologic interventions
  Consult Medical Control as needed
  ‌Carbon Monoxide/Smoke Inhalation
  Symptoms
Mild intoxication:
- Nausea
- Fatigue
- Headache
- Vertigo
- Lightheadedness
Moderate to severe:
- Altered mental status
- Tachypnea
- Tachycardia
- Convulsion
- Cardiopulmonary arrest
  Patient Care Goals
  EMT-B
  
  Paramedic
  - Place in position of comfort
  - 100% oxygen via non-rebreather mask or bag valve mask or advanced airway as indicated
  - Obtain 12 lead/4 lead as indicated
  - Perform medication cross check for all medication administrations
  - IV / IO access as appropriate for patient condition
  - Acquisition and interpretation of 12 lead/4 lead
  Consult Medical Control as needed
  Pearls
Consider this in homes where everyone is feeling ill at the same time.
Pregnant patients are much more susceptible for carbon monoxide poisoning due to the fetus’
hemoglobin (fetal hemoglobin) binding to carbon monoxide even more tightly.
‌Cyanide
Symptoms
Anxiety
Vertigo
Weakness
Headache
Tachypnea
Nausea/vomiting
Dyspnea
Tachycardia
Severe poisoning causes altered mental status, arrhythmias, seizures, respiratory arrest
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- 100% oxygen via non-rebreather mask or bag valve mask or advanced airway as indicated
- Obtain 12 lead/4 lead as indicated
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- Consider obtaining EKG
- Administer the Hydroxycobalamin (Cyanokit) if immediately available on scene (should be auto-dispatched to scene of fires with suspected entrapped victims)
  - Adult: Initial dose is 5 g administered over 15 minutes slow IV
    - Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute
      - Gently mix the cyanokit with 200 mL of LR/NS/D5W by rocking back an forth in vial, DO NOT shake the vial
  - An additional 5 g dose may be administered with medical consultation.
  - Pediatric: Administer hydroxocobalamin (Cyanokit) 70 mg/kg (reconstitute concentration is 25 mg/mL)
    - Each 5 g vial of hydroxocobalamin for injection is to be reconstituted with 200 mL of LR, NS or D5W (25 mg/mL) and administered at 10-15 mL/minute
    - 70 mg/kg = 2.8 mL/kg
  - Maximum single dose is 5 g
Consult Medical Control as needed
Pearls
Cyanide should be suspected in occupational or other smoke exposures (e.g. firefighting), industrial accidents, natural catastrophes, suicide and murder attempts, chemical warfare and terrorism (whenever there are multiple casualties of an unclear etiology).
Consider early in hypotensive, critically ill patients who are removed from a fire.
Many modern day materials produce cyanide when burned.
‌Opioid Overdose
Symptoms
exhibiting miosis (pinpoint pupils)
decreased mental status
respiratory depression
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- Naloxone
  - Adult: 0.4-0.5mg IV
  - Adult: 2mg IM/IN
  - Pediatric: 0.1 mg/kg IV/IM/IN (max dose 2mg)
Consult Medical Control as needed
Pearls
The treatment for opioid overdose is respiratory support; the antidote is naloxone. The BVM is more important/should come before antidote administration
Smaller doses of naloxone can be used to help the patient breathe without putting the patient into acute withdrawal
- This can be especially important to consider in patients who have mixed ingestions.
Some patients have pulmonary edema with poor oxygenation after opioid overdose and naloxone administration.
Some patients with pontine strokes present very similar to opioid overdoses (pinpoint pupil, sonorous respirations, unresponsiveness). Consider other causes in patients who are unresponsive to Narcan; consider transport to a stroke center if there is concern for a pontine stroke.
Narcan is not indicated in adult medical cardiac arrests.
Hotline pediatric patients who are in the home of patients requiring Narcan.
‌Radiation Exposure
Symptoms
Nausea and vomiting
Burns
Altered mental status (severe exposure)
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Decontamination by HAZMAT Team/Fire Service
- Obtain 12 lead/4 lead EKG as indicated
- Perform medication cross check for all medication administrations
- IV / IO access as appropriate for patient condition
- Acquisition and interpretation of 12 lead/4 lead EKG as indicated
- Consider pain management
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Identification and treatment of life-threatening injuries and medical problems takes priority over decontamination
Don standard PPE capable of preventing skin exposure to liquids and solids (gown and gloves), mucous membrane exposure to liquids and particles (face mask and eye protection), and inhalational exposure to particles (N95 face mask or respirator)
Do not eat or drink any food or beverages while caring for patients with radiation injuries until screening completed for contamination and appropriate decontamination if needed
Use caution to avoid dispersing contaminated materials
Provide appropriate condition-specific care for any immediately life-threatening injuries or medical problems
‌Riot Control Agents
Symptoms
Eye burning, tearful eyes
Congestion
Coughing
Wheezing
Patient Care Goals
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Decontaminate the patient with normal saline, water
- Fresh air is often all that is needed
- Obtain 12 lead/4 lead EKG as indicated
- Perform medication cross check for all medication administrations
- Acquisition and interpretation of 12 lead/4 lead EKG as indicated
- Albuterol for patients with wheezing and evidence of bronchospasm
  - Adult: 5mg nebulized
  - Pediatric: 2.5 mg nebulized
Consult Medical Control as needed
Pearls
Riot Control Agents are not meant to harm, but they can trigger bronchospasm in some patients. These can be treated with albuterol.
Agents can cause corneal abrasions/irritation if in the eye. Please irrigate thoroughly.
‌Stimulant Overdose
Symptoms
Tachycardia/tachydysrhythmias
Hypertension
Diaphoresis
Delusions/paranoia
Seizures
Hyperthermia

Mydriasis (dilated pupils)

EMT-B

Paramedic

Place in position of comfort
Oxygen target SpO2 92% – 96%
Obtain blood glucose level
Consider external cooling if hyperthermic
Obtain 12 lead/4 lead EKG if possible
Perform medication cross check for all medication administrations

Consider IV/IO as appropriate
Monitor ETCO2


Richmond Agitation Sedation Score (RASS)
+4	Combative	Overly combative or violent and an immediate danger to provider
+3	Very Agitated	Aggressive, non-combative or pulls on or removes tube(s) or catheter(s)
+2	Agitated	Frequent, non-purposeful movement or patient/ventilation desynchrony
+1	Restless	Anxious or apprehensive, movements not aggressive or vigorous
0	Alert and Calm	Spontaneously pays attention to provider
-1	Drowsy	Not fully alert but sustains more than 10 seconds wake, with eye opening in response to verbal command
-2	Light Sedation	Awakens briefly for less than 10 seconds with eye contact or verbal command
-3	Moderate Sedation	Any movement, except eye contact, in response to command
-4	Unarousable	No response to voice or physical stimulation

Obtain and interpret 12 lead/4 lead EKG if possible
Consider fluid bolus
Restraints as indicated
Consider sedation if severely agitated
- RASS +3/+4 Ketamine is preferred if available
  - Adults/peds: 4mg/kg IM (MAX DOSE 400mg, NOTE IM dosing is MUCH different than IV dosing)
  - Adults/peds: 0.5-1mg/kg IV (MAX DOSE 100mg, NOTE IM dosing is MUCH different than IV dosing)
- RASS +2/+3 Droperidol is preferred (droperidol is preferred in anyone has concern for airway compromise)
  - 5-10mg IM (adults only)
  - 5mg IV (adults only)
- RASS +1 Midazolam is preferred
  - Adults: 5-10mg IM
  - Adults: 5mg IV adults
  - Pediatric: 0.1mg IV max dose of 5mg
  - Pediatric: 0.2mg IM/IN max dose of 10mg
- Consider lower dosing in patients who are elderly (65yo+) or acutely intoxicated
- Alternative agents if none of the above are available
  - Haloperidol
    - Adults: 5mg IM/IV
    - Pediatrics: 2mg IM/IV (not for kids younger than 3 or less than 15kg)
  - Lorazepam
    - Adults: 2-4mg IVIM
    - Pediatric: 0.1 mg/kg IV/IM (max dose 4mg)

Restraints Checklist

All other calming attempts have failed, which include at minimum verbal de-escalation and/or reduced stimulation.
Adequate personnel to effect restraint, with consideration to include law enforcement.
Place patient in supine position restrained with 1 arm up and 1 arm down, unless clinically
contraindicated.
Law enforcement must be immediately available if handcuffed.
EMS personnel in constant attendance.
Chemical sedation administered, if required.
Continuous EtCO2, SpO2, ECG, and vital sign monitoring.
Continuous assessment of neurovascular status every 15 minutes, which includes pulse, motion,
sensation in all extremities.
Adequate personnel for transport.
Excited delirium is considered.
Physical and/or chemical restraints reviewed on a periodic basis.
Above documented fully in ePCR, including: Efforts prior to restraint, Time of restraint, Chemical

sedation, Continuous monitoring, Neurovascular status evaluation

Consult Medical Control as needed

Pearls

Stimulants can cause significant hyperthermia and lactic acidosis. It is important to reduce the metabolic activity in patients with severe hyperthermia and lactic acidosis as this can cause death.
- Consider sedation early in severely agitated patients to help reduce metabolic activity
Cocaine has sodium channel blocking effects and can cause significant cardiac conduction abnormalities with a widened QRS. Treatment is with sodium bicarbonate similar to a tricyclic antidepressant.
- Adult and pediatric 1 mEq/kg (max 50 mEq) IVP
Patients with cocaine use and meth use are at higher risk for cardiac disease. Treat chest pain with high degree of suspicion.
‌TASER Injuries
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Remove the barbs
  - Do not remove barbed dart from sensitive areas (head, neck, hands, feet or genitals)
- Obtain 4 lead/12 lead EKG
- Obtain and interpret 4 lead /12 lead EKG
Consult Medical Control as needed
Pearls
Patients can fall when being tased- please evaluate for additional injuries
‌Topical Chemical Burn
EMT-B

Paramedic
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Remove as much chemical as possible
  - If dry chemical, brush as much off as possible
  - If wet chemical, wash of as much as possible
- Perform medication cross check for all medication administrations
- Consider placing IV/IO
- Consider pain management as indicated
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Early decontamination is the most important step.
For any ingestions of substances capable of burns (ie, drano), do a brief evaluation of the mouth to assess for irritation. Transport immediately and consider early airway intervention if the patient develops stridor, difficult maintaining secretions.
Environmental
‌Environmental Protocols Bites/Envenomation‌
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication
- Rash, skin break, wound
- Animal bite
- Human bite
dosing, electrical therapy, and equipment sizes.
- Pain, soft tissue swelling, redness
- Blood oozing from the bite wound
- Evidence of infection
- Shortness of breath, wheezing
- Allergic reaction, hives, itching
- Hypotension or shock
- Snake bite (poisonous)
- Spider bite (poisonous)
- Insect sting / bite (bee, wasp, ant, tick)
- Infection risk
- Rabies risk
- Tetanus risk
- Abscess
- rash
Patient Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- If Insect Bite:
  - Remove stinger, if appropriate
  - Apply ice pack
  - Minimize movement and remove constricting items
- If Snake Bite
  - Splint limb, bandage, and place at level below heart
  - Minimize movement and remove constricting items
  - NO ice pack
- 12 lead/4 lead acquisition as appropriate
- Perform medication cross check for all medication administrations
- Vascular access as appropriate for patient condition
- Acquisition and interpretation of 12 lead/4 lead as appropriate
- Treat for anaphylaxis as indicated
  - IM Epinephrine, up to 3 additional doses q5 minutes as needed for continued symptoms
    - Adult: 0.3 mg IM 1;1000 (1mg/mL)
    - Pediatric: 0.01 mg/kg IM 1;1000 (max 0.3mg)
    - NOTE: IM vs. IV dosing is VERY different
  - Consider Albuterol 2.5mg/3mL for wheezing, chest tightness, shortness of breath
    - Adult: 5mg nebulized
    - Pediatric: 2.5 mg nebulized
  - Consider nebulized epinephrine for stridor/other signs of upper airway obstruction
    - 2mg (of 1mg/ml) for a total of 2ml mixed with 1ml normal saline
  - Consider CPAP, if refractory to Albuterol
  - Diphenhydramine for Allergic Reaction or Dystonia
    - Adult: 50mg IV/IM
    - Pediatric: 1mg/kg IV/IM (max dose 50 mg)
  - IV fluid therapy with Isotonic Crystalloid, titrated to Adult SBP > 100 mmHg
  - Consider Dexamethasone
    - Adult: 10mg PO/IV/IM
    - Pediatric 0.6 mg/kg PO/IV/IM (max 10mg)
- Consider Push dose Epinephrine IV/IO for refractory hypotension
  - Adult 20mcg IV (10 mcg/mL 1:100,000)
  - Pediatric 10mcg IV (10 mcg/mL 1:100,000)
  - NOTE: IM vs IV dosing and concentration are VERY different
- Pain management as needed
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Do not try and catch a live animal (snake, spider, etc) to bring to the Emergency Department.
You may take pictures or bring dead animals in a jar.
Human bites have a very high risk of infection due to oral bacteria.
Dog and Cat bites should be transported/seen that day for antibiotics.
Carnivore bites are much more likely to become infected and all have risk of Rabies exposure.
Cat bites may rapidly progress to infection due to a specific bacterium (Pasteurella).
Venomous snakes in this area are generally of the pit viper family: rattlesnake, copperhead, and water moccasin.
Coral snake bites are rare in our area: Very little pain but very toxic. “Red on yellow – kill a fellow, red on black – venom lack.”
- It is NOT necessary to take the snake to the ED with the patient. Take Picture if possible.
Black Widow spider bites have minimal pain initially but may develop muscular pain and severe abdominal pain (spider is black with red hourglass on belly).
Brown Recluse spider bites can be very painful. Little reaction is noted initially but tissue necrosis at the site of the bite develops over the next few days (brown spider with fiddle shape on back). OK to use ice pack for this bite. Most are uncomplicated but in rare cases can progress to a severe systemic reaction that presents similar to sepsis known as “loxoscelism”
Evidence of infection: swelling, redness, drainage, fever, red streaks proximal to wound
Immunocompromised patients are at an increased risk for infection (diabetes, chemotherapy, transplant patients)
May use soap and water to clean wounds if time and patient condition allows.
Consider contacting the Poison Control Center for guidance. 1-800-222-1222
Bats, skunks, foxes, and raccoons are the most common rabies vectors.
‌Electrical Injuries
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Can be very painful, treat the pain
- Burns
- Cardiac Arrest
- Arrhythmias
- Compartment syndrome
- Additional trauma (from patient being thrown)
- Medical arrest
- Traumatic fall
Patient Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Identify arrhythmias
  - those in cardiac arrest may have excellent outcomes if CPR is started immediately
- Remove constricting clothing or jewelry
- Dress all open wounds
- Assess for additional traumatic injuries
- 12 lead/4 lead acquisition
- Perform medication cross check for all medication administrations
- Vascular access as appropriate for patient condition
- Acquisition and interpretation of 12 lead/4 lead
- Advanced airway management if needed
- Pain management as needed
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Patients may appear dead immediately after electrocution. These patients have excellent survival with CPR.
Internal damage/injury is often more extensive than what appears on the skin. Have a high degree of suspicion for deeper injury.
If the patient became part of the circuit, there will be an additional site near the contact with ground – electrical burns are often full thickness and involve significant deep tissue damage
Assess for potential associated trauma and note if the patient was thrown from contact point –
if patient has altered mental status, assume trauma was involved and treat accordingly
Assess for potential compartment syndrome from significant extremity tissue damage
Assess for additional injuries, as patients can spasm (causing fractures) or be thrown
Determine characteristics of source if possible – AC or DC, voltage, amperage, and also time of injury
Pay special attention to body contact points as these may show burns
‌Diving Injuries
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Joint pain
- Mental status change
- New paralysis
- Confusion, appearing intoxicated
- Coughing up blood
- Hypoxia
- Hypothermia
- Marine envenomation
- Spinal cord injury from diving
Patient Care Goals
EMT-B

Paramedic
known as “the bends”)
- Oxygen, high flow 100% if suspect decompression sickness or air embolism
  - Reduces size of air bubbles in blood stream
- Place in left lateral decubitus position and Trendelenberg if air embolism suspected
  - Traps air in the right ventricle preventing it from traveling to pulmonary arteries and blocking further blood flow from the right ventricle (which would result in cardiac arrest)
- 12 lead/4 lead acquisition
- Perform medication cross check for all medication administrations
- Vascular access as appropriate for patient condition
- Pain management as indicated (in particular with patients with decompression sickness also
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
Decompression sickness (“the bends”) occurs up to 48 hours after diving (so consider travelers)
Be alert for signs of barotrauma (pulmonary barotrauma, arterial gas embolism, pneumothorax, ear/sinus/dental barotrauma etc.) and/or decompression sickness (joint pain, mental status change, other neurologic symptoms including paralysis) or nitrogen narcosis (confusion, intoxication).
You can consider Trendelenburg and left lateral position as it is sometimes recommended to help trap the air in the dependent right ventricle, but this position may increase cerebral edema (so caution in the confused patient)
Air Embolus when in patient is positioned in Left lateral and Trendelenberg traps the air bubble in the right ventricle preventing it from going into the pulmonary arteries/systemic circulation
‌Hyperthermia
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Weakness
- Nausea & vomiting
- Cramping
- Syncope
- Diaphoresis & anhidrosis
- Altered Mental Status
- Bizarre behavior
- Hypotension
- Tachycardia
- CVA
- Dehydration
- Encephalopathy
- Meningitis / Sepsis
- Head Trauma
- Overdose / Toxin
- Hypoglycemia
- Excited delirium
- Alcohol withdrawal
Patient Care Goals
EMT-B

Paramedic
- Age-appropriate core body temperature assessment
- Oxygen, target SpO2 92 – 96%
- Move to shaded/cool environment, discontinue physical activity, PO fluids if tolerated
- If AMS, then BGL assessment
- If AMS and/or body temperature > 102.2 F, then active cooling measures per patient condition:
  - Ice packs to neck, axilla and groin, wet patient, and increased airflow
- 12 lead/4 lead acquisition
- Perform medication cross check for all medication administrations
- Vascular access
- Consider infusing Isotonic Crystalloid fluids titrated to effect
- If AMS, then may infuse cold Isotonic Crystalloid if available up to 30 mL/kg or titrated to effect
- If shivering develops, Midazolam or lorazepam for sedation
  - Midazolam
    - Adults: 5-10mg IM/IN
    - Adults: 5mg IV adults
    - Pediatric: 0.2mg IM/IN, max dose of 10mg,
    - Pediatric: 0.1mg IV max dose of 5mg
  - Lorazepam
    - Adults: 2-4mg IVIM
    - Pediatrics 0.1 mg/kg IV/IM (max dose 4mg)
Consult Medical Control as needed
Pearls
Signs of improvement to help titrate to effect include improved heart rate, decrease body temperature, resolution of thirst, feeling the need to urinate and/or increased urination, improvement in mental status, improvement in skin conditions, etc.
If increased temperature, utilize passive cooling by removing excessive clothing or covers.
NSAIDS should not be used in the setting of environmental heat emergencies.
Exertional heat stroke should be suspected in anyone with a history of recent exertion and bizarre behavior, seizure, or syncope.
Any AMS should have blood glucose performed. Severe heat emergencies may lead to liver dysfunction and hypoglycemia.
If AMS and cold isotonic crystalloid fluids are not available, then begin isotonic crystalloid boluses.
Damage caused by heat stroke is determined by how high the temperature got and how long it remained elevated.
Cold water immersion is the most effective means of cooling.
Active cooling should be removed when body temperature reaches 102.2 F.
‌Hypothermia
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Hypothermia appears quickly in children
- Cold, clammy
- Shivering
- Mental status changes
- Extremity pain or sensory abnormality
- Bradycardia
- Hypotension or shock
- Metabolic disorder (hypoglycemia, hypothyroidism)
- Toxins
- Environmental exposure
- Shock
- Sepsis
Patient Care Goals
EMT-B

Paramedic
- Oxygen, target SpO2 92 – 96%
- Temperature less than 95 F (< 35 C): Remove wet clothing, blankets as needed
- Handle very gently if < 88 F (< 30 C)
  - Can quickly deteriorate to cardiac arrest
- Blood glucose assessment
- Use heat packs
- Increase temperature of transport compartment
- Vascular access
- Warm IV Isotonic Crystalloid if available
Consult Medical Control as needed
Pearls
Extremes of age are more susceptible (young and old)
< 34 C (93.2 F), shivering may diminish at < 31 C (87.8 F) shivering may stop.
With temperature less than 30 C (88 F) ventricular fibrillation is common cause of death. Handle patients gently to reduce the risk. Transport immediately for re-warming.
If the temperature is unable to be measured, treat the patient based on the suspected temperature.
Hypothermia may produce severe physiologic bradycardia. Do not treat unless profound hypotension unresponsive to fluids.
Hypothermia:
o Mild: 89.6 – 95 F (32 – 35 C)
o Moderate: 82.4 – 89.6 F (28 – 32 C)
o Severe: < 82.4 F (< 28 C)
During warming, cold blood may re-enter central circulation causing a subsequent decrease in body temperature.
Cardiac arrest secondary to hypothermia have high resuscitation potential and should not be terminated on the scene
‌Lightning Injuries
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Fern-like rash
- Burns
- Cardiac Arrest
- Arrhythmias
- Compartment syndrome
- Additional trauma (from patient being thrown)
- Seizures
- Confusion
- Numbness/paralysis
- Amnesia
- Fixed pupils (autonomic dysfunction
- Medical cardiac arrest
- Traumatic arrest
- Stroke
- Herniation
- hypothermia
Patient Care Goals
EMT-B
- Reverse triage-cardiac arrests treated first
- Oxygen, target SpO2 92 – 96%
Paramedic
- Identify arrhythmias
  - those in cardiac arrest may have excellent outcomes if CPR is started immediately
- Remove constricting clothing or jewelry
- Dress all open wounds
- Assess for additional traumatic injuries
- Acquisition of 4 lead/12 lead
- Vascular access as appropriate for patient condition
- Acquisition and interpretation of 4 lead/12 lead
- Pain management if indicated
  - Acetaminophen/Ibuprofen for mild to moderate pain
    - Acetaminophen
      - Adult: up to 1000mg PO
      - Pediatric: 15 mg/kg PO (max 1000mg)
    - Ibuprofen
      - Adult: 600mg PO
      - Pediatric: 10mg/kg PO (max 600mg)
  - Morphine 0.1 mg/kg IV/IM(2-4 mg max pediatrics, 4-8mg max for adult)
  - Fentanyl 1mcg/kg max 100mcg IV/IM/IN(round to nearest 12.5mcg-25mcg below 100mcg)
  - Ketamine 0.2mg/kg IV (10mg max pediatrics, 25mg max adults)
Consult Medical Control as needed
Pearls
If multiple victims present, utilize reverse triage and focus initial efforts on those in cardiac arrest first. Patients have excellent survival with CPR
Lack of bystanders and patient amnesia can make it difficult to identify lightening scenes.
Monitor EKG. Be alert for potential arrhythmias. Consider 12-lead EKG, when available. Risk of arrhythmias can occur up to 24 hours past event.
Fixed/dilated pupils may be a sign of neurologic insult, rather than a sign of death/impending death – Should not be used as a solitary, independent sign of death for the purpose of discontinuing resuscitation in this patient population
May have stroke-like findings as a result of neurologic insult
May have secondary traumatic injury as a result of overpressurization, blast or missile injury Lichtentberg figures is a physical finding that may be seen (pictured below)
‌OB Protocols
‌Labor and Childbirth
Assessment
History:
Signs & Symptoms:
Differential:
- Due date of LMP
- Time contractions started & how often
- Rupture membranes
- Time / amount of any vaginal bleeding
- Sensation of fetal activity
- Past medical and pregnancy/delivery history
- Medications
- If known high risk pregnancy
- Episodic pain
- Vaginal discharge or bleeding
- Crowning of urge to push
- Meconium
- Urge to defecate
- Abnormal presentation:
- Buttock
- Foot
- Hand
- Prolapsed cord
- Placenta previa
- Abruptio placenta
- Premature labor
Clinical Management Options
EMT-B

Paramedic
- High Flow Oxygen to all mothers with imminent childbirth
- Always check for nuchal cord once the head has been delivered
- Reference complications of delivery maneuvers
- Wipe the face and mouth clean with a clean towel
  - If there is evidence of meconium (brown/yellow amniotic fluid) suction the mouth than nostrils.
- If baby is not in distress, consider delayed cord clamping for up to 60 seconds.
- Skin to skin contact for mother and baby and encourage infant to breast-feed.
  - Breast feeding helps contract the uterus to prevent post-partum hemorrhage
- If post-partum hemorrhage
  - fundal massage
  - check perineum for significant lacerations and apply direct pressure if indicated
- See Clinical Procedures for Birthing and Position Complications
- Vascular access with Isotonic Crystalloid titrated to SBP 90 mmHg for vaginal hemorrhage
Contact Medical Control as needed
Pearls
Document all times (delivery, contraction frequency, and length)
Record APGAR at 1 minute and 5 minutes after birth.
If maternal seizures: refer to the Obstetrical Emergencies Guideline. Eclampsia can occur up to 2 months post-partum.
After delivery, allowing child to nurse and massaging the uterus (lower abdomen) will promote uterine contraction and help to control postpartum bleeding.
Post-partum hemorrhage defined as blood loss > 1000mL or > 500mL with signs/symptoms of hypotension. The perineum should be checked for bleeding from vaginal tears. Bleeding should be controlled by direct pressure over the laceration.
The most common cause of post-partum hemorrhage is uterine atony due to prolonged labor, or multiple gestations.

Complications of Delivery Maneuvers

Most deliveries proceed without complications – If complications of delivery occur, the following are recommended:

Shoulder dystocia – if delivery fails to progress after head delivers, quickly attempt the following
1. Hyperflex mother’s hips to severe supine knee-chest position
2. Apply firm suprapubic pressure to attempt to dislodge shoulder
3. Apply high-flow oxygen to mother
4. Transport as soon as possible
5. Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team
Prolapsed umbilical cord
1. Placed gloved hand into vagina and gently lift head/body off cord
  1. Assess for pulsations in cord
  2. Maintain until relieved by hospital staff.
2. Consider placing mother in prone knee-chest position or extreme Trendelenburg
3. Apply high-flow oxygen to mother
4. Transport as soon as possible
5. Contact/transport to closest appropriate receiving facility for direct medical oversight and to prepare team
Breech birth
1. Place mother supine, allow the buttocks and trunk to deliver spontaneously, then support the body while the head is delivered
2. If head fails to deliver, place gloved hand into vagina with fingers between infant’s face
  and uterine wall to create an open airway
3. Apply high-flow oxygen to mother
4. Transport as soon as possible
5. Contact direct medical oversight and/or closest appropriate receiving facility for direct medical oversight and to prepare team
6. The presentation of an arm or leg through the vagina is an indication for immediate transport to hospital
7. Assess for presence of prolapsed cord and treat as above
Nuchal Cord
1. Once the baby’s head as been delivered, check an umbilical cord around the neck
2. If the cord is loose, pull over the head
  1. It is essential not to break the cord, do not pull hard
3. If the cord is tight, clamp the cord and cut. Then have the mother push to deliver the baby quickly
  1. Anticipate need for oxygen and resuscitation if the cord is cut prior to delivery.

‌Eclampsia/Pre-Eclampsia

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Assessment
History:	Signs & Symptoms:	Differential:
Past medical history Hypertension meds Prenatal care Prior pregnancies / births Gravida / Para	Upper abdominal pain jaundice Seizures Hypertension Severe headache Visual changes	Pre-eclampsia / Eclampsia Chronic hypertension CHF Seizure disorder

Edema of the hands and face

Clinical Management Options

EMT-B

Oxygen, target SpO2 to 92-96%
Airway management as indicated
Acquisition of 4 lead/12 lead ECG as appropriate

Paramedic

Vascular access
Give Magnesium Sulfate (give Magnesium sulfate if pregnant and has a seizure)
- 4g IV slow over 5 minutes
Can consider lorazepam, or midazolam if seizure continue after Magnesium
- Midazolam
  - 5-10mg IM/IN
  - 5mg IV
- Lorazepam
  - 2-4mg IVIM
Monitoring & Interpretation of 4 lead/12 lead ECG and EtCO2

Pearls

Eclamptic seizures may occur up to 2 months post-partum. Always consider in pregnant/recently pregnant seizing patient.
Magnesium is the first line treatment. Patient’s will continue to seize if not provided magnesium
- Some patients have a seizure disorder and pregnancy. You can consider lorazepam or midazolam if seizures continue after magnesium as this may be a sign of a separate seizure disorder.
Severe headache, vision changes, edema, or RUQ pain may indicate preeclampsia.
In the setting of pregnancy, hypertension is defined as a SBP greater than >140 or a DBP > 90, or relative increase of 30 systolic and 20 diastolic from the patient’s normal (pre-pregnancy) blood pressure.
Magnesium may cause hypotension and decreased respiratory drive, monitor closely.
If > 20 weeks consider left lateral position.
‌OB Emergencies
Assessment
History:
Signs & Symptoms:
Differential:
- Past medical history
- Hypertension meds
- Prenatal care
- Prior pregnancies / births
- Gravida / Para
- Vaginal bleeding
- Abdominal pain
- Severe headache
- Visual changes
- Pre-eclampsia / Eclampsia
- Placenta previa
- Placenta abruptio
- Spontaneous abortion
Clinical Management Options
EMT-B

Paramedic
- Oxygen, target SpO2 to 92-96%
- If post-partum hemorrhage, then fundal massage and encourage infant to breast feed
- Vascular access
- Isotonic bolus for hypotension
Pearls
Any pregnant patient involved in a MVC should be seen immediately by a physician for evaluation and fetal monitoring in a Trauma Center.
Small trauma can cause placental abruption in patients who are >20 weeks pregnant. Transport to OB capable hospitals if complaining of any abdominal pain after even minor falls/injuries
Post-partum hemorrhage defined as blood loss > 1000mL or greater than 500mL with signs/symptoms of hypotension. 500mL blood loss is commonly seen in uncomplicated vaginal deliveries without signs or symptoms. The perineum should be checked for bleeding from vaginal tears which may be mistaken for uterine bleeding. Bleeding should be controlled by direct pressure over the laceration.
The most common cause of post-partum hemorrhage is uterine atony due to prolonged labor or multiple gestations
If > 20 weeks consider left lateral position.
If >20 weeks pregnant OR the uterus is above the umbilicus in a cardiac arrest patient, consider immediate transport for peri-mortem C-section.
‌Pediatric Protocols
‌Brief Resolved Unexplained Event (BRUE)
Patient Care Goals
Recognize patient characteristics and symptoms consistent with a BRUE
Promptly identify and intervene for patients who require escalation of care
Identify high risk patients and choose proper destination for patient transport
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
High Risk if:
Hx of any of the following:
- Thorough physical exam and history are critical to exclude other causes
- Maintain a high level of suspicion for non- accidental trauma
- <60 days old
- <32 weeks gestation
- >1 minute (currently or historical)
- >1 event
- Concerning history or exam
- CPR provided
- Child < 1yo
- Well appearing child
- Cyanosis or pallor
- Absent, decreased, or irregular breathing
- Marked change in tone (hyper- or hypotonia)
- Altered level of responsiveness.
- No alternative cause
- Upper or lower respiratory tract infection
- Trauma/Abuse
- Toxic Ingestion
- Sepsis
- Metabolic disorder
- GERD (spitting up)
- Seizures
- Cardiac disease/arrhythmia
- Infantile botulism
- Hypoglycemia
Patient Care Goals
EMT-B

Paramedic

Critical Aspects of History-separate into chart under pearls
- Place in position of comfort
- Obtain complete set of vitals
- POC blood glucose
- Oxygen target SpO2 92% – 96%
- ETC02 if patient will tolerate
- Cardiac monitor and continuous pulse oximetry
- Thorough physical exam of the exposed child
- Acquisition of EKG if indicated
- Consider EKG if concern for cardiac etiology or cardiac history
- IV access not indicated unless signs of shock or dehydration
- History of circumstances and symptoms before, during, and after the event, including duration, interventions done, and patient color, tone, breathing, feeding, position, location, activity, level of consciousness, bystander CPR or rescue breaths
- Other concurrent symptoms (fever, congestion, cough, rhinorrhea, vomiting, diarrhea, rash, labored breathing, fussy, less active, poor sleep, poor feeding)
- Prior history of BRUE
- Past medical history (prematurity, prenatal/birth complications, gastric reflux, congenital heart disease, developmental delay, airway abnormalities, breathing problems, prior hospitalizations, surgeries, or injuries)
- Family history of sudden unexplained death or cardiac arrhythmia in other children or young adults
- Social history: who lives at home, recent household stressors, exposure to toxins/drugs, sick contacts)
- Considerations for possible child abuse (multiple/changing versions of the story; reported mechanism of injury does not seem plausible, especially for child’s developmental stage)
Consult Medical Control as needed
Pearls
Regardless of patient appearance, all patients with a history of signs or symptoms of BRUE should be transported for further evaluation
Consider transport to a facility with pediatric critical care capability for patients with high risk criteria as above
Contact direct medical oversight if parent/guardian is refusing medical care and/or transport, especially if any high-risk criteria are present
‌Bronchiolitis/Croup Pediatric
Patient Care Goals
Promptly identify pediatric respiratory distress, failure, and/or arrest, and intervene for patients who require escalation of therapy. Deliver appropriate therapy by differentiating other causes of pediatric respiratory distress.
Patient Safety Considerations
Assessment
Pediatric Pearls:
Signs & Symptoms:
Differential:
- Nasal suctioning can rapidly improve distress
- Use approved reference document for medication dosing, electrical therapy, and equipment sizes.
- Focus on rapid and early BLS airway and ventilation tools. Intubation may not be the best option for these patients.
- Pediatric pads should be used in children < 10 kg.
- Bronchiolitis occurs in age < 2 years, otherwise consider
- Rhinorrhea
- Cough
- Fever
- Tachypnea or other signs of respiratory distress
- Bronchiolitis is a lower airway illness and can cause wheezing and coarse breath sounds
- Croup is an upper airway illness and can cause Barky cough and/or Inspiratory or Expiratory Stridor
- Asthma
- Foreign body aspiration
- Pneumonia
- GERD
- Croup
- Bronchiolitis
- Pertussis
- Epiglottitis
- Anaphylaxis
- Submersion/drowning
Patient Care Goals
EMT-B

Paramedic
Signs of Respiratory Failure-Separate checklist under pearls please
- Place in position of comfort
- Oxygen target SpO2 92% – 96%
- Suction the nose and/or mouth (via wall mount or portable suction)
- Basic airway management as needed
- Perform medication cross check for all medication administrations
- Monitor ETCO2 if the patient tolerates it
- Vascular access if critically ill
- Provide Inhaled Epinephrine for severe respiratory distress suspected secondary to suspected croup or bronchiolitis that is not improved with suctioning and/or oxygen
  - Nebulized: 1mg/ml mixed with 4ml saline
- Dexamethasone for suspected croup
  - 0.6 mg/kg IV/IM/PO (max dose 10mg)
- NIPPV for severe respiratory distress
- Change in mental status such as fatigue and listlessness
- Pallor
- Dusky appearance
- Decreased retractions
- Decreased or irregular respiratory rate
- Decreased breath sounds with decreased stridor
Consult Medical Control as needed
Pearls
Bronchiolitis is a common lung infection in children
Croup is a common upper airway infection in children
Upper airway obstruction can have inspiratory, expiratory, or biphasic stridor
Foreign bodies can mimic croup, it is important to ask about a choking event
Symptoms worsen over the course of 2-3 days after the onset of a viral syndrome
This is a clinical diagnosis and labs or imaging are rarely indicated
Suctioning can be a very effective intervention to alleviate distress, since infants are obligate nose breathers
Albuterol is not generally indicated or beneficial in the treatment of bronchiolitis but may be trialed if wheezing is present or has been effective in the past
Nebulized saline, Ipratropium and other anticholinergic agents should not be given to children with bronchiolitis in the prehospital setting
Improvement of oxygenation and/or respiratory distress should be achieved with the least invasive method possible at all times
BVM is the preferred airway management option in children. Consider Igel in patients that cannot be ventilated with BVM
About 3% of infants will require admission to the hospital, and the mortality rates vary from 0.5% to 7% in high risk patients
The management of bronchiolitis is supportive with suctioning, hydration and oxygen. No specific medications treat the infection.
‌Newborn Resuscitation/Care
Assessment
History:
Signs & Symptoms:
Differential:
- Due date and gestational age
- Multiple gestation (twins, etc.)
- Meconium
- Delivery difficulties
- Congenital disease
- Maternal medications
- Maternal risk factors:
- Substance misuse
- Smoking
- Respiratory distress
- Normal peripheral cyanosis or mottling
- Abnormal central cyanosis
- Altered level of responsiveness.
- Bradycardia
- Airway failure
- Secretions
- Respiratory drive
- Infection
- Maternal medication effect
- Hypovolemia
- Hypoglycemia
- Congenital heart disease
- Hypothermia
- Narcotic in the system from maternal drug abuse
Patient care goals
EMT-B
“minutes of life” recommendation
Paramedic
o 0.01 mg/kg (1:10,000) IV/IO
- Wipe nose and mouth with sterile gauze
- Suction if meconium or airway obstruction (routine suctioning no longer recommended)
- Vigorously dry and stimulate infant.
- Keep warm.
- If full term, good tone, and breathing/crying: allow to breastfeed & skin to skin contact for mother and baby.
- SpO2 on right hand (Preductal) – Follow Saturations Chart based on “Minutes of Life.”
  - 1 minute of life 60-65%
  - 2 min 65-70%
  - 3 min 70-75%
  - 4 min 75-80%
  - 5 min 80-85%
  - 10 min 85-95%
- If just after birth pulse is < 100: BVM on “room air” for 30 seconds @ rate of 30-60 BPM.
- If, after initial ventilations, pulse continues at:
  - < 60: Begin CPR, 120 compressions with asynchronous ventilations at 30 per minute. 3:1 ratio. Begin with room air and progress to Oxygen
  - 60 – 100: BVM only on “room air” add Oxygen as needed to increase SpO2 if less than
  - ≥ 100: Monitor and Reassess.
- BGL heel stick if indicated
- Place on monitor if indicated
- Intubate if indicated and appropriate equipment available ETT 2.0-2.5 mm
- I-gel size 1
- Continue manual ventilations until spontaneous ventilations
- Continue chest compressions until HR above 60
- Vascular access – IV or IO if cardiac arrest or critical condition (IF appropriate IO size available)
- Naloxone if mother received narcotics just prior or during childbirth
  - 0.1mg/kg IV/IO
- Dextrose infusion if BGL < 50
  - 1ml/kg (0.2g/kg) D10W IV/IO infusion
- Isotonic Crystalloid titrated to perfusion.
- For refractory bradycardia or cardiac arrest, Epinephrine
- Do not allow mother to hold newborn in arms during ambulance transport.
- Advance airway maneuvers and management as needed.
Pearls
It is very important to keep environment as warm as possible
Pulse ox is low in first minutes of life, this is normal keep oxygen levels at goal in fist minutes of life
Pulse on right wrist/hand
Avoid giving to much oxygen as this can cause brain and lung damage
If BVM necessary position child’s head in “sniffing” position
If BVM necessary only administer just enough air for chest rise (which is a tiny amount), too much breath can cause pneumothorax
BVM rate at about 30-60 breaths per minute
To avoid hyperventilation it may be helpful to count “squeeze, two, three, squeeze, two, three”
If chest compressions also required count “one and two and three and squeeze” with chest compressions occurring on each number count and then breath administered on “squeeze”

Head position

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‌Normal vital signs pediatric
Normal Respiratory Rate (breaths/min)
Age Infant (< 1 year) Toddler (1 to 3 years) Preschooler ( 4 to 5 years) School – aged child (6 to 12 years) Adolescent (13 to 18 years)	Rate 30 to 60 24 to 40 22 to 34 18 to 30 12 to 16
Heart Rate (per minute) Age	Awake Rate	Mean	Sleeping Rate
Newborn to 3 months	85 to 205	140	80 to 160
3 months to 2 years	100 to 190	130	75 to 160
2 to 10 years	60 to 140	80	60 to 90
> 10 years	60 to 100	75	50 to 90

Blood Pressure

Typical systolic BP for 1 to 10 years of age: 90 + (age in years x2) mmHg
Lower limits of systolic BP for 1 to 10 years of age: 70 + (age in years x2) mmHg
Lower range of normal systolic BP for > 10 years of age: approximately 90 mmHg
Typical mean arterial pressure: 55 + (age in years x 1.5) mmHg

‌Medications Acetaminophen‌

Aliases:	APAP, Tylenol
Indications:	Fever with or without seizures, or pain
Contraindications:	Allergy, hypersensitivity, severe hepatic impairment, or severe active liver disease
Concentrations:
Tablets		325 or 500 mg
Liquid		32 mg/mL
Adult Dosing
Indication	Dose	Route	Note

Pain Fever		Up to 1000 mg	PO		One time only

Pediatric Dosing
Indication		Dose	Route		Note
Pain Fever		15 mg/kg (Max: 1000 mg)	PO		One time only
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Pregnancy Category B. Use in caution with known thrombocytopenia and/or Liver Disease. Many medications contain Acetaminophen. Read labels of meds that patients have taken recently.
Adverse/Side Effects:	N/V, abdominal pain
Class:	Analgesic, Antipyretic
Mechanism of Action:	Equivalent to Aspirin in both analgesic and antipyretic effects. Unlike Aspirin, Acetaminophen has little effect on platelet function, no effect on homeostasis, and it is not known to produce gastric bleeding. Acetaminophen is not an NSAID, as it has no anti-inflammatory properties. Absorption is rapid. APAP is processed in the Liver.
Onset of Action	< 1 hour	Peak Effect	10 to 60 minutes	Duration of Action	4 to 6 hours

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‌Adenosine

Aliases:	Adenocard
Indications:	Supraventricular Tachycardia SVT (including WPW) refractory to vagal maneuvers
Contraindications:	2nd or 3rd degree heart block (without a functioning pacemaker); Known Sick sinus syndrome; Known History of Long QT Syndrome; Pregnancy Category C; Irregular Wide-complex tachycardia presumed to be WPW
Concentrations
Injection	3 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Supraventricular Tachycardia	12 mg	Rapid IV Push (mixed in 10 cc flush)	May repeat once

Pediatric Dosing
Indication	Dose	Route	Note

Supraventricular Tachycardia		0.2 mg/kg (Max 12 mg)		Rapid IV Push (mixed in 10 cc flush)	May repeat once
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Advising patient of the side effects of adenosine prior to administering can help minimize patient anxiety. Large bore IV, antecubital access, or IO access & IV wide open during administration; it may help to have your partner administer the fluid bolus. Start your EKG printout before administration and continue printing through bolus and conversion. Administration of adenosine will cause a period of asystole & various conversion dysrhythmias, be patient, most will transiently resolve
Adverse/Side Effects:	Flushing, Dizziness, Chest Pain, Lightheadedness, Dyspnea, Numbness, Headache, Nausea/Vomiting, Diaphoresis, Palpitations, Metallic Taste
Class:	Supraventricular Antiarrhythmic, Nucleoside
Mechanism of Action:	Slows tachycardias associated with the AV node via modulation of the autonomic nervous system without causing negative inotropic effects. It acts directly on sinus pacemaker cells and vagal nerve terminals to decrease chronotropic & dromotropic activity. Slows conduction through the AV node, blocks reentry pathways through the AV node, can transiently slow conduction in the SA node.
Onset of Action	Rapid	Peak Effect	Rapid	Duration of Action	Very Brief

‌Albuterol

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Aliases:	Ventolin, Proventil, Proair
Indications:	Bronchospasm with or without wheezing, hyperkalemia
Contraindications:	None in the emergency setting
Concentrations
Prefilled Unit Doses for Nebulization		2.5 mg/3 mL
Adult Dosing
Indication	Dose	Route	Note
Bronchospasm	5 mg	Nebulized	May repeat every 5 mins. No limit
Hyperkalemia	10 – 20 mg	Nebulized	Continuous as needed

Pediatric Dosing
Indication	Dose	Route	Note
Bronchospasm	2.5 mg	Nebulized	May repeat every 5 mins. No limit
Hyperkalemia	10 mg	Nebulized	Continuous as needed
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	None
Adverse/Side Effects:	Palpitations, Tachycardia, Anxiety, Nervousness, Dizziness, HA, Tremor, N/V, Less frequent HTN, Dysrhythmias, Chest Pain
Class:	Beta2 Agonist, Sympathomimetic
Mechanism of Action:	Acts selectively on Beta2 receptor sites in the lungs, relaxing bronchial smooth muscle, decreasing airway resistance, relief of bronchospasm, and drives potassium intracellularly. Although Albuterol is beta selective, it will cause some CNS stimulation, cardiac stimulation, increased diuresis, & gastric acid secretion.
Onset of Action	< 5 minutes	Peak Effect	30 minutes	Duration of Action	3 to 6 hours

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‌Amiodarone

Aliases:	Pacerone, Nextorone, Codarone
Indications:	V-Fib or Pulseless V-Tach(pVT) Cardiac Arrest, Post Resuscitation Care, Wide Complex Tachycardia with a Pulse, & Symptomatic A-fib.
Contraindications:	Without a pulse: None; With a pulse: bradycardia, second/third degree AV block
Concentrations
Injection		50 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Pulseless VT or VF	300 mg (1st dose) 150 mg (2nd dose)	IV Push	4 minutes between doses
Wide Complex Tachycardia with a Pulse (VT)	150 mg	IV infusion over 10 minutes	Use a pump when available

Pediatric Dosing
Indication	Dose	Route	Note
Pulseless VT or VF	5 mg/kg (max of adult doses)	IV Push	4 minutes between doses
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Use with caution in patients with known thyroid disease. Consider OLMC discussion.
Adverse/Side Effects:	Vasodilation (usually not associated with decreased cardiac output secondary to the negative inotropic effects), hypotension, bradycardia, AV block, increased QT interval, V-Tach.
Class:	Antiarrhythmic, Primarily Class III but has properties of all the Vaughan Williams classifications
Mechanism of Action:	Prolongs the duration of the action potential and refractory period of all Cardiac fibers. Depresses the Phase 0 slope by causing a sodium blockade. Causes a Beta block as well as a weak calcium channel blockade. Primarily a Potassium-channel blocker (Class III antiarrhythmic) blocks the potassium channels that are responsible for phase 3 repolarization. Blocking these channels slows (delays) repolarization, which leads to an increase in action potential duration and an increase in the effective refractory period (ERP). Relaxes vascular smooth muscle, decreases peripheral vascular resistance, and increases coronary contractility.
Onset of Action	Variable	Peak Effect	30 to 45 minutes	Duration of Action	Variable

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‌Aspirin

Aliases:	Bufferin, Zorpin
Indications:	Chest Pain from suspected Acute Coronary Syndrome/STEMI/ACO
Contraindications:	Anaphylaxis, known ulcer & active GI bleeding
Concentrations
Tablet		81 mg
Adult Dosing
Indication	Dose	Route	Note
Suspected ACS or STEMI	324 mg	PO	May give full amount if already taken earlier in the day

Pediatric Dosing
Indication	Dose	Route	Note
None
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	On blood thinners. Pregnancy Category D: There is positive evidence of human fetal risk, but the benefits from use in pregnant women may be acceptable despite the risk (e.g., if the drug is needed in a life-threatening situation or for a serious disease for which safer drugs cannot be used or are ineffective).
Adverse/Side Effects:	N/V, diarrhea, heartburn, GI bleeding
Class:	Analgesic, Antipyretic, NSAID, platelet inhibitor

Mechanism of Action:

Inhibits the formation of prostaglandins associated with pain, fever, and inflammation. Inhibits platelet aggregation by acetylating cyclooxygenase permanently disabling it so that it cannot synthesize prostaglandins and Thromboxanes. Since Thromboxane A2 is important in clotting its absence does not

allow blood to clot effectively.

Onset of Action

< 1 hour

Peak Effect

1-2 hours

Duration of

Action

4-6 hours

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‌Atropine

Aliases:	None
Indications:	Symptomatic Bradycardia (if TCP is not immediately available); Organophosphate poisoning
Contraindications:	A-Fib or A-Flutter
Concentrations
Injection			0.1 mg/mL
Adult Dosing
Indication		Dose	Route		Note
Symptomatic Bradycardia		0.5 mg	IV Push		May repeat every 3 minutes. Max 3 mg.
Organophosphate Poisoning		2-6 mg	IV Push/IM		Repeat every 3 minutes until symptoms resolve.

Pediatric Dosing
Indication		Dose	Route		Note
Symptomatic Bradycardia		0.02 mg/kg (Between 0.1 -0.5 mg)	IV Push		May repeat every 3 minutes. Max 3 mg.
Organophosphate Poisoning			IV Push/IM		Repeat every 3 minutes until symptoms resolve.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Slow administration of Atropine can cause paradoxical bradycardia
Adverse/Side Effects:	Pupil dilation, tachycardia, V-Tach, V-Fib, HA, dry mouth
Class:	Parasympatholytic & Anticholinergic
Mechanism of Action:	Competitive antagonist that selectively blocks all muscarinic responses to acetylcholine. Blocks vagal impulses, thereby increasing SA node discharge, thereby enhancing AV conduction and cardiac output. Potent anti-secretory effects caused by the blocking of acetylcholine at the muscarinic site. Atropine is also useful in the treatment of the symptoms associated with nerve agent poisoning.
Onset of Action	Immediate	Peak Effect	0.7-4 minutes	Duration of Action	Variable

‌Calcium Chloride

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Aliases:	None
Indications:	Calcium channel– or beta-blocker overdose, hyperkalemia , hypocalcemia, hypermagnesemia, Hydrofluoric acid burn, Blood product transfusion; Cardiac arrest with presumed hyperkalemia or calcium channel-blocker overdose; Pulseless VF/VT.
Contraindications:	None in the emergency setting
Concentrations
Injection		100 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Known or suspected hyperkalemia Hemorrhagic Shock Severe Hydrofluoric Acid Burn Calcium channel or Beta blocker overdose	1000 mg (1 g)	IV Push	Ensure that the IV/IO line is patent before giving the medication

Pediatric Dosing
Indication	Dose	Route	Note
Known or suspected hyperkalemia Hemorrhagic Shock Severe Hydrofluoric Acid Burn Calcium channel or Beta blocker overdose	20 mg/kg (Max 1000 mg)	IV Push	Ensure that the IV/IO line is patent before giving the medication
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Will cause tissue damage if it extravasates
Adverse/Side Effects:	Arrhythmias including bradycardia or cardiac arrest, Syncope, N/V, Hypotension, Necrosis with extravasation. Calcium chloride will precipitate when used in conjunction with sodium bicarbonate, Toxicity with digitalis, and may antagonize the effects of calcium channel blockers
Class:	Inotropic Agent (electrolyte)
Mechanism of Action:	Replaces elemental calcium, which is essential for regulating excitation threshold of nerves and muscles. Calcium is also essential for blood clotting mechanisms, maintenance of renal function, and bone tissues. Calcium increases myocardial contractile force and ventricular automaticity. Additionally, serves as an antidote for magnesium sulfate and calcium channel blocker toxicity.

Onset of Action

Immediate

Peak Effect

Immediate

Duration of

Action

Varies

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‌Dextrose (D10W)

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Aliases:
Indications:	Symptomatic hypoglycemia, altered mentation with glucose < 60, newborn with heart rate < 60 and glucose < 40.
Contraindications:	Suspected hypoglycemia: None
Concentrations
Infusion			25 g/250 mL (1 g/10 mL)
Adult Dosing
Indication		Dose	Route		Note
Symptomatic Hypoglycemia		25 g (250mL)	IV infusion		Titrate to effect. Repeat PRN

Pediatric Dosing
Indication		Dose	Route		Note
Pediatric Hypoglycemia (30 days or older)		1 g/kg (5 mL/kg)	IV infusion		Titrate to effect. Repeat PRN
Newborn Hypoglycemia (0-29 days)		0.2 g/kg (1 ml/Kg)	IV infusion		Titrate to effect. Repeat PRN
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Use with caution in patients with suspected increased ICP.
Adverse/Side Effects:	Patients may complain of warmth, pain, or burning at the injection site. Extravasation causes necrosis. Infusing through larger vessels decreases the risk of necrosis
Class:	Carbohydrate
Mechanism of Action:	Glucose is readily processed in the blood. Through glycolysis, glucose is turned into pyruvate giving off a small amount of chemical energy (ATP). Pyruvate is further processed through the Citric Acid Cycle yielding even more energy. Glucose is a large molecule and is incapable of being absorbed into a cell without insulin and therefore increases damage to epithelium. It also causes an osmotic pressure as concentrations vary across membranes.
Onset of Action	Fast	Peak Effect	Varies	Duration of Action	Varies

‌Dexamethasone

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Aliases:	Decadron
Indications:	Inflammation to the respiratory tract. Adrenal insufficiency/crisis

Contraindications:	None in emergency setting
Concentrations
Injection			2-10 mg/mL
Adult Dosing
Indication		Dose	Route		Note
Bronchospasm		10 mg	PO/IV/IM		Use the IV form for any route
Airway edema/croup
Adrenal Insufficiency/Crisis

Pediatric Dosing
Indication		Dose	Route		Note
Bronchospasm (Age > 2 yo)		0.6 mg/kg (Max: 10 mg)	PO/IV/IM		Use the IV form for any route
Airway edema/croup
Adrenal Insufficiency/Crisis
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Avoid rapid IV push
Adverse/Side Effects:	Agitation, perineal/body burning sensation, pruritus, nausea/vomiting
Class:	Corticosteroid, anti-inflammatory drugs
Mechanism of Action:	Potent glucocorticoid with minimal to no mineralocorticoid activity. Decreases inflammation by suppressing migration of polymorphonuclear leukocytes (PMNs) and reducing capillary permeability; stabilizes cell and lysosomal membranes, increases surfactant synthesis, increases serum vitamin A concentration, and inhibits prostaglandin and proinflammatory cytokines; suppresses lymphocyte proliferation through direct cytolysis, inhibits mitosis, breaks down granulocyte aggregates, and improves pulmonary microcirculation
Onset of Action	Few minutes	Peak Effect	60 minutes	Duration of Action	36 to 54 hours

‌Diphenhydramine

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Aliases:	Benadryl
Indications:	Allergic Reaction, Anaphylaxis, Adult dystonic reaction, or Persistent nausea/vomiting
Contraindications:	Known allergy
Concentrations
Injection		50 mg/mL
Tablet		25 mg
Adult Dosing
Indication	Dose	Route	Note
Moderate/Severe Allergic Reaction – or – Dystonia	50 mg	IV/IM/PO	Slow IV Push

Mild Allergic Reaction with Only Hives/Rash		25 mg	IV/IM/PO		Slow IV Push
Persistent Nausea/Vomiting			IV/IM		Slow IV Push. May repeat x 1 after 20 minutes
Pediatric Dosing
Indication		Dose	Route		Note
Mild to Severe Allergic Reaction – or – Dystonia		1 mg/kg Max dose: 50 mg	IV/IM/PO		Do Not Administer if < 5 kg
Persistent Nausea/Vomiting		1 mg/kg Max dose: 25 mg	IV/IM
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Antihistamine toxicity: Remember: “red as a beet, dry as a bone, hot as a hare, blind as a bat, mad as a hatter, and full as a flask.” Brugada-like ECG patterns are seen with anticholinergic toxicity. Elimination mechanism concerns Potent anticholinergic agent Pregnancy Category B
Adverse/Side Effects:	Mydriasis, photophobia, ataxia, tachycardia, dizziness, drowsiness
Class:	Antihistamine, Ethanolamine, Anticholinergic
Mechanism of Action:	Diphenhydramine blocks the effects of Histamine (H1 histamine) on the H1 receptor site through a competitive competition for the peripheral H1 site. When diphenhydramine is bound the H1 site cannot be stimulated preventing the effects of histamines (swelling, etc.). As an antihistamine, diphenhydramine one of the most effective antihistamines.
Onset of Action	Rapid (Injection) Varies (PO)	Peak Effect	1-3 hours	Duration of Action	6-12 hours

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‌Droperidol

Aliases:	Inapsine
Indications:	Agitation , Atraumatic Headache, Nausea/Vomiting, Vertigo, Acute exacerbation of chronic abdominal pain
Contraindications:	Hypersensitivity to drug, patients with signs of severe prolonged QTc
Concentrations
Injection		2.5 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Agitation/Psychosis	10 mg	IM

		5 mg	IV		Give once. Trend RASS Score every 5 minutes. Treat accordingly.
Atraumatic Headache		2.5 mg	IV/IM		May repeat once after 10 minutes.
Nausea/Vomiting
Dizziness/Vertigo
Acute exacerbation of chronic abdominal pain

Pediatric Dosing
Indication		Dose	Route		Note
Agitation/Psychosis		NOT FOR PEDIATRIC USE AT THIS TIME
Atraumatic Headache
Nausea/Vomiting
Dizziness/Vertigo
Acute exacerbation of chronic abdominal pain
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	ECG monitor must be applied as soon as possible when medication is given.
Adverse/Side Effects:	Neuroleptic malignant syndrome, sinus tachycardia, hypotension, akathisia, dystonic reaction, restlessness, drowsiness, anxiety
Class:	Butyrophenone neuroleptic.
Mechanism of Action:	Like haloperidol, droperidol antagonizes multiple receptor sites in the CNS including serotonin, GABA, norepinephrine, and especially, dopamine. There is evidence that butyrophenones antagonize dopamine-mediated neurotransmission at the synapse as well as block postsynaptic dopamine receptor sites. The antiemetic activity of droperidol is most likely due to blockade of dopamine receptors in the chemoreceptor trigger zone of the brain. It is associated with prolongation of the QTc interval and serious arrhythmias including torsade de pointes. Droperidol delays the recharging of potassium channels, thereby blocking the rapid component of the delayed rectifier potassium current, within minutes of a dose at the upper limit of the dosage range.
Onset of Action	3 to 10 minutes	Peak Effect	30 minutes	Duration of Action	2-4 hours

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‌Epinephrine

Aliases:	Adrenaline
Indications:	Cardiac arrest , Bradycardia, Allergic reaction or Anaphylaxis , Respiratory distress with presumed bronchospasm , Uncontrollable external hemorrhage, shock, croup/bronchiolitis in kids
Contraindications:	None in the emergency setting
Concentrations

Injection	1 mg/10 mL (0.1 mg/mL or 100 mcg/mL)
Injection	1 mg/mL (1 mg/mL or 1000 mcg/mL)
Infusion	4 mcg/mL
Adult Dosing
Indication		Dose		Concentration	Route	Note
Cardiac Arrest		1 mg		(0.1 mg/mL)	IV	Every 5 minutes. Max of 3 doses
Push Dose Epinephrine		20 mcg		(10 mcg/mL)	IV	Titrate to MAP > 65 mmHg
Non-hemorrhagic Hypotension Bradycardia		2-20 mcg/min		Infusion
Anaphylaxis Respiratory failure from bronchospasm Angioedema		0.3 mg		(1 mg/mL)	IM	May repeat every 5 minutes up to total 1.2 mg
		2 mg		(1 mg/mL)	Nebulizer	2 mg (2 mL) mixed with 1 ml NS
Uncontrollable external hemorrhage		1 mg		(1 mg/mL)	Topical	Topical soaked in gauze or IN atomizer for epistaxis
					Nebulizer	Tonsil, mix 1 mL into 2.5 ml NS
Pediatric Dosing
Indication		Dose		Concentration	Route	Note
Cardiac Arrest		0.01 mg/kg (Max 1 mg)		(0.1 mg/mL)	IV	Repeat after 4 minutes
Push Dose Epinephrine		10 mcg		(10 mcg/mL)	IV	Repeat every minute PRN
Non-hemorrhagic Hypotension Bradycardia		0.1 – 1 mcg/kg/min		Infusion
Anaphylaxis		0.01 mg/kg (Max 0.3 mg)		(1 mg/mL)	IM
		0.1 – 1 mcg/kg/min		Infusion	Give for anaphylactic shock
Severe Bronchospasm Angioedema		0.01 mg/kg (Max 0.3 mg)		(1 mg/mL)	IM
Stridor/Barking/Croup Bronchiolitis (< 2 y/o)		1 mg		(1 mg/mL)	Nebulizer	Mix with 4 mL NS
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:	Harm of epinephrine is small when indicated even with history of CAD
Adverse/Side Effects:	Palpitations, anxiety, tremulousness, headache, dizziness, nausea, vomiting, increased myocardial oxygen demand
Class:	Sympathetic Agonist. Epinephrine is a naturally occurring catecholamine. It is a potent alpha- and beta-adrenergic stimulant with more profound beta effects.
Mechanism of Action:	Epinephrine works directly on alpha- and beta-adrenergic receptors with effects of increased heart rate, cardiac contractile force, increased electrical activity in the myocardium, increased systemic vascular resistance, increased blood pressure, and increased automaticity. It also causes bronchodilation.
Onset of Action	<1 minute	Peak Effect	Few minutes	Duration of Action	Varies

‌Etomidate

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Aliases:	Amidate
Indications:	Temporary Procedural Sedation , induction prior to intubation
Contraindications:	Hypersensitivity to Etomidate. Coma
Concentrations
Injection			2 mg/mL
Adult Dosing
Indication		Dose	Route		Note
Rapid Sequence Induction		0.3 mg/kg	IV		Give once. Consider half dose in the setting of shock.
Brief Procedural Sedation		0.1 mg/kg
Pediatric Dosing
Indication		Dose	Route		Note
Rapid Sequence Induction		0.3 mg/kg (Max: 40 mg)	IV		Give once. Consider half dose in the setting of shock.
Brief Procedural Sedation		0.1 mg/kg (Max: 20 mg)
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Adverse/Side Effects:	Apnea/respiratory depression, bradycardia, myoclonus (muscle spasms), hypotension, nausea/vomiting
Class:	Sedative
Mechanism of Action:	Etomidate appears to facilitate GABAminergic neurotransmission by increasing the number of available GABA receptors, possibly by displacing endogenous inhibitors of GABA binding. Etomidate also inhibits steroidogenesis, which prevents its long- term use for ICU sedation. Inhibition is probably due to blockage of 11-beta- hydroxylation within the adrenal cortex. Reduced plasma cortisol and aldosterone levels appear to be unresponsive to ACTH stimulation.
Onset of Action	<1 minute	Peak Effect	Rapid	Duration of Action	3 to 5 minutes

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‌Fentanyl

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Aliases:	Sublimaze
Indications:	Pain management, ACS or STEMI, Constant Crush Injury > 4 hours, Procedural sedation
Contraindications:	Hypotension or Respiratory depression
Concentrations
Injection		50 mcg/mL
Adult Dosing

Indication		Dose	Route		Note
Analgesia (Moderate to Severe) Procedural Sedation		1 mcg/kg	IV/IM/IN		Round to nearest 25 mcg. Be sure to give IM/IN if 1st IV attempt fails or delayed. Repeat every 5 minutes PRN Avoid in headache

Pediatric Dosing
Indication		Dose	Route		Note
Analgesia (Moderate to Severe) Procedural Sedation		1 mcg/kg	IV/IM/IN		Round to nearest 12.5 mcg. Consider diluting in syringe with NS Be sure to give IM/IN if 1st IV attempt fails or delayed. Repeat every 5 minutes PRN Avoid in headache
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Narcan should be available, Lower doses should be considered in elderly and frail patients.
Adverse/Side Effects:	Fentanyl may cause muscle rigidity, particularly involving the muscles of respiration. As with other narcotic analgesics, the most common serious adverse reactions reported to occur with fentanyl are respiratory depression, apnea, rigidity, and bradycardia. Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm, and diaphoresis. May cause Respiratory Depression.
Class:	Opioid, Schedule II controlled substance
Mechanism of Action:	Competitive agonist that binds to opioid receptors which are found principally in the central and peripheral nervous system.
Onset of Action	Immediate (IV) 7 – 8 minutes (IN/IM)	Peak Effect	Rapid (IV) 15 to 21 minutes (IM/IN)	Duration of Action	30 to 60 minutes (IV) 1 to 2 hours (IM)

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‌Haloperidol

Aliases:	Haldol
Indications:	Used to treat certain mental/mood disorders (e.g., schizophrenia, schizoaffective disorders) & Tourette’s disorder, Severe nausea/vomiting, Acute exacerbation of chronic abdominal pain , acute agitation
Contraindications:	Severe toxic central nervous system depression, Parkinson’s disease
Concentrations
Injection			5 mg/mL
Adult Dosing
Indication		Dose	Route		Note
Agitation/Psychosis		5 mg	IV/IM		May repeat once after 10 minutes
Severe nausea/vomiting
Atraumatic headache
Acute exacerbation of chronic abdominal pain

Pediatric Dosing
Indication		Dose	Route		Note
Agitation/Psychosis		2 mg	IV/IM		May repeat once after 10 minutes. Not for children under 3 y/o or 15 kg.
Severe nausea/vomiting
Atraumatic headache
Acute exacerbation of chronic abdominal pain
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Elderly Patients with Dementia-Related Psychosis Pregnancy Category C
Adverse/Side Effects:	Tachycardia, hypotension, and hypertension. QT prolongation and/or ventricular arrhythmias. Dystonia
Class:	Antipsychotic
Mechanism of Action:	Phenylbutylpiperadine; antagonizes dopamine D1 and D2 receptors in brain; depresses reticular activating system and inhibits release of hypothalamic and hypophyseal hormones
Onset of Action	3 to 20 minutes (IV) 20 to 30 minutes (IM)	Peak Effect	20 – 30 minutes	Duration of Action	3 hours (IV) 2 hours (IM)

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‌Hydroxycobalamin

Aliases:	Cyanokit
Indications:	Known or suspected cyanide poisoning/smoke inhalation.
Contraindications:	Known anaphylactic reactions to Hydroxocobalamin or cyanocobalamin
Adult Dosing
Indication		Dose	Route		Note
Cyanide Poisoning		5 g	IV infusion over 15 minutes		Mix 5 g vial into 200 ml isotonic crystalloid for concentration of 25 mg/ml.

Pediatric Dosing
Indication		Dose	Route		Note
Cyanide Poisoning		70 mg/kg (Max 5 g)	IV infusion over 15 minutes		Mix 5 g vial into 200 ml isotonic crystalloid for concentration of 25 mg/ml.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:
Adverse/Side Effects:	Anaphylaxis, chest tightness, edema, urticaria, pruritus, dyspnea, rash, and hypertension. Also, effects skin (turns red), urine and secretions.
Class:	Cobalamin derivative; Vitamin
Mechanism of Action:	Hydroxocobalamin binds with Cyanide to form nontoxic cyanocobalamin, which is then excreted in the urine
Onset of Action	Rapid	Peak Effect	Varies	Duration of Action	Varies

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‌Ibuprofen

Aliases:	Motrin, Advil
Indications:	Pain, fever, swelling from an acute injury
Contraindications:	Known hypersensitivity. Should not be given to patients who have experienced asthma, urticaria, or allergic-type reactions after taking Aspirin or other NSAIDs. Known pregnancy. Should be avoided in patient with advanced kidney disease.
Solution		20 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Analgesia (Any level)	600 mg	PO	One dose only. May combine with Acetaminophen. Avoid in headache
Fever
Swelling from an acute injury


Pediatric Dosing
Indication		Dose	Route		Note
Analgesia (Any level)		10 mg/kg (Max 600 mg)	PO		Must be over 6 months old. One dose only. May combine with Acetaminophen. Avoid in headache
Fever
Swelling from an acute injury
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer
Precautions:
Adverse/Side Effects:	Aspirin-sensitive asthma, coagulation disorders or patients receiving anticoagulants should be carefully monitored.
Class:	Non-Steroidal Anti-Inflammatory Drug (NSAID)
Mechanism of Action:	Ibuprofen possesses analgesic and antipyretic activities. Its mode of action, like that of other NSAIDs, is not completely understood, but may be related to prostaglandin synthetized inhibition, by blocking the enzyme in your body that makes prostaglandins. Decreasing prostaglandins helps to reduce pain, swelling, and fever.
Onset of Action	30 to 60 minutes	Peak Effect	1 to 2 hours	Duration of Action	6 to 8 hours

‌Ipratropium

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Aliases:	Atrovent
Indications:	Respiratory Distress (Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema), Drowning, Organophosphate exposure.
Contraindications:	Known hypersensitivity
Unit Dose		0.5 mg/Unit
Adult Dosing
Indication	Dose	Route	Note
Respiratory distress	0.5 mg	Nebulizer	Administer with Albuterol and repeat as needed.
Drowning
Organophosphate exposure			Repeat as needed.

Pediatric Dosing
Indication	Dose	Route	Note
Respiratory distress	0.5 mg	Nebulizer	Administer with Albuterol and repeat as needed.
Drowning
Organophosphate exposure			Repeat as needed.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Use caution when administering this drug to elderly patients and those with cardiovascular disease or hypertension
Adverse/Side Effects:	Palpitations, anxiety, dizziness, headache, nervousness, tremor, hypertension, arrhythmias, chest pain, nausea, vomiting
Class:	Anticholinergic
Mechanism of Action:	Ipratropium is a parasympatholytic used in the treatment of respiratory emergencies. It causes bronchodilation and dries respiratory tract secretions. Ipratropium acts by blocking acetylcholine. 15% of dose reaches lower airway.
Onset of Action	<15 minutes	Peak Effect	1 to 2 hours	Duration of Action	4 to 5 hours

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‌Isotonic Crystalloid Fluids

Aliases:	Normal Saline (0.9%), Lactated Ringer’s, or Plasma-Lyte
Indications:	Hypovolemia, Sepsis, Dehydration, Establishing vascular access and medication administration
Contraindications:	Fluid overload resulting in pulmonary edema and/or congestive heart failure
Adult Dosing
Indication	Dose	Route	Note
Hypovolemia	10 to 20 mL/kg (max of 2000 mL) May give in increments of 250 to 1000 mL boluses	IV	May titrate dose and administration rate based on assessment, MAP > 65 or permissive hypotension when indicated, and most appropriate clinical operating guideline
Sepsis
Dehydration
Establishing vascular access and medication administration
Pediatric Dosing
Indication	Dose	Route	Note
Hypovolemia	Pediatric: 20 ml/kg boluses Newborn: 10 ml/kg boluses	IV	May titrate dose and administration rate based on assessment, mental status and vital signs, and most appropriate clinical operating guideline
Sepsis
Dehydration
Establishing vascular access and medication administration
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:
Adverse/Side Effects:	Crystalloid fluids are administered for volume expansion as indicated. Crystalloid fluids, such as Lactated Ringers or Normal Saline, do not add oxygen binding capacity. Rapid volume resuscitation of crystalloid fluids, preferably through large- bore line, may be indicated in the acute setting. Always monitor for signs of fluid overload and titrate to a desired effect. Maintenance infusion is indicated as

	needed to maintain patent access or minimum volume to maintain volume homeostasis.
Class:	Isotonic to human plasma
Mechanism of Action:	Approximate concentrations of various solutes and do not exert as osmotic effect, expand intravascular volume without disturbing ion concentration or significant fluid shift.
Onset of Action	Immediate	Peak Effect	Varies	Duration of Action	Varies

‌Ketamine

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Aliases:	Ketalar
Indications:	Pain , Severe bronchospasm, Procedural sedation, Rapid sequence induction , Severe Agitation, Lifesaving procedure
Contraindications:	Uncontrolled Hypertension, Hypersensitivity. Be cautious administering to older adults and elderly.
Concentrations
Injection	10 mg/mL
Injection	100 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Pain Severe bronchospasm	10 mg	IV infusion over 10 minutes	If the patient is hemodynamically unstable defined as MAP < 65 and/or respiratory failure, then ketamine may be used first for pain. If the patient is hemodynamically stable defined as MAP > 65 and no respiratory failure, then the appropriate amount of fentanyl (up to 100 mcg) should be administered first; then ketamine can be administered x 1 10 minutes later if no relief in pain has occurred.
Pain Severe bronchospasm	25 to 50 mg	IM
Procedural Sedation Alcohol Withdrawal Refractory Status Epilepticus	100 mg	Slow IV Push	May repeat every 2 minutes PRN Consider 50 mg increments for hypotensive patients to achieve sedation without CV collapse
Rapid Sequence Induction	200 mg	Slow IV Push
Severe Agitation/Excited Delirium Lifesaving Procedure	300 mg	IM	May repeat IM every 5 minutes PRN. Lifesaving procedure when IV/IO access cannot be obtained.
Pediatric Dosing
Indication	Dose	Route	Note
Pain Severe Bronchospasm	0.2 mg/kg (Max: 10 mg)	IV/IO infusion over 10 minutes	Must be >3 months old and see pediatric dosing chart for patient weight minimums.

			0.4 mg/kg	IM
			(Max: 25 mg)
Procedural sedation Lifesaving procedure Severe Agitation/Excited			1 mg/kg (Max: 100 mg)	Slow IV Push
			4 mg/kg (Max:	IM
Delirium Refractory Status			300 mg)
Epilepticus
Rapid Sequence Induction			2 mg/kg (Max:	Slow IV Push
			200 mg)
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Laryngospasms and other forms of airway obstruction have occurred. Use with caution in patients with history of Schizophrenia. Be aware that in lower dosing some patients may experience partial disassociation.
Adverse/Side Effects:	Respiratory depression may occur, Laryngospasms, Hypertension, Emergence Reactions (Hallucinations, Delirium), dizziness, nausea, vomiting
Class:	Ketamine hydrochloride is a rapid-acting dissociative anesthetic.
Mechanism of Action:	The anesthetic state produced by ketamine hydrochloride has been termed “dissociative anesthesia” in that it appears to selectively interrupt association pathways of the brain before producing somesthetic sensory blockade. It may selectively depress the thalamoneocortical system before significantly obtunding the more ancient cerebral centers and pathways (reticular-activating and limbic systems).
Onset of Action	< 30 secs (IV) 3 – 15 mins (IM)	Peak Effect	Fast (IV) 5 – 30 mins (IM)	Duration of Action	IV Anesthetic: 5 – 10 mins IM Anesthetic: 12 – 25 mins Analgesia: 15 – 30 mins

‌Lidocaine

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Aliases:	Xylocaine
Indications:	V-Fib or Pulseless V-Tach (pVT) Cardiac Arrest, Post Resuscitation Care, Wide Complex Tachycardia with a Pulse, Pain Management for IO Flush, Eye Injury, Pain Management for Kidney Stone
Contraindications:	Second- and third-degree heart blocks, CHF
Concentrations
Injection	20 mg/mL
Adult Dosing
Indication	Dose	Route	Note
V-fib or pVT Cardiac Arrest	100 mg	IV Push	May repeat every 4 minutes PRN. Max total dose – 3 mg/kg
Wide Complex Tachycardia with a Pulse
IO Flush	40 mg	Slow IO Push	Dilute in 10 mL with IVF

Pediatric Dosing
Indication	Dose	Route	Note
V-fib or pVT Cardiac Arrest		IV Push

Wide Complex Tachycardia with a Pulse			1 mg/kg (Max: 100 mg)		May repeat every 4 minutes PRN. Max total dose – 3 mg/kg
IO Flush			0.5 mg/kg (Max: 40 mg)	Slow IO Push	Dilute in 10 mL with IVF
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	CNS depression may occur when the drug exceeds 300mg/hr. Lidocaine should be used with caution when administered concomitantly with Procainamide and beta- blockers as drug toxicity may result.
Adverse/Side Effects:	Drowsiness, seizures, confusion, hypotension, bradycardia, heart blocks, nausea, vomiting, and respiratory and cardiac arrest
Class:	Antiarrhythmic (Class 1b), Sodium channel blocker
Mechanism of Action:	Lidocaine depresses depolarization and automaticity in the ventricles and increases the ventricular fibrillation threshold by increasing phase IV repolarization.
Onset of Action	45 to 60 seconds	Peak Effect	Fast	Duration of Action	10 to 20 minutes

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‌Lorazepam

Aliases:	Ativan
Indications:	Procedural/maintenance sedation, Anticonvulsant, Rapid Sequence Induction, Acute behavioral emergencies, EtOH withdrawal, Uncontrolled Anxiety/Panic Attack
Contraindications:	Allergy, Shock, Coma, Closed Angle Glaucoma
Concentrations
Injection		2 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Seizure EtOH Withdrawal	2-4 mg	IM/IV	Repeat every 5 minutes PRN
Agitation/Anxiety	2-4mg	IM/IV	Repeat every 5 minutes PRN Trend RASS Score every 5 minutes
Procedural Sedation

Pediatric Dosing
Indication	Dose	Route	Note
Seizure	0.1 mg/kg (Max: 4 mg)	IM/IV	Repeat every 5 minutes PRN
Procedural Sedation Agitation/Anxiety	0.1 mg/kg (Max: 4 mg)	IM/IV	Repeat every 5 minutes PRN

					Trend RASS Score every 5 minutes
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Pregnancy Category D. Premedication with an opiate may potentiate lorazepam and lead to apnea. Reducing the dose to 50% is suggested in elderly and patients under the influence of other CNS depressants
Adverse/Side Effects:	Minor: N/V, Headache, Drowsiness, Lethargy, Cough, Hiccups. Major: Respiratory Depression, Apnea, Hypotension, Cardiac Arrest, Paradoxical CNS stimulation.
Class:	Short-acting benzodiazepine central nervous system (CNS) depressant.
Mechanism of Action:	Acts at the level of the limbic, thalamic, and hypothalamic regions of the CNS through potentiation of GABA (inhibitory neurotransmitter). Decreases neural cell activity in all regions of CNS. Anxiety is decreased by inhibiting cortical and limbic arousal. Promotes relaxation through inhibition of spinal motor reflex pathway, also depresses muscle & motor nerve function directly. As an anticonvulsant, augments presynaptic inhibitions of neurons, limiting the spread of electrical activity. However, it does not alter the electrical activity of the seizure’s focus. Much longer acting the midazolam with later peak effect.
Onset of Action	IV: 3 – 5 mins IM: 15-30 mins	Peak Effect	IV: 1 hour IM: within 3 hours	Duration of Action	IV/IM about 6 hours

‌Magnesium sulfate

Aliases:
Indications:	V-Fib or Pulseless V-Tach(pVT) Cardiac Arrest, Wide Complex Tachycardia with a Pulse, All Torsade de Pointes, Respiratory Distress or Failure from asthma/COPD, OB Seizures (eclampsia)
Contraindications:	Hypotension, third degree AV block, routine dialysis patients, known hypocalcemia.
Concentrations
Injection		500 mg/mL
Adult Dosing
Indication	Dose	Route	Note
V-fib or pVT Cardiac Arrest	2 g	Slow IV Push	Refractory VF/pVT only
Tachycardia with a Pulse: AFib/AFlutter with RVR Torsades de Pointes		IV Infusion over 5 minutes
Respiratory Distress/Failure
OB Seizures	4 g

Pediatric Dosing

Indication		Dose	Route		Note
V-fib or pVT Cardiac Arrest		50 mg/kg (Max: 2 g)	Slow IV Push		Refractory VF/pVT only
Wide Complex Tachycardia WITH a Pulse (Torsade de Pointes)			IV Infusion over 5 minutes
Respiratory Distress/Failure
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Magnesium Sulfate should be administered slowly to minimize side effects. Use with caution in patients with known renal insufficiency. In hypermagnesemia Calcium Chloride should be available as an antidote if serious side effects occur
Adverse/Side Effects:	Hypotension, cardiac arrest, respiratory/CNS depression, flushing, sweating, bradycardia, decreased deep tendon reflexes, drowsiness, respiratory depression, arrhythmia, hypothermia, itching, and rash.
Class:	Antiarrhythmic (Class V), Electrolyte
Mechanism of Action:	Magnesium Sulfate is a salt that dissociates into the Magnesium cation and the sulfate anion. Magnesium is an essential element in numerous biochemical reactions that occur within the body. Magnesium Sulfate acts as a calcium channel blocker and blocks neuromuscular transmission. Hypomagnesemia can cause refractory ventricular fibrillation. Magnesium Sulfate is also a central nervous system depressant used for seizures associated with eclampsia and it is also a bronchodilator.
Onset of Action	Immediate	Peak Effect	Fast	Duration of Action	30 minutes

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‌Midazolam

Aliases:	Versed
Indications:	Procedural/maintenance sedation, Anticonvulsant, Rapid Sequence Induction, Acute behavioral emergencies, EtOH withdrawal, Uncontrolled Anxiety/Panic Attack
Contraindications:	Allergy, Shock, Coma, Closed Angle Glaucoma
Concentrations
Injection		5 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Seizure EtOH Withdrawal	10 mg	IM/IN	Repeat every 5 minutes PRN
	5 mg	IV
Agitation/Anxiety	5 mg	IM/IN/IV	Repeat every 5 minutes PRN Trend RASS Score every 5 minutes
Procedural Sedation

Pediatric Dosing

Indication		Dose	Route		Note
Seizure		0.2 mg/kg (Max: 10 mg)	IM/IN		Repeat every 5 minutes PRN
		0.1 mg/kg (Max: 5 mg)	IV
Procedural Sedation Agitation/Anxiety			IM/IN/IV		Repeat every 5 minutes PRN Trend RASS Score every 5 minutes
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Pregnancy Category D. Premedication with an opiate may potentiate midazolam and lead to apnea. Reducing the dose to 50% is suggested in elderly and patients under the influence of other CNS depressants
Adverse/Side Effects:	Minor: N/V, Headache, Drowsiness, Lethargy, Cough, Hiccups. Major: Respiratory Depression, Apnea, Hypotension, Cardiac Arrest, Paradoxical CNS stimulation.
Class:	Short-acting benzodiazepine central nervous system (CNS) depressant.
Mechanism of Action:	Acts at the level of the limbic, thalamic, and hypothalamic regions of the CNS through potentiation of GABA (inhibitory neurotransmitter). Decreases neural cell activity in all regions of CNS. Anxiety is decreased by inhibiting cortical and limbic arousal. Promotes relaxation through inhibition of spinal motor reflex pathway, also depresses muscle & motor nerve function directly. As an anticonvulsant, augments presynaptic inhibitions of neurons, limiting the spread of electrical activity. However, it does not alter the electrical activity of the seizure’s focus. Midazolam has twice the affinity for benzodiazepine receptors than diazepam and has more potent amnesic effects. It is short acting and roughly 3-4 times more powerful than diazepam.
Onset of Action	IV: 3 – 5 mins IN: ~ 10 mins IM: 5 – 15 mins	Peak Effect	IV: 3 – 5 mins IN: ~ 15 mins IM: 15 – 30 mins	Duration of Action	IV: < 2 hours (single dose) IN: ~ 30 mins IM: ~ 2 hours

‌Morphine

Aliases:	Morphine
Indications:	Pain management, ACS or STEMI, Constant Crush Injury > 4 hours, Procedural sedation
Contraindications:	Hypotension or Respiratory depression
Concentrations
Injection 4mg/ml
Adult Dosing
Indication	Dose	Route	Note
Analgesia (Moderate to Severe) Procedural Sedation	0.1mg/kg max 4-8mg	IV/IM	Repeat every 5 minutes PRN

					Avoid in headache

Pediatric Dosing
Indication		Dose	Route		Note
Analgesia (Moderate to Severe) Procedural Sedation		0.1mg/kg max 2-4mg	IV/IM/IN		Consider diluting in syringe with NS Repeat every 5 minutes PRN Avoid in headache
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Narcan should be available, Lower doses should be considered in elderly and frail patients.
Adverse/Side Effects:	As with other narcotic analgesics, the most common serious adverse reactions reported to occur with morphine are respiratory depression, apnea, rigidity, and bradycardia. Other adverse reactions that have been reported are hypertension, hypotension, dizziness, blurred vision, nausea, emesis, laryngospasm, and diaphoresis. May cause Respiratory Depression.
Class:	Opioid, Schedule II controlled substance
Mechanism of Action:	Competitive agonist that binds to opioid receptors which are found principally in the central and peripheral nervous system.
Onset of Action	Immediate	Peak Effect	5-10 minutes	Duration of Action	2-4 hours

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‌Naloxone

Aliases:	Narcan
Indications:	Reversal of respiratory depression caused by opiates or synthetic narcotics
Contraindications:	Known allergy, known hypersensitivity, neonates with narcotic use by mother.
Concentrations
Injection		0.4 mg/mL
Injection		1 mg/mL
Adult Dosing
Indication	Dose	Route	Note
Opioid Overdose	0.4 – 0.5 mg	IV	Repeat PRN until ventilation is sufficient by patient
	2 mg	IM/IN

Pediatric Dosing
Indication	Dose	Route	Note

Opioid Overdose		0.1 mg/kg (Max: 2 mg)	IM/IN/IV		Repeat PRN until ventilation is sufficient by patient
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	The goal is to make the patient breath sufficiently on their own. Alertness is not required for success.
Adverse/Side Effects:	Tachycardia, hypotension with rapid administration, HTN, dysrhythmias, N/V, and diaphoresis. In neonates, opioid withdrawal may be life-threatening if not recognized
Class:	Opioid antagonist
Mechanism of Action:	Naloxone hydrochloride is an opioid antagonist that antagonizes opioid effects by competing for the same receptor sites. Naloxone hydrochloride reverses the effects of opioids, including respiratory depression, sedation, and hypotension.
Onset of Action	IV: ~ 2 minutes IM: 2 – 5 minutes IN: ~ 5 minutes	Peak Effect	IV: Fast IM/IN: 15 – 30 minutes	Duration of Action	Varies on route & opioid IV has a shorter duration than IM

‌Nitroglycerin

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Aliases:	Nitrostat
Indications:	Chest Pain, CHF/Pulmonary Edema
Contraindications:	Hypotension, hypovolemia, severe bradycardia, or tachycardia, use of erectile dysfunction drugs within past 24hrs up to 48 hours depending on use of extended- release medications.
Concentrations
Sublingual Spray/Tablet		400 mcg (0.4 mg) per dose
Injection/Infusion		100 – 400 mcg/mL
Adult Dosing
Indication	Dose	Route	Note
Chest Pain – ACS suspected	0.4 mg	Sublingual	Repeat every 5 mins PRN. Maintain SBP > 100 mmHg
	5-50 mcg/min	Infusion	For refractory chest pain or STEMI/ACO only. Titrate to pain relief or SBP > 100 mmHg.
Pulmonary Edema from Acute Heart Failure (Hypertensive Crisis)	1st dose: 1000 mcg	Slow IV Push	After NIPPV, consider IV Push before infusion. Goal SBP 140-160 mmHg. Titrate infusion PRN.
	2nd dose: 200 to 400 mcg/min	Infusion


Pediatric Dosing
Indication		Dose	Route		Note
None
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Headache, Tachycardia
Adverse/Side Effects:	Hypotension, Syncope
Class:	Nitrate
Mechanism of Action:	Potent vasodilator with antianginal, anti-ischemic, and antihypertensive effects. Relaxes vascular smooth muscle by an unknown mechanism. Decreases peripheral vascular resistance, preload, and afterload.
Onset of Action	SL: 1-3 minutes IV: Immediate	Peak Effect	5 minutes	Duration of Action	Less than 10 minutes

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‌Ondansetron

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Aliases:	Zofran
Indications:	Moderate to severe nausea, vomiting
Contraindications:	Known allergy, do not use Zofran concurrently with Procainamide, Haldol, or amiodarone due to QT prolongation.
Concentrations
Injection	2mg/mL
Tablet	4 mg/dose
Adult Dosing
Indication	Dose	Route	Note
Moderate to Severe Nausea/Vomiting	4 mg	PO/IV/IM	Repeat every 15 minutes PRN

Pediatric Dosing
Indication	Dose	Route	Note
Moderate to Severe Nausea/Vomiting	0.1 mg/kg (Max: 4 mg)	IM/IV/PO	IM preferred over IV
	4 mg	PO	For 25 kg and up
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Caution use in patients with long QTc syndrome or on drugs that prolong the QTc.
Adverse/Side Effects:	Arrhythmias (including ventricular and supraventricular tachycardia, premature ventricular contractions, and atrial fibrillation), bradycardia, electrocardiographic alterations (including second-degree heart block, QT/QTc interval prolongation, and ST segment depression), palpitations, and syncope.
Class:	Anti-emetic, Selective Serotonin (5HT3) Receptor Antagonist

Mechanism of Action:

Ondansetron reduces the activity of the vagus nerve, which activates the vomiting center in the medulla oblongata and blocks serotonin receptors in the chemoreceptor trigger zone. It has little effect on vomiting caused by motion

sickness. Safely tolerated at high dose ranges.

Onset of Action

<30 minutes

Peak Effect

30 to 120

minutes

Duration of

Action

Varies

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‌Oral glucose

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Aliases:
Indications:	Hypoglycemia (< 60 mg/dl) with patients who can protect their airway
Contraindications:	Known allergy, patients who are unable to protect their airway
Concentrations
Solution			15 g/dose
Adult Dosing
Indication		Dose	Route		Note
Hypoglycemia		15g	PO		May repeat every 15 minutes PRN.

Pediatric Dosing
Indication		Dose	Route		Note
Hypoglycemia		15g	PO		May repeat every 15 minutes PRN May substitute with juice with added sugar.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Ensure adequate airway protection by patient
Adverse/Side Effects:	Nausea
Class:	Monosaccharide, Carbohydrate
Mechanism of Action:	After absorption from GI tract, glucose is distributed in the tissues and provides a prompt increase in circulating blood sugar
Onset of Action	< 10 minutes	Peak Effect	Varies	Duration of Action	Varies

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‌Oxygen

Aliases:	O2
Indications:	SpO2 < 94%, signs of respiratory distress or failure, signs of hypoxia or hypoxemia, exposure to toxic gases
Contraindications:	None in the emergency setting
Concentrations

Adult Dosing
Indication		Dose	Route		Note
Hypoxia		1-25 lpm	Inhaled		Titrate to saturation of 92-96%
Exposure to toxic gases		15-25 lpm	Inhaled		Regardless of saturations
Pre-airway placement		25 lpm	Inhaled		Nasal Cannula before and during airway placement

Pediatric Dosing
Indication		Dose	Route		Note
Hypoxia		1-25 lpm	Inhaled		Titrate to saturation of 92-96%
Exposure to toxic gases		15-25 lpm	Inhaled		Regardless of saturations
Pre-airway placement		25 lpm	Inhaled		Nasal Cannula before and during airway placement
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:
Adverse/Side Effects:	Excessive oxygenation can be harmful, especially with neonates, therefore titrate flow rates and frequently assess oxygen needs. Can dry mucous membranes, prolong high concentration therapy can affect respiratory drive and consciousness of COPD patients.
Class:	Naturally occurring atmospheric gas
Mechanism of Action:	Reverses hypoxemia
Onset of Action	Immediate	Peak Effect	Rapid	Duration of Action	< 2 minutes

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‌Pralidoxime

Aliases:

2-PAM, Protopam

Indications:	Organophosphate Toxidrome
Contraindications:	Documented hypersensitivity
Concentrations
Injection			300 mg/mL
Adult Dosing
Indication		Dose	Route		Note
Organophosphate Toxidrome/Nerve Gas Exposure		600 mg	IM		Use in an autoinjector. Repeat PRN until symptoms resolve.

Pediatric Dosing
Indication		Dose	Route		Note
Organophosphate Toxidrome/Nerve Gas Exposure		600 mg	IM		Use in an autoinjector. Repeat PRN until symptoms resolve.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:	Pregnancy class C. May precipitate myasthenia crisis.
Adverse/Side Effects:	Laryngospasm, Muscle paralysis, Hypertension, Sinus tachycardia, Mania.
Class:	Cholinesterase reactivator
Mechanism of Action:	Pralidoxime is a cholinesterase reactivator that reverses muscle paralysis after organophosphate poisoning. Organophosphate compounds inhibit cholinesterase via phosphorylation of the enzyme. The inhibited cholinesterase is unable to metabolize acetylcholine resulting in an accumulation of the neurotransmitter. Acetylcholine is present in the central nervous system, parts of the autonomic nervous system, and at the skeletal muscle end plates; therefore, accumulation of this neurotransmitter after organophosphate poisoning adversely affects each of these systems. In the somatic nervous system, acetylcholine accumulation leads to paralysis. The clinical effects of pralidoxime are most evident at skeletal neuromuscular junctions. Pralidoxime reverses the paralysis by removing the phosphoryl group from the inhibited cholinesterase molecule, reactivating the enzyme, and restoring the body’s ability to metabolize acetylcholine.
Onset of Action	Few minutes	Peak Effect	5 – 15 minutes	Duration of Action	75 minutes

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‌Sodium Bicarbonate

Aliases:	Baking Soda
Indications:	Hyperkalemia, Tricyclic or Sodium Channel Blocker Overdose, Crush Syndrome
Contraindications:
Concentrations


Adult Dosing
Indication		Dose	Route		Note
Hyperkalemia		1 mEq/kg (Max: 50 mEq)	IV Push		Give once
TCA/Sodium Channel Blocker Overdose					Repeat every 1-2 minutes PRN until QRS narrows
Crush Syndrome					Give once prior to releasing body part.

Pediatric Dosing
Indication		Dose	Route		Note
Hyperkalemia		1 mEq/kg (Max: 50 mEq)	IV Push		Give once
TCA/Sodium Channel Blocker Overdose					Repeat every 1-2 minutes PRN until QRS narrows
Crush Syndrome					Give once prior to releasing body part.
Use Handtevy or Approved Pediatric Reference Guide for Amount to Administer

Precautions:
Adverse/Side Effects:	Alkalosis, Hyperirritability, Seizures, Tetany (electrolyte imbalance), Cardiac & respiratory arrest. Lowering of serum potassium, Decreased fibrillation threshold.
Class:	Alkalinizing Agent
Mechanism of Action:	In the presence of hydrogen ions, sodium bicarbonate dissociates to sodium and carbonic acid, the carbonic acid picks up a hydrogen ion changing to bicarbonate and then dissociates into water and CO2, functioning as an effective buffer and alkalinizing the blood. In summary, increases plasma bicarbonate, which can buffer metabolic acids and move TCAs and phenobarbital off receptor sites and back into circulation.
Onset of Action	Rapid	Peak Effect	Fast	Duration of Action	8 to 10 minutes

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Medical Protocols

Resuscitation Protocols

Trauma Protocols

Toxicology Protocols

OB Protocols

Pediatric Protocols

Medical Protocols

9

Resuscitation Protocols

53

Trauma Protocols

78

Toxicology Protocols

96

Environmental Protocols

108

OB Protocols

119

Pediatric Protocols

126

Medications

136

FOR NON-NEONATAL PEDIATRIC ARREST REFER TO THIS PROTOCOL

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