Paramedic/A-EMT/Basic EMT
Approved 8.1.2013
1
This book is dedicated to the memory of Dr. Darren Bean, Medical Director for the
City of Madison Fire Department, who was instrumental in the development of the
ALS system and expanding Dane County EMS. Dr. Bean died on May 10, 2008 while
on duty transporting a patient in his capacity as a MedFlight physician.
It was Dr. Bean’s vision to have protocols and procedures that were consistent
throughout Dane County, and he worked tirelessly with the Dane County ALS
Service Providers and Dane County EMS to achieve this goal.
In memoriam, we thank Dr. Bean for his vision, energy, and dedication.
2
Table of Contents-Protocols
Preliminary Information
Overview
Acknowledgements
Suppositions
Authorization
General Principles for Medical Care
Paramedic Intercept Guidance
Medical Transport Destination
Physician On Scene
Patient Care During Transport
Patient Care Standards During Interfacility Transport
Radio Report Format
Transfer of Care at Hospitals
DNR
Authorized Pharmaceuticals
6
6
6
6
7
10
11
12
13
14
15
17
18
19
Adult Protocols
General Approach to All Adult Patients
Abdominal Pain/GI Bleeding
Airway Emergencies:
Adult Dyspnea
Adult Airway Management
Rapid Sequence Airway
Allergic Reaction
Altered Mental Status
Behavioral Emergencies/Excited Delirium
Bites and Envenomations
Cardiac Arrest:
General Approach
Asystole
Pulseless Electrical Activity (PEA)
Ventricular Fibrillation/Pulseless Ventricular Tachycardia
Post-Resuscitation Care
Hypothermia: Therapeutic/Induced
Termination of Resuscitation
No Resuscitation Indicated
Cardiac Arrhythmias:
Atrial Fibrillation or Flutter
Bradycardia
Supraventricular Tachycardia
Wide-Complex Tachycardia
Polymorphous Ventricular Tachycardia (Torsades de Pointes)
Chest Pain
3
20
23
25
30
33
40
43
46
48
50
52
54
56
58
60
63
64
65
67
70
72
75
77
Table of Contents-Protocols
Hazardous Material Exposures:
Cyanide Toxicity and Smoke Inhalation
Nerve Agent/WMD
Hypertensive Emergencies
Hyperthermia
Hypothermia
Intravenous Access
Obstetrics/Gynecology:
Perinatal Emergencies
Vaginal Bleeding
Childbirth/Labor
Overdose and Poisonings:
General Approach
Tricyclic and Tetracyclic Antidepressant Overdose
Cholinergic Poisoning/Organophosphates
Antipsychotics/Acute Dystonic Reaction
Beta Blocker Toxicity
Calcium Channel Blockers
Carbon Monoxide
Cocaine and Sympathomimetic Overdose
Opiate
Pain Management—Adult
Policy Custody
Taser
Refusal of Medical Care
Refusal of Transport After Treatment Given:
Bronchospasm Resolved After Nebulizer Treatment
Induced Hypoglycemia—Resolved
Sedation/Sedative Agent Use
Seizure
Shock (Non-Trauma)
Stroke—Suspected
Syncope
Trauma:
General Approach to All Patients
Burns—Thermal
Chest Injuries
Head Injuries
Eye Injuries
Extremity
Traumatic Cardiac Arrest
Sexual Assault
Spinal Immobilization—Indications:
4
81
84
87
89
91
93
95
96
99
102
104
106
107
108
109
110
111
113
114
115
118
119
120
122
123
124
125
128
131
134
137
140
143
144
147
148
151
153
154
Table of Contents-Protocols
Pediatric Protocols
General Approach to All Pediatric Patients
Airway Emergencies:
Pediatric Dyspnea
Pediatric Airway Management
Allergic Reactions—Pediatric
Altered Mental Status—Pediatric
Apparent Life-Threatening Event (ALTE)
Cardiac Arrest:
General—Pediatric
159
160
163
166
168
170
171
Cardiac Arrhythmia:
Pediatric Bradycardia
Pediatric Wide Complex Tachycardia with Pulse
Pediatric Narrow Complex Tachycardia (SVT) with Pulse
Newborn Resuscitation
Overdose, Poisoning, or Ingestion—Pediatric
Pain Management—Pediatric
Seizure—Pediatric
Trauma:
Pediatric General
Pediatric Burns
Pediatric Head Trauma
Procedures
Pharmaceuticals
Abbreviations
176
179
180
183
186
188
191
194
196
200
203
259
316
5
Authorization
In accordance with Wisconsin Statute 256 and Chapter 110 of the Wisconsin Administrative Code,
effective 8/1/2013 the following medical treatment protocols are authorized by the Medical Director for use in
the Dane County EMS System. Changes to these protocols can be made only with authorization of the
Medical Director.
Michael T. Lohmeier, MD
Dane County Medical Director
Overview
The Dane County EMS Protocols contained within this document are intended to provide and ensure uniform
treatment for all patients who receive care from EMS agencies and provider participating in the Dane County
EMS System. These protocols apply exclusively to agencies responding to activation of the 911 system within
Dane County. Any other use must receive prior approval from the Medical Director of Dane County EMS.
While attempts have been made to address all patient care scenarios, unforeseen circumstances and patient
care needs will arise. For these instances medical personnel should follow the “General Approach” protocols
(or other appropriate protocol), exercise their own judgment, and contact Medical Control for additional
physician orders as needed. The patient’s best interest should be the final determinant for all decisions.
Acknowledgements
The Medical Director wishes to thank the following for their hard work and commitment during the
development of these protocols.
Dr. Christian Zuver
Dr. Lee Faucher
Dr. Melissa Schultz
Dr. Michael Kim
Dr. Suresh Agarwal
Dr. Ankush Gosain
Melissa Schultz
Denise DeSerio
Carrie Meier
Dane County Medical Advisory Subcommittee
Meriter Hospital
St. Mary’s Hospital
Stoughton Hospital
UW Hospital
VA Hospital
Suppositions
□ The term Advanced EMT is considered a licensed EMT – Intermediate Technician.
□ For the situation of drug shortages, any alternatives to the drugs listed in the protocols must be
approved by medical control before use.
□ BIAD – Blindly Inserted Airway Device. Examples include: King LTS-D – LMA - Combitube
6
The following measures shall be applied to help promote prompt and efficient emergency medical
care to the sick, ill, injured or infirmed. They shall be utilized by EMS personnel in the field, in the
Emergency Department, and when dealing with On-line Medical Control Physicians.
1)
The Safety of EMS personnel is paramount. Each scene must be properly evaluated for crew
safety and hazards upon arrival and throughout patient care. Assess the need for additional
public safety resources as soon as possible after arrival.
2)
Proper Personal Protective Equipment and Body Substance Isolation must be utilized
according to agency and industry standard.
3)
A patient is any person who is requesting and/or in need of medical attention or medical
assistance of any kind.
4)
A patient care encounter shall be considered any event when subjective or objective signs or
symptoms, or a patient complaint, results in evaluation or treatment.
5)
All patients in the care of EMS shall be offered transport by ambulance to the nearest
appropriate hospital, regardless of the nature of the complaint. In the event a patient for whom
EMS has responded to refuses transport to the hospital, a properly executed refusal process
must be completed.
6)
In accordance with system guidelines, the only appropriate transport destination for EMS
patients transported by ambulance is an Emergency Department. Exceptions to this are
outlined within the specific protocols. Additional details concerning hospital destination based
on clinical criteria are outlined in specific protocols.
7)
For all 911 calls, upon initial patient contact, be prepared for immediate medical intervention
appropriate for the call level (defibrillation, airway management, drug therapy, etc.)
8)
Upon arrival at a scene where an initial EMS crew is rendering patient care, all subsequent
arriving EMS crews should immediately engage the on-scene crew. The goal is to determine
the status of assessment and seamlessly assist in patient care.
9)
Prior to the transfer of care between crews, the provider rendering initial care should directly
interface with the provider assuming care, to ensure all pertinent information is conveyed.
10)
For all patients in cardiac arrest, call into dispatch with the “patient contact time” at the time of
initial patient contact, and with the “first shock time” at the time of initial defibrillation.
11)
Try to always obtain verbal consent prior to treatment. Respect the patient’s right to privacy
and dignity. Courtesy, concern and common sense will ensure the best possible patient care.
Service MD Approval:______
General Principles 1 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
7
Continued:
12)
The provider should generally be able to decide within three (3) minutes after patient contact if
advanced life support (ALS) measures will be needed.
If identified by EMT Basic or Advanced, ALS should be requested immediately.
If identified by Paramedic, ALS measures should be instituted simultaneously with the initial
assessment. A comprehensive exam is appropriate after the patient has been stabilized.
13)
Generally, initial assessment and therapy should be completed within 10 minutes after patient
contact. Except for extensive extrication, or atypical situations, trauma patients should be en
route to the receiving facility within 10 minutes and medical patients should be en route to the
receiving facility within 20 minutes. Additional therapy, if indicated, should be performed during
transport.
14)
For all 911 calls where EMTs and Paramedics are in attendance, the Paramedic shall make
final patient care decisions.
15)
Prior to the administration of medication, assess for the possibility of medication allergies. If
any questions arise in reference to medication allergies, contact on-line Medical Control prior to
giving any medications.
16)
When caring for pediatric patients, use the Broselow-Luten® weight/length based system to
determine medication dosages and equipment sizes.
17)
An EMS Patient Care Report will be generated at the conclusion of each patient encounter.
Patient care reports should be transmitted to the receiving hospital in accordance with state
requirements.
18)
For cases that do not exactly fit into a treatment category, refer to the general illness protocol
and contact OLMC as needed.
19)
Following training and successful competency assessment by their respective agencies, those
licensed at the EMT-Basic, Advanced and Paramedic level are authorized to:
□ Apply tourniquets
□ Utilize pulse oximetry
□ Utilize capnography monitoring devices
□ Perform blood glucose evaluations
□ Perform CPAP
□ Place and ventilate blind insertion airway devices (BIAD)
□ Place and utilize orogastric tubes via the gastric port of a BIAD
□ Acquire and transmit 12 Lead ECGs
Individual Agencies must request and receive State of WI approval prior to implementation of these
skills.
Service MD Approval:______
General Principles 2 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
8
20)
To perform as a Basic EMT/ A-EMT/ Paramedic, personnel must be knowledgeable and
proficient in the scope of practice described and taught in the National Scope of Practice
Standardized Curriculum, approved by the Wisconsin EMS Unit, and must maintain active
state licensure.
21)
Members of your service who are credentialed with and function on your service with an RN,
PA, or MD license may only practice within the scope of the agency’s license.
22)
Perform all procedures as per the Dane County EMS System Procedures manual. If a
procedure that is not addressed in the manual is deemed necessary, contact OLMC for orders
prior to proceeding.
23)
If OLMC gives orders for performance of a procedure that is not covered in the Dane County
EMS system Procedures Manual, but is within the providers scope of practice, follow the
National Standard Curriculum.
24)
For all patients requiring the administration of narcotics or sedative agents, continuous cardiac,
oxygen saturation, and ETCO2 monitoring shall be performed.
25)
The Poison Control Center should be contacted when handling calls involving poisonous/
hazardous material exposures, overdoses or suspected envenomation. In the event that the
Poison Control Center gives recommendations or orders that are not contained within these
protocols, EMS providers are authorized to carry out their instructions. The Poison Control
Center can be reached at 1.800.222.1222
26)
All defibrillators used in the Dane County EMS System must be able to deliver biphasic energy.
27)
When using supplemental oxygen in accordance with adult or pediatric treatment protocols,
adhere to the following:
a)
In patients who are non-critical, and have no evidence of respiratory distress, use
only the concentration of oxygen needed to achieve oxygen saturation over 93%.
Typically this may be accomplished by the use of a nasal cannula.
b)
For patients with serious respiratory symptoms, persistent hypoxia, or where
otherwise specified by protocol, use 100% supplemental oxygen via nonrebreather mask or BVM. Use caution in instances of rising end-tidal CO2.
28)
Precautions:
Droplet precautions: standard PPE, a standard surgical mask for providers who accompany patients in the
back of the ambulance and a surgical mask or NRB O2 mask for the patient. This level of precaution should be
utilized when influenza, meningitis, mumps, streptococcal pharyngitis, pertussis, and other illnesses spread via
large particle droplets are suspected.
Contact precautions: standard PPE, a gown, change of gloves after every patient contact, and strict
handwashing precautions. This level of precaution is utilized when multi-drug resistant organisms (ie. MRSA),
scabies, zoster (shingles), or other illness spread by contact are suspected.
Airborne precautions: standard PPE, N95 mask on EMS personnel and surgical mask or NRB O2 mask on
patient. This level is used if tuberculosis is suspected.
Service MD Approval:______
General Principles 3 of 3
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
9
Standards Policy
Policy:
To define the circumstances in which a Paramedic should be requested to intercept with an
ambulance not staffed with a Paramedic and to provide guidance for the intercept process.
If the Paramedic’s estimated time of arrival is longer than the time it would take to transport the
patient to the hospital via BLS ambulance, the patient should be transported without delay. In general
BLS should not wait on scene for ALS.
Types of Patient Problems that MAY require Paramedic Intercept:
a)
b)
c)
d)
e)
f)
g)
h)
i)
j)
k)
Cardiopulmonary arrest
Unconsciousness that does not respond to glucose administration
Difficulty breathing/compromised airway
Multi-system trauma
Chest Pain – suspected cardiac
Diabetic with persistent altered level of consciousness
Patients with unstable or deteriorating vital signs
Active persistent seizures, first seizure, or seizure following head trauma
Significant allergic reaction
Childbirth complications
Any other situation in the opinion of the BLS provider or Medical Control that may
benefit from advanced level care.
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
10
Standards Policy
All patients should be transported to the hospital of their choice (when operationally feasible) unless
the patient is unstable.
All patients whose condition is judged to be unstable will be transported to the closest appropriate
receiving facility.
If several hospitals are within the same approximate distance from the scene. Allow the patient, and/
or patients’ family to select the receiving facility of their choice.
For transport destination of Stroke, STEMI, Trauma, or OB (>20weeks) patients, refer to the
appropriate protocol.
At the time of protocol publication the following centers have appropriate credentialing:
Stroke:
Meriter
St. Mary’s – Madison
UW Hospital
VA Hospital
STEMI:
Meriter
St. Mary’s – Madison
UW Hospital
VA Hospital
Trauma:
UW Hospital
OB:
Meriter
St. Mary’s – Madison
Sauk Prairie
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
11
Standards Policy
Policy:
The control of the scene of an emergency should be the responsibility of the individual in attendance
who is the most appropriately trained in providing pre-hospital stabilization and transport. As a
representative of the Medical Director of an EMS system, the pre-hospital provider fulfills that role.
Occasions will arise when a Physician on the scene will desire to direct prehospital care. A
standardized scheme for dealing with these contingencies will optimize the care given to the patient.
The Physician desiring to assume care of the patient must:
□
Provide documentation of his/her status as a physician (MD or DO) to include a current
copy of his/her license to practice medicine in Wisconsin.
□
Assume care of the patient and allow documentation of his/her assumption of care on
the patient care report.
□
Agree to accompany the patient during transport to the hospital.
Contact with Medical Control must be established as soon as possible. The Medical Control
Physician must agree and relinquish the responsibility of patient care to the physician on-scene, in
order for care to be transferred.
Orders provided by the Physician assuming responsibility for the patient should be followed as long
as they do not, in the judgment of the pre-hospital provider, endanger patient well-being. The prehospital provider may request the Physician to attend to the patient during transport, if the suggested
treatment varies significantly from standing orders.
If the physician's care is judged by the pre-hospital provider to be potentially harmful to the patient,
the provider should:
□
Politely voice his/her objection.
□
Immediately place the on-scene physician in contact with the Medical Control Physician.
When conflicts arise between the physician on scene and the Medical Control Physician, EMS
personnel should:
□
Follow the directives of the Medical Control Physician.
□
Offer no assistance in carrying out the order in question; offer no resistance to the
physician performing this care.
□
If the physician on scene continues to carry out the order in question, offer no resistance
and enlist the aid of law enforcement.
All interactions with physicians on the scene must be completely documented in the Patient Care
Report, including the name and license number of the on-scene physician.
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
12
Standards Policy
The following situation shall require > 1 attendant in the back of an ambulance.
Medical or Traumatic cardiac arrest or post-resuscitation care
Patients requiring active airway assistance (ETT, BIAD, BVM)
Imminent delivery
For scenarios not covered above:
□
if the provider requests a second attendant.
A second attendant is not required if there will be an unacceptable delay in transport.
NOTE: Only a student with a current training permit at the appropriate level of care may assist
with patient care.
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
13
Standards Policy
This policy can ONLY be used if your agency has State approval to provide
Interfacility Transport.
Although primary responsibility is not for interfacility transports, situations may arise necessitating
such transport
Regardless of the provider, interfacility transport requires unique skills and capabilities, both in
clinical and operational coordination. Adhere to the following standards for all interfacility
transports:
□ Interfacility transport decisions (including but not limited to transport staffing, equipment and
transport destination) should be made on the patient’s medical needs.
□ Match provider skills and equipment with patient care needs
□ Coordination between hospitals and interfacility transporters is essential before transport is
initiated to ensure that patient care is provided at the appropriate level and does not exceed
the capabilities of the interfacility transport provider.
□ If EMS crewmembers are not capable/skilled in managing devices or medications, or if the
devices/medications are not listed in these protocols and must be continued during transport,
an adequately trained care provider from the transferring facility whose credentials are
acceptable to the transporting agency must accompany the patient during transport.
Contact Medical Control with any questions or concerns
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
14
Standards Policy
For all patients transported by EMS, radio contact should be made with the receiving facility prior to
arrival. When possible, in order to provide sufficient notification of the patient’s condition and
estimated time of arrival, radio contact should be made at least 5 minutes prior to arrival.
Use the following triage categories and triage levels (colors) to assist the receiving facility in
prioritizing incoming calls.
TRIAGE CATEGORIES
Categories
Trauma
Medical
Red
Yellow
Green
STEMI alert
Stroke alert
Pediatric
Haz‐Mat
PNB
MD's Orders
Definitions
indicates patient is a trauma patient
indicates patient is a medical patient
High acuity of illness or injury, unstable or critical
Serious condition, but not critical or unstable
Low acuity of illness or injury
meets STEMI criteria per Chest Pain protocol
meets stroke alert criteria as per Stroke protocol
indicates patient is <12 years of age (medical) or less than
18 years of age (trauma)
indicates patient was involved in a Haz/Mat incident
Cardiopulmonary Arrest
Indicates physican orders are needed
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
15
Standards Policy
Radio Call to an Emergency Department
Begin each transmission with the following:
□
Agency name and unit number
□
Triage category and triage level (ie. Medical Red, STEMI alert)
□
Estimated time of arrival
After the receiving facility acknowledges the initial information, give a concise report which
includes the following:
□
Repeat the triage category and triage level
□
Age and gender of patient
□
Chief complaint or problem
□
Provide pertinent detail as to the following:
~vital signs
~glasgow coma score/level of consciousness
~mechanism of injury (if trauma)
~description of injuries (if trauma)
~treatment provided or under way
~any anticipated delay in transport (ie. extrication)
MEDICAL CONTROL CONTACT
Contact Medical Control for any additional orders or with questions needed to meet the patient’s
needs during on-scene care or transport
Any quality concerns involving Medical Control should be forwarded to the Dane County Medical
Director for review as soon as possible.
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
16
Standards Policy
Once on hospital property, the receiving facility assumes responsibility for all further medical care
delivered to EMS transported patients. Dane County EMS personnel are not authorized to follow prehospital protocols after arrival at an Emergency Department and OLMC should not be contacted for
orders.
Exceptions to this should occur only in the following circumstances:
Life-threatening situations such as cardiac arrest, airway emergencies or imminent delivery of
a newborn.
Continuation of treatment started prior to arrival (ie. Nebulizers, CPAP, IV fluids)
When specifically instructed to continue care by the ED physician (when possible document
the physician’s name and the time the verbal order was given)
To assure all known pertinent information is conveyed to the hospital staff, crews should interface with
nursing staff promptly to give a verbal report and written report**. Transporting personnel shall
provide to the receiving facility all known pertinent incident, patient identification and patient care
information at the time the patient is transferred. In addition turn over all pre-hospital 12 lead EKGs to
the ED staff. Patient care reports may be transmitted by physical (paper) means or electronic means.
NOTE: ** Administrative Rule 110.34(7) states, “...submit a written report to the receiving
hospital upon delivering a patient and a complete patient care report within 24 hours of patient
delivery. A written report may be a complete patient care report or other documentation
approved by the department and accepted by the receiving hospital.”
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
17
Standards Policy
Policy:
To clarify State of Wisconsin Do Not Resuscitate:
If a patient is found to be wearing a Wisconsin “Do-Not-Resuscitate” DNR bracelet, no
resuscitative measure should be undertaken, including compressions, artificial
ventilation, defibrillation, or the use of advanced airways.
Emergency Provider as appropriate will provide:
Clear airway
Control bleeding
Administer Oxygen
Provide pain medication
Position for comfort
Provide emotional support
Splint
Emergency Provider will NOT provide:
Perform chest compressions
Insert advanced airways
Administer cardiac resuscitation drugs
Provide ventilatory assistance
Defibrillate
Any other forms must be validated by contacting
Medical Control before stopping any resuscitative efforts
Service MD Approval:______
Policy
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
18
Authorized Pharmaceuticals
Generic Name
Trade Name
Adenosine
Albuterol
Amiodarone
Aspirin
Atropine
Calcium Chloride
Dextrose (5%, 12.5%, 25%, 50%)
Diazepam
Diltiazem
Diphenhydramine
Dopamine
DuoDote Kit
Epinephrine 1:1,000
Epinephrine 1:10,000
Etomidate
Famotidine
Fentanyl
Glucagon
Glucose, Oral
Haloperidol
Hydroxocobalamin
Ipratropium Bromide
Ketamine
Lidocaine 2%
Lorazepam
Magnesim Sulfate 10%
Mark 1 Kit
Methylprednisolone
Midazolam
Morphine Sulfate
Naloxone
Nitroglycerin
Ondansetron
Rocuronium
Sodium Bicarbonate 8.4%, 4.2%
Succinylcholine
Vassopressin
Adenocard
Proventil
Cordarone
Route
IV/IO
Nebulized
IV/IO
PO
IV/IO
IV/IO
IV/IO
Valium, Diastat
PR/IM
Cardizem
IV/IO
Benadryl
IV/IO/IM
Intropin
IV/IO
IM
Adrenaline
IM
Adrenalin
IV/IO
Amidate
IV/IO
Pepcid
IV/IO
Sublimaze
IV/IO/IN
GlucaGen
IV/IM
Glutose
PO
Haldol
IM
Cyanokit
IV/IO
Atrovent
Nebulized
Ketalar
IM
Xylocaine
IV/IO
Ativan
IV/IM
IV/IO
IM
Solu‐Medrol
IV/IO
Versed
IV/IM/IN
IV/IO
Narcan
IV/IO/IM/IN
Nitrostat, Nitrolingual SL
Zofran
IV/IO/ODT
Zemuron
IV/IO
IV/IO/Nebulized
Anectine
IV/IO
Pitressin
IV/IO
19
Levels
P
EMT, A, P
P
EMT, A, P
P
P
A, P
P
P
P
P
P
EMT, A, P
P
P
P
P
EMT, A, P
EMT, A, P
P
P
EMT, A, P
P
P
P
P
P
P
P
P
A, P
A, P
P
P
P
P
P
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Scene Safety
-Bring all necessary equipment to patients side
‐Demonstrate professionalism and courtesy
PPE (consider contact, droplet, or airborne)
CARDIAC ARREST
Cardiac Arrest Protocol
Airway Protocol
Vital Signs**
General Protocol
Initial Assessment
BLS Maneuvers
Consider Spinal Immobilization
If Pediatric Patient – use Broselow Tape
Consider supplemental O2
2013
Consider 12 Lead EKG* and/or
cardiac monitor
IV Protocol if appropriate ***
Appropriate PROTOCOL
Transport patient per Transport Destination policy
M
Patient doesn’t fit a protocol or you have
exhausted standing protocols?
Consult Medical Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Vital signs, mental status with GCS and location of injury or complaint…..then to specific protocol
*12 Lead EKG should be done EARLY on a possible STEMI patient.
**Vital signs include
Blood Glucose Reading – if any weakness, altered mental status or history of diabetes.
Oxygen Saturation and Capnography if condition warrants
Nothing by mouth, unless patient is a known diabetic with hypoglycemia and able to self‐administer oral glucose paste or a
glucose containing beverage or unless indicated by specific protocol.
***if evidence of dehydration or BP<90mmHg systolic administer 250ml 0.9% NaCl and refer to appropriate protocol. If
hypoglycemic refer to altered level of consciousness protocol.
Any patient contact which does not result in an EMS transport must have a completed refusal form.
Required vital signs on every patient include blood pressure, pulse, respirations, pain‐severity.
Pulse oximetry and temperature documentation is dependent on the specific complaint
Timing of transport should be based on the patients clinical condition and the transport policy.
Never hesitate to consult medical control for patient who refuses
Orthostatic vital sign procedure should be performed in situation where volume status is in question.
General Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
20
General Approach to All Adult Patients
The following measures will serve as the “General Patient Care Protocol—Adult”
and apply to the management of all adult patients.
All Providers

Scene Safety

PPE (consider contact, droplet, and/or airborne)

Initial assessment (BLS maneuvers and consider c-spine immobilization)

Establish patent airway

Provide Supplemental oxygen to maintain SpO2 ≥ 93 %, or if any respiratory
signs or symptoms present

Obtain, record and monitor vital signs

Perform a 12-lead ECG if chest pain, abdominal pain above the umbilicus or
ischemic equivalent symptoms

Record and monitor continuous O2 saturation and Capnography (if available)
if condition warrants

Record Blood Glucose Level if any weakness, altered mental status or history
of diabetes

Nothing by mouth, unless patient is a known diabetic with hypoglycemia and
is able to self-administer oral glucose paste, or a glucose containing
beverage:
 Glucose paste 15 g or other oral glucose agent (e.g. orange juice) if
patient alert enough to self administer oral agent

Transport patient to nearest appropriate Emergency Department

Minimize on-scene time when possible
Advanced EMT
 Consider IV 0.9% NaCl TKO/KVO or IV lock
 If evidence of dehydration (tachycardia, dry mucous membranes, poor
skin turgor) or hypovolemia, administer boluses of 0.9% NaCl at 250
ml (up to 500 ml total if no hypotension)
 If BP<90 mmHg systolic, administer boluses of 0.9% NaCl at 250 ml
until systolic BP>90 mmHg, max individual dose 2 L
▪ Contraindicated if evidence of congestive heart failure
(e.g. rales)
▪ If Hypoglycemic (Blood glucose < 70 mg/dL) with IV
access:
21
o Dextrose 12.5-25g or D10W 100ml
 Repeat Dextrose once if blood glucose <70
mg/dL after 10 minutes
 If Hypoglycemic (Blood glucose < 70 mg/dL) without IV access
 Glucose paste 15 g or other oral glucose containing agent (e.g.,
orange juice) if patient alert enough to self administer oral agent
 If unable to take oral glucose administer Glucagon 1 mg IM
Paramedic

When condition warrants (specified as “Full ALS Assessment and Treatment “
in individual protocols)
 Advanced airway/ventilatory management as needed
 Perform cardiac monitoring
 IV 0.9% NaCl TKO/KVO or IV lock
 If evidence of dehydration (tachycardia, dry mucous
membranes, poor skin turgor) or hypovolemia, administer
boluses of 0.9% NaCl at 250 ml (up to 500 ml total if no
hypotension)
 If BP<90 mmHg systolic, administer boluses of 0.9% NaCl at 250 ml
until systolic BP>90 mmHg, max individual dose 2 L

Contraindicated if evidence of congestive heart failure
(e.g. rales)

If Hypoglycemic (Blood glucose < 70 mg/dL) with IV
access:
o Dextrose 12.5g-25g IV or D10W 100mL IV
 Repeat Dextrose 12.5-25 g once if blood
glucose <70 mg/dL after 10 minutes
 If Hypoglycemic (Blood glucose < 70 mg/dL) without IV access
 Glucose paste 15 g or other oral glucose containing agent (e.g.,
orange juice) if patient alert enough to self administer oral agent
 If unable to take oral glucose administer Glucagon 1 mg IM
Contact Medical Control with any additional orders or questions
22
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs and Symptoms
Pain
Tenderness
Nausea
Vomiting
Diarrhea
Dysuria
Constipation
Vaginal Bleeding/Discharge
Pregnancy
Other Symptoms:
Fever, Headache,
Weakness, malaise, myalgias,
cough,
Headache, rash, mental status
change
Differential
Pneumonia or PE
Liver (hepatitis, CHF)
Peptic Ulcer disease / Gastritis
Gallbladder
MI
Pancreatitis
Kidney Stone
Abdominal Aneurysm
Appendicitis
Bladder/prostate disorder
Pelvic
Spleen enlargement
Diverticulitis
Bowel obstruction
Gastroenteritis
Medical Protocol
History:
Age
Past Medical/surgical history
Medications
Onset
Provocation
Quality
Region / Radiation / Referred
Severity 1‐10
Time
Fever
Last meal eaten
Last bowel movement
Menstrual history (pregnancy)
General Approach to All Adult Patients
A
IV Protocol
A
2013
Blood Pressure
<90mmHg
>90mmHg
A
Normal saline bolus
500 ml (max 2L)
A
Nausea and/or vomiting
No
Yes
P
If severe
Ondansetron (Zofran)
4 mg IV/IM/ODT
P
Consider
Chest Pain Protocol
Pain Control Protocol
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Neck, Heart, Lung, Abdomen, Back, Extremities, Neuro
Nothing by mouth
If pain is above the umbilicus, perform 12‐Lead EKG, refer to CHEST PAIN PROTOCOL if indicated
Abdominal pain in women of childbearing age should be treated as ectopic pregnancy until proven otherwise
The diagnosis of abdominal aneurysm should be considered with abdominal pain in patients over 50
Repeat vital signs after each bolus
Appendicitis may present with vague, peri‐umbilical pain which migrates to the RLQ over time
Increased initial NS Bolus of 500ml approved by Medical Advisory subcommittee to accommodate volume loss from GI bleed.
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
23
Abdominal Pain/GI Bleeding
All Providers

General Patient Care Protocol—Adult

Nothing by mouth

If pain is above the umbilicus, perform 12-lead EKG, refer to Chest Pain
Protocol if indicated.
Advanced EMT


Consider IV Protocol
Consider Fluid Bolus-500ml NS (max 2 liters)
Paramedic

Full ALS Assessment and Treatment

For Patients with severe nausea or vomiting:
 Ondansetron (Zofran), 4 mg IV/IM/Oral Disintegrating Tablet (ODT)

Refer to Pain Management Protocol if indicated
Contact Medical Control for any additional orders or questions
24
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs and Symptoms
Shortness of breath
Pursed lip breathing
Decreased ability to
speak
Increased respiratory
rate and effort
Wheezing, rhonchi
Use of accessory
muscles
Fever, cough
Tachycardia
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
25
2013
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
* Online Medical Control if age >50, HR >150 or History of Coronary Artery Disease
**CPAP – start at 5cm of H2O and titrate up to maximum 15cm of H2O for effect
***Nitro contraindication use of Phosphodiesterase-5 (PDE-5) inhibitor within last 24 hours (Viagra,
Levitra); 48 hours (Cialis)
Position Patient for Comfort
If cardiac origin a possibility and no contraindication, administer Aspirin 324 mg PO
Medical Protocol
History:
Asthma; COPD –
chronic bronchitis,
emphysema, CHF
Home treatment
(oxygen, nebulizer)
Medications
(theophylline, steroids,
inhalers)
Toxic exposure, smoke
inhalation
Differential
Asthma
Anaphylaxis
Aspiration
COPD (Emphysema,
Bronchitis)
Pleural effusion
Pneumonia
Pulmonary embolus
Pneumothorax
Cardiac (MI and CHF)
Pericardial tamponade
Hyperventilation
Inhaled toxin (Carbon
Monoxide, etc)
Drowning/Near Drowning
Foreign body obstruction
Carbon monoxide poisoning
Legend
EMT
A‐EMT
Paramedic
A
P
M
Medical Control
A
P
M
General Approach to all Adult Patients
Airway Adult
Protocol
Assess Airway Patency
Breathing Adequacy
APNEA
INSUFFICIENT
SUFFICIENT
RR <10 or >20
VS, SpO₂, EtCO₂
Consider CPAP
Procedure
Consider Airway
Adult Protocol
Supplemental O₂
NO
Reassess VS, RR, SpO₂,
EtCO₂
Wheezing?
History of CHF, rales,
peripheral edema,
HTN, pink sputum
NO
YES
A
IV Protocol
YES
Albuterol 2.5mg/3ml
Ipratropium 0.5mg/2.5ml
Repeat Albuterol x2 (max 3 doses)
A
2013
Acute Bronchospasm
Consider CPAP
Procedure**
SpO₂ <93%
YES
NO
EtCO₂ >45
Medical Protocol
Fatigue
Altered LOC
Airway Obstruction
Procedure
OBSTRUCTION
Pulmonary
Edema
SEVERE
P
MethylPrednisolone
125mg IV
P
SEVERE
NO Improvement
P
No Speaking
Little/no air movement
ASA 324mg PO
12 Lead EKG
Epinephrine 1:1,000*
0.3mg IM
IV Protocol
SEVERE
Magnesium Sulfate 2g IV in
100ml D5 over 20 min.
P
A
AWAKE and following commands
Consider CPAP
Procedure**
Consult Medical
Control
A
AWAKE and
following commands
P
M
Nitroglycerin 0.4mg SL every
3 minutes if SBP >90mmHg
and no PDE***
M
Ondansetron 4mg IV/IO
Morphine 5‐10mg IV if SBP
>150mmHg
Dopamine 5‐20mcg/kg/min if
SBP <90mmHg
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
26
P
Airway Emergencies: Adult Dyspnea
All Providers

General Patient Care Protocol—Adult

Supplemental oxygen to maintain SPO2 > 93%
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer if wheezing or history of
Asthma/COPD. Albuterol may be repeated to a maximum of 3
administrations.

If symptoms Severe (not speaking, little or no air movement) consider
 Epinephrine 1:1000, 0.3mg IM, if available
 OLMC if Age >50, HR>150 or History of CAD

Perform obstructed airway procedures per BLS standards.

Consider CPAP if available and symptoms are moderate to severe
 If history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 10 cm of H20 for effect

If cardiac origin a possibility and no contraindication, administer Aspirin 324
mg PO
Advanced EMT

Consider IV Protocol if indicated
Acute Pulmonary Edema Suspected

(History of CHF, peripheral edema elevated SBP)

Nitroglycerin 0.4 mg SL every 3 min:
o Contraindicated if SBP <90 mmHg
o Contraindicated if use of a Phosphodiesterase-5 (PDE-5) inhibitor
within last 24 hours (Viagra, Levitra); 48 hours (Cialis)

Aspirin 324 mg PO

Consider CPAP if symptoms moderate/severe:
o Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for effect
27
Paramedic

Full ALS Assessment and Treatment

Observe for signs of impending respiratory failure: Refer to Airway
Management Protocol if indicated:
 Hypoxia (O2 sat < 90%) not improved with 100% O2
 Poor ventilatory effort
 Altered mental status/decreased level of consciousness
 Inability to maintain patent airway
Acute Bronchospasm (wheezing with or without history of Asthma or COPD)

Mild Symptoms:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer if not already given

May repeat Albuterol (Proventil) PRN for continued wheezing

Moderate Symptoms:
 As for mild symptoms, additionally:
 Methylprednisolone (Solumedrol) 125 mg IV if wheezing
persists after 1st nebulizer treatment
 Consider CPAP if symptoms moderate to severe
 Start at 5cm of H2O and titrate up to maximum 10 cm of H20 for
effect

Severe Symptoms (not speaking, little or no air movement):
 As above, additionally:
 Epinephrine 0.3 mg 1:1000 IM

 OLMC if age >50, HR>150 or history of CAD
Magnesium Sulfate 2 g IV in 100 ml D5W over 10 min

Do not use if CHF or history of Renal Failure
Acute Pulmonary Edema Suspected

(History of CHF, peripheral edema elevated SBP)

Nitroglycerin 0.4 mg SL every 3 min:
 Contraindicated if SBP <90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PDE-5) inhibitor
within last 24 hours (Viagra, Levitra); 48 hours (Cialis)

Aspirin 324 mg PO

Consider CPAP if symptoms moderate/severe:
 Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for effect
28

If SBP > 150 consider Morphine Sulfate 5-10 mg IV

For Hypotension (systolic BP <90 mmHg):
 Consider Dopamine infusion at 5-20 mcg/kg/min titrated to maintain
SBP >90 mmHg

If severe nausea or vomiting:
 Ondansetron (Zofran) 4 mg IV/IO/ODT

For bronchospasm (wheezing) associated with Acute Pulmonary Edema:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer
 May repeat Albuterol (Proventil) PRN for continued wheezing

Consider Airway Management Protocol
Drowning/Near Drowning

Full ALS Assessment and Treatment

Spinal Immobilization if indicated

Protect from heat loss

Patients may develop delayed onset respiratory symptoms:
 Consider CPAP for patients with significant dyspnea or hypoxia
 Start at 5cm of H2O and titrate up to maximum 15 cm of H20 for
effect
 Airway Protocol as needed
 Refer to appropriate protocol if cardiac arrest present
Contact Medical Control for any additional orders or questions
 Acute Bronchospasm: Contact Medical Control prior to Epinephrine
administration if:
 Age > 50 years
 Heart Rate >150
 History of Coronary Artery Disease
29
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
Supplemental
Oxygen
A
P
M
Assess ABC’s
-Respiratory Rate
‐Effort
‐Adequacy
Pulse Oximetry
ADEQUATE
Maintain SPO2 >93%
Basic Maneuvers First
‐open airway
‐suction
‐nasal or oral airway
INADEQUATE
Awake and
Protecting Airway
Altered, Apneic
SUCCESSFUL
Consider CPAP
OBSTRUCTION
BIAD
OR
P
RSA
x2
Success < 2 attempts
P
Airway Obstruction Procedure
x2
Resume BVM
NO
M
P
Percutaneous Cricothyrotomy
(surgical airway)
Simultaneously Contact Medical Control
M
P
LEMON
Look externally
Evaluate with the
3:3:2 rule
Mallampati
classification
Obstruction
Neck Mobility
Transport to Closest Facility
M
Consult Medical
Control
M
Pearls
If capnography is available it is expected to be used with all methods of intubation. Document results
If an effective airway is being maintained by BVM with continuous pulse oximetry values of >93%, it is acceptable to continue
with basic airway measures instead of using a Blind insertion device or intubation.
For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation
An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the
nasal passage
Ventilatory rate should be 10‐12 per minute to maintain an ETCO2 of 35‐45. Avoid hyperventilation
Quality assurance should always be completed after the use of blind insertion device or intubation
Maintain C‐spine immobilization for patients with suspected spinal injury
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s and or BURP ( Backwards, Up, Rightward Pressure) maneuver should be used to assist with difficult intubations
Consider Endotracheal Introducer (Bougie) for incompletely visualized airway.
Hyperventilation in deteriorating head trauma should only be done to maintain an ETCO2 of 30‐35
Gastric tube placement should be considered in all intubated patients if available
It is important to secure the endotracheal tube well and consider c‐collar to better maintain ETT placement
Suction all debris, secretions from the airway if necessary
Service MD Approval:______
Airway Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
30
2013
Post Placement Management
Gastric Decompression
GOOD AIR EXCHANGE
NO AIR EXCHANGE
NO CHEST RISE
YES
Confirm Airway Placement
ETCO2 and Exam
Continue BVM
Maintain SpO₂ >93%
SUCCESS
Airway Protocol
BVM
UNSUCCESSFUL
Airway Emergencies: Adult Airway Management
All Providers

General Patient Care Protocol—Adult

Supplemental oxygen to maintain SPO2 > 93%

If suspicion of trauma, maintain C-spine immobilization.

Suction all debris, secretions from the airway if necessary

Consider CPAP if protecting airway and awake
 If history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 10 cm of H20 for effect
 If no history of Asthma or COPD, Start at 5cm of H2O and titrate up to
maximum 15 cm of H20 for effect

Perform Basic Airway Maneuvers: open airway, nasal/oral airway; BVM if
needed.
 BVM:

Ventilate once every 5-6 seconds (10-12 times/minute)

If signs of airway obstruction refer to appropriate protocol

If patient does not respond to above measures or deteriorates consider
advanced airway placement

Monitor oxygen saturation and end-tidal CO2 continuously
Advanced EMT

Consider IV Protocol if indicated
Paramedic

Full ALS Assessment and Treatment

Follow algorithm if invasive airway intervention is needed (BIAD/ETT):
 Apnea
 Decreased level of consciousness with respiratory failure (i.e. hypoxia
[O2 sat < 93%] not improved by 100% oxygen, and/or respiratory rate
< 8)
 Poor ventilatory effort (with hypoxia not improved by 100% oxygen)
 Unable to maintain patent airway
 Follow appropriate procedure (Video Laryngoscopy, King LTS-D,
Direct Laryngoscopy, etc)
31
Following placement of the ETT/BIAD confirm proper placement:
 Observe for presence of alveolar waveform on capnography
 Assess for absence of epigastric sounds, presence of breath sounds,
and chest rise and fall
 Record tube depth and secure in place using a commercial holder if
applicable
 Utilize head restraint devices (i.e. “head-blocks”) or rigid cervical collar
and long spine board as needed to help secure airway device in place
Capnography/ETCO2 Monitoring

Digital capnography (waveform) is the system standard for ETCO2 monitoring.

Only in the event digital capnography is not available due to on-scene
equipment failure, is continuous colorimetric monitoring of ETCO2 an
acceptable alternative.

Continuous ETCO2 monitoring is a MANDATORY component of invasive
airway management.
 If ETCO2 monitoring cannot be accomplished by either of the above
methods, the invasive device MUST be REMOVED, and the airway
managed non-invasively.
 If an alveolar waveform is not present with capnography (i.e. flat line),
briefly check the filter line coupling to assure it is securely in place then
remove the ETT or BIAD and proceed to the next step in the algorithm.
32
Under no circumstances should transport be
delayed for Rapid Sequence Airway (RSA) if the
additional time to perform the procedure is greater
than the transport time.
P
x2
2 PARAMEDICS ARE REQUIRED AT ALL TIMES
Simultaneously Contact Medical Control
P
x2
Airway Protocol Unsuccessful
PreOxygenate (T-5 minutes)
100% O₂ x 5 minutes
8 vital capacity breaths with 100% O₂ (BVM/NRB)
2013
Pearls
Indications:
Age >18 unless specific
permission given prior to
procedure by Medical
Control
Need for invasive airway
management in the setting
of an intact gag reflex or
inadequate sedation to
perform non‐
pharmacologically assisted
airway management (apnea,
decreased LOC with
respiratory failure, poor
ventilatory effort (with
hypoxia not improved by
100% O2), Unable to
maintain patent airway by
other means, Burns with
suspected significant
inhalation injury)
Contraindications:
Medication sensitivities
Inability to ventilate via BVM
Suspected Hyperkalemia
Myopathy or neuromuscular
disease
History of Malignant
Hyperthermia
Recent crush injury or major
burn (>48 hours after injury)
End Stage Renal Disease
Recent Spinal Cord Injury (72
hours – 6 months)
Airway Protocol
Service MD Approval:______
Preparation (T-8 minutes)
IV, O₂, EKG, SpO₂, BP
Check Laryngoscope, ETT, stylet, syringes
Check rescue airway device
Meds drawn up and labeled
PreTreatment (T-3 minutes)
Cricoid Pressure / Sellick’s maneuver
Lidocaine 1.5mg/kg IV/IO IF head injured (max 150mg)
Paralysis and Induction (T+0 minutes)
Etomidate 0.3 mg/kg (max 20mg)
Succinylcholine 2 mg/kg (max 200mg)
Placement with Proof (T+ 30 seconds)
ETCO₂ (continuous), Auscultation
Secure Device
SUCCESSFUL
UNSUCCESSFUL
Post Placement Airway Management (T+ 60 seconds)
Morphine 3 mg IV/IO and Midazolam 3 mg IV/IO
Repeat x2 if necessary
Rocuronium 1mg/kg IV/IO IF transport time >10 minutes
Continue BVM
Maintain SpO₂
>93%
Airway Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
33
Airway Emergencies: Rapid Sequence Airway
Under no circumstances should transport be delayed for RSA if the additional
time to perform the procedure is greater than the transport time.
2 PARAMEDICS ARE REQUIRED AT ALL TIMES
All Providers

General Patient Care Protocol—Adult

Preoxygenate with 100% oxygen

Basic Airway maneuvers: open airway, nasal and/or oral airway; BVM
Paramedic

Full ALS assessment and treatment

Simultaneously contact OLMC

Assess for Indications:
 Age ≥18 unless specific permission given prior to procedure by
medical control
 Need for invasive airway management in the setting of an intact gag
reflex or inadequate sedation to perform non pharmacologically
assisted airway management:
 Apnea
 Decreased level of consciousness with respiratory failure (i.e.
hypoxia [O2 sat < 90%] not improved by 100% oxygen, and/or
respiratory rate < 8)
 Poor ventilatory effort (with hypoxia not improved by 100%
oxygen)
 Unable to maintain patent airway by other means
 Burns with suspected significant inhalation injury

Preoxygenate 100% oxygen at 15L/min for at least 5 min or 8 Vital Capacity
(deep) breaths with 100% O2
 Only assist ventilations with BVM if patient’s ventilations are
inadequate or if hypoxemic (O2 Saturation < 93% on supplemental
oxygen)

Assisted ventilations increase risk of aspiration during laryngoscopy

Patients cannot have any contraindications to succinylcholine or other RSA
drugs:
 Inability to ventilate via BVM
 Suspected Hyperkalemia
34
 Myopathy or neuromuscular disease
 History of Malignant Hyperthermia
 Recent crush injury or major burn (>48 hours after injury)
 End Stage Renal Disease
 Recent Spinal Cord Injury (72 hours-6 months)
Procedure

Preparation (T-8 minutes):
 Monitoring (continuous ECG, SpO2, Blood Pressure)
 2 Patent IV’s required (IO is acceptable)
 Functioning laryngoscope and BVM with highflow O2
 Endotracheal Tube(s), stylet, syringe(s)
LEMON
Look
externally
Evaluate with
the 3:3:2 rule
Mallampati
classification
Obstruction
Neck Mobility
 BIAD(s) and appropriate syringe(s)
 Alternative/rescue airway (LMA and surgical airway kit) immediately
available
 All medications drawn up and labeled (including post procedure
sedation)
 Suction: on and functioning
 End-Tidal CO2 device on and operational (colorimetric immediately
available as a back up only)
 Assess for difficult airway—LEMON


Preoxygenation (T-5 minutes):

100% oxygen via NRB for 5 minutes or 8 Vital Capacity breaths
(Deep breaths) via NRB or BVM.

Minimize BVM to decrease gastric distention and risk of
vomiting/aspiration.
Pretreatment (T-3 minutes):
 Evidence of head injury or stroke:
 Lidocaine 1.5 mg/kg IV/IO (max 150 mg)
 Begin cricoid pressure/Sellick’s maneuver

Paralysis and Induction (T + 0 minutes):
 Etomidate 0.3 mg/kg IV/IO (max dose 20 mg)
 Succinylcholine 2 mg/kg IV/IO (max dose 200 mg)

Placement with Proof (T + 30 seconds):
 Place BIAD or ETT
 Confirm with:
 End Tidal CO2 waveform
35


Auscultation
Physical findings
 Secure device, note position

Post-Placement Airway Management (T + 60 seconds):
 Sedation


Morphine Sulfate 3 mg IV/IO AND Midazolam 3 mg IV/IO after
tube confirmed with ETCO2 (check BP prior to administration):

May repeat X 2 as needed for sedation
If additional paralysis needed and transport time is > 10 minutes
consider:

Rocuronium 1 mg/kg IV/IO
(long acting paralytics mandates sedation as above)
Contact Medical Control for any additional orders or questions
36
SIMULTANEOUSLY CONTACT MEDICAL CONTROL
Preparation (T-8 minutes)










Monitoring (continuous ECG, Sp02, Blood Pressure)
2 patent IVs
Functioning Laryngoscope and BVM with highflow O2
Endotracheal tube(s), stylet, syringe(s)
BIAD(s) and appropriate syringe(s)
Alternative/Rescue Airway (LMA and surgical airway kit) immediately
available
All medications drawn up and labeled (including post-procedure sedation)
Suction--turned on and functioning
End Tidal CO2 device on and operational (colorimetric immediately available
as back-up only)
Assess for difficult airway--LEMON
Preoxygenate
100% O2 x 5 minutes (NRB) or 8 VC breaths with 100% O2 (BVM/NRB)
Pretreatment (T-3 minutes)



Evidence of head injury or stroke
Lidocaine 1.5 mg/kg IV/IO (max 150 mg)
Begin cricoid pressure/Sellick’s maneuver
Paralysis and Induction (T=0)


Etomidate 0.3 mg/kg (max 20 mg)
Succinylcholine 2 mg/kg (max 200 mg)
Placement with Proof (T+30 seconds)



Place BIAD/ETT
Confirm with:
--End Tidal CO2 waveform
--Auscultation
--Physical Findings
Secure Device, note position
Post-Placement Management (T+1 minute)
Sedation: Morphine 3 mg IV/IO AND Midazolam 3 mg IV/IO, repeat X2 as needed.
If additional paralysis needed and transport time > 10 minutes:
Rocuronium 1 mg/kg IV/IO
37
Airway Emergencies: Failed Airway
When in failed airway scenario, immediate transport to the nearest
emergency department is required
Simultaneously Contact Medical Control
All Providers

General Patient Care Protocol—Adult

If ventilation ineffective with single person BVM, place nasal and/or oral airway
and begin two-person BVM.

Attempt ventilation with BVM and oral and/or nasal airway:

Acceptable air exchange:
 Continue with BVM, rapid transport indicated
 Monitor oxygen saturation, end tidal carbon dioxide and cardiac
parameters continuously

If unable to ventilate effectively with basic airway maneuvers using BVM and
patient has no gag reflex, place advanced airway.
Paramedic

Full ALS Assessment and Treatment

Simultaneously notify OLMC

Failed Intubation/BIAD

Attempt ventilation with BVM and oral and/or nasal airway:
 Acceptable air exchange:
 Continue with BVM, rapid transport indicated
 Monitor oxygen saturation, end tidal carbon dioxide and cardiac
parameters continuously
 Unacceptable air exchange:
 Place BIAD (if not previously attempted)

Acceptable air exchange:
38
 Monitor oxygen saturation, end tidal carbon dioxide
and cardiac parameters continuously

No air exchange:
 Can’t intubate/place advanced airway/can’t ventilate
situation

Percutaneous Cricothyrotomy (Surgical
Airway)
39
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Onset and location
Insect sting or bite
Food allergy / exposure
Medication allergy / exposure
New clothing, soap, detergent
Past history of reactions
Past medical history
Medication history
Medical Protocol
Differential
Urticaria (rash only)
Anaphylaxis (systemic effect)
Shock (vascular effect)
Angioedema (drug induced)
Aspiration / Airway
obstruction
Vasovagal event
Asthma or COPD
CHF
Signs and Symptoms
Itching or hives
Coughing / wheezing
Respiratory distress
Chest or throat constriction
Difficulty swallowing
Hypotension or shock
Edema
General Approach to All Adult Patients
Mild Reaction
Hives / Rash Only
No respiratory component
IV Protocol
Epinephrine 1:1000
Auto‐Injector * 0.3mg
Epinephrine 1:1000 IM
A
A
Albuterol 2.5mg/3ml &
Ipratropium 0.5mg/2.5ml**
P
Diphenhydramine
50 mg IV/IM/IO
P
Famotidine
20 mg in 100 ml D5W
P
P
Albuterol 2.5mg/3ml &
Ipratropium 0.5mg/2.5ml
A
IV Protocol
P
Diphenhydramine
50 mg IV/IM/IO
P
Famotidine
20 mg in 100 ml D5W
P
P
A
Pearls
RECOMMENDED EXAM: Mental Status, Skin,
Heart, Lungs
*Contact Medical Control: prior to
administering epinephrine in patients who
are >50 years of age, have a history of
cardiac disease, or if the patients heart rate
is >150. Epinephrine may precipitate
cardiac ischemia. These patients should
receive a 12 Lead EKG
Famotidine, IV piggyback over 15 minutes (if
not already given)
**May repeat Albuterol PRN for continued
wheezing – max 3 doses
The shorter the onset from symptoms to
contact, generally the more severe the
reaction
A
*0.3mg
2013
A
Moderate Reaction
Dyspnea, Wheezing,
Chest Tightness
Severe Reaction
Evidence of Impending
Respiratory Distress or Shock
A
IV Protocol
P
Diphenhydramine
50 mg IV/IM/IO
P
Famotidine
20 mg in 100 ml D5W
P
P
P
Methylprednisolone
125 mg IV/IO
Imminent Cardiac
Arrest ***
P
Epinephrine 1:10,000
0.5mg IV
P
M
Simultaneously
Contact Medical
Control
M
*** Severe bradycardia, unresponsive, no obtainable
blood pressure or radial pulse
A
P
Continued Severe
Symptoms
Epinephrine Infusion:
MP
Mix 2mg (1:1000) in 250ml NS
Start at 2mcg/min
(max 10mcg/min)
PM
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
40
Allergic Reaction
All Providers

General Patient Care Protocol—Adult

Assist patient in self-administration of previously prescribed epinephrine
auto-injector (Epi-Pen)

If wheezing present:
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer
 May repeat Albuterol PRN for continued wheezing (max 3
doses)
Mild Reaction (Itching/Hives)
 Advanced EMT
 Consider IV Protocol
 Paramedic
 Full ALS Assessment and Treatment


Consider Diphenhydramine (Benadryl) 50 mg IV/IM/IO
Consider Famotidine 20 mg in 100 ml D5W, IV Piggyback over
15 min
Moderate Reaction (Dyspnea, Wheezing, Chest Tightness)
As for mild symptoms, additionally:
 All Providers
 Albuterol (Proventil) 2.5 mg/3 ml and Ipratropium Bromide 0.02%
(Atrovent) 0.5 mg/2.5 ml via nebulizer, if not already given
 May repeat Albuterol PRN for continued wheezing (max 3
doses)
 Advanced EMT
 Consider IV Protocol
 Paramedic
 Diphenhydramine (Benadryl) 50 mg IV/IM/IO (if not already given)
 Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not
already given)
41
Severe Systemic Reaction (SBP <90mmHg, Stridor, Severe Respiratory Distress)
As for moderate symptoms, additionally:
 All Providers
 Epinephrine 1:1000, 0.3 mg IM (OLMC for approval if age>50,
HR>150, history of CAD)
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer
 May repeat PRN for continued wheezing (max 3 doses)
 Advanced EMT
 Consider IV Protocol
 Consider Fluid Bolus-500cc NS (max 2 liters)
 Paramedic
 Diphenhydramine (Benadryl) 50 mg IV/IM/IO (if not already given)
 Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not
already given)
 Methylprednisolone (Solumedrol) 125 mg IV/IO
Imminent Cardiopulmonary Arrest (severe bradycardia, unresponsive, no obtainable
blood pressure or radial pulse)
 Paramedic
 As for severe systemic reaction, additionally:
 Epinephrine 1:10,000, 0.5 mg IV
Cardiac Arrest
 Paramedic

Refer to the appropriate protocol based on presenting rhythm

In the setting of cardiac arrest, the following items should be performed in the
post-resuscitative phase, when time allows:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer
 May repeat PRN for continued wheezing (max 3 doses)

Diphenhydramine (Benadryl) 50 mg IV/IO (if not already given)

Famotidine 20 mg in 100 ml D5W, IV Piggyback over 15 min (if not already
given)

Methylprednisolone (Solumedrol) 125 mg IV/IO (if not already given)
Contact Medical Control for any additional orders or questions
 Epinephrine Infusion:
 Mix 2 mg (1:1000) in 250 ml NS
 Start at 2 mcg/min, maximum 10 mcg/min
42
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
General Approach to All Adult Patients
Blood Glucose
Glucose <70
A
IV Protocol
Glucose >70
A
A
A
A
Consider other causes: Head injury,
OD/toxic ingestion, stroke, hypoxia,
hypothermia
No Improvement in
Altered Mental Status
P
Improved
Assess Cardiac Rhythm
P
12 Lead EKG
A
M
Consider
*Naloxone 2mg IV/IO/IN**/IM
Every 3 minutes (max 8mg)
2013
Consider Oral Glucose 15g if
awake and no risk of aspiration
If no IV, Glucagon 1mg IM if
unable to use glucose
Dextrose 12.5‐25g
Or D10W 100mL IV A
Differential
Head Trauma
CNS (stroke, tumor, seizure,
infection)
Cardiac (MI, CHF)
Hypothermia
Infection (CNS or other)
Thyroid (hyper/hypo)
Shock (septic, metabolic, traumatic)
Diabetes (hyper/hypo)
Toxicologic or Ingestion
Acidosis/Alkalosis
Environmental exposure
Pulmonary (hypoxia)
Electrolyte abnormality
Psychiatric disorder
Medical Protocol
Signs and Symptoms
Decreased mental status
Lethargy
Change in baseline mental
status
Bizarre behavior
Hypoglycemia (cool/
diaphoretic skin)
Hyperglycemia (warm, dry
skin, fruity breath, kussmaul
respirations, signs of
dehydration
Irritability
History:
Known Diabetic,
Medic alert tag
Drugs, drug paraphernalia
Report of illicit drug
Use or toxic ingestion
Past medical history
Medications
History of Trauma
Change in condition
Changes in feeding or sleep
habits
Contact Medical Control
IV bolus 250 ml x1
If clinically hypovolemic (orthostatic
hypotension/dry mucous membranes)
A
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Pay special attention to the head exam for
signs of bruising or other injury.
* Naloxone (Narcan) can be administered in 0.4 mg increments titrated to respiratory drive and level of consciousness
** for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed with additional doses as needed.
(Paramedics may give 1 mg per nare)
Be aware of AMS as presenting sign of an environmental toxin or Hazmat exposure and protect personal safety
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after Dextrose or glucagon
Do not let alcohol confuse the clinical picture. Alcoholics frequently develop hypoglycemia and may have unrecognized injuries
Low glucose (<70), normal glucose (70‐120), high glucose (>250)
Consider restraints if necessary for patients and/or personnel's protection per the restraint protocol
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
43
Altered Mental Status
All Providers

General Patient Care Protocol—Adult

Blood Glucose
 If hypoglycemic (Blood glucose < 70mg/dL)
Glucose paste 15 g or other oral glucose agent (e.g. orange
juice) if patient alert enough to self-administer
If hypoglycemic and unable to take oral glucose:
 Consider Glucagon 1mg IM

If Stroke suspected, see Stroke Protocol

If Head Injury suspected, see Trauma/Head Injury Protocol

If severely agitated and/or violent see Behavioral Emergencies Protocol

If cardiac arrhythmia present see appropriate Cardiac Arrhythmia Protocol
Advanced EMT

Consider IV Protocol

If Drug (narcotic) overdose suspected:
 Naloxone (Narcan) 2 mg IV/IO every 3 minutes (maximum 8 mg)
▪ Naloxone (Narcan) can be administered in 0.4 mg increments
titrated to respiratory drive and level of consciousness
▪ If IV access has not been established, Naloxone (Narcan) 2
mg IM or 0.5 mg per nare IN (total 1.0mg per administration)
● If hypoglycemic
 Dextrose 12.5g-25g IV or D10W 100mL IV
▪ May repeat as needed every 5-10 minutes to blood glucose
>100 mg/dL

If Clinically hypovolemic (orthostatic hypotension / dry mucous membranes)
IV bolus 250ml x1.
Paramedic
● Full ALS Assessment and treatment
● If hypoglycemic (Blood glucose < 70 mg/dL) with IV access:
 Dextrose 12.5g-25g IV or D10W 100mL IV
 May repeat as needed every 5-10 minutes to blood glucose
>100 mg/dL
● If hypoglycemic (Blood glucose < 70 mg/dL) without IV access:
44
 Glucose paste 15 g or other oral glucose agent (e.g. orange juice) if
patient alert enough to self administer
● If hypoglycemic and unable to take oral glucose:
 Glucagon 1 mg IM
● If Drug (narcotic) overdose suspected:
 Naloxone (Narcan) 2 mg IVP every 3 minutes (maximum 8 mg)
▪ Naloxone (Narcan) can be administered in 0.4 mg
increments titrated to respiratory drive and level of
consciousness
▪ If IV access has not been established, Naloxone
(Narcan) 2 mg IM or IN via mucosal atomizer device
Note:
Patients presenting with altered mental status, who
respond to Narcan are not candidates for informed
refusal. Due to the relatively short half-life of Narcan,
these patients are at risk for return of symptoms. These
patients should be transported to the emergency
department, regardless of an apparently normal mental
status.
Contact Medical Control for any additional orders or questions
45
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
(Excited Delirium)
A
P
M
History:
Situational crisis
Psychiatric illness/medications
Injury to self or threats to
others
Medic alert tag
Substance abuse / overdose
Diabetes
Signs and Symptoms
Anxiety, agitation, confusion
Affect change, hallucinations
Delusional thoughts, bizarre
behavior
Combative / violent
Expression of suicidal /
homicidal thoughts
Scene Safety
Medical Protocol
Differential
See altered mental status
differential
Alcohol intoxication
Toxin / substance abuse
Medication effect / overdose
Withdrawal syndromes
Depression
Bipolar (manic‐depressive)
Schizophrenia
Anxiety disorders
General Approach to All Adult Patients
Remove patient from stressful environment
Use verbal calming techniques (reassurance, calm,
establish rapport)
GCS and Pupil Assessment on all patients
Paramedics should be considered EARLY
NEVER restrain in the PRONE position
2013
Go to appropriate protocol:
Altered Mental Status Protocol
Overdose / Toxic Ingestion Protocol
Head Trauma Protocol
Service MD Approval:______
Check glucose if any suspicion of hypoglycemia
Altered Mental Status
Protocol
<70
>70
Restraint Procedure *
Haloperidol 5mg IM if <60kg or 10mg IM if >60kg**
Lorazepam 1‐2mg IM (can be combined with
Haloperidol)
P
A
P
IV Protocol
A
250 ml bolus (max 2L total)
If Cocaine/Sympathomimetic toxicity
suspected:
M
Lorazepam 1mg IV/IM
Repeat 1mg IV/IM if needed
If patient refuses care
Contact Medical Control
P
M
P
OR
M P
Ketamine 4mg/kg IM
P M
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lung, Neuro
SAFETY FIRST!
* Never retrain or transport in prone position
**Avoid if recent history of MAO inhibitor use (ie. Phenelzine,
Transylcypomine)
Consider Haloperidol for patients with history of psychosis
Do not overlook the possibility of associated domestic violence or child abuse
If patient in excited delirium suffers cardiac arrest, follow appropriate cardiac
arrest protocol.
All patients who receive either physical or chemical restraint MUST
continuously be observed by ALS personnel on scene or immediately upon
their arrival.
Any patient handcuffed or restrained by law enforcement, law enforcement
must ride in ambulance
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
46
Behavioral Emergencies/Excited Delirium
Strongly Consider Paramedic Assistance
All Providers

General Patient Care Protocol—Adult

Apply physical restraints if needed to ensure patient/crew safety. Adhere to
procedure on Physical Restraint of Agitated Patients when this process is
deemed necessary

Blood Glucose Measurement-if < 70 mg/dl, refer to Altered Mental Status
Protocol

Assess and treat for hyperthermia
Advanced EMT
 Consider IV Protocol
Paramedic

When Chemical or Physical restraints are used, perform Full ALS
Assessment and Treatment

For patients with severe agitation compromising patient/crew safety, or for
patients who continue to struggle against physical restraints:
 Haloperidol (Haldol) 5 mg IM if, 60 kg or 10mg IM if >60 kg
 Avoid if recent history of MAO inhibitor use (e.g. Phenelzine,
Tranylcypromine)
 Lorazepam (Ativan) 1-2 mg IM (can be combined in same syringe as
Haldol)
If concerns for Excited Delirium:
 250 ml bolus Normal Saline IV – x4 (2L max)

If cocaine/sympathomimetic toxicity strongly suspected:
 Lorazepam (Ativan) 1 mg IV/IM
 Repeat Lorazepam (Ativan) 1 mg IM/IV if adequate sedation not
achieved on initial dose

Note: NEVER restrain or transport in prone position!
Contact Medical Control for all refusals or non-transports
Contact Medical Control for any additional orders or questions
Paramedics - Ketamine 4 mg/kg IM with Medical Control
Permission
47
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Type of bite/sting
Description or bring creature/
photo with patient for
identification
Time, location, size of bite/sting
Previous reaction to bite/sting
Domestic vs. wild
Tetanus and rabies risk
Immunocompromised patient
Signs and Symptoms
Rash, skin break, wound
Pain, soft tissue swelling,
redness
Blood oozing from the bite/
wound
Evidence of infection
Differential
Animal bite
Human bite
Snake bite (poisonous)
Spider bite (poisonous)
Insect sting/bite (bee, wasp,
ant, tick)
Infection risk
Rabies risk
Tetanus risk
Medical Protocol
General Approach to All Adult Patients
Irrigate/Cleanse wound with 0.9%
NaCl (remove any large debris)
Remove stinger if wasp/bee
(if easily removed)
Mark edematous area with pen and
note time
Immobilize affected part and remove
distal jewelry
Refer to Pain Control Protocol if there is
significant pain
If there is allergic reaction refer to
Allergic Reaction Protocol
A
M
Contact Medical
Control
IV Protocol
If SBP<90mmHg, consider 500 ml bolus NS (total 2L)
P
M
If no improvement from 2L fluid bolus
Dopamine infusion at 5‐20mcg/kg/min titrated to
maintain SBP>90mmHg
A
Service MD Approval:______
P
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Extremities (location of injury), and a complete Neck, Lung, Heart, Abdomen, Back,
and Neuro exam if systemic effects are noted.
Human bites have higher infection rates than animal bites due to normal mouth bacteria
Carnivore bites are much more likely to become infected and all have risk of rabies exposure
Cat bites may progress to infection rapidly due to a specific bacteria (pasteurella multicoda)
Snake bites: amount of envenomation is variable, generally worse with larger snakes and early in spring, if no pain or swelling
envenomation is unlikely, it is NOT necessary to take the snake to the ED with the patient.
Black widow spider bites tend to be minimally painful, but over a few hours, muscular pain and severe abdominal pain may
develop (spider is black with red hourglass on belly)
Brown recluse spider bites are minimally painful to painless. 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).
An alternative to bringing the offender to the Emergency Department would be to take a picture of the animal/insect
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
48
Bites and Envenomations
All Providers

General Patient Care Protocol—Adult

Irrigate/Cleanse wound with 0.9% NaCl (remove any large debris)

Remove stinger if wasp/bee (if easily removed)

Mark edematous area with pen and note time

Immobilize affected part and remove distal jewelry

Attempt to identify what caused bite and bring to Emergency Department if
dead (use caution when handling dead snakes as envenomation has
occurred secondary to reflex motor movement) – an alternative is taking a
picture of the animal/insect.

Refer to Allergic Reaction Protocol as indicated

Transport to closest appropriate facility
Advanced EMT

Consider IV Protocol

For hypotension (SBP<90 mmHg) consider 500 ml IV 0.9% NaCl fluid
boluses up to 2L.
Paramedic

Full ALS Assessment and Treatment

For hypotension (SBP<90 mmHg) not improved with fluid boluses up to 2L
0.9% NaCl, or when fluid boluses are contraindicated:
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain SBP>90
mmHg
Contact Medical Control for any additional orders or questions
49
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs and Symptoms
Unresponsive
Apneic
Pulseless
History:
Events leading to arrest
Estimated downtime
Past Medical History
Medications
Existence of terminal illness
Signs of lividity, rigor mortis
DNR
Differential
Medical or Trauma
Vfib vs Pulseless Vtach
Asystole
Pulseless electrical activity
(PEA)
Withhold Resuscitation
Cardiac Protocol
General Approach to All Adult Patients
Criteria for Death/No Resuscitation Indicated
YES
Call “patient contact” to dispatch when you arrive at
patients side
Continue compressions until
Defib pads in place and monitor
charged.
YES
Adequate Bystander CCR or CPR?
NO
2013
AT ANY TIME
Return of spontaneous
circulation ‐>
Go to Post Resuscitation
Protocol
Immediately perform compressions
at a rate of 100 compressions per
minute for 2 minutes
Stop compressions for rhythm
analysis (<5seconds)
If VT or VF (or AED
advises shock)
DEFIBRILLATE
(call 1st shock to dispatch)
If PEA/Asystole – (or
AED advises no shock)
do NOT shock
Go to appropriate Protocol and
Resume compressions
A
IV Protocol
A
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status
Immediately after defibrillation, resume chest compressions with a different operator compressing. Do not pause for post‐shock rhythm
analysis. Stop compressions only for signs of life (patient movement) or rhythm visible through compressions on monitor or pre‐defibrillation
rhythm analysis every 2 minutes and proceed to appropriate protocol
CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac nature. It is not indicated in those situations
where other etiologies are probable (OD, drowning, hanging, etc.) In these instances CPR is indicated
CCR is not to be used on individuals less than 18 years of age.
Successful resuscitation requires planning and clear role definition
In the event a patient suffers cardiac arrest in the presence of EMS, the absolute highest priority is to apply the AED/Defibrillator and
deliver a shock immediately if indicated.
Reassess airway frequently and with every patient move.
DO NOT INTERRUPT CHEST COMPRESSIONS!
Designate a “code leader” to coordinate transitions, defibrillation and pharmacological interventions. “Code Leader” ideally should have no
procedural tasks.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
50
Cardiac Arrest: General Approach
General

CCR is indicated in ADULT patients that have suffered cardiac arrest of a presumed cardiac
nature. It is not indicated in those situations where other etiologies are probable (overdose,
drowning, hanging etc.). In these instances CPR is indicated.

CCR is not to be used on individuals less than 18 years of age.

Successful resuscitation requires planning and clear role definition.

In the event a patient suffers cardiac arrest in the presence of EMS (EMS witnessed
Cardiac Arrest), the absolute highest priority is to apply the AED/Defibrillator and
deliver a shock immediately if indicated.

Reassess airway frequently and with every patient move.

DO NOT INTERRUPT CHEST COMPRESSIONS!

Designate a “code leader” to coordinate transitions, defibrillation and pharmacological
interventions. “Code Leader” should ideally not have any procedural tasks. If the “code
leader” is needed for a specific task, a new leader must be designated.
All Providers

General Patient Care Protocol (including blood glucose)

Check responsiveness and check for a carotid pulse

Call “patient contact” to dispatch when you arrive at the patient’s side

If adequate bystander compressions ongoing, continue compressions until monitor
pads in place and monitor charged. Stop compressions for rhythm analysis (< 5 sec)
 If VT or VF (or AED Advises Shock), defibrillate

Call “first shock” time to dispatch
 If PEA/Asystole, go to appropriate protocol and resume compressions

Immediately after defibrillation, resume chest compressions with a different operator
compressing. Do not pause for post-shock rhythm analysis. Stop compressions only
for signs of life (patient movement) or rhythm visible through compressions on
monitor or pre-defibrillation rhythm analysis every 2 minutes

If compressions are not being performed upon arrival or if compressions are not
deemed adequate, immediately perform compressions at a rate of 100 compressions
per minute for 2 minutes.
Advanced EMT

Consider IV Protocol
Paramedic
See Protocol based on presenting rhythm
51
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Past Medical History
Medications
Events leading to arrest
End stage renal disease
Estimated downtime
Suspected hypothermia
Suspected Overdose
DNR
Signs and Symptoms
Pulseless
Apneic
No electrical activity on ECG
No auscultated heart tones
Differential
Medical or Trauma
Hypoxia
Potassium (hypo/hyper)
Drug Overdose
Acidosis
Hypothermia
Device (lead) error
Death
Cardiac Protocol
Cardiac Arrest Protocol
Withhold Resuscitation
YES
Criteria for Death / No resuscitation
NO
AT ANY TIME
Return of spontaneous
circulation ‐>
Go to Post Resuscitation
Protocol
A
IV Protocol
P
P
Termination of
Resuscitation Protocol
Epinephrine 1mg IV/IO
every 3‐5 minutes
2013
5 cycles of CPR unless arrest
witnessed by AED equipped
personnel
A
P
Consider Correctable Causes
Hypoxia – secure airway and ventilate
Hypoglycemia – Dextrose 12.5‐25g or D10W 100ml IV/IO
Hyperkalemia – Sodium bicarbonate 1mEq/kg IV/IO
‐ Calcium Chloride 1g IV/IO
Hypothermia – Active Rewarming
Calcium Channel and B-Blocker OD – Glucagon 3mg IV/IO
Calcium Channel Blocker OD – Calcium Chloride 1g IV/IO
(avoid if patient on Digoxin/Lanoxin)
Tricyclic antidepressant OD – Sodium Bicarbonate 1mEq/kg IV/IO
Possible Narcotic OD – Naloxone 2mg IV/IO
YES
P
After 20 Minutes
Criteria for Discontinuation
NO
Pearls
RECOMMENDED EXAM: Mental Status
When Asystole is seen on the cardiac monitor, confirmation of the rhythm shall
include a printed rhythm strip as well as interpretation of the rhythm in more than
one lead.
Low amplitude Vfib or PEA may be difficult to distinguish from asystole when using only
the cardiac monitor for interpretation.
Continue Epinephrine
and correctable causes
M
Consult Medical
Control
M
Service MD Approval:______
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
52
Cardiac Arrest: Asystole
Note: When Asystole is seen on the cardiac monitor, confirmation of the rhythm shall
include a printed rhythm strip, as well as interpretation of the rhythm in more than
one lead. Low amplitude V-Fib or PEA may be difficult to distinguish from asystole
when using only the cardiac monitor for interpretation.
All Providers

Follow Cardiac Arrest—General Approach Protocol
Paramedic

Consider and treat possible causes
Potential Causes of Asystole
 Hypoxia


Treatment
Secure airway and ventilate
Dextrose 25 g IV/IO; repeat as
needed to achieve blood glucose >70
Sodium bicarbonate 1 mEq/kg IV/IO
Calcium Chloride 1 g IV/IO
Active re-warming
See below

Hypoglycemia



Hyperkalemia (end stage renal
disease)
Hypothermia
Tablets (drug overdose)

Epinephrine 1 mg IV/IO every 3-5 min during arrest

Drug overdoses (see specific drug OD/toxicology section)




 Glucagon 3 mg IV/IO for calcium channel and B-blocker OD
 Calcium Chloride 1 g IV/IO for calcium channel blocker OD
 Avoid if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1 mEq/kg, IV/IO for Tricyclic antidepressant OD
 Naloxone (Narcan) 2 mg IV/IO for possible narcotic OD

If no response to resuscitative efforts in 20 minutes (at least 2 rounds of
drugs) consider discontinuation of efforts (see Termination of Resuscitation
Protocol)
Contact Medical Control for any additional orders or questions
53
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs and Symptoms
Pulseless
Apneic
Electrical activity on ECG
No heart tones on
auscultation
Cardiac Protocol
History:
Past Medical History
Medications
Events leading to arrest
End stage renal disease
Estimated downtime
Suspected hypothermia
Suspected Overdose
DNR
Differential
Hypovolemia (trauma, AAA,
other)
Cardiac Tamponade
Hypothermia
Drug Overdose (Tricyclics,
Digitalis, Beta Blockers,
Calcium channel blockers)
Massive MI
Hypoxia
Tension pneumothorax
Pulmonary embolus
Acidosis
hyperkalemia
Cardiac Arrest Protocol
A
P
Epinephrine 1mg IV/IO
every 3‐5 minutes
P
Do NOT discontinue
compressions unless there
is a definite pulse
P
Service MD Approval:______
2013
AT ANY TIME
Return of spontaneous
circulation ‐>
Go to Post Resuscitation
Protocol
A
IV Protocol
Consider Correctable Causes
Hypovolemia (most common) – NS 1-2L IV/IO
Hypoxia – secure airway and ventilate
Hydrogen Ion (acidosis) – Sodium Bicarbonate 1mEq/kg IV/IO
Hyperkalemia – Sodium bicarbonate 1mEq/kg IV/IO
‐ Calcium Chloride 1g IV/IO
Hypothermia – Active Rewarming
Calcium Channel and B-Blocker OD – Glucagon 3mg IV/IO
Calcium Channel Blocker OD – Calcium Chloride 1g IV/IO
(avoid if patient on Digoxin/Lanoxin)
Tricyclic antidepressant OD – Sodium Bicarbonate 1mEq/kg IV/IO
Possible Narcotic OD – Naloxone 2mg IV/IO
Cardiac Tamponade – NS 1‐2 L IV/IO and expedite transport
Tension pneumothorax – Needle thoracostomy
Coronary or Pulmonary Thrombosis – Expedite Transport
Pearls
RECOMMENDED EXAM: Mental Status
Consider each cause listed in the differential: survival is based on identifying and
correcting the cause.
Discussion with Medical Control can be a valuable tool in developing a differential
diagnosis and identifying possible treatment options.
M
Consult Medical
Control
Termination of
Protocol
MResuscitation
after 20 minutes
P
M
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
54
Cardiac Arrest:
Pulseless Electrical Activity (PEA)
All Providers

Follow Cardiac Arrest—General Approach Protocol
Paramedic

Consider and treat possible causes
Potential Causes of PEA
Treatment

Hypovolemia (most common)

Normal Saline 1-2 liters IV/IO

Hypoxia

Secure airway and ventilate

Hydrogen Ion (acidosis)

Sodium Bicarbonate 1 mEq/kg IV/IO

Hyperkalemia (end stage renal disease)


Sodium Bicarbonate 1 mEq/kg IV/IO
Calcium Chloride 1 g IV/IO

Hypothermia

Active rewarming

Tablets (drug overdose)

See below

Tamponade, Cardiac


Normal Saline 1-2 liters IV/IO
Expedite transport

Tension pneumothorax

Needle thoracostomy

Thrombosis, Coronary

Expedite transport

Thrombosis, Pulmonary

Expedite transport

Epinephrine 1 mg IV/IO every 3-5 minutes

Do not discontinue compressions unless there is a definite pulse

Drug overdoses (see specific drug in OD/toxicology section)
 Glucagon 3 mg IV/IO for calcium channel and B blocker
 Calcium Chloride 1 g IV/IO for calcium channel blocker or suspected
hyperkalemia (dialysis patient)
▪ Avoid if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1 mEq/kg, IV/IO for Tricyclic antidepressant OD
 Naloxone (Narcan) 2 mg IV/IO for possible narcotic OD

If no response to resuscitative efforts in 20 minutes (at least 2 rounds of
drugs) consider discontinuation of efforts (see Termination of Resuscitation
Protocol)
55
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
Ventricular Fibrillation
Pulseless Vent. Tachycardia
A
P
M
History:
Estimated down time
Past medical history
Medications
Events leading to arrest
Renal failure / dialysis
DNR or living will
Differential
Asystole
Artifact / Device failure
Cardiac
Endocrine / Metabolic
Drugs
Pulmonary
Signs and Symptoms
Unresponsive, apneic,
pulseless
Ventricular fibrillation or
ventricular tachycardia on
EKG
Cardiac Arrest Protocol
Cardiac Protocol
Defibrillate x1 *
AT ANY TIME
Rhythm Changes to
Nonshockable Rhythm
Go to appropriate
protocol
After defibrillation resume CCR without pulse check
Apply non‐rebreather as soon as other care activities will not be
interrupted
After 2 minutes of CCR
Check rhythm – if VF/VT persists
Defibrillate – CCR immediatly
A
AT ANY TIME
Return of spontaneous
circulation ‐>
Go to Post Resuscitation
Protocol
P
Epinephrine 1mg IV/IO
every 3‐5 minutes
A
P
Consider Vasopressin 40 units IV/IO
with 1st or 2nd epi dose only
2013
P
Establish IV/IO
P
After 2 minutes of CCR
Check rhythm – if VF/VT persists
Defibrillate – CCR immediatly
P
P
M
Amiodarone 300mg IV/IO bolus
For persistent VT/VF give Amiodarone
150mg IV/IO bolus on second round
P
If Polymorphous VT or hypomagnesemic state‐
Magnesium Sulfate 2g IV/IO push over 1‐2 min
If suspected hyperkalemia or tricyclic OD
Sodium Bicarbonate 1mEq/kg IV/IO
If suspected hyperkalemia – Calcium Chloride 1g IV/IO
Termination of
Resuscitation Protocol
M
YES
Continue cycle
of compressions
and Drug,
rhythm check,
compressions
shock etc.
P
Criteria for
Discontinuation after
20 minutes
NO
Pearls
RECOMMENDED EXAM: Mental Status
*Call first defibrillation time to 911 Center
Reassess and document advanced airway placement and EtCO2 frequently, after every
move, and at transfer of care.
Treatment priorities are: uninterrupted chest compressions, defibrillation, then IV
access and airway control.
M
Consult Medical
Control
M
Service MD Approval:______
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
56
Cardiac Arrest: Ventricular Fibrillation/
Pulseless Ventricular Tachycardia
All Providers

Follow Cardiac Arrest—General Approach Protocol
Defibrillate for persistent VF/VT

use manufacturer recommended energy settings, typically 200J or 360 J
⇒ Continue Chest Compressions immediately after shock (do not stop for
pulse or rhythm check)
⇒ Call first defibrillation time to dispatch

Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
 Defibrillate at 200 J (360 J if available)
 Continue compressions immediately after shock (do not stop for pulse
or rhythm check)
Paramedic

Epinephrine 1 mg IV/IO every 3-5 min during arrest

Vasopressin 40 Units IV/IO with 1st or 2nd Epinephrine doses only

Analyze rhythm after 2 minutes of good CPR; If VF/VT persists:
 Defibrillate at 200 J (360 J if available)
 Continue Chest Compressions immediately after shock (do not stop for
pulse or rhythm check)

Amiodarone 300mg IV/IO bolus
 For persistent VT/VF give Amiodarone 150 mg IV/IO bolus on second
round

Continue cycle of Compressions & Drug  Rhythm Check  Compressions
 Shock  Compressions & Drug  Rhythm Check  Compressions 
Shock as needed

Additional interventions to consider in special circumstances
 Magnesium Sulfate 2 g IV/IO push over 1-2 minutes only if suspected
Polymorphous VT (torsades de pointes) or hypomagnesemic state
(chronic alcohol or diuretic use)
 Sodium Bicarbonate 1 mEq/kg, IV/IO if suspected hyperkalemia
(dialysis patient) or tricyclic antidepressant OD
 Calcium Chloride 1 g IV/IO if suspected hyperkalemia (dialysis patient)
Contact Medical Control for any additional orders or questions
57
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Respiratory Arrest
Cardiac Arrest
Differential
Continue to address specific
differentials associated with the
original dysrhythmia
Signs and Symptoms
Return of pulse
Repeat Primary Assessment
P
P
Consider Induced Hypothermia Protocol
Continue Ventilatory Support
A
P
IV Protocol
Cardiac Monitor
Cardiac Protocol
100% Oxygen
ETCO2 goal 40
RR <12
DO NOT HYPERVENTILATE
A
P
Vital Signs (including PulseOx)
12 Lead EKG
Hypotension
SBP<90mmHg
A
P
Normal Saline bolus
250ml x2
Re Arrest
Combative
A
If not improved by NS bolus
‐Dopamine infusion 5‐20
mcg/kg/min titrated to
maintain SBP >90mmHg
‐ Additional 250 ml bolus x2
to 2L max
2013
Continue anti‐arrythmic if ROSC
was associated with its use
P
Lorazepam 1‐2 mg slow IV/IO may
repeat x1 (max dose 4mg) or
Midazolam 1‐2 mg slow IV/IO may
repeat x1 (max dose 4mg)
P
Follow appropriate
arrest protocol
P
M
Consult Medical
Control if needed
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
Hyperventilation is a significant cause of hypotension and recurrence of cardiac arrest in the post resuscitation phase and must be avoided
at all costs. ETCO2 goal is 40mmHg.
Most patient’s immediately post resuscitation will require ventilatory assistance
The condition of post‐resuscitation patients fluctuates rapidly and continuously, and they require close monitoring. Appropriate post‐
resuscitation management may best be planned in consultation with medical control
Common causes of post‐resuscitation hypotension include hyperventilation, hypovolemia, pneumothorax, and medication reaction to ALS
drugs
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
58
Cardiac Arrest: Post Resuscitation Care
All Providers

General Patient Care Protocol—Adult

Maintain assisted ventilation as needed

Supplemental 100% oxygen

ETCO2 if available
Paramedic

Full ALS Assessment and Treatment

Monitor ETCO2, goal is 40mmHg, DO NOT HYPERVENTILATE

For hypotension (systolic BP <90 mmHg) not improved by fluid boluses, or
when fluid administration is contraindicated:
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP
>90 mmHg

If VF/pulseless VT occurred during arrest AND Amiodarone was
administered, no additional anti-arrhythmic is required unless arrhythmia
recurs.

If VF/VT reoccurs after previous conversion with Amiodarone 300 mg:
 Defibrillate and administer Amiodarone 150 mg IV/IO

If patient becomes combative, administer:
 Lorazepam (Ativan) 1-2 mg slow IV/IO may repeat X 1 (maximum dose
4 mg) or
 Midazolam (Versed) 1-2 mg slow IV/IO, may repeat X 1 (maximum 4
mg)

Consider Therapeutic/Induced Hypothermia Protocol

Transport to nearest appropriate facility
Contact Medical Control for any additional orders or questions
59
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Non‐traumatic cardiac arrests
(drownings and hangings/
asphyxiation are permissible in this
protocol)
Signs and Symptoms
Cardiac Arrest
ROSC post‐cardiac arrest
Differential
Continue to address specific
differentials associated with the
original dysrhythmia
12 Lead EKG
Assessment and document GCS
Criteria for Inclusion
Transport
and continue
post
resuscitation
care
Does NOT
Meet
criteria
Witnessed Cardiac Arrest with ROSC
Not Pregnant
Age = or >18
No evidence of trauma or intracranial hemorrhage
Significant altered level of consciousness (not following commands, no
purposeful movement, incomprehensible speech)
No known surgery within the preceding 2 weeks
No history of bleeding disorder (warfarin/coumadin and heparin are
NOT contraindications)
Patient must have airway secured (BIAD/ETT)
2013
MEETS CRITERIA
P
Pearls
Must have secured airway to
undergo cooling
Most patients suffering from
cardiac arrest with ROSC die
with anoxic brain injury.
Therapeutic hypothermia
serves to improve the chance of
a good neuro outcome.
Closely monitor ventilation,
target ETCO2 to 40 mmHg, do
not hyperventilate
If at any time there is a loss of
spontaneous circulation,
discontinue cooling and go to
the appropriate protocol.
Perform RSA to secure airway (ETT/BIAD)
IF:
1) Airway not already in place
AND
2) Airway placement will NOT delay transport
P
Administer Midazolam 1‐2
mg every 3‐5 minutes IV/
IO to a max of 10mg
P
Administer 30 ml/kg of
cool saline (4° C) to a max
of 2L
Cardiac Protocol
Paramedic
Only
Protocol
ROSC
P
P
P
Apply Ice Packs to axilla, groin
and neck
P
If Shivering ‐
Rocuronium 1 mg/kg IV/IO
P
P
If Systolic BP<90mmHg
Initiate Dopamine infusion
at 5‐20mcg/kg/min, titrate
to SBP >90mmHg
P
M
Consult Medical
Control if needed
Service MD Approval:______
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
60
M
Cardiac Arrest: Hypothermia
Therapeutic/Induced
Most patients suffering from cardiac arrest with return of spontaneous circulation
(ROSC) die with anoxic brain injury. Therapeutic hypothermia serves to improve the
chance of a good neurologic outcome.
Criteria for inclusion:

Witnessed cardiac arrest with ROSC

Not pregnant

Age  18 years

No evidence of trauma or intracranial hemorrhage

Significant altered level of consciousness
 Not following commands
 No purposeful movement
 Incomprehensible speech

No known surgery within the preceding 2 weeks

No history of bleeding disorder
 Warfarin/Coumadin and Heparin are NOT contraindications

Patient must have airway secured (BIAD/ETT)
Paramedic

Full ALS Assessment and Treatment

12-Lead EKG

Ensure all inclusion/exclusion criteria are met.

If airway not secured and it will not delay transport to the appropriate
receiving facility, perform RSA, refer to Rapid Sequence Airway Protocol as
needed.

Assess neurological status prior to intubation, document each of the three
GCS criteria.

Once airway secured/sedated, expose patient and apply ice packs to axilla,
groin and neck.

Administer Midazolam 1-2 mg every 3-5 minutes IV/IO to a max of 10 mg.

Administer 30 ml/kg of cool saline (4°C) to a max of 2 liters IV.

If shivering, administer Rocuronium 1 mg/kg IV/IO.
61

If systolic blood pressure < 90 mmHg, initiate Dopamine infusion at 5-20
mcg/kg/min, titrate to SBP > 90 mmHg

Closely monitor ventilation, target ETCO2 to 40 mmHg, do not hyperventilate.

If at any time there is loss of spontaneous circulation, discontinue cooling and
go to the appropriate protocol.
Contact Medical Control for any additional orders or questions
62
Policy:
Unsuccessful cardiopulmonary resuscitation (CPR) and other advanced life support
(ALS) interventions may be discontinued prior to transport or arrival at the hospital
when this procedure is followed:
Note: When asystole is seen on the cardiac monitor, confirmation of the rhythm shall include a
PRINTED rhythm strip, as well as documented interpretation of the rhythm strip in more than one
lead. Low amplitude V-fib or PEA may be difficult to distinguish from asystole when using only the
cardiac monitor display for interpretation.
Procedure:
1)
Discontinuation of CPR and ALS intervention may be implemented by a
Paramedic without Medical Control consultation in a non-hypothermic adult
provided all 7 criteria exist:
□ Arrest is presumed to be of cardiac origin
□ Initial rhythm is asystole, confirmed in two leads on a printed strip
□ Terminal rhythm is asystole confirmed in two leads on a printed strip
□ Secure airway confirmed by digital capnography (ETT/BIAD)
□ At least four doses of Epinephrine have been administered
□ Cardiac Arrest refractory to minimum of 20 minutes of ACLS
□ Quantitative EtCO2 value is <10mmHg with effective CPR, after 20 minutes of
ACLS
2)
Field termination if the above 7 criteria aren’t met after 20 minutes of ACLS must
be approved by Medical Control.
3)
The paramedic has the discretion to continue resuscitation efforts if scene
safety, location, patients age, time of arrest, or bystander input compels this
decision.
DO NOT TERMINATE RESUSCITATION IF PATIENT HAS BEEN MOVED TO THE
AMBULANCE OR IF TRANSPORT HAS BEEN INITIATED.
Contact Medical Control for any additional orders or questions.
Basic and A-EMT need to call Medical Control for Permission to Cease
Resuscitation!
Service MD Approval:______
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
63
Policy:
Resuscitation can be withheld in Medical Cardiopulmonary Arrest under the following
circumstances:
□ Adult patient >18 years of age AND
□ Pulseless, Apneic and no other signs of life present AND
□ Asystole verified in two (2) leads AND
□ Not exposed to an environment likely to promote hypothermia AND
□ The presence of one or more of the following:
*Rigor Mortis
*Decomposition of body tissues
*Dependent lividity OR
*When the patient has a valid State of Wisconsin DNR order/bracelet/
wristband
If unknown DNR status or questions regarding validity of DNR status, initiate
resuscitation and contact OLMC.
Service MD Approval:______
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
64
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Medications
(Aminophylline, diet pills,
thyroid supplements,
decongestants, Digoxin)
Diet (caffeine, chocolate)
Drugs (nicotine, cocaine)
Past medical history
History of palpitations/heart racing
Signs and Symptoms
Tachycardia
QRS <0.12 sec
Dizziness, CP, SOB
Potential presenting rhythm
Sinus tachycardia
Atrial fibrillation/flutter
Multifocal atrial tachycardia
A
A
IV Protocol
HR <150
And no symptoms
Monitor
and
Transport
HR >150, Afib on monitor
Serious signs and symptoms
BP <90mmHg, Altered LOC
Sedation if patient condition allows and SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam 1‐2 mg IV/IO/IN
Titrate to max total dose of Fentanyl 200 mcg and
Midazolam 4mg
12 Lead EKG
No History of WPW
Diltiazem 0.25 mg/kg IV over 5 minutes
(max 20 mg per dose)
If unsuccessful afer 10 min and SBP
>100mmHg
Diltiazem 0.35 mg/kg IV (max 20mg)
P
P
History of WPW
P
Amiodarone 150mg IV in 100ml
D5W over 10 minutes
May repeat 1x if SBP >100mmHg
P
M
Synchronized Cardioversion
First Energy Level: 100 Joules
If no response:
200 J
If no response:
200 J (300 J if available)
If no response:
200 J (360 J if available)
Consult Medical
Control
P
2013
HR >150, Afib on
monitor
and
SBP >90mmHg
and mild symptoms
P
P
Cardiac Protocol
General Approach to all Adult Patients
Differential
Heart Disease (WPW, Valvular)
Sick sinus syndrome
Myocardial Infarction
Electrolyte imbalance
Exertion, pain, emotional stress
Fever
Hypoxia
Hypovolemia or Anemia
Drug effect / OD (see HX)
Hyperthyroidism
Pulmonary embolus
P
M
Service MD Approval:______
After rate control/conversion
12 Lead EKG
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Repeat Blood Pressure after Diltiazem administration.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
65
Cardiac Arrhythmias:
Atrial Fibrillation or Flutter
All Providers

General Patient Care Protocol-Adult

12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

Do not delay treatment if patient is unstable by obtaining 12-lead ECG unless
diagnosis is in question
Stable or borderline – Systolic BP >90 mmHg and mild symptoms (chest pain, SOB
or lightheadedness)

No history of WPW:
 Diltiazem 0.25 mg/kg IV over 5 min (Max 20 mg per dose)
 If unsuccessful after 10 min and SBP >100 mmHg
 Diltiazem 0.35 mg/kg IV (max 20mg)

History of WPW
 Amiodarone 150 mg IV in 100 ml D5W over 10 min
 If unsuccessful and SBP>100 mmHg, may repeat one time
Unstable (serious signs and symptoms-pulmonary edema, BP<90 mmHg systolic,
altered consciousness) AND atrial fibrillation at a rate >150 beats/minute

Sedation if patient condition and time allows (hold if SBP <90mmHg):
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg

Synchronized Cardioversion
 1st energy level:
100 Joules
 If no response:
200 J
 If no response:
200 J (300 J if available)
 If no response:
200 J (360 J if available)
Contact Medical Control for any additional orders or questions
66
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
General Approach to All Adult Patients
12 Lead EKG
A
A
IV Protocol
Monitor
NO
YES
A
Transport
A
IV NS Bolus 250ml
2013
Hypotension ‐ SBP <90mmHg,
Altered Mental Status or
Chest Pain
Cardiac Protocol
Differential
Acute Myocardial Infarction
Hypoxia
Pacemaker failure
Hypothermia
Sinus Bradycardia
Athletes
Head Injury (elevated ICP) or
Stroke
Spinal Cord Lesion
Sick sinus syndrome
AV Blocks (1°, 2°, 3°)
Overdose
Signs and Symptoms
HR <60/minute with hypotension,
acute altered mental stufs, chest
pain, acute CHF, seizures, syncope,
or shock secondary to bradycardia
Chest Pain
Respiratory distress
Hypotension or Shock
Altered mental Status
Syncope
History:
Past medical history
Medications
‐Beta Blockers
‐Calcium Channel blockers
‐Clonidine
‐Digoxin
Pacemaker
No Improvement
Medication
Overdose?
P
Atropine 0.5mg IVP, repeat every 3
minutes as needed (max 3.0mg/kg
P
No Improvement
Appropriate Overdose
Protocol
P
Dopamine 5‐20mcg/kg/min IV
P
External Pacing
Procedure
P
No Improvement
P
Unstable
Epi Infusion 2‐10mcg/min titrate to
HR>60, SBP <180 (max 10mcg/min)
P
Unstable
Continuous
Monitoring
Improved
Pearls
RECOMMENDED EXAM: Mental Status, Neck, Heart,
Lungs, Neuro
*Start at lowest MA’s, increase until electrical capture with
pulses achieved
Start rate at 70 or default and increase rate to achieve
systolic BP >90mmHg (maximum 100 beats/min)
Therapies are only indicated when serious signs and
symptoms are present. If symptoms are mild,
provide supportive care and expedite transport.
In wide complex slow rhythm consider hyperkalemia
Be sure to aggressively oxygenate the patient and
support respiratory effort
Continuous
Monitoring
P
Sedation
Protocol
Transport
P
M
Consult
Medical
Control
P
Fentanyl
25‐50mcg
IV/IO (max
200 mcg)
P P
P
Midazolam
1‐2mg
IV/IO (max
4mg)
M
Service MD Approval:______
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
67
P
Cardiac Arrhythmias:
Bradycardia
All Providers

General Patient Care Protocol-Adult

12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

Do not delay transport if patient is unstable by obtaining a 12 lead ECG
unless diagnosis is in question
Note: The following therapies are indicated only when serious signs and
symptoms are present. If symptoms are mild, provide supportive care and
expedite transport.
Symptomatic (SBP<90mmHg, altered mental status or severe chest pain)

Atropine 0.5 mg IVP, Repeat every 3 minutes as needed (Maximum dose
3mg)

If symptoms persist after Atropine or any delay in establishing IV:
 Initiate transcutaneous pacing using demand mode
 Start at lowest MA’s; increase until electrical capture with pulses
achieved
 Start rate at 70 and increase rate to achieve systolic BP >90mmHg
(Maximum 100 beats/minute)
 Sedation if patient condition and time allows (hold if SBP<90 mmHg):
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
 For hypotension (systolic BP <90 mmHg) and/or Bradycardia (HR<60)
not improved by above
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain HR
>60 and SBP >90 mmHg but SBP <180 mmHg.
 If above unsuccessful:
68

Epinephrine infusion at 2-10 mcg/min titrated to maintain HR>60
and SBP >90 mmHg but SBP <180mmHg.
 If drug induced, treat for specific drug overdose
 Calcium Chloride 1g IV/IO for calcium channel blocker OD



Contraindicated if patient on Digoxin/Lanoxin
 Glucagon 3mg IV/IO for calcium channel blocker
OD if no response to Calcium Chloride
Glucagon 3mg IV/IO for Beta Blocker OD
Naloxone (Narcan) can be given in 0.4 mg increments titrated to
level of consciousness and respiratory drive


If IV access has not been established, Naloxone
(Narcan) 2 mg IM or via Mucosal Atomizer Device
Sodium Bicarbonate 1 mEq/kg IV/IO for Tricyclic antidepressant
OD
Contact Medical Control for any additional orders or questions
69
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs and Symptoms
HR >150 bpm
QRS <0.12 sec (if QRS >0.12 sec,
go to V‐Tach protocol
If history of WPW, go to V‐Tach
protocol
Dizziness, CP, SOB
Potential presenting rhythm
Atrial/Sinus tachycardia
Atrial fibrillation/flutter
Multifocal atrial tachycardia
Differential
Heart Disease (WPW, Valvular)
Sick sinus syndrome
Myocardial Infarction
Electrolyte imbalance
Exertion, pain, emotional stress
Fever
Hypoxia
Hypovolemia or Anemia
Drug effect / OD (see HX)
Hyperthyroidism
Pulmonary embolus
Cardiac Protocol
History:
Medications
(Aminophylline, diet pills,
thyroid supplements,
Decongestants, Digoxin)
Diet (caffeine, chocolate)
Drugs (nicotine, cocaine)
Past medical history
History of palpitations/heart
racing
Syncope / near syncope
General Approach to all Adult Patients
A
Stable
Ventricular rate >150
Unstable
Ventricular rate >150
12 Lead EKG
P
Adenosine Phosphate 6 mg rapid
IVP over 1‐3 seconds with 20 cc
NS flush
(repeat with 12mg rapid IVP if no
response in 2 min)
May repeat x1.
P
Consult Medical Control
M
P
If NO Response
Sedation if patient condition allows and SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam 1‐2 mg IV/IO
Titrate to max total dose of Fentanyl 200 mcg and
Midazolam 4mg
P
Diltiazem 0.25mg/kg slow IV over 5 min
(max 20mg)
(NOT for use with or hx of WPW)
Amiodarone 150mg IV over 10 min
P
2013
Vagal Maneuvers
(Valsalva or Cough)
M P
Adenosine Phosphate 6mg rapid IVP over 1‐3 seconds
with 20 cc NS flush ‐ (repeat with 12mg rapid IVP if no
response in 2 min) May repeat x1.
P
P
M
A
IV Protocol
P
Synchronized Cardioversion
First Energy Level: 50 Joules
If no response:
100 J
If no response:
200 J
If no response:
200 J (300 J if available)
If no response:
200 J (360 J if available)
P M
P
P
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
If patient has a history or 12 Lead EKG reveals Wolfe Parkinson White (WPW), NO NOT administer Calcium Channel Blocker (Diltazem) or Beta
Blockers
Adenosine will not terminate non SVT rhythms such as Afib or Aflutter..
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
70
Cardiac Arrhythmias:
Supraventricular Tachycardia
All Providers

General Patient Care Protocol—Adult

12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment
 Do not delay treatment if patient is unstable by obtaining 12-lead ECG
unless diagnosis is in question
Stable or borderline (Ventricular rate >150)

Vagal maneuvers (Valsalva or Cough)

Adenosine Phosphate (Adenocard) 6 mg rapid IVP over 1-3 seconds with 20
ml Normal Saline flush
 If no response in 2 minutes, Adenosine Phosphate (Adenocard) 12 mg
rapid IVP over 1-3 seconds with 20 ml Normal Saline flush.
 If no response in 2 minutes, may repeat Adenosine Phosphate
(Adenocard) 12mg rapid IVP x1.
Unstable with serious signs and symptoms (Ventricular rate >150)

May give brief trial of Adenosine 6mg rapid IVP over 1-3 seconds with 20 cc
Normal Saline flush

Sedation if patient condition and time allows (hold if SBP<90mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg

Synchronized Cardioversion
 First energy level:
50 Joules
 If no response:
100 J
 If no response:
200 J
 If no response:
200 J (300 J if available)
 If no response:
200J (360 J if available)
Contact Medical Control for any additional orders or questions
 Diltiazem 0.25mg/kg slow IV over 5 min (Max 20mg)
 NOT FOR USE WITH OR HISTORY OF WPW
 Amiodarone 150mg IV over 10 min
71
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Past Medical History /
medications, diet, drugs
Syncope / near syncope
CHF
Palpitations
Pacemaker
Allergies: lidocaine / novacaine
Signs and Symptoms
Ventricular tachycardia on ECG
(Runs or sustained)
Conscious, rapid pulse
Chest pain, shortness of breath
Dizziness
Rate usuaally 150‐180bpm for
sustained Vtach
QRS >.12 sec
Differential
Artifact / Device failure
Cardiac
Endocrine / Metabolic
Drugs
Pulmonary
Cardiac Protocol
General Approach to all Adult Patients
Vfib/
Pulseless
Vtach
Protocol
NO
Palpable pulse?
(Paramedics: Wide, regular rhythm with QRS >0.12sec)
YES
A
A
IV Protocol
12 Lead EKG
Stable and SVT highly likely
(Rate >150)
P
P
Adenosine
Phosphate 6mg
rapid IVP over
1‐3 seconds with
20 cc NS flush
(repeat with 12mg
rapid IVP if no
response in 2 min)
May repeat x1.
P
No
Response
P
Amiodarone 150mg
in 100ml D5W IV
Piggyback over 10
minutes
May repeat every 15
min
(Max 450mg total)
P
P
Sedation if patient condition allows and
SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam
1‐2 mg IV/IO/IN
Titrate to max total dose of Fentanyl 200
mcg and Midazolam 4mg
2013
Stable and unknown
Wide complex or Vtach
Likely (Rate >150)
Unstable
With serious signs and
symptoms
P
Synchronized Cardioversion **
First Energy Level: 100 Joules
If no response:
200 J
If no response:
200 J (300 J if available)
If no response:
200 J (360 J if available)
P
IF wide complex tachy reoccurs
Following cardioversion
M
Contact Medical Control
M
P
If hyperkalemia suspected in any wide complex
tachycardia (ie. Renal failure patient)
Calcium Chloride 1g IV/IO*
Sodium Bicarbonate 1mEq/kg IV/IO
Pearls
-RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
* Calcium Chloride Contraindicated for patient on Digoxin/Lanoxin
Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.
Service MD Approval:______
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.
** If delays in synchronization occur and condition is critical, go immediately to unsynchronized shocks
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
72
P
Cardiac Arrhythmias:
Wide‐Complex Tachycardia
All Providers

General Patient Care Protocol-Adult

12 Lead EKG
Advanced EMT
 Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

Do not delay treatment by obtaining 12-lead ECG unless diagnosis is in
question

In general, assume unknown wide complex tachycardia, at rates over 150
represent ventricular tachycardia
Stable and unknown wide complex or ventricular tachycardia likely
(rate >150)

Consider Adenosine Phosphate (Adenocard) 6 mg rapid IVP over 1-3
seconds with 20 ml Normal Saline flush
 For atypical presentation of SVT
 If no response after first dose and patient still stable move to
Amiodarone.

Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10 minutes
 Repeat Amiodarone 150 mg in 100ml D5W IV Piggyback over 10
minutes every 15 minutes (Maximum of 450 mg total)
Unstable wide complex tachycardia (rate >150)

Sedation if patient condition and time allows (hold for SBP <90 mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg
73

Synchronized Cardioversion:
 1st energy level
100 Joules
 If no response
200 J
 If no response
200 J (300 J if available)
 If no response
200 J (360 J if available)

If delays in synchronization occur and condition is critical, go immediately to
unsynchronized shocks

If wide complex tachycardia reoccurs following electrical cardioversion:
 Amiodarone 150 mg in 100 ml D5W IV Piggyback, over 10 minutes,
every 15 minutes (maximum 450 mg cumulative total dose)

If hyperkalemia suspected in any wide complex tachycardia (e.g. renal failure
patient) administer the following medications:
 Calcium Chloride 1g IV/IO
 Contraindicated if patient on Digoxin/Lanoxin
 Sodium Bicarbonate 1mEq/kg IV/IO
Contact Medical Control for any additional orders or questions
74
Signs and Symptoms
Ventricular tachycardia on ECG
(Runs or sustained)
Conscious, rapid pulse
Chest pain, shortness of breath
Dizziness
Rate usuaally 150‐180bpm for
sustained Vtach
QRS >.12 sec
History:
Past Medical History /
medications, diet, drugs
Syncope / near syncope
CHF
Palpitations
Pacemaker
Allergies: lidocaine / novacaine
Differential
Artifact / Device failure
Cardiac
Endocrine / Metabolic
Drugs
Pulmonary
Vfib/
Pulseless
Vtach
Protocol
Palpable pulse?
(Paramedics: Wide, regular rhythm with QRS >0.12sec)
NO
YES
A
IV Protocol
12 Lead EKG
STABLE
P
P
NO Response
P
Amiodarone
150mg in 100ml
D5W IV Piggyback
over 10 minutes
May repeat every
15 min
(Max 450mg
total)
A
P
M
A‐EMT
Paramedic
Medical Control
A
UNSTABLE
Sedation if patient condition allows and
SBP >90mmHg
Fentanyl 25‐50 mcg and Midazolam 1‐2
mg IV/IO
Titrate to max total dose of Fentanyl 200
mcg and Midazolam 4mg
2013
P
Magnesium Sulfate 2g
slow IV in 10ml NS over
1‐2 min
A
P
M
Cardiac Protocol
Legend
EMT
General Approach to all Adult Patients
P
No Response
And
UNSTABLE
P
P
Synchronized Cardioversion
First Energy Level: 100 Joules
If no response:
200 J
If no response:
200 J (300 J if available)
If no response:
200 J (360 J if available)
P
If delays in synchronization occur and
condition is critical, go immediately to
unsynchronized shocks
M
Contact Medical Control
M
Pearls
-RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
* Calcium Chloride Contraindicated for patient on Digoxin/Lanoxin
Adenosine may not be effective in identifiable atrial flutter/fibrillation, yet is not harmful.
Service MD Approval:______
Monitor for hypotension after administration of Calcium Channel Blocker or Beta Blockers
Monitor for respiratory depression and hypotension associated with Midazolam
Continuous pulse oximetry is required for all SVT patients
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention.
Do NOT delay treatment if patient is unstable by obtaining 12 Lead EKG unless diagnosis is in question.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
75
Cardiac Arrhythmias:
Polymorphous Ventricular Tachycardia
(Torsades de Pointes)
All Providers

General Patient Care Protocol-Adult

12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment
 Do not delay treatment if patient is unstable by obtaining a 12-lead
ECG unless diagnosis is in question
Stable

Magnesium Sulfate 2 g slow IV in 10 ml NS over 1-2 minutes

If no response, Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10
minutes
 Repeat Amiodarone 150 mg in 100 ml D5W IV Piggyback over 10
minutes every 15 minutes (Maximum of 450 mg total)
Unstable-or if no response to the above measures:

Sedation if patient condition and time allows (hold if SBP < 90mmHg)
 Fentanyl 25-50 mcg and Midazolam 1-2 mg IV/IO
 Titrate to maximum total dose of Fentanyl 200 mcg and
Midazolam 4 mg


Synchronized Cardioversion:
 1st energy level
100 Joules
 If no response
200 J
 If no response
200 J (300 J if available)
 If no response
200 J (360 J if available)
If delays in synchronization occur and condition is critical, go immediately to
unsynchronized shocks
Contact Medical Control for any additional orders or questions
76
Legend
EMT
A‐EMT
Paramedic
A
P
M
Medical
Control
A
P
M
Signs and Symptoms
CP (pain, pressure, aching,
vice like tightness)
Location (substernal,
epigastric, arm, jaw, neck,
shoulder)
Radiation of pain
Pale, diaphoresis
Shortness of Breath
Nausea, vomiting, dizziness
Time of Onset
Differential
Trauma vs. Medical
Angina vs. MI
Pericarditis
Pulmonary embolism
Asthma / COPD
Pneumothorax
Aortic dissection or aneurysm
GE reflux or hiatal hernia
Esophogeal spasm
Chest wall injury or pain
Pleural pain
OD (Cocaine) or Methamphetamine
General Approach to All Adult Patients
Obtain and Transmit 12 Lead EKG within 5 minutes of
arrival
Aspirin 324 mg PO
A
IV Protocol
250ml if hypotensive
M
Patient assisted Nitroglycerin 0.4mg
SL, repeat every 5 minutes as needed
if SBP >90mmHG and not
contraindicated*
M
A
Nitroglycerin 0.4mg SL if IV***
established, repeat every 5 minutes
as needed if SBP >90mmHG and not
contraindicated*
A
P
P
P
Nausea or Vomiting
Ondansetron (Zofran) 4 mg slow IV
A
STEMI ALERT
Transport to PCI (Percutaneous Coronary Intervention) capable
hospital
University of WI Hospitals and Clinics
Meriter Hospital
St. Marys Hospital (not Sun Prairie ED)
VA Hospital
(patient preference should be taken into account)
2013
P
For hypotension (<90mmHg) not
improved by fluid or if fluid
contraindicated – Dopamine infusion
at 5‐20 mcg/kg/min titrated to
maintain SBP >90mmHg
Morphine Sulfate 2‐4mg slow IVP,
repeat every 5 minutes as needed
(max 15mg) or Fentanyl 25‐50 mcg
slow IV, repeat every 5 minutes (max
200mcg)**
If Runs of Vtach:
Amiodarone 150 mg in 100 ml D5W
IV piggyback over 10 minutes
(isolated PVCs do not require
treatment)
IF symptoms for <12 hours, and any of the following:
Paramedic interprets ST segment elevation >1mm in two
or more contiguous leads
Defib interpretation of “**ACUTE MI**” on EKG
New Left BBB (confirmed by comparing to prior EKG)
Cardiac Protocol
History:
Age
Medications
Viagra, Levitra, Cialis
Past Medical History (MI, Angina, Diabetes,
post menopausal)
Allergies (ASA, morphine, lidocaine)
Recent physical exertion
Palliation/Provocation
Quality (crampy, constant, sharp, dull, etc.
Region/Radiation/Referred
Severity (1‐10)
Time (onset/duration/repitition)
Notify facility EARLY
P
P
P
P
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Lung, Heart, Abdomen, Back,
Extremities, Neuro
*Nitro Contraindications: SBP<90, Use of a Phosphodiesterase-5 (PED5)
inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra [Vardenafil]) and
48 hours for Cialis (Tadalifil)- Use with caution in Acute Inferior Wall MI, or
Right Ventricular infarct (ST elevation in V4R)
Patient Assisted Nitro -send EKG and have OLMC determine if Nitro
appropriate
**Morphine contraindicated if SBP<90mmHg, use with caution in right
ventricular or posterior wall MI (ST elevation in posterior leads with marked
depression in V1-V4)
*** If unable to establish IV, send EKG and contact OLMC for permission to
proceed with Nitro
Elderly patients, diabetics, and woman are more likely to experience angina
(cardiac chest pain) in an atypical fashion – presenting as vague weakness,
SOB, arm, back or jaw discomfort, etc.
Cardiac Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
77
Chest Pain
All Providers

General Patient Care Protocol—Adult

Obtain and transmit 12-lead ECG within 5 minutes of arrival

Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is not
contraindicated or taken within the last hour.

Assist patient in self-administration of previously prescribed Nitroglycerin
 Contact Medical Control for consultation regarding 12 Lead EKG
interpretation prior to assisting with patient Nitro.
 Contraindicated if systolic BP < 90 mmHg
 Contraindicated if use of a Phosphodiesterase-5 (PED5) inhibitor
within last 24 hours (Viagra [Sildenafil] or Levitra [Vardenafil])
 This contraindication extends to 48 hours for Cialis (Tadalifil)

Repeat patient assisted Nitroglycerin administration every 5 minutes as
needed for continued chest pain (provided SBP remains > 90 mmHg) with
assessment of patient before and after each NTG dose

See STEMI alert information below
Advanced EMT


IV Protocol
For suspected cardiac chest pain:
o Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is
not contraindicated or given already
o Nitroglycerin 0.4 mg SL, every 5 minutes as needed for chest pain
 IV access must be secured before Nitroglycerin
administration (if unable, contact Medical Control)
Contraindicated if systolic BP < 90 mmHg
Contraindicated if use of a Phosphodiesterase-5 (PED5)
inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra
[Vardenafil])
 This contraindication extends to 48 hours for Cialis (Tadalifil)
o Use with caution in Acute Inferior Wall MI, or Right Ventricular infarct
(ST elevation in V4R)
o Be prepared to administer IV NS boluses at 250 mL if hypotension
develops


78
Paramedic

Full ALS Assessment and Treatment

Obtain 12-lead ECG within 5 minutes of arrival

Identify the presence of ECG changes suggestive of Acute Myocardial Infarct
(AMI)
 See STEMI Alert below
 Prior to transport notify receiving hospital as per STEMI Alert Criteria

For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or
when fluid boluses are contraindicated
 Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP
> 90 mmHg
 For suspected cardiac chest pain:
o Aspirin 324 mg PO chewed if patient is able to swallow and Aspirin is
not contraindicated or given already
o Nitroglycerin 0.4 mg SL, every 5 minutes as needed for chest pain
 IV access must be secured before Nitroglycerin
administration (If unable, contact Medical Control)




Contraindicated if systolic BP < 90 mmHg
Contraindicated if use of a Phosphodiesterase-5 (PED5)
inhibitor within last 24 hours (Viagra [Sildenafil] or Levitra
[Vardenafil])
This contraindication extends to 48 hours for Cialis (Tadalifil)
IV access must be secured before Nitroglycerin
administration (If unable, contact Medical Control)
o Use with caution in Acute Inferior Wall MI, or Right Ventricular infarct
(ST elevation in V4R)
o Be prepared to administer IV NS boluses at 250 mL if hypotension
develops
o Morphine Sulfate 2-4 mg slow IVP; repeat every 5 minutes as needed
(Maximum 15 mg) or Fentanyl 25-50 mcg slow IV; repeat every 5
minutes (Maximum 200 mcg)
 Contraindicated if systolic BP < 90 mmHg


Use with caution in right ventricular or posterior wall MI
(ST elevation in posterior leads with marked depression
in V1-V4)
Runs of Ventricular Tachycardia:
 Amiodarone 150 mg in 100 ml D5W IV piggyback over 10 minutes
 Isolated PVCs do not require treatment
79

For patients with severe nausea or vomiting:
 Ondansetron (Zofran) 4 mg slow IV
All Providers
STEMI Alert (ST Segment Elevation Myocardial Infarction)

A STEMI Alert will be instituted for patients having chest pain or ischemic
equivalent symptoms for < 12 hours, and any of the following
 Computer interpretation of “**ACUTE MI**” on 12-lead ECG (EMT
Basic or Advanced)
 Paramedic Interprets - ST segment elevation  1mm in two or more
contiguous leads
 Paramedic Interprets - New Left Bundle Branch Block (confirmed by
comparing to prior ECG)

Patients meeting STEMI Alert criteria should be transported to a PCI
(Percutaneous Coronary Intervention) capable hospital
 PCI Capable hospitals in the Madison Area:
 University of Wisconsin Hospitals and Clinics
 Meriter Hospital
 St. Mary’s Hospital Madison
 VA Hospital

Patient preference should be taken into account when determining the
transport destination.

Early notification/ECG transmission to the receiving facility is imperative.

Activation of the STEMI Process must be documented in the Patient Care
Run Sheet
Contact Medical Control for any additional orders or questions
80
Assure your local Fire Department is dispatched to assist if necessary.
Consult Emergency Response Guidebook (ERG) before attempting to handle any toxic chemical exposure patient
Upon identifying a possible toxic exposure or overdose: Contact the Regional Poison Control Center (1‐800‐222‐1222)
Upon identifying a possible hazmat exposure: Contact City of Madison HIT for chemical information via the 911
Communications Center
Chemical Burns and Dermal Exposure
Special Response Protocols
All Providers
General Patient Care Protocol—Adult
Refer to the Burn Protocol
Stop the burning process
Remove all clothing prior to irrigation
If a caustic liquid is involved, flush with copious amounts of water
For chemical burns with eye involvement, immediately begin flushing the eye with normal
saline and continue throughout assessment and transport
If a dry chemical is involved, brush it off, then flush with copious amount of water
Do not use water to flush the following chemicals:
Elemental metals (sodium, potassium, lithium), and phenols
Remove obvious metallic fragments from the skin
Cover the burn with mineral oil or cooking oil
Phenols penetrate the skin more readily when diluted with water
If available, dilute with the following (listed in order of efficacy)
Polyethylene glycol (PEG)
Glycerol
Vegetable Oil
As a last resort use extremely large amounts of soap and water with continuous
irrigation until all phenols are removed
Apply a burn sheet or dry sterile dressing to burn areas
For inhaled toxin with acute bronchospasm:
Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and
Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
Advanced EMT
Consider IV Protocol
Paramedic
Full ALS assessment and treatment
Observe for signs of impending respiratory failure; Refer to
the Airway Management Protocol if needed
Refer to Pain Management Protocol if needed
Other possible #’s for assistance:
Chemtrec: 1-800-424-9300
Chemtell: 1-888-255-3924
Infotract: 1-800-535-5053
Contact Medical Control for any
additional orders or questions
For persistent burning sensation of
the airways (after Albuterol/
Atrovent) in the setting of Chlorine/
Chloramine exposure:
4.2 % Sodium Bicarbonate
5ml via nebulizer
Mix 2.5 ml of 8.4 % Sodium
Bicarbonate with 2.5 ml of 0.9 %
Normal Saline for a 5 ml nebulizer
3E: 1-800-451-8346
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
81
Hazardous Material Exposures:
Basic Approach
Assure that local Fire Department is responding with EMS if appropriate.
Consult Emergency Response Guidebooks (ERG) before attempting to handle
any toxic chemical exposure patient
Upon identifying a possible toxic exposure or overdose:
Contact the Regional Poison Control Center (1-800-222-1222)
Upon identifying a possible hazmat exposure: Contact City of Madison HIT for
chemical information via the 911 Communications Center
Other possible #’s for assistance:
Chemtrec: 1-800-424-9300
Chemtell: 1-888-255-3924
Infotract: 1-800-535-5053
3E: 1-800-451-8346
Chemical Burns and Dermal Exposure
All Providers

General Patient Care Protocol—Adult

Refer to the Burn Protocol

Stop the burning process

Remove all clothing prior to irrigation

If a caustic liquid is involved, flush with copious amounts of water

For chemical burns with eye involvement, immediately begin flushing the eye
with normal saline and continue throughout assessment and transport

If a dry chemical is involved, brush it off, then flush with copious amount of
water
82

Do not use water to flush the following chemicals:
 Elemental metals (sodium, potassium, lithium), and phenols
 Remove obvious metallic fragments from the skin
 Cover the burn with mineral oil or cooking oil
 Phenols penetrate the skin more readily when diluted with water
 If available, dilute with the following (listed in order of efficacy)
 Polyethylene glycol (PEG)
 Glycerol
 Vegetable Oil
 As a last resort use extremely large amounts of soap and water with
continuous irrigation until all phenols are removed

Apply a burn sheet or dry sterile dressing to burn areas

For inhaled toxin with acute bronchospasm:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer
Advanced EMT
 Consider IV Protocol
Paramedic

Full ALS assessment and treatment

Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed

Refer to Pain Management Protocol if needed
Contact Medical Control for any additional orders or questions
 For persistent burning sensation of the airways (after
Albuterol/Atrovent) in the setting of Chlorine/Chloramine
exposure:
 4.2 % Sodium Bicarbonate 5ml via nebulizer
 Mix 2.5 ml of 8.4 % Sodium Bicarbonate with 2.5 ml
of 0.9 % Normal Saline for a 5 ml nebulizer
83
A
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M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Signs
Altered mental status
Seizures or coma
Dyspnea/tachypnea
Respiratory distress/apnea
Hypertension (early)
Hypotension (late)
Cardiovascular collapse/Cardiac Arrest
Symptoms
Headache
Confusion
Shortness of Breath
Chest Pain or tightness
Nausea/Vomiting
General Approach to All Patients
Special Response Protocols
Scene Safety – SCBA if toxic inhalation suspected
Remove patient from contaminated area
Administer 100% Oxygen
A
IV Protocol
A
*Administer Cyanokit® 5g
IV/IO over 15 minutes
P
Use NaCl 0.9% as the dilutent for Cyanokit® as per
manufacturer instructions
P
Expedite transport and treat other
conditions as per appropriate protocol
Service MD Approval:______
Consult Medical Control
M
If severe symptoms persist (patient in extremis)
contact OLMC for consideration
of repeat dosing
M
Pearls
*Contraindicated in patients with known anaphylactic reactions to hydroxocobalamin or cyanocobalamin
Cyanide poisoning may result form inhalation, ingestion or dermal exposure to cyanide containing compounds, including smoke form closed‐space
fires. The presence and extent of the poisoning are often unknown initially. Treatment decisions must be made on the basis of clinical history and
signs and symptoms of cyanide intoxication.
Not all patients who have suffered smoke inhalation from a closed space fire will have cyanide poisoning. Other conditions such as burns, trauma
or other toxic inhalations (ie. Carbon monoxide) may be the cause of symptoms. When smoke inhalation is the suspected source of cyanide
exposure assess the patient for the following:
● Exposure to fire or smoke in an enclosed space ● Presence of soot around the mouth, nose or oropharynx ● Altered Mental Status
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
84
Hazardous Materials Exposure:
Cyanide Toxicity and Smoke Inhalation
Cyanide poisoning may result from inhalation, ingestion or dermal exposure to
cyanide containing compounds, including smoke from closed-space fires. The
presence and extent of the poisoning are often unknown initially. Treatment
decisions must be made on the basis of clinical history and signs and symptoms of
cyanide intoxication.
Not all patients who have suffered smoke inhalation from a closed-space fire will
have cyanide poisoning. Other conditions such as burns, trauma or other toxic
inhalations (e.g. carbon monoxide) may be the cause of symptoms. When smoke
inhalation is the suspected source of cyanide exposure assess the patient for the
following:

Exposure to fire or smoke in an enclosed space

Presence of soot around the mouth, nose or oropharynx

Altered mental status
Common Signs and Symptoms of Cyanide Toxicity
Symptoms





Signs







Headache
Confusion
Shortness of breath
Chest Pain or tightness
Nausea/Vomiting
Altered mental status
Seizures or coma
Dyspnea/tachypnea
Respiratory distress/apnea
Hypertension (early)
Hypotension (late)
Cardiovascular collapse/cardiac arrest
All Providers

General Patient Care Protocol—Adult

Supplemental 100% Oxygen
Advanced EMT
 Consider IV Protocol
Paramedic

Perform Full ALS Assessment and Treatment

When clinical suspicion of Cyanide poisoning is high
 Administer Cyanokit 5 g IV/IO over 15 minutes
85



Use NaCl 0.9% as the diluent for Cyanokit as per manufacturer
instructions
Contraindicated in patients with known anaphylactic reactions to
hydroxocobalamin or cyanocobalamin
Expedite transport and treat other conditions as per appropriate protocol
Contact Medical Control for any additional orders or questions
 If severe symptoms persist (patient in extremis) contact
OLMC for consideration of repeat dosing of Cyanokit
86
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EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Differential
Nerve agent exposure (ie. VX, Sarin,
Soman, etc.)
Organophosphate exposure
(pesticide)
Vesicant exposure (ie. Mustard gas)
Respiratory irritant exposure (ie.
Hydrogen sulfide, ammonia,
chlorine, etc.)
History:
Exposure to chemical, biologic,
radiologic or nuclear hazard
Potential exposure to unknown
substance/hazard
M
M
Alert Medical Control Immediatly
Signs and Symptoms
Visual Disturbances
Headache
Nausea/vomiting
Salivation
Lacrimation
Respiratory distress
Diaphoresis
Seizure activity
Respiratory arrest
Special Response Protocol
Ensure Scene Safety and SCBA if toxic inhalation suspected
General Approach to All Patients
Obtain history of exposure
Observe for specific toxidromes
Initiate triage and/or decon as indicated
Assess Symptoms
MAJOR*
Must show symptoms before treatment
MINOR*
A
A
IV Protocol
Adult
P
Atropine 2mg IV/IO/IM every 5min
until symptoms resolve
Pediatric
Adult
**MARK 1 kit x3 immediately
Repeat Atropine 2mg IV/IO/IM every 5 min
Until symptoms resolve
P
Atropine 0.02mg‐0.05mg/kg IV/IO/IM
every 5min until symptoms resolve
Lorazepam 1‐2mg IV/IO/IM or
Diazepam Auto Injector 10mg IM
P
Monitor and Reassess
M
Re‐ Contact
Medical Control
Pediatrics
<7 – 1 MARK 1 kit
8‐14 – 2 MARK 1 kits
>15 – 3 MARK 1 kits
Repeat Atropine 0.02mg‐0.05mg/kg
IV/IO/IM every 5 min until symptoms resolve
M
P
Lorazepam 0.1mg IV/IO/IM
Service MD Approval:______
Pearls
* Minor: salivation, lacrimation, visual disturbances
Major: altered mental status, seizure, respiratory distress, respiratory arrest
** MARK 1 and DuoDote kits carried on response vehicles are for Responders ONLY. There use referenced above
implies that the WMD stockpile has been released and delivered to the scene. Trained EMT Basic and
Advanced may also assist with Mark 1 IM injections
Follow local HAZMAT protocols for decon and use of PPE
For patients with major symptoms, there is no limit for atropine dosing
The main symptom that the atropine addresses is excessive secretions so atropine should be given until salivation improves.
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
87
Hazardous Materials Exposure: Nerve Agent/WMD
SIMULTANEOUSLY ALERT OLMC
All Providers






General Patient Care Protocol—Adult
Ensure Scene safety and proper PPE
Obtain history of exposure, observe for toxidromes
Initiate triage/Decontamination
Consider need for additional resources
Mark 1 Kit/DuoDote as below
 Mark 1 and DuoDote Kits carried on response vehicles are for
Responders ONLY. There use referenced below implies that the WMD
stockpile has been released and delivered to the scene
Paramedic

Full ALS Assessment and Treatment

Assess symptoms
 Minor symptoms: salivation, lacrimation, visual disturbances
 Adults

Atropine 2 mg IV/IO/IM every 5 minutes until symptoms
resolve
Pediatrics
Atropine 0.02-0.05 mg/kg every 5 minutes until
symptoms resolve
 Major symptoms: altered mental status, seizures, respiratory distress,
respiratory arrest
 Adults
MARK 1 Kit X 3 IM IMMEDIATELY
o Repeat Atropine 2 mg IV/IO/IM every 5 minutes
until symptoms resolve


Lorazepam 1-2 mg IV/IO/IM or Diazepam Auto-injector
10mg IM
Pediatrics

≤ 7 years old 1 MARK 1 Kit

8-14 years old, 2 MARK 1 kits

≥ 15 years old 3 MARK 1 Kits
o Repeat Atropine 0.02-0.05 mg/kg IV/IO every 5
minutes until symptoms resolve

Lorazepam 0.1mg/kg IM/IV/IO
Contact Medical Control for any additional orders or questions
88
A
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M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Documented Hypertension
Related diseases: diabetes,
CVA, renal failure, cardiac
Medications (compliance ?)
Erectile dysfunction medication
Pregnancy
Signs and Symptoms
One of these
Systolic BP 200 or greater
Diastolic BP 110 or greater
And at least one of these
Headache
Nosebleed
Blurred vision
Dizziness
Differential
Hypertensive encephalopathy
Primary CNS injury (Cushings
response = bradycardia with
hypertension)
Myocardial Infarction
Aortic dissection (aneurysm)
Pre‐eclampsia/Eclampsia
Medical Protocol
General Approach to All Adult Patients
Check BP in both arms
If Respiratory Distress Consider
Adult Dyspnea Protocol
2013
Consider
Chest Pain Protocol
12 Lead EKG
If Altered Mental Status, Stroke, Pulmonary
Edema, Chest Pain or Elevated Blood
Pressure
Refer to Specific Protocol
A
M
IV Protocol
Consult Medical
Control if needed
A
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs Abdomen, Back, Extremities, Neuro
Never treat elevated blood pressure based on one set of vital signs
Symptomatic hypertension is typically revealed through end organ damage to the cardiac, CNS, or renal systems
All symptomatic patients with hypertension should be transported with their head elevated.
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
89
Hypertensive Emergencies
Focus on addressing the manifestations of hypertensive emergencies, such as chest
pain or heart failure. Prehospital treatment of isolated hypertension may result in
critical reductions in target organ perfusion due to uncontrolled lowering of blood
pressure.
All Providers

General Patient Care Protocol—Adult
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment
Symptomatic:


Chest Pain present, refer to the specific protocol
For patients with altered mental status, signs of stroke or pulmonary edema,
who are found to have elevated blood pressure, refer to the specific protocol
Asymptomatic:

Provide supportive care
Contact Medical Control for any additional orders or questions
90
A
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EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Age
Exposure to increased temperatures
and/or humidity
Past medical history / medication
Extreme exertion
Time and length of exposure
Poor PO intake
Fatigue and/or muscle cramping
Differential
Fever (Infection)
Dehydration
Medications
Hyperthyroidism (Storm)
Delirium tremens (DT’s)
Heat cramps
Heat Exhaustion
Heat stroke
CNS lesions or trauma
Signs and Symptoms
Altered mental status or
unconsciousness
Hot, dry or sweaty skin
Hypotension or shock
Seizures
Nausea
Move patient to cooler enviroment
HEAT EXHAUSTION
HEAT CRAMPS
Dizziness, lightheaded, headache, irritability,
normal or decreased LOC, normal or
decreased BP, tachycardia, normal or
elevated temperature
Painful spasms of the extremities or
abdominal muscles, normal mental status
and vitals)
Keep patient supine
100% oxygen
Remove clothing
Sponge with cool water and fan
Oral fluids
Sponge with cool water
A
Overdose
Protocol
IV PROTOCOL
A
HEAT STROKE
Marked alteration in LOC, extremely high
temperature (often >104°F)may be sweating
or have red/hot/dry skin
Semi‐reclining with head
elevated 15‐30°
100% oxygen
Rapid cooling (prevent shivering as it
increases temperature)
Cold packs, sponge with
cool water, fan
A
YES
Cocaine or sympathomimetic
toxicity suspected?
Medical Protocol
General Approach to All Adult Patients
IV PROTOCOL
A
Transport
NO
M
Contact Medical
Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Neuro
Extremes of age are more prone to heat emergencies (ie. Young and old)
Predisposed by use of: tricyclic antidepressants, phenothiazine, anticholinergic medications, and alcohol.
Cocaine, Amphetamines, and Salicylates may elevate body temperatures.
Sweating generally disappears as body temperature rises above 104°F (40°C)
Intense shivering may occur as patient is cooled.
Heat Cramps consists of benign muscle cramping 2° to dehydration and is not associated with an elevated temperature
Heat Exhaustion consists of dehydration, salt depletion, dizziness, fever, mental status changes, headache, cramping, nausea, and vomiting. Vital
signs usually consist of tachycardia, hypotension, and an elevated temperature
Heat Stroke consists of dehydration, tachycardia, hypotension, temperature >104°F (40°C), and an altered mental status
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
91
Hyperthermia
All Providers

General Patient Care Protocol—Adult

Move patient to cooler environment
Heat Cramps (Painful spasms of the extremities or abdominal muscles, normal
mental status and vital signs)

Oral fluids as tolerated

Sponge with cool water
Heat Exhaustion (Dizziness, light-headedness, headache, irritability, normal or
slightly decreased LOC, normal or decreased BP [hypovolemia], tachycardia, normal
or slightly elevated temperature)

Keep patient supine

Supplemental 100% oxygen

Remove clothing

Sponge with cool water and fan
Heat Stroke (Marked alteration in LOC, extremely high temperature [often > 104]
may be sweating or have red/hot/dry skin)

Semi-reclining with head elevated 15-30

Supplemental 100% oxygen

Rapid cooling (prevent shivering as it increases body temperature)

Cold packs, sponge with cool water, fan
Advanced EMT

Consider IV Protocol
Paramedic

If symptoms are moderate to severe, perform Full ALS Assessment and
Treatment

Hyperthermia may result from cocaine or sympathomimetic toxicity
 If cocaine/sympathomimetic toxicity strongly suspected, refer to the
Cocaine/Sympathomimetic Protocol

Expedite Transport
Contact Medical Control for any additional orders or questions
92
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Past medical history
Medications
Exposure to environment even in normal
temperatures
Exposure to extreme cold
Extremes of age
Drug use: alcohol, barbituates
Infections / sepsis
Length of exposure/ wetness
Signs and Symptoms
Cold, clammy
Shivering
Mental status changes
Extremity pain or sensory abnormality
Bradycardia
Hypotension or shock
Differential
Sepsis
Environmental exposure
Hypoglycemia
CNS dysfunction
Stroke
Head Injury
Spinal Cord Injury
Medical Protocol
General Approach to All Adult Patients
Remove Wet Clothing
Measure Temperature
<95°F
(35°C)
Handle Gently
Apply Warm blankets/hotpacks
A
IV PROTOCOL
Warm fluid if available
max 2L
>95°F
(35°C)
Appropriate
Protocol
Based on patient
symptoms
A
M
Contact Medical
Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Neuro
If cardiac arrest occurs with core temp >88°F: refer to appropriate protocol, prolong interval between drugs to 5 minutes, if
defibrillation is necessary, limit to one shock, continue CPR
If cardiac arrest occurs with core temp <88°F contact Medical Control
NO PATIENT IS DEAD UNTIL WARM AND DEAD
Extremes of age are more susceptible (young and old)
With temperatures less than 30°C (86°F) ventricular fibrillation is a common cause of death. Handling patients gently may prevent
this from occuring.
If the temperature is unable to be measured, treat the patient based on the suspected temperature
Hypothermia may produce severe bradycardia so take at least 45 seconds to palpate a pulse
Hot packs can be activated and placed in the armpit and groin area if available. Care should be taken not to place the packs directly
against the patients skin.
Consider withholding CPR if patient has organized rhythm or has other signs of life. Discuss with medical control
Intubation can cause ventricular fibrillation so it should be done gently by the most experienced person.
Do not hyperventilate the patient as this can cause ventricular fibrillation
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
93
Hypothermia
All Providers

General Patient Care Protocol—Adult

Remove wet clothing

Measure temperature, If < 95F (35C), handle gently

Warm blankets/warm temperature
Advanced EMT

Consider IV Protocol

If available, and no contraindications, administer warmed 0.9% Normal saline
(max 2L)
Paramedic

Full ALS Assessment and Treatment

If available, and no contraindications, administer warmed 0.9% Normal saline
(max 2L)

If Cardiac Arrest occurs with a temp > 88F
 Refer to appropriate protocol
 Prolong interval between drugs to 5 minutes
 If defibrillation is necessary, limit to one shock
 Continue CPR

If cardiac arrest with temp < 88F
 Contact OLMC
Contact Medical Control for any additional orders or questions
94
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Advanced EMT/Paramedic
Assess need for IV to administer IV Fluids, Medications in emergent or potentially emergent
conditions
Place catheter per procedure manual
When possible utilize 20g or larger on medical patients and 16 gauge or larger in trauma or
hypovolemic shock patients.
If peripheral IV attempts are unsuccessful, reconsider need for IV access. If life threatening
situation place intraosseous line
General Protocols
Peripheral IV is the access of choice, lower extremity peripheral IV should rarely be utilized
Once access obtained, monitor infusion site, unless administering fluid boluses, either
saline lock the catheter or place at TKO rate.
Consider intraosseous access for any life-threatening event
Paramedic
If extremity IV attempts are unsuccessful, reconsider need for IV access.
If patient hypotensive, but alert and responsive to pain – consider external jugular vein IV
access.
●
If patient unstable, go directly to Intraosseous access.
General Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
95
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Past medical history
Hypertension meds
Prenatal care
Prior pregnancies / births
Gravida / Para
Differential
Pre‐eclampsia / Eclampsia
Placental Previa
Placenta abruption
Spontaneous abortion
Signs and Symptoms
Seizures
Hypertension
Severe headache
Visual changes
Edema of hands and face
Blood Glucose Measurement
<70
>70
A
IV Protocol
Oral Glucose 15g* or Glucagon 1mg
IM
A
IV Protocol
A
P
If Seizure activity or SBP >160mmHg on
two readings
Magnesium Sulfate 4g in 100ml D5W IV
over 10 minutes
P
if Glucose <70
Dextrose 12.5g‐25g slow IVP or D10W
100mL
A
2013
Continued Seizure
P
Lorazepam 1‐2mg, slow IV/IO
Or
Midazolam 5mg IV/IO/IM/IN
(Max dose Lorazepam 4.0mg,
Midazolam 10.0mg)
P
Seizure not controlled by above OR
Seizure reoccurs
P
Lorazepam 1‐2mg, slow IV/IO
Or
Midazolam 5mg IV/IO/IM/IN
(Max dose Lorazepam 4.0mg,
Midazolam 10.0mg)
Pediatric and OB Protocols
General Approach to all Adult Patients
P
Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
* If alert enough to self administer Glutose
Pregnancy induced hypertension, pre‐eclampsia and eclampsia are conditions typically encountered in late 2nd or
3rd trimester pregnancy, and less commonly in the postpartum period. Clinical manifestations may include elevated
blood pressure (SBP>160mmHg), headache, confusion or agitation..
Service MD Approval:______
OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
96
Obstetrics / Gynecology
Perinatal Emergencies
Pregnancy-induced hypertension, pre-eclampsia and eclampsia are conditions
typically encountered in late 2nd or 3rd trimester pregnancy, and less commonly in the
postpartum period. Clinical manifestations may include elevated blood pressure
(SBP > 160 mmHg), headache, confusion or agitation.
All Providers

General Patient Care Protocol-Adult

Blood Glucose measurement
 If hypoglycemic (Blood glucose < 70mg/dL)
Glucose paste 15 g or other oral glucose agent (e.g. orange
juice) if patient alert enough to self-administer
If hypoglycemic and unable to take oral glucose:
 Consider Glucagon 1mg IM
Advanced EMT

Consider IV Protocol

Blood Glucose measurement
If < 70 mg/dL administer Dextrose 12.5g-25g slow IVP or D10W 100mL
Paramedic

Full ALS Assessment and Treatment

Blood Glucose measurement
 If < 70 mg/dL administer Dextrose 12.5g-25g slow IVP or D10W
100mL

Administer Magnesium Sulfate 4 g in 100 ml D5W IV over 10 minutes for
either of the following:
 Systolic BP > 160 mm Hg on two readings
 Seizure activity

For active seizures, in addition to Magnesium Sulfate choose one of the
following options:
 Lorazepam (Ativan) 1-2 mg, slow IV/IO
-OR Midazolam (Versed) 5 mg IV/IO/IM/IN
97

For seizure not controlled by the above, or if seizure reoccurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 1-2 mg, slow IV/IO
-OR Midazolam (Versed) 5 mg IV/IO/IM/IN
Max dose of Lorazepam is 4 mg and Max dose of Midazolam is 10 mg
Contact Medical Control for any additional orders or questions
98
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Past medical history
Hypertension meds
Prenatal care
Prior pregnancies / births
Gravida / Para
Differential
Pre‐eclampsia / Eclampsia
Placental Previa
Placenta abruption
Spontaneous abortion
Signs and Symptoms
Vaginal Bleeding
Abdominal pain
Pediatric and OB Protocols
General Approach to all Adult Patients
Trimester in Pregnancy?
1st or 2nd Trimester or UNKNOWN
3rd Trimester
Position of Comfort
Left lateral recumbant
position
Left lateral recumbant position if
hypotensive
Blood Pressure
Blood Pressure
<90mmHg
<90mmHg
A
A
>90mmHg
Normal Saline Bolus 250 ml
until BP >90mmHg
A
>90mmHg
Transport to hospital
Complaint of Labor?
Does not need to be a OB
receiving facility
NO
2013
A
Normal Saline Bolus 250 ml
until BP >90mmHg
X4 (max 2L)
YES
Childbirth Protocol
Transport to hospital
OB receiving facility*
M
Contact Medical Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
* Imminent deliver or medically unstable mother: Transport to nearest ED (not nearest OB receiving facility)
Non‐traumatic abdominal, pelvic or back complaints, vaginal bleeding, spotting or any vaginal fluid leak or discharge: Transport to closest OB receiving
facility.
Whenever possible, transport to patient’s requested OB receiving facility (ie. High risk pregnancy with pre‐selected OB destination) if patient not having
imminent delivery.
OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
99
Vaginal Bleeding
All Providers
1st or 2nd trimester or unknown pregnancy status
Position of comfort, consider lateral recumbent position if hypotensive
3rd Trimester Bleeding (>26 weeks)
Lateral recumbent position
Do not place finger or hand inside birth canal during assessment

If gestational age known to be < 20 weeks, transport to closest hospital

If gestational age known or possibly ≥ 20 weeks, transport to nearest OB
receiving facility
Advanced EMT

Consider IV Protocol

If BP<90 mmHg systolic, administer boluses of 0.9%NaCl at 250 ml until
systolic BP>90 mmHg
Paramedic

If bleeding moderate or heavy, perform Full ALS Assessment and Treatment
Contact Medical Control for any additional orders or questions
100
Obstetrical Transport Destination
Patient known to be < 20 weeks gestation

1st day of last menstrual period < 20 weeks ago

Available information verifying gestational age < 20 weeks (e.g., known due
date)
 Refer to Medical Transport Destination for more information
Does not have to be an OB receiving facility
Patient known or possibly ≥ 20 weeks gestation

Imminent delivery or medically unstable mother:
 Transport to nearest ED (not nearest OB receiving facility)

Non-traumatic abdominal, pelvic or back complaints, vaginal bleeding,
spotting or any vaginal fluid leak or discharge:
 Transport to closest appropriate obstetric receiving facility

Contact appropriate obstetric facility ED for radio report and any additional
direction/assistance
Whenever possible, transport to patient’s requested obstetric receiving facility
(e.g. high risk pregnancy with pre-selected obstetrical destination) if patient
not having imminent delivery
Contact Medical Control for any additional orders or questions
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Signs and Symptoms
Spasmodic pain
Vaginal discharge or bleeding
Crowning or urge to push
Meconium
Differential
Abnormal presentation
Buttock
Foot
Hand
Prolapsed cord
Placenta previa
Abruptio placenta
Pediatric and OB Protocols
History:
Due Date
Time contractions started /how often
Rupture of membranes
Time / amount of any vaginal bleeding
Sensation of fetal activity
Past medical and delivery history
Medications
Gravida / Para Status
High Risk Pregnancy
General Approach to all Adult Patients
Supplemental Oxygen
Inspect perineum
(No digital vaginal exam)
Presenting part NOT the
head
Crowning
Activate ALS
Meconium
present
Refer to OB Procedures
Newborn Resuscitation
protocol
M
Contact Medical Control
Double clamp cord 10‐12 inches from abdomen
Cut cord between clamps
maintain body temperature **
Begin Transport to
nearest OB receiving
facility
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Pearls
RECOMMENDED EXAM(of mother): Mental Status, Heart, Lungs, Abdomen, Neuro
Document all times (delivery, contraction frequency, and length)
If maternal seizures occur, refer to the Obstetrical Emergencies protocol
**Allow spontaneous delivery of the placenta; do not apply traction to umbilical cord for placental delivery. If
placental delivery occurs, package in biohazardous waste bag and hand over to hospital staff upon arrival
Gently massage abdominal wall overlying the uterine fundus until firm.
Some perineal bleeding is normal with any childbirth. Large quantities of blood or free bleeding are abnormal.
Record APGAR at 1 minute and 5 minutes after birth.
Service MD Approval:______
OB Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Delivery:
‐Slow, controlled delivery of head; apply gentle
perineal pressure
‐Observe for meconium staining
‐If present, suction oral pharynx and nose as
Begin Transport
immediately to nearest
OB receiving facility
Obstetrics / Gynecology: Childbirth
All Providers

General Patient Care Protocol-Adult

Supplemental oxygen

Do not place fingers or hand inside the birth canal for assessment

If presenting part is not the head (i.e., foot-, arm-, or buttock-first),
immediately begin transport to the nearest OB receiving facility while further
care continues
Delivery

Slow, controlled delivery of head; apply gentle perineal pressure

Observe for meconium staining

If present, suction oral pharynx and nose as soon as head is delivered

Following delivery, follow newborn resuscitation protocol

Double clamp cord 10-12 inches from abdomen

Cut cord between clamps

Maintain body temperature

Allow spontaneous delivery of placenta; do not apply traction to umbilical cord
for placental delivery
 If placental delivery occurs, package in biohazardous waste bag and
hand over to hospital staff upon arrival
Postpartum

For neonate, see Newborn Resuscitation Protocol

Assess for postpartum hemorrhage

Gently massage abdominal wall overlying the uterine fundus until firm

Transport to nearest OB receiving facility

See newborn resuscitation for care of the neonate
Contact Medical Control for any additional orders or questions
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History:
Ingestion or suspected ingestion of
a potentially toxic substance
Substance ingested, route,
quantity
Time of ingestion
Reason (suicidal, accidental,
criminal)
Available medications in home
Post medical history, medications
Signs and Symptoms
Mental Status Changes
Hypotension / Hypertension
Decreased respiratory rate
Tachycardia, dysrhythmias
Seizures
Nothing by Mouth
12 Lead EKG
A
IV Protocol
A
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Consult Medical
Control if needed
2013
Refer to specific protocol once agent has been identified
or is strongly suspected
Medical Protocol
General Approach to All Adult Patients
Differential
Tricyclic antidepressants (TCAs)
Acetaminophen (Tylenol)
Aspirin
Depressants
Stimulants
Anticholinergic
Cardiac medications
Solvents, alcohols, cleaning
agents
Insecticides (organophosphates)
M
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
* for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed with additional doses as needed
Do not rely on patient history of ingestion, especially in suicide attempts. Make sure patient is still not carrying other medications or any weapons
Bring bottles, contents, and emesis to ED
Tricyclic : 4 major areas of toxicity: seizures, dysrhythmias, hypotension, decreased mental status or coma; rapid progression from alert to death
Acetaminophen: initially normal or nausea/vomiting. If not detected and treated, causes irreversible liver failure
Aspirin: Early signs consist of abdominal pain and vomiting. Tachypnea and altered mental status may occur later. Renal dysfunction, liver failure
and/or cerebral edema among other things can take place later
Depressants: decreased HR, decreased BP, decreased temperature, decreased respirations, non‐specific pupils
Stimulants: Increased HR, increased BP, increased temperature, dilated pupils, seizures
Anticholinergic: increased HR, increased temperature, dilated pupils, mental status changes
Cardiac Medications: dysrhythmias and metal status changes
Solvents: nausea, coughing, vomiting, and mental status changes
Service MD Approval:______
Insecticides: increased or decreased HR, increased secretions, nausea, vomiting, diarrhea, pinpoint pupils
Consider restraints if necessary for patient's and or personnel’s protection per the restraint procedure
Consider contacting poison control center for advice 1-800-222-1222
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Overdose and Poisonings:
General Approach
For any overdose or poisoning, contact should be made with the Regional Poison
Control Center (RPCC) 1-800-222-1222.
Whenever possible, determine the
agent(s) involved, the time of the ingestion/exposure, and the amount ingested.
Bring empty pill bottles, etc. to the receiving facility.
All Providers



General Patient Care Protocol-Adults
Nothing by mouth
12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Refer to the specific protocol when an agent has been identified or is strongly
suspected
Contact Medical Control for any additional orders or questions
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Tricyclic &Tetracyclic
Antidepressant
Advanced EMT
Consider IV Protocol
M
Category
Tricyclic
Antidepressants
Other Cyclic
Antidepressants
Selective Serotonin
Reuptake Inhibitors
(SSRIs)
Consult Medical
Control if needed
M
Drugs
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
●
Overdose Effects
Amitriptyline (Elavil, Endep, Vanatrip, Levate)
Clomipramine (Anafranil)
Doxepin (Sinequan, Zonalon, Tridapin)
Imipramine (Tofranil, Impril)
Nortryptyline (Aventyl, Pamelor, Norventyl)
Desipramine (Norpramin)
Protriptyline (Vivactil)
Trimipraine (Surmontil)
Amitriptyline+Chlordiazepoxide (Limbitrol)
Maprotiline (Iudiomil)
Amoxapine (Asendin)
Buproprion (Wellbutrin)
Trazadone (Desyrel, Trazorel)
Citalopram (Celexa)
Fluoxetine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (paxil)
Sertraline (Zoloft)
●
Hypotension
●
Anti-cholinergic
effects(tachycardia,
seizures, altered mental
status, mydriasis)
●
AV conduction blocks
(prolonged QT interval, wide
QRS)
●
VT and VF
●
Similar to tricyclics
●
Seizures
●
Hypertension,
tachycardia, agitation,
diaphoresis, shivering,
●
Malignant Hperthermia
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Full ALS Assessment and Treatment
For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid
resuscitation is contraindicated:
Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90
mmHg
If wide QRS complex (≥ 0.10 sec), hypotension, or any arrhythmias:
Sodium Bicarbonate 1 mEq/kg IV/IO
Repeat Sodium Bicarbonate 1 mEq/kg IV/IO in 5-10 minutes
If any of the following conditions occur, refer to the appropriate protocol:
Polymorphous Ventricular Tachycardia
Altered Mental Status
Seizures
Medical Protocol
Paramedic
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A‐EMT
Paramedic
Medical Control
Cholinergic Poisoning /
Organophosphates
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All Providers
General Patient Care Protocol-Adult
Toxicity to ambulance crew may result from inhalation or topical exposure
Supplemental 100% oxygen
Decontaminate patient
Remove all clothing and contain run-off of toxic chemicals when flushing
Advanced EMT
Medical Protocol
Wear protective clothing including masks, gloves and eye protection
Consider IV Protocol
2013
Paramedic
Full ALS Assessment and Treatment
For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses, or when fluid
resuscitation is contraindicated
Dopamine infusion at 5-20 mcg/kg/min titrated to maintain systolic BP > 90
mmHg
If severe signs of toxicity, (severe respiratory distress, bradycardia, heavy respiratory
secretions) do not rely on pupil constriction to diagnose or titrate medications:
Atropine 2 mg IVP every 5 minutes, titrate dosing by assessing improvement
in respiratory effort/bronchial secretions
Consider Mark 1 Kit, see Nerve Agent protocol
If any of the following conditions occur, refer to the appropriate protocol:
Altered Mental Status
Seizures
M
Consult Medical
Control if needed
M
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Antipsychotics / Acute Dystonic
Reaction
Medical Protocol
Haloperidol
Prolixin
Thorazine
Prochlorperazine (Compazine)
Promethazine (Phenergan)
Advanced EMT
Consider IV protocol
2013
Paramedic
Full ALS Assessment and Treatment
For Dystonic reactions, administer
Diphenhydramine (Benadryl) 25 mg IV
Repeat Diphenhydramine 25 mg IV if inadequate response in 10 minutes
M
Consult Medical
Control if needed
M
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Beta Blocker Toxicity
●
●
●
●
●
●
●
Single Agent Medication
Proprandolol (Inderal)
Atenolol (Tenormin)
Metroprolol (Lopressor, Toprol)
Nadolol (Corgard)
Timolol (Blocadren)
Labetolol (Trandate)
Esmolol (Brevibloc)
●
●
●
●
●
●
Medical Protocol
Examples of commonly used Beta Blocker medications:
Combination Medication
Corzide (Nadolol/bendroflumethlazide)
Inderide (Propranolol/HCTZ)
Lopressor HCT (Metoprolol/HCTZ)
Tenoretic (Atenolol/Chlorthalidone)
Timolide (Timolo/HCTZ)
Ziac (Bisoprolol/HCTZ)
2013
Advanced EMT
Consider IV Protocol
Paramedic
Full ALS Assessment and Treatment
For all patients with cardiovascular toxicity, defined by:
Chest Pain, SBP < 90 mmHg or altered mental status, AND
Heart Rate < 60 or 2nd or 3rd degree heart blocks
Administer the following agents:
Atropine 0.5 mg IV/IO, may repeat X 2
use with caution in the setting of 2º or 3º heart block
If no response, Glucagon 3 mg IV/IO
If vomiting after Glucagon, administer Ondansetron (Zofran) 4
mg IV
If no response, begin Transcutaneous Pacing
M
Consult Medical
Control if needed
M
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Calcium Channel Blockers
Examples of commonly used Calcium Channel Blocker medication:
Medical Protocol
Amlodipine (Norvasc)
Felodipine (Plendil, Renedil)
Isradipine (DynaCirc)
Nicardipine (Cardene)
Nifedipine (Procardia, Adalat)
Verapamil (Calan)
Diltiazem (Cardizem)
Advanced EMT
Consider IV Protocol
2013
Paramedic
Full ALS Assessment and Treatment
For all patients with cardiovascular toxicity, defined by:
Chest Pain, SBP < 90 mmHg or altered mental status, AND
Heart Rate < 60 or 2nd or 3rd degree heart blocks
Administer the following agents
Atropine 0.5 mg IV/IO, may repeat X 2
use with caution in the setting of 2º or 3º heart block
If no response, administer Calcium Chloride 1 g IV/IO
Contraindicated if patient taking Digoxin (Lanoxin)
If no response, may repeat Calcium Chloride 1 g IV/IO
no response, begin Transcutaneous Pacing
M
Consult Medical
Control if needed
M
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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History:
Known or suspected CO exposure
Suspected source/duration exposure
Age
Known or possible pregnancy
Reason (accidental, suicidal)
Measured atmospheric levels
Past medical history, medications
Signs and Symptoms
Altered mental status / dizziness
Headache, Nausea/Vomiting
Chest Pain/Respiratory distress
Neurological impairments
Vision problems/reddened eyes
Tachycardia/tachypnea
Arrhythmias, seizures, coma
Differential
Effects of other toxic fire by product
Acute cardiac event
Acute neurological event
Flu/GI illness
Acute intoxication
Diabetic Ketoacidosis
Headache or non‐toxic origin
General Approach to All Adult Patients
Scene Safety – SCBA if toxic inhalation suspected
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Remove patient from contaminated area
Administer 100% Oxygen
COHb% (SpCO) Measurement Available?
SpCO<5%
Paramedic
Medical Control
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Appropriate Protocol based on
symptoms
Not available
SpCO>5%
No treatment for CO required
Appropriate Protocol based on
symptoms
A‐EMT
SpCO >5%
SpCO <15%
SpO2 >90%
Symptoms of CO
and/or hypoxia?
Special Response Protocols
Legend
EMT
SpCO >15%
SpO2 <90%
100% Oxygen via
NRB
Transport to ED
YES
NO
Service MD Approval:______
If cardiac/
respiratory/
neurological
symptoms are also
present, go to
appropriate
protocol
No treatment for CO required*
Recommend evaluation of home/
work environment for presence of
CO
M
Consult Medical Control
M
Pearls
*Fetal hemoglobin has a greater attraction for CO than maternal hemoglobin. Females who are known to be pregnant or who could be pregnant
should be advised that EMS-measured SpCO levels reflect the adults level and that fetal COHb levels may be higher. Recommend Hospital
evaluation for any CO exposed pregnant person.
The absence (or low detected levels of) COHb in not a reliable predictor of firefighter or victim exposure to other toxic byproducts of fire – also
consider Cyanide Poisoning Protocol
Attempt to evaluate other correctable causes when possible
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Overdose and Poisonings:
Carbon Monoxide
All Providers

General Patient Care Protocol—Adult

Wear appropriate PPE (SCBA) as indicated

Remove the patient from the contaminated source

Supplemental 100% oxygen, document time oxygen started

If CO monitoring available
 Document initial CO level
 Follow Carboxyhemoglobin SpCo Monitoring Procedure
Paramedic

Full ALS Assessment and Treatment

For smoke inhalation patients also consider Cyanide poisoning (See Hazardous
Materials—Basic Approach Protocol)
Contact Medical Control for any additional orders or questions
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Cocaine and Sympathomimetic
All Providers
Medical Protocol
General Patient Care Protocol—Adult
Advanced EMT
Consider IV Protocol
Paramedic
M
Consult Medical
Control if needed
2013
Full ALS Assessment and Treatment
For patients with Sympathomimetic toxidrome (e.g. hypertension, tachycardia, agitation):
Lorazepam (Ativan) 1-2 mg, slow IV
If no IV access, Midazolam (Versed)
5 mg IM/IN if < 60 years old
2.5 mg IM/IN if > 60 years old
Repeat either medication once in 5-10 minutes if signs and symptoms continue
If seizures occur, refer to Seizure Protocol
Refer to Behavioral Emergency Protocol
M
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Opiates
All Providers
Advanced EMT
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Consult Medical
Control if needed
2013
●
Consider IV Protocol
For patients with opiate toxidrome (ie. Coma, pinpoint pupils, respiratory depression)
□ Naloxone (Narcan) 2 mg IV/IO every 3 minutes
Naloxone (Narcan) can be administered in 0.4 mg increments titrated to
respiratory drive and level of consciousness
If IV access has not been established, Naloxone (Narcan) 2 mg IM or
Advanced EMT ‐ 0.5 mg per nare IN (total 1.0mg per administration),
Paramedics - 1.0 mg per nare (total 2.0mg per administration)
□ Repeat every 3 minutes if signs and symptoms continue (max 8.0mg)
If respiratory depression not improved, refer to Airway protocol
Medical Protocol
General Patient Care Protocol—Adult
Airway Protocol for respiratory depression
M
Overdose and Poisoning:
Opiates
Single Agent Medication
● Oxycodone
● Hydrocodone
● Morphien
● Heroin
● Dilaudid
● Fentanyl
● Codeine
Combination Medication
● Vicodin
● Norcodin
● Percocet
● Darvocet
● Vicoprofen
Long Acting*
● Oxycontin
● MS Contin
● Methadone
* May Need Repeat Dosing
Service MD Approval:______
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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History:
Age
Location
Duration
Severity (1‐10)
Past medical history
Medications
Drug Allergies
Differential
Per the specific protocol
Musculoskeletal
Visceral (abdominal)
Cardiac
Pleural / Respiratory
Neurogenic
Renal (colic)
Signs and Symptoms
Severity (pain scale)
Quality (sharp, dull, etc)
Radiation
Relation to movement,
respiration
Increased with palpation
Medical Protocol
General Approach to All Adult Patients
Patient care according to PROTOCOL
Based on specific complaint
Pain Severity >6 out of 10
A
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A
IV Protocol
Morphine Sulfate 2‐5mg slow IVP every 5 min until relief achieved
(max 15mg)*
OR
Fentanyl 50‐75mcg slow IVP every 5 min until relief achieved
(max 200mcg)* If available consider Intranasal administration,
same dose as above divided between nares
Continuous Respiratory
monitoring
SPO₂ and End Tidal CO₂
P
After each dose:
Reassess pain level
Ondansetron 4mg slow IV for severe nausea or vomiting
M
Contact Medical Control for
additional orders or questions
OLMC must authorize a
change in Opiate once
administration has begun.
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Area of pain, Neuro
* Contraindicated if SBP <90mmHg
Analgesic agents may be administered under standing orders for patients experiencing moderate / severe pain (typically >6/10)
Common Complaints: trauma/isolated extremity injury, Burns (without airway, breathing or circulation compromise), sickle crisis,
Acute chest pain (follow protocol), Kidney stone highly suspected (follow abdominal pain protocol)
Vitals and pain scale should be documented before and after every medication dose.
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Pulse Oximetry
Pain Management—Adult
All Providers

General Patient Care Protocol

Assess baseline pain level (0-10 scale: 0=no pain, 10=worst pain)
Advanced EMT

Consider IV Protocol
Paramedic

Analgesic agents may be administered under standing orders for patients
experiencing moderate/severe pain (typically ≥ 6/10)

Common complaints:
 Trauma/isolated extremity injury
 Burns (without airway, breathing or circulation compromise)
 Sickle crisis
 Acute Chest Pain, in accordance with the Chest Pain protocol
 Kidney stone highly suspected, in accordance with the Abdominal Pain
protocol
Agents for pain control

Morphine Sulfate 2-5 mg slow IVP every 5 minutes until pain relief achieved
(Maximum 15 mg)
-OR
Fentanyl 50-75 mcg slow IVP every 5 minutes until pain relief achieved
(Maximum 200 mcg)
 Both are contraindicated if SBP  90 mmHg
 If available consider Intranasal administration, same dose as above
divided between nares.

After each drug dosage administration
 Reassess and document the patient’s pain level (0-10 scale)
 Note adequacy or ventilation and perfusion
 Assess and document vital signs

Continuously monitor oxygen saturation and end tidal CO2

For severe nausea or vomiting, Ondansetron (Zofran) 4 mg slow IV
116
Contact Medical Control for any additional orders or questions
Medical Control must authorize a change in Opiate once administration
has begun. Listed maximum dosages pertain unless other orders given
by medical control
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After assessing the patient and treating any obvious conditions, transport to the ED should
be offered in a manner consistent with the Dane County EMS System General Guidelines.
If the detained patient refuses transport, execute a standard refusal process as detailed in
protocol.
Advise the Law Enforcement Officer (LEO) of the patient’s decision, and if all criteria are
met, release the patient to the LEO.
If the patient does not meet refusal criteria, advise the LEO that transport is
indicated and coordinate a safe transport of the detained patient in accordance
with Agency SOPs.
If the LEO requires EMS transport in a scenario where the patient has refused,
comply with the LEO’s request and transport the patient to the nearest
appropriate ED.
2013
In scenarios where a LEO is unwilling to allow transport of a detained patient after EMS personnel
have determined transport is indicated (i.e. requested transport, is not a candidate for refusal, or
obvious medical necessity) adhere to the following:
Assure that the LEO understands transport is indicated and that medical clearance prior to
incarceration is not a procedure performed by EMS.
Contact On-Line Medical Control for further input and assistance as needed.
If these actions fail to resolve the issue, defer to the officer’s legal authority to retain custody
of the patient.
Document the interaction well, including the law enforcement agency and officer involved.
Special Response Protocol
When called to a scene to assess a person in police custody, perform all assessment and
treatment consistent with the standards set for the typical, non-detained patient. EMS personnel
are not equipped to perform formal medical clearance for patients in police custody prior to jail
transport.
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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All Providers
Confirm scene safety with law enforcement
Turn patient supine if found in a prone position
Secure the taser prongs in place if not removed by law enforcement
Do not remove the prongs if lodged in the patient and left in place by law
enforcement unless there is interference with important patient care measures
Paramedic
2013
If the patient requires Chemical or Physical restraints, perform Full ALS Assessment and
Treatment
For patients with severe agitation resulting in interference with patient care or patient/crew
safety, or for patients who continue to struggle against restraints refer to Behavioral
Emergencies Protocol
Transport patient supine or lateral recumbent position only
Special Response Protocol
For patients who have been controlled by law enforcement via a Taser device, follow this protocol
in conjunction with any protocol that applies to underlying conditions (e.g. behavioral emergencies,
cocaine/sympathomimetic toxicity, agitated delirium)
Patient transport in the prone position is not authorized!
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Special Response Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
119
General guidelines for patient refusal of treatment and/or transport:
A patient is any person who is requesting and/or is in need of medical attention or medical
assistance of any kind.
All patients shall be assessed and offered transport by ambulance to the nearest appropriate
emergency department, regardless of the nature of the complaint.
In the event a patient, or his/her guardian, refuses transport to the hospital, a properly
executed refusal process must be completed.
Three-Step Process for EMS personnel when accepting a refusal of care:
Step 1:
Determine if the patient is legally recognized as an
informed decision maker.
Step 2:
Determine if the patient’s decision making capacity
appears to be intact.
Step 3:
Document the interaction well.
Step 1
To undergo the informed refusal of medical care process, the patient should be one of the following:
A person 18 years of age
A court-emancipated minor
A legally married person of any age
An unwed pregnant female < 18 years of age only when the medical concern relates to her
pregnancy
A parent (of any age)/ or legal guardian on behalf of their child when the refusal of care does
not place the child at risk
Involve OLMC for any refusal involving a minor when the parent/legal guardian cannot be
contacted
Step 2
To undergo the informed refusal of medical care process, the patient or his/her guardian’s decisionmaking process cannot be impaired by medical or psychiatric conditions:
All of the following must be present:
Awake, alert and oriented to person, place, time and situation (A+OX4)
Is not experiencing a medical condition which may interfere with informed decision
making capacity (e.g. hypoxia, hypoglycemia, head injury, sepsis etc.)
Does not appear clinically intoxicated or under the influence of substances which may
impair decision making and judgment
Does not express suicidal or homicidal ideations, and does not otherwise pose an
obvious threat to themselves or others
Is not experiencing hallucination or other apparent thought disorder
continued 120
Refusal of Medical Care ‐ continued
Step 3
The following items should be documented for every refusal:
A mental status examination as detailed in Step 2 above
A physical examination (including vital signs)
Perform blood glucose level and oxygen saturation when appropriate
Pediatric Refusals
The following scenarios require OLMC contact prior to completing the refusal process:
Refusals involving patients less than 1 year old
Pediatric refusals where significant vital sign/ or physical exam abnormalities are
present
In the event a parent or guardian refuses medical care for a minor when there is reasonable
concern that this decision poses a threat to the well-being of the minor:
Contact the OLMC Physician for input
Enlist the aid of law enforcement personnel for patient and crew safety
If an immediately life threatening condition exists, transport the patient to the nearest
appropriate emergency department.
Refusal of Transport After ALS Initiated:
Contact OLMC for refusal situations that arise after advanced life support measures have
been initiated
Exceptions to this requirement are:
Bronchospasm, resolved after nebulizer treatment (see protocol)
Insulin-induced hypoglycemia, resolved after glucose administration (see protocol)
M
Consult Medical
Control if needed
121
M
Refusal of Transport After Treatment Given
Bronchospasm Resolved After Nebulizer Treatment
After treatment of bronchospasm, and return to an asymptomatic state, some patients will refuse
transport to the hospital. The following items should be accounted for and included in the assessment
and documentation:
The presentation is consistent with a mild exacerbation of asthma
No severe dyspnea at onset
No pain, sputum, fever or hemoptysis
Not clinically hypoxic (oxygen saturation > 92%)
Significant improvement after a single nebulizer treatment
Complete resolution of symptoms
Vital signs within normal limits after treatment (BP, pulse, respiratory rate and oxygenation)
Additional patient safety measures that should be considered:
A family member or caregiver should be available to stay with the patient and assist if a relapse
occurs
Assure the patient understands transport has been offered and subsequently refused
Inform the patient to follow-up with their physician as soon as possible and/or to re-contact 911
if symptoms reoccur
If the above are accounted for, a properly executed refusal of medical care can be accepted
from the patient or custodian without contacting Medical Control.
M
Consult Medical
Control if needed
122
M
Refusal of Transport After Treatment Given
Insulin-Induced Hypoglycemia—Resolved
This protocol applies only to insulin dependent diabetic patients refusing transport after the resolution
of insulin-induced hypoglycemia by the administration of intravenous glucose. This protocol cannot
be used if the patient takes any oral diabetes medications. After treatment of insulin-induced
hypoglycemia and return to an asymptomatic state, some patients will refuse transport to the hospital.
The following items should be accounted for and included in the assessment and documentation.
The patient is on Insulin only (does not take any oral diabetes medications)
The presentation is consistent with hypoglycemia
Rapid improvement, and complete resolution of symptoms after glucose
Vital signs within normal limits after glucose given (BP, pulse, respiratory rate, oxygenation and
blood sugar > 70)
There is no indication of an intentional overdose or dosing error
Additional patient safety measures that should be considered:
A family member or caregiver should be available to stay with the patient and assist if a relapse
occurs
Assure the patient understands transport has been offered and subsequently refused
Inform the patient to follow-up with their physician as soon as possible and/or to re-contact 911
if symptoms reoccur
If the above are accounted for, a properly executed refusal of medical care can be accepted
from the patient or custodian without contacting Medical Control.
M
Consult Medical
Control if needed
123
M
Sedation/Sedative Agent Use
Because sedation is a continuum, it is not always possible to predict how an individual patient
receiving an agent with sedative properties will respond. This protocol is to be used in conjunction
with any protocol that involves the use of medication given by any route, which may result in sedation.
Examples of medications that may result in sedation are narcotics, benzodiazepines, haloperidol,
diphenhydramine, and ketamine.
Minimal Sedation (anxiolysis): A drug induced state in which patients respond normally to verbal
commands. Although cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected.
Moderate sedation (“conscious sedation”): A drug-induced depression of consciousness during which
patients respond purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. Airway patency, spontaneous ventilations, gag reflex, and cardiovascular function are
maintained.
Deep Sedation: Only to be used in patients with a secured airway. A drug induced depression of
consciousness, during which patients cannot be easily aroused but respond purposefully after
repeated or painful stimulation. The ability to independently maintain ventilatory function may be
impaired. Patients will require assistance in maintaining a patent airway and spontaneous ventilations
may be inadequate.
The goal of sedative agent use is to produce the minimal degree of sedation that achieves the
desired clinical effect. Sedative agent use should ideally result in minimal or moderate
sedation only.
Paramedic
Full ALS Assessment and Treatment
Continuously monitor the following:
Patency of airway
Vital signs
Oxygen saturation and capnography
Cardiac rhythm
Level of consciousness and ability to follow commands
Assure that appropriate equipment and personnel are immediately available for care and
resuscitation if problems arise
Document the indications for sedation
M
Consult Medical
Control if needed
124
M
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Reported/witnessed seizure
activity
Previous seizure history
Medical alert tag information
Seizure medications
History of Trauma
History of Diabetes
History of Pregnancy
Signs and Symptoms
Decreased Mental Status
Sleepiness
Incontinence
Observed seizure activity
Evidence of trauma
Unconscious
Supplemental O2 – Protect Patient from Injury
Blood Glucose – treat if appropriate
A
A
IV Protocol
Assess Patient
Active Seizure
Not seizing
P
P
P
Diazepam rectal gel if available*
P
Seizure Re-occurs
P
YES
Lorazepam 1‐2mg IV/IO (max dose 4mg)
Or
Midazolam
5mg IV/IO/IM/IN if <60 years old
2.5 mg IV/IO/IM/IN if >60 years old
(max dose 10mg)
P
Service MD Approval:______
Still Seizing?
NO
Monitor vitals and
transport
2013
Monitor vitals and transport
Lorazepam 1‐2mg IV/IO
(max dose 4mg)
Or
Midazolam
5mg IV/IO/IM/IN if <60
years old
2.5 mg IV/IO/IM/IN if >60
years old
(max dose 10mg)
Medical Protocol
General Approach to all Adult Patients
Differential
CNS (Head) Trauma
Tumor
Metabolic, Hepatic, or Renal Failure
Hypoxia
Electrolyte abnormality (Na, Ca, Mg)
Drugs, Medications, Non‐compliance
Infection/Fever
Alcohol withdrawal
Eclampsia
Stroke
Hyperthermia
Hypoglycemia
P M
Consult Medical Control for
additional Benzodiazepines
M P
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Extremities, Neuro
Status epilepticus is defined as two or more successive seizures without a period of consciousness or recovery. This is a true emergency
requiring rapid airway control, treatment and transport
Grand mal seizures (generalized) are associated with loss of consciousness, incontinence, and tongue trauma
* Diazepam
Focal seizures (petit mal) effect only a part of the body and are not usually associated with a loss of consciousness
12+ Years (0.2mg/kg)
Jacksonian seizures are seizures which start as a focal seizure and become generalized
Dose
Weight
Be prepared for airway problems and continued seizures
(kg)
(lb)
(mg)
Assess possibility of occult trauma and substance abuse
14-27
30-60
5
Be prepared to assist ventilations especially if diazepam or midazolam is used
28-50
61-111
10
For any seizure in a pregnant patient, follow the OB emergencies protocol
51-75
112-166
15
Diazepam is not effective when administered IM. It should only be given rectally.
76-111 167-244
20
Midazolam is well absorbed when administered IM.
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
125
Seizure
All Providers

General Patient Care Protocol—Adult

Supplemental 100% oxygen
 Nasal cannula is sufficient if no active seizures and no respiratory
signs or symptoms

Protect patient from injury
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

If Blood Glucose < 70 mg/dL, treat per Altered Mental Status/Hypoglycemia
Protocol

For active seizures choose one of the following options:
 Lorazepam (Ativan) 1-2 mg IV/IO
- OR  Midazolam (Versed)
 5 mg IV/IO/IM/IN if < 60 years old
 2.5 mg IM/IN/IO/IV if > 60 years old
- OR 
Diazepam rectal gel (Diastat) if available
12 + Years (0.2mg/kg)
Weight
Dose
(Kg)
(Lb)
(mg)
14-27
30-60
5
28-50 61-111
10
51-75 112-166
15
76-111 167-244
20
126

For seizure not controlled by the above, or if the seizure re-occurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 1-2 mg IV/IO
- OR -
 Midazolam (Versed)
 5 mg IV/O/IM/IN if < 60 years old
 2.5 mg IM/IN if > 60 years old
Maximum dose of Lorazepam is 4 mg
Maximum dose of Midazolam is 10 mg

If hypoxic seizures, drug induced seizures, seizures from head trauma, stroke
or eclampsia suspected
 Treat as above and refer to appropriate protocol for further care
Contact Medical Control for any additional orders or questions
 Additional Benzodiazepines
127
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Blood Loss – vaginal or GI
bleeding, AAA, ectopic
Fluid loss – vomiting, diarrhea,
fever
Infection
Cardiac Ischemia (MI, CHF)
Medications
Allergic reaction
Pregnancy
History of poor oral intake
General Approach to All Adult Patients
A
A
IV Protocol
Trauma
Cardiac
Medical Protocol
Differential
Shock
Hypovolemic
Cardiogenic
Septic
Neurogenic
Anaphylactic
Ectopic Pregnancy
Dysrhythmias
Pulmonary Embolus
Tension pneumothorax
Medication effect / OD
Vasovagal
Physiologic (pregnancy)
Signs and Symptoms
Restlessness, confusion
Weakness, dizziness
Weak, rapid pulse
Pale, cool, clammy skin
Delayed capillary refill
Hypotension
Coffee‐ground emesis
Tarry stools
Non Cardiac
Non Trauma
A
Normal Saline fluid bolus‐250mL
May repeat until SBP>90mmHg or max 2L
P
A
If no improvement after 4th fluid
bolus ‐ Consider Dopamine
5‐20 mcg/kg/min IV titrated to SBP
>90mmHg
M
Consult Medical
Control if needed
M
Treament per appropriate
Cardiac Protocol
P
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Hypotension can be defined as a systolic blood pressure of less than 90
Consider performing orthostatic vital signs on patients in non-trauma situation if suspected blood or fluid loss
Consider all possible causes of shock and treat per appropriate protocol
Reassess for pulmonary edema after each fluid bolus (lung sounds, respiratory distress, EKG)
For non-cardiac, non-trauma hypotension, Dopamine should only be started after 1 liter of NS have been given.
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
128
2013
Treatment per appropriate
Trauma Protocol
Shock (Non‐Trauma)
Shock is defined as a state of inadequate organ perfusion and tissue oxygenation.
It is evidenced by the presence of any of the following signs and symptoms:





Hypotension
Narrow pulse pressure
Tachypnea
Tachycardia
Delayed capillary refill





Mottled skin appearance
Diaphoresis
Cool clammy skin
Pallor
Altered mental status
Signs and symptoms vary depending upon the stage of shock, which may be
compensated (normal perfusion maintained) or decompensated (unable to maintain
normal perfusion).
Categories of shock

Obstructive shock: Caused by an obstruction that interferes with return of
blood to the heart (e.g. tension pneumothorax, cardiac tamponade, massive
pulmonary embolus)

Hypovolemic shock: Caused by decreased blood or water volume.
Hypovolemic shock may be hemorrhagic or non-hemorrhagic

Distributive shock: Caused by abnormal distribution of blood resulting from
vasodilaton, vasopermeability or both. Distributive shock may result from
anaphylactic reactions, sepsis, or spinal cord injury

Cardiogenic shock: Caused as a result of cardiac pump failure, usually
secondary to severe Left Ventricular failure. May result from massive MI
Perform the following in conjunction with protocols that apply to the specific etiology
of the shock state (e.g. allergic reactions, STEMI, etc.):
Advanced EMT

Consider IV Protocol
 Do not delay transport for IV insertion

IV 0.9% NaCl en route (if not contraindicated):
 Administer 250 ml boluses until systolic BP > 90 mmHg
 Total amount of IVF should not exceed 2 L
 Boluses may be given in rapid succession if systolic remains < 90
mmHg
Paramedic

Full ALS Assessment and Treatment
 Do not delay transport for IV insertion

IV 0.9% NaCl en route (if not contraindicated):
129
 Administer 250 ml boluses until systolic BP > 90 mmHg
 Total amount of IVF should not exceed 2 L
 Boluses may be given in rapid succession if systolic remains < 90
mmHg

If systolic BP remains < 90 mmHg after 4th bolus (1000ml):
 Consider Dopamine infusion at 5-20 mcg/kg/min, titrated to maintain
SBP > 90 mmHg
Contact Medical Control for any additional orders or questions
130
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Previous CVA, TIA’s
Previous cardiac,/vascular
surgery
Associated diseases: diabetes,
hypertension, CAD
Atrial Fibrillation
Medications (blood thinners)
History of Trauma
Differential
See Altered Mental Status
TIA (Transient Ischemic Attack)
Seizure
Hypoglycemia
Stroke
Thrombotic Embolic (~85%)
Hemorrhagic (~15%)
Tumor
Trauma
General Approach to all Adult Patients
Blood Glucose
Glucose <70
Glucose >70
Altered Mental Status
Protocol*
Cincinnati Stroke Scale
Positive
If Positive and
Symptoms <24 hour,
early notification of
Stroke Alert and rapid
transport to stroke
center
Medical Protocol
Signs and Symptoms
Altered mental status
Weakness / Paralysis
Blindness or other sensory loss
Aphasia / Dysarthria
Syncope
Vertigo / Dizziness
Vomiting
Headache
Seizures
Respiratory pattern change
Hypertension / Hypotension
2013
Negative
12 Lead EKG
Consider other protocols as indicated:
Altered Mental Status
Hypertension
Hypotension
Seizure
Overdose / Toxic Ingestion
Service MD Approval:______
M
Consult Medical
Control
M
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremities, Neuro
* Reassess for Stroke if no improvement with Altered Mental Status Protocol
Remember FAST in radio report: Facial Droop, Arm Strength, Speech, Time last normal
Cincinnati Stroke scale in procedure section
Supplemental oxygen via nasal only if O2 saturation <93%
Keep head of stretcher at 30-45° elevation (unless clinical condition will not allow)
Spinal immobilization if indicated; elevate head of backboard 15-30°
Do NOT delay transport to start IV
Onset of symptoms is defined as the last witnessed time the patient was symptom free (ie awakening in the morning with stroke symptoms would
be defined as an onset time of the previous night when patient was symptom free)
Be alert for airway problems (swallowing difficulty, vomiting/aspiration)
Hypoglycemia can present as a localized neurologic deficit, especially in the elderly
Document the stroke scale (including the EMD stroke scale results if available)
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
131
Stroke—Suspected
Early recognition and transport of stroke is essential to good patient outcomes. Any
patient presenting with a normal blood glucose (> 70 mg/dL), a positive Cincinnati
Pre-Hospital Stroke Screen and onset of symptoms (when last seen normal) less
than 24 hours should have early notification of the stroke center (STROKE ALERT)
and rapid transport.
All Providers

General Patient Care Protocol-Adult

Supplemental oxygen via nasal cannula only if O2 saturation < 93%

Keep head of stretcher at 30-45 elevation (unless clinical condition will not
allow)

Spinal Immobilization if indicated; elevate head of backboard 15-30

Check Blood Glucose

Give nothing by mouth (oral glucose is permitted if patient is able to self
administer)

Cincinnati Pre-Hospital Stroke Screen

If patient blood glucose is ≥ 70 mg/dl, Cincinnati Pre-Hospital Stroke Screen
is positive and onset of symptoms (when last seen normal) is < 24 hours,
immediately notify ED (STROKE ALERT) and commence rapid transport.
Advanced EMT

Consider IV Protocol

If hypoglycemic (<70 mg/dL) with IV access
 Dextrose 12.5g-25g slow IV push or D10W 100mL
 May repeat as needed every 5-10 minutes to blood glucose >
70 mg/dL

If hypoglycemic (< 70 mg/dL) without IV access
 Glucose paste 15 g or other oral glucose agent (e.g., orange juice) if
patient alert enough to self administer oral agent
- OR  Glucagon 1 mg IM

DO NOT DELAY TRANSPORT TO OBTAIN IV ACCESS
Paramedic

Full ALS Assessment and Treatment

Check blood glucose
132

For hypotension (systolic BP < 90 mmHg) not improved by fluid boluses or
when fluid resuscitation is contraindicated
 Dopamine infusion 5-20 mcg/kg/min titrated to maintain systolic BP >
90 mmHg
Contact Medical Control for any additional orders or questions
133
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Cardiac history, stroke, seizure
Occult blood loss (GI, ectopic)
Females: LMP, vaginal bleeding
Fluid loss: nausea, vomiting,
diarrhea
Past Medical History
Medications
Signs and Symptoms
Loss of consciousness with
recovery
Lightheadedness, dizziness
Palpitations, slow or rapid pulse
Pulse irregularity
Decreased blood pressure
General Approach to all Adult Patients
Blood Glucose
Glucose <70
Altered Mental Status
Protocol
>70
IV Protocol ‐ NS bolus 250ml to
maintain SBP >90mmHg (max 2L)
A
2013
A
12 Lead EKG
P
If SBP <90mmHg not improved by
fluid
Dopamine infusion 5‐20 mcg/kg/min
titrated to maintain SBP >90mmHg
Medical Protocol
Differential
Vasovagal
Orthostatic hypotension
Cardiac syncope
Micturation / Defecation syncope
Psychiatric
Stroke
Hypoglycemia
Seizure
Shock (see shock protocol)
Toxicologic (alcohol)
Medication effect (Hypertension)
P
AT ANY TIME
If relevant signs / symptoms found
Go to appropriate protocol:
DYSRHYTHMIA
ALTERED MENTAL STATUS
M
Consult Medical
Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Back, Extremities, Neuro
Assess for signs and symptoms of trauma if associated or questionable fall with syncope
Consider dysrhythmias, GI bleed, ectopic pregnancy, and seizure as possible causes of syncope.
Spinal Immobilization Protocol if appropriate
.
Medical Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
134
Syncope
All Providers

General Patient Care Protocol-Adult

12 Lead EKG
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

For hypotension (systolic BP < 90 mmHg) not improved by NS fluid boluses
or when fluid resuscitation is contraindicated
 Dopamine infusion 5-20 mcg/kg/min titrated to maintain systolic BP >
90 mmHg

If hypoglycemic (< 70mg/dL), treat per Altered Mental Status/Hypoglycemia
Protocol

If ECG rhythm is bradycardia, heart block or dysrhythmia see specific protocol

If Altered Mental Status persists, or if Acute Stroke suspected, refer to
appropriate protocol.
Contact Medical Control for any additional orders or questions
135
136
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Time and mechanism of injury
Damage to structure or vehicle
Location in structure or vehicle
Others injured or dead
Speed and details of MVC
Restraints/ protective equipment
Past medical history
medications
Signs and Symptoms
Pain, swelling
Deformity, lesions, bleeding
Altered Mental Status or unconscious
Hypotension or shock
Arrest
General Approach to All Adult Patients
Differential
Chest
Tension Pneumothorax, flail chest,
pericardial tamponade, open chest
wound, hemothorax
Intra‐abdominal bleeding
Pelvis/femur fracture
Spine fracture / Cord injury
Head injury (see head trauma)
Extremity fracture/dislocation
HEENT (Airway Obstruction)
Hypothermia
Trauma Protocol
Presentation or Mechanism Consistent with Trauma
YES
NO
Appropriate Medical
Protocol
Assess ABC’s
INADEQUATE
Airway, Adult
Protocol
ADEQUATE
Spinal Immobilization Protocol
Obvious Bleeding?
YES
NO
Disability and GCS
Direct Pressure
Service MD Approval:______
Complete Head to Toe
Survey
Pressure Point
Tourniquet for uncontrolled
extremity hemorrhage
Vital Signs
Abnormal**
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs,
Abdomen, Extremity, Back, Neuro
* Pleural Decompression should only be preformed when all 3
criteria are present:
1-severe respiratory distress with hypoxia
2-unilateral decreased or absent lung sounds (may see
tracheal deviation away from collapsed lung)
3-evidence of hemodynamic compromise (ie. Shock,
hypotension, tachycardia, altered mental status)
** Abnormal: hypotension, Tachycardia, Hypoxia
If indicated perform pleural decompression at the 2nd
intercostal space, mid-clavicular line
Assess all patients for major trauma criteria. Major trauma
patients should have transport initiated within 10 minutes of
arrival on scene whenever possible. In the setting of major
trauma, DO NOT prolong scene time to perform procedures
unless immediately necessary to stabilize patient (ie.
Hemorrhage control). Initiate all other procedures while
enroute to the trauma center.
Disability – assessment neurological deficits: paralysis,
weakness, abnormal sensation, etc.
A
IV Protocol
250ml bolus NS x2
YES
P
Notify receiving
hospital
A
Tension
Pneumothorax?
NO
P
Pain Control
Protocol
Decompress*
M
Contact Medical
Control
Normal
M
High suspicion severe injury
Facility/Provider discretion
Rapid Transport to Trauma
Receiving Facility <10 minutes
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
137
Trauma:
General Approach to All Trauma Patients
Assess all patients for major trauma criteria. Major trauma patients should have
transport initiated within 10 minutes of arrival on scene whenever possible. In the
setting of major trauma, DO NOT prolong scene time to perform procedures unless
immediately necessary to stabilize patient (e.g. hemorrhage control). Initiate all
other procedures en-route to the trauma center.
All Providers

General Patient Care Protocol—Adult

Secure airway/spinal immobilization if indicated

Supplemental 100% oxygen if any respiratory symptoms

Examine patient for obvious bleeding

Control active bleeding with direct pressure

Assess disability-neurologic status/record Glasgow coma score

Head to toe examination to assess for injuries

Restrain as needed
Paramedic

When conditions warrant (specified as “Full ALS Assessment and Treatment”
in individual protocol)
 Advanced airway/ventilatory management as needed
 Perform cardiac monitoring
 Record and monitor O2 saturation
 Microstream capnography if any acute respiratory symptoms
 IV 0.9% NaCl TKO/KVO or IV lock
 If SBP < 90 mmHg, administer boluses of 0.9%NaCl at 250 ml
until SBP > 90 mmHg
 Assess for Tension Pneumothorax
 Tension pneumothorax should be suspected in patients who
exhibit

Severe respiratory distress with hypoxia

Unilateral decreased or absent lung sounds (may see
tracheal deviation away from collapsed lung field)

Evidence of hemodynamic compromise (e.g. shock,
hypotension, tachycardia, altered mental status)
138


Pleural decompression for tension pneumothorax should only
be preformed when all 3 of the above criteria are present; If
indicated perform pleural decompression at the 2nd intercostal
space, mid-clavicular line
Refer to Pain Management Protocol as needed
Contact Medical Control for any additional orders or questions
139
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
History:
Type of exposure (heat, gas, chemical)
Inhalation injury
Time of injury
Past medical history and medications
Other trauma
Loss of consciousness
Tetanus/immunization status
Signs and Symptoms
Burns, pain, swelling
Dizziness
Loss of consciousness
Hypotension/shock
Airway compromise/distress
Singed facial or nasal hair
Hoarseness/wheezing
Differential
Superficial (1st degree) red and painful
Partial thickness (2nd degree) blistering
Full thickness (3rd degree) painless/charred or leathery skin
Thermal
Chemical
Electrical
Radiation
General Approach to All Adult Patients
Transport to Burn Center
Trauma Protocol
2nd degree burns greater than 10% total body surface area or
those on hands, feet, face or groin
3rd degree burns
Electrical burns (spinal immobilization if high voltage, monitor for
cardiac arrhythmias, initiate fluid resuscitation immediately
Chemical burns (remove clothing, brush away dry powder before
irrigating, flush with copious warm water on scene and continue
irrigation enroute, eyes: remove contacts and irrigate
continuously with NS for at least 30 minutes, avoid hypothermia
ABC’s
*Airway Protocol
Remove or cool heat source if present
Remove all clothing, contact lenses,
and jewelry (especially rings)
If inhalation injury – place patient on
100% O2, monitor ETCO2 continuously
Maintain core temperature
Cover burn with plastic wrap, plastic chucks, or
clean dry dressings
IV Protocol
A
Large bore in unburned skin if possible
If burn is >20%TBSA 2nd/3rd degree burns – NS at 500ml/hr
If burn is >30%, place 2 large bore IVs
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Lung, Heart, Abdomen, Extremities, Back,
and Neuro
Burn patients are trauma patients, evaluate for multisystem trauma
Assure whatever has caused the burn, is no longer contacting the injury (stop the burning process)
Early intubation is required when the patient experiences significant inhalation injuries
Potential CO exposure should be treated with 100% oxygen.
Circumferential burns to extremities are dangerous due to potential vascular compromise
secondary to soft tissue swelling
Burn patients are prone to hypothermia – never apply ice or cool burns, must maintain normal
body temperature
Evaluate the possibility of child abuse with children and burn injuries
*Signs and symptoms of inhalation injury: carbonaceous sputum, facial burns or edema,
hoarseness, singed nasal hairs, agitation, anxiety, cyanosis, stupor or other signs of hypoxia
A
Consider Pain Management Protocol
M
Contact Medical
Control
M
Service MD Approval:______
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
140
Trauma: Burns—Thermal
All Providers






General Patient Care Protocol – Adult
o Stay focused on ABC’s, don’t get side tracked by burn!
o DON’T BECOME A SECOND VICTIM!
Remove or cool heat source if present (e.g. clothing, tar)
o Cool burns with room temperature water for 3-5 minutes only except
for tar burns which will take an extended time to cool.
o NEVER COOL WITH ICE! The goal is to bring burns to room
temperature, not cold.
Remove all clothing, contact lenses, and jewelry, especially rings
Maintain core temperature. Keep patient warm and dry with sheets and
blankets. Cover burns with plastic wrap, plastic chucks, or clean, dry
dressings.
If inhalation injury is suspected
o Place patient on 100% oxygen – DO NOT DECREASE
o Monitor ETCO2 continuously (if available)
Estimate Total Body Surface Area (TBSA)
o Rule of Nines
o For scattered burns, use the size of patient’s hand, including fingers, to
equal 1% burn.
INDICATIONS FOR TRANSFER TO A BURN
CENTER
 2nd Degree burns greater than 10% total
body surface area or those on hands, feet,
face, or groin
 3rd degree burns
 Electrical burns
- Spinal immobilization if high voltage
electrical injury
- Monitor for cardiac arrhythmias
- Initiate fluid resuscitation immediately
 Chemical burns
- Remove clothing
- If dry powder is present, brush away
before irrigating
- Flush with copious warm water on
scene and continue irrigation enroute
to UW Hospital
- Chemical injuries to eyes are an
EMERGENCY. Remove contacts and
irrigate continuously with normal saline
for at least 30 minutes.
- Avoid hypothermia
141
Advanced EMT
 Consider IV Protocol



Place large bore peripheral IV’s in unburned skin if possible
If TBSA % greater than 20% of 2nd and 3rd degree burns, initiate fluid
resuscitation with 0.9% Normal Saline at 500ml/hour
If TBSA greater then 30%, place 2 large bore peripheral IV’s
Paramedic

Observe for signs of impending loss of airway; Refer to the Airway
Management Protocol as needed:
 Hypoxia
 Poor ventilatory effort
 Altered Mental status/decreased level of consciousness
 Inability to maintain patent airway
 Signs or Symptoms of Inhalation injury
 Carbonaceous sputum
 Extensive facial burns or facial edema
 Hoarseness
 Singed nasal hairs
 Agitation, anxiety, cyanosis, stupor or other signs of hypoxia
● If inhalation injury is suspected
 Place patient on 100% oxygen-DO NOT DECREASE
 Monitor ETCO2 continuously
 Consider Airway Management Protocol
 If moderate to severe pain, see Pain Management Protocol
Contact Medical Control for any additional orders or questions
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Trauma: Chest Injuries
General Patient Care Protocol—Adult
Assess breath sounds frequently
Assess for ventilatory compromise and assist with BVM as needed
For open/sucking chest wounds, apply occlusive dressing sealed on three (3) sides or
commercially available chest seal
Remove temporarily to vent air if respiratory status worsens
Paramedic
Full ALS Assessment and Treatment
Assess for flail segment
Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol as needed:
Hypoxia
Poor ventilatory effort
Altered mental status/decreased level of consciousness
Inability to maintain patent airway
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Trauma Protocol
Any local EMS Agency changes to this document must follow the
76 DCEMS Protocol Change Policy and be approved by WI EMS
143
Trauma Protocol
All Providers
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Medical Control
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History:
Type of injury
Mechanism (blunt vs. penetrating)
Loss of consciousness
Bleeding
Past medical history
Medications
Evidence of multi‐trauma
Signs and Symptoms
Pain, swelling, bleeding
Altered mental status
Unconscious
Respiratory distress / failure
Vomiting
Major traumatic mechanism of injury
seizure
Differential
Skull fracture
Brain injury (concussion, contusion,
hemorrhage, or laceration)
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Spinal injury
Abuse
General Approach to All Adult Patients
Trauma Protocol
Restrain as needed
Spinal Immobilization Protocol
elevate head of backboard to 15°‐30°
(if normotensive or hypertensive)
Obtain and Record GCS
A
A
IV Protocol
Airway Protocol
Maintain Pulse Ox >93%
EtCO2 target 40
Seizure Protocol
YES
Seizure?
Service MD Approval:______
NO
P
Lorazepam 1‐2mg IV/IO (max 4mg)
Or
Midazolam 1‐2mg IV/IO (max 4mg)
P
Severe Agitation/Combative?
YES
NO
Monitor and Reassess
M
Contact Medical
Control
M
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs, Abdomen, Extremity, Back, Neuro
If GCS <12 consider Air transport or Rapid Transport
Airway interventions can be detrimental to patients with head injury by raising intracranial pressure, worsening hypoxia (and secondary brain
injury) and increasing risk of aspiration. Whenever possible these patients should be managed in the least invasive manner to maintain O2
saturation >90% (ie. NRB, BVM with 100% O2)
Acute herniation should be suspected when the following signs are present: acute unilateral dilated and non‐reactive pupil, abrupt deterioration in
mental status, abrupt onset of motor posturing, abrupt increase in blood pressure, abrupt decrease in heart rate.
Only in suspected acute herniation – hyperventilate (rate 20/minute) and target EtCO2 30‐35mmHg
Increased intracranial pressure (ICP) may cause hypertension and bradycardia (Cushings response)
Hypotension usually indicates injury or shock unrelated to the head injury and should be treated aggressively
Most important vital sign to monitor and document is level of consciousness (GCS)
Concussions are periods of confusion or LOC associated with trauma which may have resolved by the time EMS arrives. Any prolonged confusion or
mental status abnormality which does not return to normal within 15 minutes or any documented loss of consciousness should be evaluated ASAP by
a physician.
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
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Trauma: Head Injuries
All Providers






General Patient Care Protocol-Adult
Supplemental oxygen
Restrain as needed
Spinal Immobilization
If normotensive or hypertensive
Elevate head of backboard 15 - 30
Paramedic

Full ALS Assessment and Treatment
 Advanced airway/ventilatory management as needed
Note: Airway interventions can be detrimental to patients with head injury
by raising intracranial pressure, worsening hypoxia (and secondary brain
injury) and increasing risk of aspiration. Whenever possible these patients
should be managed in the least invasive manner to maintain O2 saturation
> 93% (i.e. NRB, BVM with 100% O2)

Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed:
 Hypoxia
 Poor ventilatory effort
 Altered mental status/decreased level of consciousness
 Inability to maintain patent airway
For patients with assisted ventilation

Administer eucapneic (normal rate 12-15/min) ventilations

Titrate to target an ETCO2 of 40 mmHg

Acute herniation should be suspected when the following signs are present:
 Acute unilateral dilated and non-reactive pupil
 Abrupt deterioration in mental status
 Abrupt onset of motor posturing
 Abrupt increase in blood pressure
 Abrupt decrease in heart rate

Hyperventilation (ventilatory rate of 20) is a temporizing measure which is
only indicated in the event of acute herniation

If signs of herniation develop, increase ventilatory rate to 20/minute and target
an ETCO2 of 30-35 mmHg
145

If severely agitated/combative and unable to de-escalate by any other means,
consider:
 Lorazepam 1-2 mg IV/IO, max 4 mg
OR
 Midazolam 1-2 mg IV/IO, max 4 mg
Contact Medical Control for any additional orders or questions
 Additional sedation for combative patients
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Trauma: Eye Injuries
General Patient Care Protocol—Adult
Measure visual acuity
If injury is secondary to a chemical exposure:
Remove patient from source if safe to do so
Remove contact lenses if appropriate; transport with patient
Irrigate the eyes with 0.9 % Normal Saline for a minimum of 20 minutes
Determine chemical involved, bring MSDS sheet if available
If eye injury is due to trauma:
Stabilize any penetrating objects
Do not remove any impaled object
Protective metal shield unless impaled object precludes
Prevent patient bending or standing
If blood observed in anterior chamber, transport with head elevated 60
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Trauma Protocol
Any local EMS Agency changes to this document must follow the
76 DCEMS Protocol Change Policy and be approved by WI EMS
147
Trauma Protocol
All Providers
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Medical Control
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History:
Type of injury
Mechanism: crush/penetrating/amputation
Time of injury
Open vs. closed wound / fracture
Wound contamination
Medical history
medications
Signs and Symptoms
Pain, swelling
Deformity
Altered sensation/motor function
Diminished pulse/capillary refill
Decreased extremity temperature
Differential
Abrasion
Contusion
Laceration
Sprain
Dislocation
Fracture
Amputation
General Approach to All Adult Patients
Trauma Protocol
Wound care
Control Hemorrhage with Pressure
Splinting as required**
If hemorrhage can not be controlled by direct
pressure and is life threatening then consider
Tourniquet procedure*
A
IV Protocol
If life or limb threatening event or if pain medication needed
A
250 ml NS bolus to maintain SBP >90mmHg (max 2L)
Pain Control Protocol
If amputation: clean amputated part and wrap part in sterile dressing soaked in NS and
place in an air tight container, place container on ice if available
M
Contact Medical
Control
Service MD Approval:______
M
Pearls
RECOMMENDED EXAM: Mental Status, Extremity, Neuro
*Apply commercially available tourniquet device as proximal on extremity as possible, commercial must be at least 1.5 inches wide, non-commercial
must be at least 2 inches wide. Tighten tourniquet until bright red bleeding has stopped. Secure in place and expedite transport to Level 1 trauma
center. Document time of placement in patient care report and on device (if possible). Notify medical control of tourniquet use.
**Check distal pulses, capillary refill, sensation/movement prior to splinting: If pulse present, splint in position found if possible; If pulse absent, attempt
to place the injury into anatomical position
Open wounds/fractures should be covered with sterile dressings and immobilized in the presenting position
Dislocations should be immobilized to prevent any further movement of the joint
Check distal pulses, capillary refill and sensation after splinting
Peripheral neurovascular status is important (CMS)
In amputations, time is critical. Transport and notify medical control immediately.
Hip dislocations and knee and elbow fracture/dislocations have a high incidence of vascular compromise.
Urgently transport any injury with vascular compromise
Blood loss may be concealed or not apparent with extremity injuries
Lacerations must be evaluated for repair within six hours from the time of injury
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
148
Trauma: Extremity
All Providers

General Patient Care Protocol—Adult

Remove or cut away clothing to expose area of injury

Control active bleeding
 For uncontrollable hemorrhage (heavy bleeding despite aggressive
direct pressure):
 Apply commercially available tourniquet device as proximal on
extremity as possible, minimum 2” proximal to the hemorrhage
site.

Do not place over a joint

Commercial Tourniquets must be at least 1.5 inches wide






Non-Commercial Tourniquets must be at least 2 inches
wide
Tighten tourniquet until bleeding has stopped
Secure in place and expedite transport to Level 1 Trauma
Center
Document time placed on chart and on device (if possible)
Notify receiving center of presence, time placed, and location of
tourniquet
Check distal pulses, capillary refill, sensation/movement prior to splinting
 If pulse present, splint in position found if possible
 If pulse absent, attempt to place the injury into anatomical position

Open wounds/fractures should be covered with sterile dressings and
immobilized in the presenting position

Dislocations should be immobilized to prevent any further movement of the
joint

Check distal pulses, capillary refill and sensation after splinting
Advanced EMT
 Consider IV Protocol
Paramedic

Full ALS Assessment and Treatment

For isolated extremity trauma:
 Stabilize BP (SBP  90 mmHg)
 Refer to the Pain Management protocol as needed
Contact Medical Control for any additional orders or questions
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Trauma: Traumatic Amputations
All Providers

General Patient Care Protocol—Adult

For uncontrollable hemorrhage (heavy bleeding despite aggressive direct
pressure):
 Apply tourniquet device as proximal on extremity as possible, a
minimum of 2” proximal to the hemorrhage site.
▪ Do not place over a joint
▪ Commercial Tourniquet must be at least 1.5 inches wide
▪ Non-Commercial Tourniquet must be 2 inches wide
 Tighten tourniquet until bleeding has stopped
 Secure in place and expedite transport to Level 1 Trauma Center
 Document time placed on chart and on device (if possible)
 Notify receiving center of presence, time placed, and location of
tourniquet

If amputation incomplete:
 Attempt to stabilize with bulky pressure dressing
 Splint inline

If amputation complete:
 Cleanse amputated part with sterile saline
 Wrap in sterile dressing moistened in sterile saline
 Place in plastic bag if possible
 Attempt to cool with cool pack during transport
Advanced EMT

Consider IV Protocol
Paramedic

For isolated extremity trauma:
 Stabilize BP (SBP 90 mmHg)
 Refer to Pain Management protocol as needed
Contact Medical Control for any additional orders or questions
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History:
Patient who has suffered traumatic injury
and is now pulseless
Signs and Symptoms
Evidence of penetrating trauma
Evidence of blunt trauma
General Approach to All Adult Patients
PNB and: (one or more of the following)
Trauma Protocol
Injuries Incompatible with life? (Incineration,
decapitation, hemicorporectomy) OR
Rigor Mortis OR
Decomposition of body tissue OR
Dependent Lividity OR
Evidence of significant time lapse
Differential
Medical condition preceding traumatic
event as cause of arrest.
Tension Pneumothorax
Hypovolemic Shock
External hemorrhage
Unstable pelvic fracture
Displaced long bone fracture(s)
Hemothorax
Intra‐abdominal hemorrhage
Retroperitoneal hemorrhage
Criteria does not apply for:
PNB after blunt or penetrating trauma and:
pulseless and apneic
lack of pupillary reflexes and spontaneous movement
Asystole or agonal rhythm <20 on monitor
Lightening or other high voltage injury,
Drowning, Suspected Hypothermia,
Cardiac Arrest Inconsistent with arrest
due to trauma, or Transport has been
initiated
PNB after traumatic injury when transport to nearest
ED is >15 minutes and:
pulseless and apneic
lack of pupillary reflexes and spontaneous movement
Asystole or agonal rhythm <20 on monitor
YES
Withhold Resuscitative Efforts
NO
Appropriate Cardiac Arrest Protocol
Contact Law Enforcement and/or
Medical Examiner
M
Contact Medical
Control
Service MD Approval:______
M
Pearls
Injuries obviously incompatible with life include decapitation, massively deforming head or chest injuries, or other features of a particular patient
encounter that would make resuscitation futile, when in doubt, place patient on the monitor.
Consider using medical cardiac arrest protocols if uncertainty exists regarding medical or traumatic cause of arrest.
As with all major trauma patients, transport should generally not be delayed for these patients
Where the use of spinal immobilization interferes with performance of quality CPR, make reasonable efforts to manually limit patient movement
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
151
Trauma: Indications for Withholding Resuscitation
in Traumatic Cardiopulmonary Arrest
CPR can be withheld in Traumatic Cardiopulmonary Arrest under the following
circumstances:

Pulseless, apenic, and no other signs of life present AND

The presence of one or more of the following:
 Rigor Mortis
 Decomposition of body tissues
 Dependant Lividity
 Injuries incompatible with life (e.g. incineration, decapitation,
hemicorporectomy)
 Evidence of significant time lapse since pulselessness
- OR -

Patients who present pulseless after blunt trauma or penetrating trauma
provided that all other signs of life are absent:
 Pulseless and Apenic
 Lack of pupillary reflexes and spontaneous movement
 Asystole or agonal rhythm < 20 on cardiac monitor
- OR -

Patients who become pulseless after severe traumatic injury when transport
to the NEAREST ED cannot be accomplished within 15 minutes (i.e.,
prolonged extrications), provided that all other signs of life are absent and
transport has not been initiated:
 Pulseless and apenic
 Lack of pupillary reflexes and spontaneous movement
 Asystole or agonal rhythm < 20 on cardiac monitor
This criteria does not apply in the following scenarios:

When the Cardiac Arrest is inconsistent with Cardiac Arrest due to trauma

Lightning or other high voltage injuries

Drowning

Suspected hypothermia

Transport has been initiated
Contact Medical Control for any additional orders or questions
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General Patient Care Protocol
For victims of sexual assault who meet major trauma criteria, transport to Level 1 Trauma
Center
For all other cases, transport to nearest appropriate Emergency Department
□ If medically stable and appropriate consider transport to SANE
(Sexual Assault Nurse Examiner) capable facility.
Provide supportive care as indicated by patient’s condition
Preserve evidence
□ Paper bags are preferred to plastic in evidence preservation.
□ If present, defer to law enforcement for proper chain of custody.
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Trauma Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS
153
Trauma Protocol
Trauma: Sexual Assault
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Determining the need for spinal immobilization requires a careful assessment of the injury, the patient’s complaints and overall condition,
and the patient’s ability to recognize and convey the presence of spinal injury symptoms. It is not feasible to “clear” the spine in the
prehospital setting. Spinal immobilization should always be applied when any doubt exists as to the possibility of spinal trauma. The
following algorithms (Blunt and Penetrating Trauma) can be used to assist EMS in making the most appropriate decision about the need for
spinal immobilization.
Blunt Trauma
Altered Level of Consciousness?
GCS <15
Presence of neurologic deficit or complaints₂ ?
Test Motor functioning both upper and lower extremities
(entire extremity)
Test sensation in both upper and lower extremities (start
proximal and work towards hands and feet)
Ask about numbness and tingling in extremities.
NO
Any of the following:
YES
YES
YES
▪ spinal pain or tenderness ₁
▪neurologic deficit or complaint₂
▪anatomical deformity of the spine
YES
NO
Trauma Protocol
YES
Immobilize
Penetrating Trauma
If in Doubt - Immobilize
NO
Concerning Mechanism of
Injury*?
NO
Any of the following:
▪ Evidence of (significant) clinical
intoxication
▪ Distracting Injury₃
▪ Inability to communicate₄
Immobilize
Immobilization not indicated
NO
Immobilization not indicated
M
Medical Control
If Needed
M
Service MD Approval:______
Pearls
₁ Tenderness to the midline posterior neck and back, including the paraspinal musculature
₂ Examples are numbness, focal weakness, focal sensory deficit, parasthesias
₃ Examples are long bone fractures, dislocations, large lacerations, degloving injuries, serious burns or any other injury causing functional impairment.
₄ Examples include language barrier, hearing or speech impairment, dementia and age (young children)
* Concerning MOI:
‐Any mechanism that produces a violent impact on the head, neck, torso or pelvis
‐Incidents that produce sudden acceleration or deceleration, including lateral bending forces
‐ Any fall, especially in the elderly
‐ Ejection or fall from a moving mode of transportation
‐ Shallow‐water drowning or diving injuries – must immobilize
‐ High voltage electrical injuries – must immobilize
If spinal immobilization is indicated but refused by the patient:
Advise the patient of the indication for immobilization and the risks of refusing the intervention.
If the patient allows, apply the cervical collar even if backboard is refused.
Maintain spinal alignment as best as can be achieved during transport.
Clearly document refusal of immobilization
For patients who cannot tolerate supine position due to clinical condition: apply all elements the patient can tolerate, maintain spinal alignment as best
as can be achieved during transport, clearly document clinical condition that interfered with full immobilization.
Determining the presence of neurological signs and symptoms requires careful assessment and history taking.
Trauma Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
154
Spinal Immobilization: Indications
Determining the need for spinal immobilization requires a careful assessment of the
injury, the patient’s complaints and overall condition, and the patient’s ability to
recognize and convey the presence of spinal injury symptoms. It is not feasible to
“clear” the spine in the prehospital setting. Spinal immobilization should always be
applied when any doubt exists as to the possibility of spinal trauma. The following
algorithms (Blunt and Penetrating Trauma) can be used to assist EMS in making the
most appropriate decision about the need for spinal immobilization.
Blunt Trauma
Assess for concerning mechanism of injury:






Any mechanism the produces a violent impact on the head, neck, torso or
pelvis
Incidents that produce sudden acceleration or deceleration, including lateral
bending forces
Any fall with neck pain, back pain, altered mental status and/or neurologic
deficit, especially in the elderly
Ejection or fall from a moving mode of transportation
Shallow-water drowning or diving injuries
High-voltage electrical injuries
Assess patient’s ability to clearly communicate and/or comprehend the
nature of their injuries:

Altered level of consciousness
 GCS < 15
 Evidence of significant intoxication
 Dementia

Speech or hearing impairment

Age (young children)

Language barrier
Assess for physical signs or symptoms of spinal trauma:

Spinal pain or tenderness, including paraspinal muscles

Neurologic deficit or complaint, including parasthesia, paralysis, or weakness

Anatomical deformity of the spine
155
Assess for presence of distracting injuries, including but not limited to:

Long bone fractures

Joint dislocations

Abdominal or thoracic pain, or obvious visceral injury

Large lacerations, degloving injuries or crush injuries

Any injury producing acute functional impairment

Craniofacial injuries
IF ANY OF THE ABOVE MENTIONED FEATURES ARE PRESENT,
OR IF ANY QUESTION, IMMOBILIZE!
Contact Medical Control for any additional orders or questions
156
Immobilize all patients with the following conditions:

High voltage electrical injuries (does not include Taser use)

Shallow water drowning or diving injuries
If spinal immobilization is indicated but refused by the patient:

Advise the patient of the indication for immobilization and the risks of refusing
the intervention.

If the patient allows, apply the cervical collar even if backboard is refused.

Maintain spinal alignment as best as can be achieved during transport.

Clearly document refusal of immobilization.
For patients who cannot tolerate supine position due to clinical condition:

Apply all elements of spinal immobilization that the patient will tolerate.

Maintain spinal alignment as best as can be achieved during transport.

Clearly document the clinical condition that interfered with full immobilization.
Contact Medical Control for any additional orders or questions
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The following measures will apply to the management of all pediatric patients:
A Child shall be defined as:
Age <12 years of age or weight <40 kg (if age unknown)
No signs of puberty if age/weight not able to be determined
For PALS resuscitation <8 years
For Major Trauma <18 years
All Providers
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
159
2013
Contact Medical Control for any additional orders or questions
Pediatric Protocol
Ensure scene safety
Scene survey to determine environmental conditions, mechanism of injury or illness and potential for hazardous
conditions
Form general impression of patient’s condition
Establish patient responsiveness
Immobilize spine if cervical or other spine injury suspected
Assess airway and breathing, manage as appropriate
Supplemental 100% Oxygen if any respiratory signs or symptoms
Assess circulation and perfusion by measuring heart rate, and observing skin color, temperature, capillary refill and the
quality of central/peripheral pulses.
□ For children with absent pulses, initial cardiopulmonary resuscitation
Control hemorrhage using direct pressure or a pressure dressing
Measure Blood Pressure in children older than 3
Evaluate mental status including pupil reaction, motor function and sensation
Vital Signs for Children
□ For mental status, use the AVPU scale:
• A‐ The patient is alert and oriented (age appropriate)
Respiratory
Systolic Blood
Age Group
Rate
Heart Rate
Pressure
• V – The patient is responsive to verbal stimulus
Newborn
30-60
120-180
>60
• P – The patient is responsive to painful stimulus
Infant
(1-12 Months)
20-40
100-140
>70
• U – The patient is unresponsive to any stimulus
Toddler
(1-3 years)
20-34
90-130
>75
Expose the child only as necessary to perform further assessments
Preschooler
Maintain the child’s body temperature throughout assessment
(3-5 Years)
20-30
80-120
>80
School Age
Utilize the Broslow‐Luten® system for estimating patient weight
(6-12 Years)
18-30
70-110
>80
Advanced EMT
Adolescent
(13+ Years)
12-20
60-100
>90
●
Consider IV Protocol
Paramedic
●
When condition warrants (specified as “Full Pediatric ALS Assessment and Treatment” in individual
protocols):
□
Airway/ventilatory management as needed
□
Perform cardiac monitoring
□
Record and monitor O2 saturation
□
Record and monitor End‐tidal CO2
□
If symptoms severe or for medication access IV 0.9% NaCl TKO/KVO or IV Lock
●
If signs of shock administer boluses of 0.9% NaCl at 20 ml/kg until signs of shock resolve or 60 ml/kg
total
●
If signs of severe cardiopulmonary compromise (poor systemic perfusion, hypotension, altered consciousness
and/or respiratory distress/failure) and IV attempts unsuccessful (max 2 attempts) in a child consider
intraosseous access
□
If a child’s condition is critical or unstable, initiate transport without delay
●
Perform procedures, history and detailed physical exam en route to the hospital
●
Unless specified in protocol, all medication dosages and equipment sizes should be calculated using the Broselow‐
Luten system
□
Reassess the patient frequently
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History:
Time of arrest
Possibility of foreign body
Medical history
Medications
Fever or respiratory infection
Other sick siblings
History of trauma
Signs and Symptoms
Wheezing or stridor
Respiratory retractions
Increased heart rate
Altered level of
consciousness
Anxious appearance
General Approach to all Pediatric
Patients
Ventilatory Insufficiency
Respiratory Failure
Assess ABC’s
Stridor?
YES
NO
Airway, Pediatric
Protocol
Drooling, Dysphonia, Fever,
“Toxic Appearing”
Pulse Ox and Lung Sounds
NO
Wheezing?
YES
Allergic
Reaction
Suspected?
NO
Supplemental O₂
Keep SpO₂ >93%
Supplemental O₂
Keep SpO₂ >93%
YES
Albuterol 2.5mg/3ml
Ipratropium 0.5mg/2.5ml
May repeat Albuterol (total 3
doses)***
IMPROVED
Comfort and
transport
As appropriate
WORSENING
A
UNCHANGED
P
M
P
Consider Inhaled Epi
3ml of 1:1,000 mixed in 3ml NS
M
IV Protocol
Position of
Comfort
Supplemental O₂
As tolerated
Transport
Rapidly
A
2013
Epi IM**
0.01mg/kg
(0.3max)
NO
YES
Pediatric and OB Protocols
Differential (Life Threatening)
Allergic reaction
Asthma
Aspiration
Foreign body
Infection
Pneumonia, croup, epiglotits
Congenital heart disease
Medication or toxin
Trauma
Methylprednisolone 2mg/kg IV or IM (max dose 125mg)
Magnesium Sulfate 50mg/kg IV (max 2g) in 100ml D5W
over 5‐10min*
P
P
M
Contact Medical Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Abdomen, Extremities, Neuro
*Magnesium sulfate contraindicated if history of renal failure
** Epi Pen Jr. .15mg <60pounds, Epi Pen .30mg >60pounds.
*** If Basic or A-EMT is needing to provide additional Albuterol, Medical Control or Paramedics should be consulted.
Whenever available utilize capnography
Pulse oximetry should be monitored continuously if initial saturation is <96%, or there is a decline in patient status despite normal pulse oximetry
readings.
Do not force a child into a position. They will protect their airway by their body position
The most important component of respiratory distress is airway control
Bronchiolitis is a viral infection typically affecting infants which results in wheezing which may not respond to beta‐agonists. Consider Epinephrine if
patient <18 months and not responding to initial beta‐agonist treatment
Croup typically affects children <2years of age. It is viral, possible fever, gradual onset, no drooling is noted.
Epiglotitis typically affects children >2 years of age. It is bacterial, with fever, rapid onset, possible stridor, patient wants to sit up to keep airway
open, drooling is common. Airway manipulation may worsen the condition.
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
160
Airway Emergencies: Pediatric Dyspnea
All Providers

General Patient Care Protocol—Pediatric

Supplemental 100% oxygen

For Bronchospasm:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer (if additional Albuterol
needed, contact Medical Control or Paramedic Intercept)

If severe:
 Hypoxia: < 93%, severe respiratory distress, anaphylactic shock, stridor
 Assist with patient-prescribed Epinephrine auto-injector (e.g. Epi-Pen or
Epi-Pen Jr.)

If foreign body obstruction is suspected refer to foreign body protocol

If partial upper airway obstruction or stridor without severe respiratory distress
 Do nothing to upset the child
 Perform critical assessments only
 Have parent administer blow by supplemental oxygen
 Place patient in position of comfort
 Do not attempt vascular access
 Expedite transport

If complete airway obstruction or severe respiratory distress, failure or arrest
 Airway/ventilatory management as needed
Advanced EMT

Consider IV Protocol

For Bronchospasm:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium Bromide
0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer (if additional Albuterol
needed, contact Medical Control or Paramedic Intercept)

If patient shows signs of worsening respiratory distress, inadequate ventilations
or respiratory failure in the setting of bronchospasm or a history of asthma
 Epinephrine 1:1000 at 0.01 mg/kg (max 0.3 mg) IM
161
Paramedic

Full Pediatric ALS Assessment and Treatment

For Bronchospasm:
 Albuterol (Proventil) 2.5mg/3ml via nebulizer every 15 minutes (max 3
treatments)

If patient shows signs of worsening respiratory distress, inadequate ventilations
or respiratory failure in the setting of bronchospasm or a history of asthma
 Epinephrine 1:1000 at 0.01 mg/kg (max 0.3 mg) IM
 May repeat epinephrine every 15 minutes X 2 additional doses (3
total) if severe symptoms present
 May administer at same time nebulizer is being administered
 Methylprednisolone (Solu-Medrol) 2 mg/kg IV or IM (Maximum individual
dose 125 mg)
 Magnesium Sulfate 50mg/kg IV (max individual dose 2g) in 100 ml D5W
over 20 minutes; contraindicated if history if renal failure
Drowning/Near Drowning

Ventilatory management as indicated/100% O2 as indicated

Spinal Immobilization if indicated

Protect from heat loss

Patients may develop delayed onset respiratory symptoms

Refer to appropriate protocol if cardiac arrest present
Paramedic - Contact Medical Control for any additional orders or
questions
 Nebulized Epinephrine
162
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
Supplemental Oxygen
ADEQUATE
Maintain SPO2 >93%
Assess ABC’s
-Respiratory Rate
‐Effort
‐Adequacy
Pulse Oximetry
INADEQUATE
UNSUCCESSFUL
If > 4 feet, Blind insertion
airway device(Paramedic‐ if
<4feet LMA)
Only one attempt
P
Or
Endotracheal Intubation
Only one attempt
LONG TRANSPORT
OR NEED
TO PROTECT
AIRWAY
OBSTRUCTION
SUCCESSFUL
Continue BVM
SUCCESSFUL
Airway Obstruction Procedure
(per AHA standards)
UNSUCCESSFUL
P
UNSUCCESSFUL
Resume BVM
Attempt LMA or BIAD
Confirm with ETCO2 and exam
UNSUCCESSFUL
M P
If available, consider gastric
decompression
Perform needle cricothyrotomy and
jet insufflation
M
Consult Medical
Control
P M
2013
SUCCESSFUL
Laryngoscope and Magill
forceps
Pediatric and OB Protocol
Basic Maneuvers First
‐open airway
‐suction
‐nasal or oral airway
‐BVM
M
Service MD Approval:______
Pearls
If Capnography is available it is expected to be used with all methods of airway placement. Document results
If an effective airway is being maintained by BVM with continuous pulse oximetry values of >93, it is acceptable to continue with
basic airway measures instead of using a Blind insertion device or intubation.
For the purposes of this protocol a secure airway is when the patient is receiving appropriate oxygenation and ventilation
An intubation attempt is defined as passing the laryngoscope blade or endotracheal tube past the teeth or inserted into the nasal
passage
Ventilatory rate should be 30 for neonates, 25 for toddlers, 20 for school age children, and 12 for adolescents. Maintain an ETCO2 of
30‐35. Avoid hyperventilation
Quality assurance should always be completed after the use of blind insertion device or intubation
Maintain C‐spine immobilization for patients with suspected spinal injury
Do not assume hyperventilation is psychogenic – use oxygen, not a paper bag.
Sellick’s and or BURP maneuver should be used to assist with difficult intubations
Hyperventilation in deteriorating head trauma should only be done to maintain an ETCO2 of 30‐35
Gastric tube placement should be considered in all intubated patients if available
It is important to secure the endotracheal tube well and consider c‐collar to better maintain ETT placement
Suction all debris, secretions from the airway if necessary
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
163
Airway Emergencies: Pediatric Airway Management
All Providers

General Pediatric Patient Care Protocol

If suspicion of trauma, maintain c-spine immobilization

Suction all debris, secretions from airway

Bag valve mask ventilate as needed

Ventilate at a rate of 20 breaths/minute for all ages

Supplemental 100% O2

Have assistant apply cardiac monitor as soon as possible

Monitor end-tidal CO2 and oxygen saturation continuously
Advanced EMT

Consider IV Protocol
Paramedic

Have assistant apply cardiac monitor as soon as possible
 Address cardiac rhythm abnormalities per appropriate protocol

Monitor end-tidal CO2 and oxygen saturation continuously

Follow sequence listed below (use Broselow-Luten® tape to select appropriate
equipment)
164
 Following placement of ETT or LMA confirm proper placement
 Assess epigastric sounds, breath sounds and chest rise and fall
 Observe for presence of alveolar waveform on capnography
 Record tube depth and secure in place using a commercial tube holder (if
available)
 Utilize head restraint device (i.e. “head blocks”) or rigid cervical collar and
long spine board as needed to help secure airway in place
Capnography/ETCO2 Monitoring

Digital capnography (waveform) is the system standard for ETCO2 monitoring.

Only in the event digital capnography is not available due to on-scene
equipment failure, is continuous colorimetric monitoring of ETCO2 an
acceptable alternative.

Continuous ETCO2 monitoring is a MANDATORY component of invasive
airway management.
 If ETCO2 monitoring cannot be accomplished by either of the above
methods, the invasive device MUST be REMOVED, and the airway
managed non-invasively.
 If an alveolar waveform is not present with capnography (i.e. flat line),
briefly check the filter line coupling to assure it is securely in place then
remove the ETT/LMA or LTA and proceed to the next step in the
algorithm.
Foreign Body Airway Obstruction

Immediate transport is indicated

If unresponsive open airway using a head tilt/chin lift (if no trauma)
 If < 1 year old, administer up to 5 back blows and 5 chest thrusts
 If  1 to 8 years, administer compressions and attempts at ventilation until
the foreign body is dislodged

If ventilation is unsuccessful (O2 saturations cannot be kept > 93 %) perform in
the following order:
 Reposition airway and attempt bag valve mask assisted ventilation again
 If unsuccessful, establish direct view of object with laryngoscope and
attempt to remove it with Magill forceps
 If unsuccessful, re-attempt BVM ventilation; If oxygen saturation > 93%
with BVM proceed no further and expedite transport

If patient cannot be ventilated/oxygenated with the above measures,
Paramedics- simultaneously contact medical control and perform needle
cricothyrotomy and needle jet insufflation as a last resort.

Expedite transport to nearest emergency department
Contact Medical Control for any additional orders or questions
165
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
History:
Onset and location
Insect sting or bite
Food allergy / exposure
Medication allergy / exposure
New clothing, soap, detergent
Past history of reactions
Past medical history
Medication history
Differential
Urticaria (rash only)
Anaphylaxis (systemic effect)
Shock (Vascular effect)
Angioedema (drug induced)
Aspiration / Airway
obstruction
Vasovagal event
Asthma or COPD
CHF
Signs and Symptoms
Itching or hives
Coughing / wheezing
Or respiratory distress
Chest or throat constriction
Difficulty swallowing
Hypotension or shock
Edema
Pediatric Protocol
General Approach to All Pediatric Patients
Allergic Reaction suspected – history/exposure to allergen
Severe Reaction
Anaphylactic shock, Stridor, lip swelling
Severe respiratory distress
Mild Reaction
Hives / Rash Only
No respiratory component
Moderate Reaction
Dyspnea, Wheezing,
Chest Tightness
Epinephrine 1:1000 Auto‐Injector *
0.3mg >60lb 0.15mg <60lb
A
Consider IV Protocol
Diphenhydramine
1mg/kg IV/IM (max 50mg)
A
P
Worsening
Consider IV Protocol
A
P
P
0.3mg >60lb 0.15mg <60lb
.01mg/kg (max 0.3mg)
Pearls
RECOMMENDED EXAM: Mental
Status, Skin, Heart, Lungs
A
A
Diphenhydramine
1mg/kg IV/IM (max 50mg)
P
Methylprednisolone
2 mg/kg IV/IM (max 125mg)
P
M
No Improvement
Repeat Epinephrine
M
Severe
Reactions
Improvement
* Online Medical Control if HR
>150 or History of Coronary Artery
Disease
**May repeat Albuterol PRN for
continued wheezing – max 3
doses
The shorter the onset from
symptoms to contact, generally
the more severe the reaction
NS Bolus 20ml/kg if hypotensive
P
Epinephrine 1:1000 Auto‐Injector *
Epinephrine 1:1000 IM*
IV Protocol
A
Worsening
A
A
Albuterol 2.5mg/3ml** &
Ipratropium 0.5mg/2.5ml
Diphenhydramine
1mg/kg IV/IM (max 50mg)
P
.01mg/kg (max 0.3mg)
2013
Albuterol 2.5mg/3ml** &
Ipratropium 0.5mg/2.5ml
P
Epinephrine 1:1000 IM*
A
A
For severe reactions:
M
Contact Medical Control
M
MP
Famotidine 0.5mg/kg in 100ml
D5W IV Piggyback (max dose
20mg) over 15 minutes
*** Severe bradycardia, unresponsive, no
obtainable blood pressure or radial pulse
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
166
P M
Allergic Reactions: Pediatric
All Providers

General Patient Care Protocol-Pediatrics


Nothing by mouth
Moderate Reaction (Dyspnea, Wheezing, Chest Tightness)
 As above plus:
 Albuterol (Proventil) 2.5 mg/3 ml via nebulizer and Ipratropium
Bromide 0.02% (Atrovent) 0.5 mg/2.5 ml via nebulizer


May repeat Albuterol in 15 minutes for continued wheezing
Severe Systemic Reaction (Anaphylactic shock, Stridor, Severe respiratory
distress)
 As above plus:
 Epinephrine 1:1000 solution, 0.01 mg/kg IM (Max dose 0.3 mg)

Massage injection site vigorously for 30-60 seconds
Advanced EMT

Consider IV Protocol
Paramedic

If moderate or severe symptoms, perform Full Pediatric ALS Assessment and
Treatment

Mild Reaction (hives)
 As above plus: Diphenhydramine (Benadryl) 1 mg/kg IV (maximum 50 mg)
 May be administered IM if no IV access available

Severe Systemic Reaction (Anaphylactic shock, Stridor, Severe respiratory
distress)
 As above plus:
Methylprednisolone (Solumedrol) 2 mg/kg IV or IM (Maximum
individual dose 125 mg)
Contact Medical Control for any additional orders or questions
 All Providers –Repeat epinephrine if signs of severe reaction or shock
persist after initial dose
 Paramedics - For severe reactions, Famotidine 0.5mg/kg in 100 ml D5W
IV Piggyback (max dose 20mg) over 15 minutes.
167
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
General Approach to All Pediatric Patients
Glucose Level
2months‐12years <70
<2months <40
Glucose Level
2months‐12years >70
<2months >40
Blood Glucose
A
Consider IV Protocol
A
A
Dextrose 10% at 4ml/kg
(max 250mL) IV
Naloxone 0.1 mg/kg IV/IO/IN*
(max dose 2.0mg)
A
Consider other causes: Head injury,
OD/toxic ingestion, stroke, hypoxia,
hypothermia
A
P
Assess Cardiac Rhythm
P
NO
Return to baseline?
YES
Refusal of transport after
treatment given
protocol
M
Consult Medical
Control
M
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro. Pay
special attention to the head exam for signs of bruising or other injury.
* for Intranasal administration A-EMT should administer 0.5mg per nare, total of 1mg and then proceed
with additional doses as needed
Be aware of AMS as presenting sign of an environmental toxin or Hazmat exposure and protect
personal safety
It is safer to assume hypoglycemia than hyperglycemia if doubt exists. Recheck blood glucose after
Dextrose or glucagon
Consider restraints if necessary for patients and/or personnel's protection per the restraint protocol
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
168
2013
Glucagon
<1 year old – 0.5 mg IM
>1 year old – 1.0 mg IM
A
Differential
Head Trauma
CNS (stroke, tumor, seizure,
infection)
Cardiac (MI, CHF)
Hypothermia
Infection (CNS or other)
Thyroid (hyper/hypo)
Shock (septic, metabolic, traumatic)
Diabetes (hyper/hypo)
Toxicologic or Ingestion
Acidosis/Alkalosis
Environmental exposure
Pulmonary (hypoxia)
Electrolyte abnormality
Psychiatric disorder
Pediatric Protocol
Signs and Symptoms
Decreased mental status or
Lethargy
Change in baseline mental
status
Bizarre behavior
Hypoglycemia (cool/
Diaphoretic skin)
Hyperglycemia (warm, dry
Skin, fruity breath, kussmaul
respirations, signs of
dehydration
Irritability
History:
Known Diabetic
Drugs, Drug Paraphernalia
Report of illicit drug
use or toxic ingestion
Past medical history
Medications
History of trauma
Change in condition
Changes in feeding or sleep
habits
Altered Mental Status: Pediatric
This protocol is intended for pediatric patients with new altered mental status of
unknown etiology.
All Providers

General Pediatric Patient Care Protocol

If trauma suspected, stabilize spine

Supplemental 100% oxygen

Blood glucose check
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL

Glucagon - <1 year old – 0.5mg or >1 year old – 1.0mg IM
Advanced EMT

Consider IV Protocol

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4ml/kg to max of 250 mL
- OR -
 Glucagon <1 year old = 0.5mg or >1 year old = 1.0mg if IV or IO
access unavailable

Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a neonate)
after treatment or unable to determine blood glucose and no change in mental
status.

If patient has continued altered mental status:
 Naloxone at 0.1 mg/kg (maximum individual dose 2 mg) via IV/IO
 If no IV access, administer IN via mucosal atomizer device (MAD),
with one-half of dose administered to each nostril.
Paramedic

Full Pediatric ALS Assessment and Treatment
Contact Medical Control for any additional orders or questions
169
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
(ALTE)
Apparent Life-Threatening Event (ALTE)
All Providers
Assume the history given is accurate and reliable
Determine the severity, nature and duration of the episode
Obtain a medical history:
Known chronic diseases
History of preterm delivery
Evidence of seizure activity
Current or recent infections
Gastroesophageal reflux
Inappropriate mixture of formula
Recent trauma
Perform a thorough physical assessment that includes the general appearance, skin color,
level of interaction with environment and evidence of trauma and blood glucose check
Transport to the nearest appropriate receiving facility
For patients < 1 year of age
If the parent/guardian is refusing medical care and/or EMS transport, OLMC must be
contacted prior to accepting a refusal.
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS
170
Pediatric Protocol
An Apparent Life Threatening Event (ALTE), often referred to as a “near miss SIDS”, is an episode
that is frightening to the observer/caregiver, and involves some combination of the following:
Apnea (central or obstructive)
Color change (cyanosis, pallor, erythema, plethora)
Marked change in muscle tone (e.g. limpness/rigid)
Choking or gagging
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
Medical
Control
M
M
History:
Time of arrest
Medical history
Medications
Possibility of foreign body
Hypothermia
Signs and Symptoms
Unresponsive
Cardiac Arrest
CPR
Pediatric and OB Protocols
General Approach to all Patients
Differential (Life Threatening)
Respiratory failure
Foreign body, secretions, infection (croup, epiglotitis)
Hypovolemia (dehydration)
Congenital heart disease
Trauma
Tension pneumothorax, cardiac tamponade, pulmonary
embolism
Hypothermia
Toxin or medication
Electrolyte abnormalities (glucose, K)
acidosis
Cardiac Monitor
Asystole/PEA
Ventricular Fibrillation/Tachycardia
Give 1 shock
Manual: 2J/kg
May use AED if >1year of age (use pediatric AED
if possible for 1‐8 years old)
AED per manufacturer recommendation if <1
Immediately start CPR, do not check for pulse
*Airway Protocol
Check Blood Glucose and treat if appropriate
A
A
IV Protocol
AT ANY TIME
Return of spontaneous
circulation ‐>
Treat per appropriate
dysrhythmia protocol
Expedite Transport
A
Give 5 cycles CPR
Check rhythm, check pulse
Shockable rhythm?
P
A
Epinephrine IV/IO
1:10,000 at 0.01mg/kg (max1mg)
Repeat every 3‐5 minutes (flush
with 10‐20 ml NS)
P
Continue CPR 5 cycles at time
Check rhythm, between cycles
2013
*Airway Protocol
Check Blood Glucose and treat if appropriate
IV Protocol
Only check pulse between cycles of CPR and
if there is a perfusing rhythm
YES
P
Give 1 shock 4J/kg or use AED as described above
Resume CPR immediately after shock
Epinephrine IV/IO
1:10,000 at 0.01mg/kg
Repeat every 3‐5 minutes (flush with 10‐20 ml NS)
Try to Identify and Treat the Cause:
P
Check rhythm, check pulse
Shockable rhythm?
YES
P
Hypoxemia – assist ventilation
Acidosis ‐
Volume depletion – 0.9%NaCl at 20ml/kg may repeat (max 60ml/kg)
Tension pneumothorax **
Hypothermia ‐ rewarm
Hypoglycemia – Dextrose 10% 4ml/kg
Hypo or Hyperkalemia‐
Give 1 shock 4J/kg or use AED as described above
Resume CPR immediately after shock
Consider
Amiodarone 5mg/kg IV/IO bolus(max dose 300mg) – Give during CPR
Magnesium 50mg/kg IV/IO for suspected torsades de pointes(max 2g)
P
M
Contact Medical Control
Pearls
RECOMMENDED EXAM: Mental Status
In order to be successful in pediatric arrests, a cause must be identified and corrected
Airway is the most important intervention. This should be accomplished immediately. Patient survival is often dependent
on airway management success.
*Airway Management by BVM is sufficient in the pediatric arrest patient. A single attempt at intubation can be made
only if time allows. Do not prolong transport or scene time to attempt intubation.
**If unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed lung) and/or evidence of
hemodynamic compromise – perform pleural decompression at 2nd intercostal space, midclavicular line
M
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
171
Cardiac Arrest, General: Pediatric
Airway management by BVM is sufficient in the pediatric arrest patient.
A single attempt at intubation can be made only if time allows. Do not prolong
transport or scene time to attempt intubation.
All Providers

General Pediatric Patient Care Protocol

Establish responsiveness

If trauma suspected, stabilize spine

Confirm apnea and pulselessness and administer CPR

Apply AED as soon as available for  8 years old
 For children 1-8 years old use pediatric AED cables/electrodes if available
 As a last resort in a child 1-8 years old, apply AED with available
cables/electrodes
 If utilizing Defibrillator in Manual Mode and shockable rhythm - Defibrillate
at 2 J/kg (maximum of 200J)

AED per manufacturer instructions for children < 1 year old

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg
Advanced EMT

Consider IV Protocol

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum 250 mL
- OR –

Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status.
172
Paramedic

Full Pediatric ALS Assessment and Treatment

Determine cardiac rhythm and refer to appropriate protocol for further
management actions

Due to the child’s critical condition, initiate transport without delay
Contact Medical Control for any additional orders or questions
173
Cardiac Asystole and PEA: Pediatric
Asystole and Pulseless Electrical Activity
Paramedic

Follow Cardiac Arrest, General—Pediatric Protocol

Confirm the presence of asystole in 2 leads

Minimize any interruptions in compressions

Using the most readily available route, administer (during CPR)
 Epinephrine 1:10,000 at 0.01 mg/kg IV/IO (max dose 1mg)
 Repeat Epinephrine as above every 3-5 minutes
 Flush medication with 10-20 ml of normal saline after each dose

Treat any suspected contributing factors:
 If hypovolemic, administer 0.9% NaCl at 20 ml/kg IV/IO bolus, may repeat
twice (to a maximum of 60 ml/kg)
 If hypoxic, secure airway and assist ventilation
 If hypothermic, rewarm
 If hyperkalemia suspected (history of renal failure/dialysis)
 Calcium Chloride (10%), 20 mg/kg IV/IO (max 1 g)
 Sodium Bicarbonate 1 mEq/kg IV/IO (max dose 50 mEq)
 If narcotic suspected, Naloxone 0.1 mg/kg (max dose 2 mg) IM/IV/IO/IN
 If toxic ingestion, see specific toxin
 Assess for tension pneumothorax
 Unilateral decreased or absent lung sounds (may see tracheal
deviation away from collapsed lung)
 Evidence of hemodynamic compromise

If tension pneumothorax suspected due to history or
condition, perform pleural decompression at 2nd intercostal
space, mid-clavicular line
Contact Medical Control for any additional orders or questions
174
Cardiac Arrest: VF/VT: Pediatric
Ventricular Fibrillation or Pulseless Ventricular Tachycardia
Paramedic

Follow Cardiac Arrest, General -Pediatric Protocol

Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia

Defibrillate at 2 J/kg (maximum of 200J)
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR

Using the most readily available route (give drug during CPR)
 Epinephrine 1:10,000 at 0.01 mg/kg IV/IO
 Repeat Epinephrine as above every 3-5 minutes
 Flush medication with 10-20 ml of normal saline after each dose

If shockable rhythm persists, Defibrillate at 4 J/kg
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR
 Amiodarone 5 mg/kg IV/IO bolus (give during CPR) (max dose 300mg)
 Magnesium 50 mg/kg IV/IO bolus for suspected torsades de pointes (max
dose 2g )

If shockable rhythm persists, Defibrillate at 4 J/kg
 Continue compressions while defibrillator charges
 Immediately resume CPR after shock
 Check rhythm after 2 minutes of CPR

Continue cycle
Contact Medical Control for any additional orders or questions
175
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
Medical
Control
M
M
Signs and Symptoms
Decreased heart rate
Delayed capillary refill or cyanosis
Mottled, cool skin
Hypotension or arrest
Altered level of consciousness
General Approach to all Patients
Heart rate in
infant <60?
Pediatric Airway Protocol
Poor perfusion
Decreased blood pressure
Respiratory insufficiency
CPR
YES
A
NO
Differential
Respiratory failure
Foreign body
Secretions
Infection (croup, epiglotits)
Hypovolemia (dehydration)
Congenital heart disease
Trauma
Tension pneumothorax
Hypothermia
Toxin or medication
Hypoglycemia
Acidosis
IV Protocol*
A
Monitor and reassess
P
Epinephrine
0.01mg/kg of a 1:10,000 solution IV/IO
(max 1mg) repeat every 3‐5min
IF no IV, Glucagon
<1 year old = 0.5mg
>1 year old = 1.0mg
A
IV Protocol
D10 IV/IO
Dextrose 10% at 4ml/kg
(max 250 ml) May repeat x1
P
2013
If Blood glucose <40mg/dL if less than 2 months
Or if Blood glucose <70mg/dL 2 months‐12 years
P
Atropine
0.02mg/kg IV/IO
(max individual dose 0.5mg) Repeat every 3‐5 min
Reassess
A
P
Pulseless
Arrest
Protocol
NO
PULSE
Continue Compromise
Improved
Pediatric and OB Protocols
History:
Past medical history
Foreign body exposure
Respiratory distress or arrest
Apnea
Possible toxic or poison exposing
Congenital disease
Medication (maternal or infant)
If signs of severe compromise despite Epi/Atropine
Consider External Cardiac Pacing**
M
Contact Medical Control
M
P
Lowest setting that provides ventricular capture 100bpm
Sedation if time allows and BP >90mmHg
Fentanyl 1.0mcg/kg and Midazolam 0.1 mg/kg IV/IO
(max Fentanyl 200mcg and Midazolam 4mg)
P
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Heart, Lungs, Abdomen, Back, Extremities, Neuro
For all drug doses not specified in protocols, please refer to Broselow-Luten tape.
* If unable to secure IV in three attempts or 90 seconds, acquire IO access
Infant =<1 year of age
The majority of pediatric arrests are due to airway problems
Most maternal medications pass through breast milk to the infant
Hypoglycemia, severe dehydration and narcotic effects may produce bradycardia
Pediatric patients requiring external transcutaneous pacing require the use of pads appropriate for pediatric
patients per the manufacturers guidelines.
Minimum Atropine dose is 0.1mg IV
** If weight >15kg, apply adult transcutaneous pacemaker, if weight <15kg use pediatric pads.
P
If severe cardiopulmonary
compromise persists
despite pacing:
Dopamine infusion
5‐20mcg/kg/min IV/IO
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
176
P
Cardiac Arrhythmia: Pediatric Bradycardia
All Providers

General Pediatric Patient Care Protocol

Supplemental 100% oxygen

Assist ventilation as needed with bag valve mask

Look for signs of obstruction
 Absent breath sounds, tachypnea, intercostal retractions, stridor or
drooling, choking, bradycardia or cyanosis
 If foreign body obstruction is suspected refer to foreign body protocol
 Open airway using head tilt/chin lift if no spinal trauma is suspected and
modified jaw thrust if spinal trauma suspected

If signs of severe cardiopulmonary compromise are present in an infant (< I year)
and the heart rate remains slower than 60 beats per minute despite oxygenation
and ventilation:
 Initiate chest compressions

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
Advanced EMT

Consider IV Protocol

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
- OR –

Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status
177
Paramedic




Full Pediatric ALS Assessment and Treatment
If signs of severe cardiopulmonary compromise persist (use first available route)
 Epinephrine 0.01 mg/kg of a 1:10,000 solution IV/IO (max 1 mg)
Repeat dose every 3-5 minutes until either the bradycardia or severe
cardiopulmonary compromise resolves.
Identify and treat possible causes of bradycardia:
 If hypoxia, open airway/assist breathing
 If hypothermic, rewarm
 If acutely deteriorating head injury, hyperventilate
 If heart bock or post heart transplant, apply transcutaneous pacer (see
below)
 If toxin ingestion, see specific toxin

If signs of severe cardiopulmonary compromise persist despite Epinephrine and
above measures
 Atropine at 0.02 mg/kg IV/IO
 Minimum dose is 0.1 mg
 Maximum individual dose is 0.5 mg
 May repeat once after 3-5 minutes

If signs of severe cardiopulmonary compromise persist despite
Epinephrine/Atropine apply transcutaneous pacemaker
 If weight  15 kg, apply adult transcutaneous pacemaker pads
 If < 15 kg use pediatric pads (small/medium electrodes) in the standard
configuration for adult size pacer pads
 Use the lowest setting that provides ventricular capture (pulse)
 Set rate to 100 beats per minute
 Sedation if patient condition and time allows (hold if SBP<90mmHg):
Fentanyl 1.0mcg/kg and Midazolam 0.1mg/kg IV/IO
Titrate to Max dose Fentanyl 200mcg and Midazolam 4mg.

If severe cardiopulmonary compromise persists despite pacing:
 Dopamine infusion at 5-20 mcg/kg/min IV/IO
Contact Medical Control for any additional orders or questions
178
Legend
EMT
A‐EMT
Paramedic
Wide Complex Tachycardia with
Pulse - Pediatric
A
A
P
P
MMedical Control M
General Approach to all Patients
Pediatric and OB Protocols
Differential (Life Threatening)
Heart Disease (congenital)
Hypo/hyper thermia
Hypovolemia or anemia
Electrolyte imbalance
Anxiety / pain/ emotional stress
Fever / infection / sepsis
Hypoxia
Hypoglycemia
Mediation/toxin/drugs
Pulmonary embolus
Trauma
Tension pneumothorax
Signs and Symptoms
Heart Rate
Child >180bpm Infant >220bpm
Pale or Cyanosis
Diaphoresis
Tachypnea
Vomiting
Hypotension
Altered LOC
Pulmonary congestion
syncope
History:
Past medical history
Medications or Toxic Ingestion
(Aminophyline, diet pills, thyroid
supplements, decongestants, digoxin)
Drugs (nicotine, cocaine)
Congenital heart disease
Respiratory distress
Syncope or near syncope
Blood Glucose Measurement and Treat if appropriate
Continuous Cardiac Monitor
P
P
Attempt to identify cause – narrow QRS duration <0.08 sec
STABLE
A
IV Protocol
A
I
P
Amiodarone 5mg/kg IV over 10
minutes
UNSTABLE
Or No IV access
P
Synchronized cardioversion at 0.5‐1.0 J/kg
(max individual dose 150mg)
P
P
May repeat Synchronized cardioversion at
1.0‐2.0 J/kg **
If rhythm changes go to appropriate
protocol
M
Contact Medical Control
2013
If time allows: Consider sedation –
Midazolam 0.1mg/kg IV/IO (max dose 2mg)
If Torsade de Pointes is suspected::
P
Magnesium Sulfate 50mg/kg in 100ml D5W
IV/IO over 10 minutes
(max individual dose 2mg)
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
**Max dose 360J
Carefully evaluate the rhythm to distinguish sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia
Separating the child from the caregiver may worsen the child's clinical condition
Monitor for respiratory depression and hypotension associated if diazepam or midazolam is used.
Continuous pulse oximety is required for all SVT patients if available
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention
As a rule of thumb, the max sinus tachycardia rate is 220 minus the patients age in years.
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
179
P
Narrow Complex Tachycardia
with Pulse (SVT)- Pediatric
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
General Approach to all Patients
Pediatric and OB Protocols
Differential (Life Threatening)
Heart Disease (congenital)
Hypo/hyper thermia
Hypovolemia or anemia
Electrolyte imbalance
Anxiety / pain/ emotional stress
Fever / infection / sepsis
Hypoxia
Hypoglycemia
Mediation/toxin/drugs
Pulmonary embolus
Trauma
Tension pneumothorax
Signs and Symptoms
Heart Rate
Child >180bpm Infant >220bpm
Pale or Cyanosis
Diaphoresis
Tachypnea
Vomiting
Hypotension
Altered LOC
Pulmonary congestion
syncope
History:
Past medical history
Medications or Toxic Ingestion
(Aminophyline, diet pills, thyroid
supplements, decongestants, digoxin)
Drugs (nicotine, cocaine)
Congenital heart disease
Respiratory distress
Syncope or near syncope
Continuous Cardiac Monitor
Paramedics: Attempt to identify cause – narrow QRS
duration <0.08 sec
A
IV Protocol
A
UNSTABLE – Severe Cardiopulmonary
Compromise
STABLE
If time and condition allows attempt vagal maneuvers
Expedite Transport
If vascular access ready:
P
Adenosine 0.1mg/kg IV/IO (max individual dose
P
2013
6mg)
May repeat twice at 0.2mg/kg if needed
(max individual dose 12mg)
UNSUCCESSFUL and Severe Cardiopulmonary Compromise
Synchronized cardioversion at 0.5‐1.0 J/kg
P
P
sedation if time permits Midazolam 0.1mg/kg IV/IO (max 2.0mg)
May repeat Synchronized cardioversion at 1.0‐2.0 J/kg **
If rhythm changes go to appropriate protocol
M
Contact Medical Control
M
Service MD Approval:______
Pearls
RECOMMENDED EXAM: Mental Status, Skin, Neck, Heart, Lungs, Abdomen, Back, Extremities, Neuro
**Max dose 360J
Carefully evaluate the rhythm to distinguish sinus tachycardia, supraventricular tachycardia, and ventricular tachycardia
Separating the child from the caregiver may worsen the child's clinical condition
Monitor for respiratory depression and hypotension associated if diazepam or midazolam is used.
Continuous pulse oximety is required for all SVT patients if available
Document all rhythm changes with monitor strips and obtain monitor strips with each therapeutic intervention
As a rule of thumb, the max sinus tachycardia rate is 220‐the patients age in years.
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
180
Cardiac Arrhythmia: Pediatric Tachycardia
Note: Infants with heart rates < 220 and children with heart rates < 180
typically will respond when the precipitating cause is treated (e.g. fever,
dehydration)
All Providers

General Pediatric Patient Care Protocol

If trauma suspected, stabilize spine

Supplemental 100% oxygen

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
Advanced EMT

Consider IV Protocol

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
- OR -
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg if IV or IO
access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (< 40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status
Paramedic

Full Pediatric ALS Assessment and Treatment
Sinus Tachycardia

Identify and treat possible causes
181
Supraventricular tachycardia with severe cardiopulmonary compromise

If time and patient condition permits, attempt vagal maneuvers

If vascular access is available, Adenosine (Adenocard) 0.1 mg/kg (Maximum
individual dose is 6 mg) via rapid IV/IO bolus (IV access in the antecubital space
is preferred)
 Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (maximum
individual dose is 12mg)

If Adenosine is unsuccessful and patient still has severe cardiopulmonary
compromise:
 Synchronized Cardioversion at 0.5-1 J/kg
 Consider sedation if time permits

Midazolam 0.1 mg/kg IV/IO (max dose 2 mg)
 May repeat synchronized cardioversion at double the initial energy
(maximal individual dose 360 J)
Ventricular Tachycardia with a pulse

If vascular access is readily available OR the patient is stable:
 Amiodarone 5 mg/kg/IV over 10 minutes, (Max individual dose is 150 mg)

If vascular access is not readily available AND the patient is unstable:
 Synchronized Cardioversion at 0.5-1.0 J/kg
 Consider sedation if time permits:
 Midazolam 0.1 mg/kg IV/IO (max dose 2 mg)
 May repeat at double the initial energy (maximal individual dose 360 J)

If Torsade de Pointes is suspected:
 Magnesium Sulfate 50mg/kg in 100 ml D5W IV/IO over 10 minutes (max
dose 2 g)
Contact Medical Control for any additional orders or questions
 Paramedic - Failed response to 2 attempts at cardioversion
182
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
General Approach to all patients
Assign Provider to
care for mother
Twin Gestation?
Call for additional
help
YES
NO
Suction mouth then
nose – activate ALS
YES
NO
Dry infant/keep warm/stimulate
Bulb syringe suction mouth/nose
P
Childbirth
Procedure if
appropriate
Note APGAR score
Respirations
60-100bpm
------------------ <60 bpm
Assess
Respiratory
Drive
Crying
Good
Tone
Immediate
CPR per
AHA
Labored Breathing
Persistent Cyanosis
Improved
Monitor
Reassess
5 Minute
APGAR
Support with
BVM
At 40‐60
breaths/min
with 100%
oxygen
Peds
Airway
Protocol
A
Consider
IV Protocol
Clear airway
SpO₂, supplemental O₂
2013
Give report
to receiving
hospital
P
Repeat until free of
meconium
Heart Rate
>100bpm
Visualize
hypopharynx and
perform deep suction
Pediatric and OB Protocols
Thick meconium in
amniotic fluid?
Treat per
appropriate
medical protocol
Support with BVM
At 40‐60 breaths/
min with 100%
oxygen
Improved
A
No Change
Reassess
Heart
Rate
A
Consider
IV Protocol
Glucose Check and
treat if appropriate
A
A
P
Consider Peds
Airway
Naloxone** 0.01mg/kg
Dextrose 10% at 4ml/kg****
Epinephrine 0.01mg/kg of a
1:10,000 solution***
A
P
M
Contact Medical Control
Rapid Transport‐ OB
receiving facility
M
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Neck, Chest, Heart, Abdomen, Extremities, Neuro
CPR in infants is 120 compressions/minute with a 3:1 compressions to ventilation ratio
Service MD Approval:______
It is extremely important to keep infant warm
* if no IV access after 3 attempts, or within 90 seconds – obtain IO access
**if respiratory depression in a newborn of a mother who received narcotics within 4 hours of delivery, use caution in infants born to opiate addicted
mothers.(Naloxone effective but may precipitate seizures)
***May repeat same dose of Epinephrine every 3‐5 minutes if no response.
****Consider hypoglycemia in infant and treat if glucose <40mg/dL ‐ D10=D50 diluted (1ml of D50 with 4ml NS).
Document 1 and 5 minute APGARS in PCR
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
183
Newborn Resuscitation
All Providers

Note gestational age, and if twin gestation is known

Assess for presence of meconium

Assess breathing or presence of crying

Assess muscle tone

Assess color

Provide warmth

Open airway and suction with bulb syringe as soon as infant is delivered.

Suction mouth first then nasopharynx

Dry, stimulate and reposition

Administer supplemental blow-by oxygen

Evaluate respirations, heart rate and color

If apnea or HR < 100, provide positive pressure ventilation using BVM and 100%
oxygen

If HR remain < 60, begin chest compressions

Note APGAR scores at 1 and 5 minutes after birth and then sequentially every 5
minutes until VS have stabilized
Paramedic

If the fluid contains meconium and the newborn has absent or depressed
respirations, decreased muscle tone or heart rate < 100 bpm
 Suction any visible meconium from the airway – refer to Childbirth
Complication Procedure as appropriate.
 After suctioning, apply positive pressure ventilation using a BVM and
100% oxygen

If apnea, or HR < 100, provide positive pressure ventilations with 100% oxygen

If HR 60-100, and no increase with positive pressure ventilations with 100%
oxygen
 Continue assisted ventilations
 Begin chest compressions
 Naloxone (Narcan) 0.01 mg/kg, IV/IO if respiratory depression in a
newborn of a mother who received narcotics within 4 hours of delivery,
use caution in infants born to opiate addicted mothers
 May Repeat Naloxone (Narcan) dose as needed to a max of 0.03 mg/kg
184
 Check blood glucose and treat glucose < 40 mg/dL
 Dextrose 10% at 4 ml/kg

If HR < 60 begin chest compressions
 IV 0.9% NaCl KVO or lock
 If no IV access obtained after 3 attempts, or within 90 seconds, obtain IO
access
 Naloxone (Narcan) 0.01 mg/kg, IV/IO if respiratory depression in a
newborn of a mother who received narcotics within 4 hours of delivery,
use caution in infants born to opiate addicted mothers
 May Repeat Naloxone (Narcan) dose as needed to a max of 0.03 mg/kg
 Epinephrine 0.01 mg/kg of a 1:10,000 solution
 Repeat Epinephrine (same dose) every 3 to 5 minutes if no
response
 Check blood glucose and treat glucose < 40 mg/dL
 Dextrose 10% at 4 ml/kg

Rapid transport
Contact Medical Control for any additional orders or questions
185
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
For any overdose or poisoning, contact should be made with the Regional Poison Control
Center (RPCC), 1-800-222-1222. Whenever possible, determine the agent(s) involved, the
time of the ingestion/exposure and the amount ingested. Bring empty pill bottles, etc., to the
receiving facility.
General Patient Care Protocol-Pediatric
Nothing by mouth
Advanced EMT
Consider IV Protocol
If respiratory depression is present and a narcotic overdose is suspected:
o
Naloxone (Narcan) 0.1 mg/kg IV/IO/IM or IN via MAD (max. dose is 2 mg)
Pediatric Protocol
All Providers
Paramedic
If any symptoms present, perform Full Pediatric ALS Assessment and Treatment
Treatment for specific toxic exposures is indicated only when patients are clearly
symptomatic. In the absence of significant symptoms, monitor closely and expedite
transport.
Organophosphates:
Dyspnea, bronchorrhea, lacrimation, vomiting/diarrhea, weakness, paralysis, seizures:
Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg), repeat every 2 minutes if needed
X 3 doses
If seizures present, see Pediatric Seizure Protocol
Tri-cyclic Antidepressant:
Hypotension, arrhythmias, wide QRS complex (0.12 sec):
Sodium Bicarbonate 1 mEq/kg IV/IO
May be repeated in 10 minutes
Beta Blocker overdose:
Bradycardia, hypotension, heart blocks:
Atropine 0.02 mg/kg IV/IO (minimum dose 0.1 mg, maximum individual dose 0.5 mg)
for bradycardia
If the symptoms persist, Glucagon 0.1 mg/kg IV/IO (Maximum dose 1 mg)
Pediatric Protocol
Service MD Approval:______
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS
186
A
P
M
Legend
EMT
A‐EMT
Paramedic
Medical Control
A
P
M
Calcium Channel Blocker overdose:
Calcium Chloride 20 mg/kg slow IV/IO (maximum dose 1g)
Pediatric Protocol
Dystonic Reactions:
Acute uncontrollable muscle contractions
Diphenhydramine (Benadryl) 1 mg/kg IV or IM (maximum dose 25 mg)
Insulin Overdose:
Hypoglycemia or unknown blood glucose and altered mental status:
Determine blood glucose and treat:
Neonates ( 2 months) < 40 mg/dL
Dextrose 10% at 4 ml/kg
Child (2 months-12 years) <70 mg/dL
Dextrose 10% at 4 ml/kg , maximum of 250 mL
- OR –
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM if IV or IO access
unavailable
Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a neonate) after
treatment or unable to determine blood glucose and no change in mental status
Contact Medical Control for any additional orders or questions
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow81the
76 DCEMS Protocol Change Policy and be approved by WI EMS
187
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
History:
Age
Location
Duration
Severity (1‐10)
If child use Wong‐Baker faces
scale
Past medical history
Medications
Drug allergies
Differential
Per the specific protocol
Musculoskeletal
Visceral (abdominal)
Cardiac
Pleural / Respiratory
Neurogenic
Renal (colic)
Signs and Symptoms
Severity (pain scale)
Quality (sharp, dull, etc)
Radiation
Relation to movement,
respiration
Increased with palpation
Pediatric Protocol
General Approach to All Pediatric Patients
Patient care according to PROTOCOL
Based on specific complaint
Pain Severity >6 out of 10
Or Indication for IV/IM Medication
A
P
Consider IV Protocol
2013
Pulse Oximetry and EndTidal CO₂
A
Morphine Sulfate 0.1mg/kg slow IV/IO, may repeat in 10 min x1
OR
Fentanyl 1.5mcg/kg IN half volume per nare (max 100mcg) may
repeat one half (½) the original dose after 10 min. if needed
P
After each dose:
Reassess pain level
Respiratory adequacy
Vital signs (SPO2, EndTidal)
Service MD Approval:______
M
Contact Medical Control for
additional orders or questions
Pearls
RECOMMENDED EXAM: Mental Status, Area of pain, Neuro
Analgesic agents may be administered under standing orders for patients
experiencing moderate / severe pain (typically >6/10)
Common Complaints: trauma/isolated extremity injury, Burns (without
airway, breathing or circulation compromise), sickle crisis
Vitals and pain scale should be documented before and after every
medication dose.
M
Fentanyl Concentration (50mcg/mL),
0.1ml=5mcg
Weight Dose
Volume of 50 mcg/mL
(kg)
(mcg)
add 0.1 ml for dead space
3‐5
10
0.2+0.1=0.3mL
6‐10
20
0.4+0.1=0.5mL
11‐15
30
0.6+0.1=0.7mL
16‐20
40
0.8+0.1=0.9mL
21‐25
50
1.0+0.1=1.1mL
26‐30
60
1.2+0.1=1.3mL
31‐35
70
1.4+0.1=1.5mL
36‐40
80
1.6+0.1=1.7mL
41‐45
90
1.8+0.1=1.9mL
2.0*mL (admin dose in
two separate
administrations 10 min
apart)
46‐50
100
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
188
Pain Management: Pediatric
All Providers

General Pediatric Patient Care Protocol

Assess baseline pain level (0-10 scale: 0=no pain; 10=worst pain)
Advanced EMT

Consider IV Protocol
Paramedic

Full ALS Pediatric Assessment and Treatment if administering narcotics

Analgesic agents may be administered under standing orders for patients
experiencing moderate/severe pain (≥ 6/10)

Common complaints:
 Isolated extremity injury
 Burns (without airway, breathing, or circulation compromise)
 Sickle crisis

Agents for pain control:
 Both are contraindicated if hypotensive:
 Morphine Sulfate 0.1 mg/kg IV/IO

May repeat every 10 min x 1
OR
 Fentanyl 1.5 mcg/kg IN via MAD with one-half of the volume
administered to each nare (max. individual dose 100 mcg)

May repeat one-half (½) the original dose after 10 minutes if
needed.
189
DOSING: Fentanyl Concentration (50 mcg/mL), 0.1 ml=5 mcg
Weight
(kg)
3-5
6-10
11-15
16-20
21-25
26-30
31-35
36-40
41-45
46-50
Dose
(mcg)
10
20
30
40
50
60
70
80
90
100
Volume of 50 mcg/mL
+ 0.1 ml for dead space
0.2+0.1=0.3 mL
0.4+0.1=0.5 mL
0.6+0.1=0.7 mL
0.8+0.1=0.9 mL
1.0+0.1=1.1 mL
1.2+0.1=1.3 mL
1.4+0.1=1.5 mL
1.6+0.1=1.7 mL
1.8+0.1=1.9 mL
2.0* mL
* administer dose in two (2) separate administrations 10 minutes apart

After each drug dosage administration:

Reassess the patient’s pain level

Note adequacy of ventilation and perfusion

Assess vital signs

Continuously monitor oxygen saturation and end tidal CO2
Contact Medical Control for any additional orders or questions
190
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
History:
Fever
Prior history of seizures
Seizure medications
Reported seizure activity
History of recent head trauma
Congenital abnormality
Signs and Symptoms
Observed Seizure activity
Altered mental status
Hot, dry skin or elevated body
temperature
General Approach to all Patients
Pediatric Airway Protocol
If <40 (<2 months of age) or
<70 (2 months to 12 years of age)
Blood Glucose
Altered Level
of Consciousness
A
P
IV Protocol
ACTIVELY
SEIZING
A
Assess Patient
If no IV, Glucagon
<1 year old.1mg/kg
– 0.5 mg IM
Glucagon
IM
Evidence of Trauma?
P
>1 year old – 1.0 mg IM
Pediatric Head Injury Protocol
A
Obtain Temperature
IV Protocol – D10
4ml/kg (max 250ml)
A
FEBRILE
I
Seizure recurs
Blood Glucose
Cooling measures
If <40 (<2 months of age) or
<70 (2 months to 12 years of age)
Glucose Level
2months‐12years >70
<2months >40
If no IV, Glucagon
Service MD Approval:______
<1 year old – 0.5 mg IM
>1 year old – 1.0 mg IM
A
D10
4ml/kg (max 250ml)
A
M
Contact Medical Control
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Heart, Lungs, Extremities,
Neuro
Addressing the ABCs and verifying blood glucose is more important than stopping
the seizure
Avoiding hypoxemia is extremely important
Status Epilepticus is defined as two or more successive seizures without a period
of consciousness or recovery. This is a true emergency requiring rapid airway
control, treatment, and transport
Grand mal seizures (generalized) are associated with loss of consciousness,
incontinences, and tongue trauma
Focal seizures (petit mal) effect only a part of the body and do not usually result
in a loss of consciousness
Jacksonian seizures are seizures which start as a focal seizure and become
generalized
Be prepared to assist ventilations especially if a benzodiazepine is used.
If evidence or suspicion of trauma, spine should be immobilized
IN an infant, a seizure may be the only evidence of a closed head injury
M
Patient Prescribed Rectal Diazepam (Diastat) if available:
DIASTAT
2-5 Years (0.5 mg/kg)
Dose
Weight
(kg)
(lb)
(mg)
6‐11
13‐25
5
12‐22
26‐49
10
23‐33
50‐74
15
34‐44
75‐98
20
DIASTAT
6-11 + Years (0.3 mg/kg)
Dose
Weight
(kg)
(lb)
(mg)
10‐18
22‐41
5
19‐37
42‐82
10
38‐55
83‐122
15
56‐74
123‐164
20
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
191
2013
Lorazepam 0.05mg/kg slow IV/IO
(max 2mg)
Or
Midazolam 0.2mg/kg IV/IO/IN
(max 2mg)
May repeat if seizure not
controlled or recurs
Or
Patient prescribed Diazepam
Pediatric and OB Protocols
Differential (Life Threatening)
Fever
Infection
Head trauma
Medication or Toxin
Hypoxia or respiratory failure
Hypoglycemia
Metabolic abnormality / acidosis
Tumor
Seizure: Pediatric
All Providers

Pediatric General Patient Care Protocol

Supplemental 100% oxygen
 Nasal cannula is sufficient if no active seizures and no respiratory signs of
symptoms

Protect patient from injury

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Child (2 months-12 years) <70 mg/dL
Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
Advanced EMT

Consider IV Protocol

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
OR
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status.
Paramedic

Full Pediatric ALS Assessment and Treatment

Determine blood glucose and treat:
 Neonates ( 2 months) < 40 mg/dL
 Dextrose 10% at 4 ml/kg
 Child (2 months-12 years) <70 mg/dL
 Dextrose 10% at 4 ml/kg , maximum of 250 mL
OR
192
 Glucagon - <1 year old = 0.5mg or >1 year old = 1.0mg IM
if IV or IO access unavailable
 Repeat Dextrose X1 if blood glucose remains < 70 mg/dL (<40 in a
neonate) after treatment or unable to determine blood glucose and no
change in mental status.

For active seizures choose one of the following options:
 Lorazepam (Ativan) 0.05 mg/kg slow IV/IO via (max. individual dose 2 mg)
OR
 Midazolam (Versed) 0.2 mg/kg IV/IO/IN via MAD (Max individual dose 2
mg)
OR
 Patient-prescribed Diazepam rectal gel (Diastat) if available
2-5 Years (0.5 mg/kg)
Weight
Dose
(kg)
(lb)
(mg)
6-11
13-25
5
12-22 26-49
10
23-33 50-74
15
34-44 75-98
20

6-11 + Years (0.3 mg/kg)
Weight
Dose
(kg)
(lb)
(mg)
10-18
22-41
5
19-37
42-82
10
38-55
83-122
15
56-74 123-164
20
For seizure not controlled by the above, or if the seizure recurs after initial
control, choose one of the following:
 Lorazepam (Ativan) 0.05 mg/kg slow IV (max individual dose 2 mg)
OR
 Midazolam (Versed) 0.2 mg/kg IV/IO/IN via MAD (max individual dose
2mg)
Contact Medical Control for any additional orders or questions
193
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
Medical
Control
M
M
Signs and Symptoms
Pain, swelling
Deformity, lesions, bleeding
Altered mental status
Unconscious
Hypotension or shock
Arrest
General Approach to all Pediatric
Patients
Pediatric = Anyone <18 years of age
Differential (Life Threatening)
Chest
Tension pneumo, flail chest,
pericardial tamponade, open chest
wound, hemothorax
Intra‐abdominal bleeding
Pelvis / femur fracture
Spine fracture / cord injury
Head injury (see head trauma)
Extremity fracture / dislocation
HEENT (airway obstruction)
Hypothermia
Presentation or Mechanism consistent with trauma?
Assess ABC’s
INADEQUATE
YES
Go to appropriate
medical protocol
ADEQUATE
Pediatric
Airway
Protocol
Spinal
Immobilization
Protocol
Obvious Bleeding?
YES
Disability and GCS (document)
Pressure Point
Complete head to toe exam
Vital
Signs
Hypotension, Tachy
Hypoxia
IV Protocol
NS Bolus 20ml/kg
NO
2013
Direct Pressure
A
NO
A
Pediatric and OB Protocols
History:
Time and Mechanism of injury
Height of any fall
Damage to structure or vehicle
Location in structure or vehicle
Others injured or dead
Speed and details of MVS
Restraints/protective equipment
Car Seat, Helmet, Pads
Ejection
Past medication history
Medications
Normal for
Age
Notify receiving hospital
Tension Pneumothorax?*
High suspicion severe
injury
Facility/provider
discretion
NO
Pain Management Protocol
YES
P
Decompression
P
M
Contact Medical Control
M
Rapid Transport to
appropriate destination
Limit scene time to 10 minutes
Pearls
RECOMMENDED EXAM: Mental Status, Skin, HEENT, Heart, Lungs, Abdomen, Extremities, Back, Neuro
*Pleural Decompression for tension pneumo ONLY if all 3 criteria present:
1) Severe respiratory distress with hypoxia 2) Unilateral decreased or absent lung sounds (may see tracheal deviation away from collapsed
lung field) 3) Evidence of hemodynamic compromise (shock, hypotension, altered mental status)
If indicated, pleural decompression at 2nd intercostal space, midclavicular line
Mechanism is the most reliable indicator of serious injury. Examine all restraints/protective equipment for damage.
In prolonged extrications or serious trauma consider air transport
Do not overlook the possibility of child abuse
Scene times should not be delayed for procedures. These should be performed enroute when possible
Bag valve mask is an acceptable method of managing the airway if pulse oximetry can be maintained about 93%
Disability – assessment of paralysis, weakness, abnormal sensation, etc.
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
194
Trauma: Pediatric
For major trauma criteria, a pediatric patient is anyone < 18 years of age
All Providers

Pediatric Patient Care Protocol

Stabilize spine

Use modified jaw thrust if airway obstructed

Supplemental 100% oxygen

Control hemorrhage using direct pressure or pressure dressing

Perform head-to-toe survey to identify injuries

Splint obvious fractures of long bones

Attempt to preserve body temperature
Advanced EMT
 Consider IV Protocol
Paramedic

If moderate or severe injuries present, perform Full Pediatric ALS Assessment
and Treatment

Assess for Pediatric Trauma Triage Criteria and initiate transport to Pediatric
Trauma Center

Assess for Tension Pneumothorax
 Severe respiratory distress with hypoxia
 Unilateral decreased or absent lung sounds (may see tracheal deviation
away from collapsed lung field)
 Evidence of hemodynamic compromise (shock, hypotension, altered
mental status)
Pleural decompression for tension pneumothorax should only be performed
when all 3 of the above criteria are present!

If indicated, perform pleural decompression at 2nd intercostal space, midclavicular line

Initiate transport to an appropriate trauma facility within 10 minutes of arrival on
the scene, unless extenuating circumstances (extrication)

Perform procedures, history and detailed physical examination en route to the
hospital

If moderate to severe pain, treat per Pediatric Pain Management Protocol

Reassess frequently
Contact Medical Control for any additional orders or questions
195
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
History:
Type of exposure (heat, gas, chemical)
Inhalation injury
Time of injury
Past medical history and medications
Other trauma
Loss of consciousness
Tetanus/immunization status
Signs and Symptoms
Burns, pain, swelling
Dizziness
Loss of consciousness
Hypotension/shock
Airway compromise/distress
Singed facial or nasal hair
Hoarseness/wheezing
Differential
Superficial (1st degree) red and painful
Partial thickness (2nd degree) blistering
Full thickness (3rd degree) painless/charred or leathery skin
Thermal
Chemical
Electrical
Radiation
General Approach to All Pediatric Patients
Pediatric and OB Protocols
Transport to Burn Center
2nd degree burns greater than 10% total body surface area or
those on hands, feet, face or groin
3rd degree burns
Electrical burns (spinal immobilization if high voltage, monitor for
cardiac arrhythmias, initiate fluid resuscitation immediately
Chemical burns (remove clothing, brush away dry powder before
irrigating, flush with copious warm water on scene and continue
irrigation enroute, eyes: remove contacts and irrigate
continuously with NS for at least 30 minutes, avoid hypothermia
ABC’s
*Airway Protocol
If inhalation injury – place patient on
100% O2, monitor ETCO2 continuously
Remove or cool heat source if present
IV Protocol
Remove all clothing, contact lenses,
and jewelry (especially rings)
Maintain core temperature
Cover burn with plastic wrap, plastic chucks, or
clean dry dressings
A
Large bore in unburned skin if possible
If burn is >20%TBSA 2nd/3rd degree burns –
Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr
6‐13 years old, start 0.9% Normal Saline at 250ml/hr
14 years and older, start 0.9% Normal Saline at 500ml/hr
Specific fluid resuscitation based on TBSA and weight will
occur at initial hospital or Burn Center
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Skin, Neck, Lung, Heart, Abdomen, Extremities, Back,
and Neuro
Burn patients are trauma patients, evaluate for multisystem trauma
Assure whatever has caused the burn, is no longer contacting the injury (stop the burning process)
Early intubation is required when the patient experiences significant inhalation injuries
Potential CO exposure should be treated with 100% oxygen.
Circumferential burns to extremities are dangerous due to potential vascular compromise
secondary to soft tissue swelling
Burn patients are prone to hypothermia – never apply ice or cool burns, must maintain normal
body temperature
Evaluate the possibility of child abuse with children and burn injuries
*Signs and symptoms of inhalation injury: carbonaceous sputum, facial burns or edema,
hoarseness, singed nasal hairs, agitation, anxiety, cyanosis, stupor or other signs of hypoxia
A
Consider Pain Management Protocol
M
Contact Medical
Control
M
Service MD Approval:______
Pediatric Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
196
Trauma: Pediatric Burns
All Providers








General Pediatric Patient Care Protocol
o Stay focused on ABC’s, don’t get side tracked by burn.
o DON’T BE A SECOND VICTIM!
Remove or cool heat source if present (e.g. clothing, tar)
o Cool burns with room temperature water for 3-5 minutes only except
for tar burns which will take an extended time to cool.
o NEVER COOL WITH ICE! The goal is to bring burns to room
temperature, not cold.
Remove all clothing, contacts, and jewelry, especially rings
Keep patient warm and dry with sheets and blankets. Cover burns with
plastic wrap, plastic chucks, clean, dry dressings, or aluminum foil.
2nd Degree burns – greater than 10% of total body surface area or those
on hands, feet, face, or groin
3rd Degree burns
Electrical burns
- Spinal immobilization if high voltage electrical injury
- Monitor for cardiac arrhythmias
- Initiate fluid resuscitation immediately
Chemical burns
- Remove clothing
- If dry powder is present, brush away before irrigating
- Flush with copious warm water on scene and continue irrigation
enroute to UW Hospital
- Chemical injuries to eyes are an EMERGENCY. Remove contacts and
irrigate continuously with normal saline – DO NOT STOP.
Assess for Pediatric Trauma Triage Criteria and initiate transport to Pediatric
Trauma Center if appropriate
Advanced EMT

Consider IV Protocol
o Place a large bore peripheral IV in unburned skin if possible.
o If TBSA % greater than 30%, place 2 large bore peripheral IV’s.
o If greater than 20% TBSA of 2nd and 3rd degree burns, initiate volume
resuscitation with 0.9% Normal Saline
 Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr
 6-13 years old, start 0.9% Normal Saline at 250ml/hr
 14 years and older, start 0.9% Normal Saline at 500ml/hr
 Specific fluid resuscitation based on TBSA and weight will occur
at initial hospital or Burn Center
197
Paramedic





Perform Full Pediatric ALS Assessment and Treatment
If not already done, consider IV Protocol
o Place a large bore peripheral IV in unburned skin if possible. If TBSA
% greater than 30%, place 2 large bore peripheral IV’s.
Observe for signs of impending loss of airway; refer to the Airway
Management Protocol as needed
- Hypoxia
- Poor ventilatory effort
- Altered mental status or decreased level of consciousness
- Inability to maintain patent airway
- Signs or symptoms of inhalation injury
 Carbonaceous sputum
 Extensive facial burns
 Hoarseness
 Singed nasal hairs
 Agitation, anxiety, cyanosis, stupor, or other signs of hypoxia
If moderate to severe pain, see Pain Management Protocol
Estimate Total Body Surface Area (TBSA)
- Rule of Nines
Age
Body Part
A = whole head
B = thigh
C = lower leg
0 yr
19
5½
5
1 yr
17
6½
5
5 yr
13
8
5½
10 yr
11
8½
6
15 yr
9
9
6½
- If greater than 20% TBSA of 2nd and 3rd degree burns, initiate volume
resuscitation with 0.9% Normal Saline
 Less than 5 years old, start 0.9 %Normal Saline at 125ml/hr
198



6-13 years old, start 0.9% Normal Saline at 250ml/hr
14 years and older, start 0.9% Normal Saline at 500ml/hr
Specific fluid resuscitation based on TBSA and weight will occur
at initial hospital or Burn Center
Contact Medical Control for any additional orders or questions
199
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
MMedical Control M
Signs and Symptoms
Pain, swelling, bleeding
Altered mental status
Unconscious
Respiratory distress / failure
Vomiting
Major traumatic mechanism of injury
seizure
Differential
Skull fracture
Brain injury (concussion, contusion,
hemorrhage or laceration)
Epidural hematoma
Subdural hematoma
Subarachnoid hemorrhage
Spinal injury
Abuse
General Approach to all Pediatric Patients
Pediatric Trauma
Protocol
Isolated Head Trauma?
Other injuries
suspected
YES
Spinal Immobilization Protocol
if normotensive or hypertensive elevate backboard 15‐30°
A
A
IV Protocol
Check Blood Glucose and treat if appropriate
Assess and Record GCS
Able to manage airway
with basic maneuvers
Basic Airway maneuvers (O₂, NRB, BVM)
As needed to maintain O₂ sat >93%
Unable to manage airway
With basic maneuvers
Secure Airway per
Pediatric Airway Protocol
No signs of
herniation
Continuous EtCO₂
If severely agitated/combative*
consider Lorazepam 0.05mg/kg
IV/IO (max 2.0mg)
P
Monitor for signs of herniation:
‐Abrupt increase in BP
‐Abrupt decrease in HR
‐Acute unilateral dilated and non‐reactive pupil
‐Abrupt deterioration in mental status
‐Abrupt onset of motor posturing
P
P
Pearls
RECOMMENDED EXAM: Mental Status, HEENT, Heart, Lungs,
Abdomen, Back, Extremities, Neuro
* unable to deescalate by any other means, then consider
Lorazepam
If GCS <12, consider air/rapid transport and if GCS <8
airway control should be anticipated
Increased intracranial pressure (ICP) may cause
hypertension and bradycardia (Cushing’s Response)
Hypotension usually indicates injury or shock unrelated to
the head injury
The most important item to monitor and document is a
change in level of consciousness.
Concussions are periods of confusion or LOC associated
with trauma which may have resolved by the time EMS
arrives. Any prolonged confusion or mental status
abnormality which does not return to normal within 15
minutes or any document loss of consciousness should be
evaluated by a physician ASAP.
2013
Transport to
appropriate
emergency
department
Pediatric and OB Protocols
History:
Time of injury
Mechanism (blunt vs. penetrating)
Loss of consciousness
Bleeding
Past medical history
Medications
Evidence of multi‐trauma
P
Signs of herniation
Hyperventilate:
P
<1 year – 35/min, >1 year – 25/min
Target EtCO₂ 30‐35
P
Contact Medical Control simultaneously
M
Contact Medical Control for additional
orders
M
Service MD Approval:______
Protocol
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
200
Trauma: Pediatric Head Injuries
All Providers

Supplemental oxygen

Stabilize spine

Check blood glucose

Apply physical restraints if needed to ensure patient/crew safety. Adhere to
procedure on Physical Restraint of Agitated Patients when this process is
deemed necessary

If normotensive or hypertensive
 Elevate head of backboard 15-30
Paramedic

Full Pediatric ALS Assessment and Treatment
 Advanced airway/ventilatory management as needed
Note: Airway interventions can be detrimental to patients with head injury by
raising intercranial pressure, worsening hypoxia (and secondary brain injury)
and increasing risk of aspiration. Whenever possible these patients should be
managed in the least invasive manner to maintain O2 saturation > 93% (i.e.,
NRB, BVM with 100% O2)

Observe for signs of impending respiratory failure; Refer to the Airway
Management Protocol if needed:
 Hypoxia
 Poor ventilatory effort
 Altered mental status/decreases level of consciousness
 Inability to maintain patent airway
For patients with assisted ventilation:

Administer ventilations at normal rate for age range

Acute herniation should be suspected when the following signs are present:
 Abrupt increase in blood pressure
 Abrupt decrease in heart rate
 Acute unilateral dilated and non-reactive pupil
 Abrupt deterioration in mental status
 Abrupt onset of motor posturing

Hyperventilation is a temporizing measure which is only indicated in the event of
acute herniation
201

If signs of herniation develop, begin hyperventilation
 If < 1 year old, 35/minute
 If > 1 year old, 25/minute
 Target an ETCO2 of 30-35 mmHg
 If severely agitated/combative and unable to deescalate by any other means,
consider:
 Lorazepam 0.05 mg/kg IV/IO (max 2.0 mg)
Contact Medical Control for any additional orders or questions
 Paramedic - Any additional sedation
202
Table of Contents
Legend
EMT
A‐EMT
Paramedic
A
A
P
P
Medical
Control
M
M
12‐Lead EKG
Airway Obstruction
Airway Orotracheal Intubation
Airway Video Laryngoscopy
Airway Suctioning ‐ Basic
Airway Suctioning ‐ Advanced
Blood Glucose Analysis
Carboxyhemoglobin SpCO Monitoring
Cardioversion
CCR ‐ Cardiocerebral Resuscitation
Chest Decompression
Childbirth Procedure
Childbirth Complications
CPAP
CPR ‐ Cardiopulmonary Resuscitation
Cricothyrotomy
Decontamination
Defibrillation ‐ Automated
Defibrillation ‐ Manual
Endotracheal Tube Introducer
External Cardiac Pacing
LMA ‐ Laryngeal Mask Airway
MCI ‐ Mass Casualty Incident
MAD ‐ Mucosal Atomizer Device
Orogastric Tube Insertion
King LTS‐D
Pulse Oximetry
RSA ‐ Rapid Sequence Airway
Restraints
Spinal Immobilization
Spinal Immobilization ‐ Football Players
Splinting
Stroke Screen
Temperature Measurement
Tourniquet
Trauma Guidelines
Venous Access ‐ Existing
Venous Access ‐ Extremity
Venous Access ‐ Intraosseous
Wound Care
204
205
206
208
210
211
212
213
214
215
220
221
222
223
224
225
226
227
228
229
230
231
234
235
236
237
241
242
243
244
245
247
248
249
250
252
253
254
256
257
Service MD Approval:______
Procedure Section
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
203
Procedure
EMT
Clinical Indications:
A
P
Suspected cardiac patient
Suspected tricyclic overdose
Electrical injuries
Syncope
CHF
Abdominal pain above the umbilicus
Undifferentiated respiratory complaints
A‐EMT
Paramedic
A
P
Procedure:
1)
2)
Assess patient and monitor cardiac status
If patient is unstable, definitive treatment is the priority. If patient is stable or stabilized after
treatment, perform a 12-Lead EKG
3)
Prepare EKG monitor and connect patient cable to electrodes
4)
Expose chest and prep as necessary. Modesty of the patient should be respected.
5)
Apply chest leads and extremity leads using the following landmarks:
-RA: Right arm or as directed by manufacturer
-LA: Left arm or as directed by manufacturer
-RL: Right leg
-LL: Left leg
-V1: 4th intercostal space at right sternal border
-V2: 4th intercostal space at left sternal border
-V3: Directly between V2 and V4
-V4: 5th intercostal space at midclavicular line
-V5: Level with V4 at left anterior axillary line
-V6: Level with V5 at left midaxillary line
6)
Instruct patient to remain still
7)
Press the appropriate button to acquire the 12-Lead EKG (complete age and gender questions
correctly)
8)
Print data as per guidelines and attach a copy of the 12-Lead to the PCR. Place the name and
age of the patient on the paper copy of the EKG
Paramedic: If STEMI identified, notify STEMI Hospital immediately. Report STEMI alert and a
detailed report to follow. If able transmit the EKG as soon as possible.
Non-Paramedic:
transmit the 12-Lead EKG as soon as obtained. If transmission does not work,
read the defibrillator interpretation that prints on the EKG to Medical Control.
11)
Document the procedure, time and results on/with the PCR.
12)
An EMT-Basic may perform a 12-Lead EKG; a Paramedic, however should review it before
implementing any treatment modalities.
Service MD Approval:______
Procedure 1
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
204
Procedure
A
P
Clinical Indications:
EMT
A‐EMT
Paramedic
Complete or partial obstruction of the airway due to a foreign body.
Patient with unknown illness or injury who cannot be ventilated after proper opening of the airway.
A
P
Procedure:
Foreign Body Airway Obstruction - >1 year old, conscious
□ If coughing, wheezing and exchanging air, do not interfere with the victims efforts to expel the
foreign body.
□ If unable to speak, weak or absent cough or no air exchange
→ Use abdominal thrusts (Heimlich Maneuver) if victim > 1 year
▪make a fist with one hand
▪place the thumb side of your fist against the victims abdomen in midline, above the
navel but below the breastbone.
▪grasp your fist with your other hand and press your fist into the victims abdomen with
a quick, upward thrust.
▪ repeat steps above until the object is expelled or the victim becomes unresponsive.
Foreign Body Airway Obstruction - < 1 year old, conscious
□ If coughing, wheezing and exchanging air, do not interfere with the victims efforts to expel the
foreign body.
□ If unable to cry or speak, weak or absent cough or no air exchange
→ Support the victim in the head down position with your non-dominant hand and forearm.
→ Perform back blows with the heel of your dominant hand between the shoulder blades
→ Repeat the steps above until the object is expelled or the victim becomes unresponsive.
Foreign Body Airway Obstruction - unconscious
□ If patient was responsive and then became unresponsive
→ lower the victim to the ground and begin CPR, starting with compressions (do not check
for a pulse)
→ Every time you open the airway to give breaths, open the mouth wide and look for the
object
→ If you see an object that can easily be removed, remove it with your finger
→ If you do not see an object, continue CPR
→ If a foreign object is visualized but cannot be removed with finger, attempt to remove it
with the Magill forceps
___________________________________________________________________________________
PARAMEDICS:
▪ If the foreign body is not visualized or it cannot be retrieved, attempt endotracheal
intubation with appropriate size ET Tube or 0.5 smaller
▪ If ETT cannot pass and patient is > 1 year old but <12 years old perform needle jet
insufflation
▪If ETT cannot pass and patient is >12 years old perform cricothyrotomy with pertrach
per procedure section
Transport rapidly to the closest facility!
Service MD Approval:______
Procedure 2
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Procedure
Clinical Indications:
P
Paramedic
Respiratory or Cardiac Arrest
Inadequate ventilation with Bag Valve Mask
Impending respiratory failure:
□ Decreased level of consciousness with hypoxia unimproved by 100% oxygen, apnea, and/or
respiratory rate <8
□ OR poor ventilatory effort (with hypoxia unresponsive to 100% Oxygen)
□ OR unable to maintain patent airway
Airway obstruction
P
Equipment:
Laryngoscope handle with appropriate size blade.
Proper size endotracheal tube (ETT) plus back up ETT 0.5-1.0 mm smaller
Water-soluble lubrication gel, (lubricate distal end of tube at cuff)
10cc syringe (larger syringe if low pressure cuff)
Stylet, (insert into ET tube and do not let stylet extend beyond tip of ET tube)
Tape or ETT securing device
Proper size oral pharyngeal airway
BVM
Oxygen source
Suction device
Stethoscope
Capnography
Oxygen saturation monitor
Procedure:
Patient/equipment preparation:
□ Maintain cervical alignment and immobilization, as necessary
□ Attach proper blade to laryngoscope handle and check light
□ Check endotracheal tube cuff
□ Raise gurney so that patient's nose is at intubator’s xiphoid (if possible)
□ Confirm patient attached to cardiac monitor and oxygen saturation monitor
□ Ready ETCO2 detection device
□ Specify personnel to:
~apply cricoid pressure
~ maintain cervical alignment and immobilization during procedure
~watch cardiac and oxygen saturation monitors
Continued on page 2
Service MD Approval:______
Procedure 3.1
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206
Procedure
P
Paramedic
P
Intubation:
□ preoxygenate patient with 100% Oxygen (BVM or NRB) before intubation attempt to achieve O2
saturation >93% for 5 minutes or 8 vital capacity breaths. Have assistant apply cricoid pressure
(Sellicks’s maneuver) during entire procedure.
□ Remove all foreign objects, such as dentures, oral pharyngeal airways, etc. and suction the
patient’s airway if needed. (Do not remove an esophageal located ETT if in place from prior
attempt)
□ Grasp laryngoscope handle in left hand.
□ Grasp ET tube in right hand
□ Insert the blade into the right side of the patient’s mouth sweeping the tongue to the left side
□ Visualize the vocal cords while avoiding any pressure on the teeth
□ Insert the endotracheal tube until the cuff passes the vocal cords. (Insert far enough so that at
balloon port tubing is even with lips)
□ Typical depth = tube size (ID) x3 (example would be tube depth of 24 for a 8.0mm tube)
□ Remove the laryngoscope blade
□ Inflate the endotracheal cuff with the syringe with 5-10cc of air (low pressure cuff may require
larger volume) and remove the syringe from inflation valve
□ Confirm tube placement
□ Ventilate with BVM and:
~observe immediate (within 6 breaths) ETCO2 waveform and number with capnography
~watch for chest rise AND
~listen to abdomen to ensure tube is not esophageal
□ Then, listen for bilateral breath sounds
□ Observe oxygen saturation
Note: regardless of the apparent presence of lung sounds, tube misting and chest rise, or lack of gastric
sounds, if ETCO2 does not indicate proper tube location (alveolar waveform), ETT must be removed.
If unilateral right sided breath sounds are heard consider:
□ Right mainstem intubation
□ If present, deflate the cuff and withdraw tube 1-2cm
□ Repeat auscultation procedure as above for breath sounds
If bowel sounds heard with bagging or ETCO2 device does not indicate proper ETT placement,
deflate cuff, remove tube and ventilate with BVM for two minutes
If intubation attempt unsuccessful, refer to the next step in the Airway, Adult Protocol
If successful tube placement:
□ Secure tube using an endotracheal securing device
□ Document depth of tube
□ Reassess lung sounds and patient clinical status
□ Insert oral pharyngeal airway, or use ET tube holder with built in bite block (if available)
□ Ensure c-spine is immobilized
□ Continue ventilations
□ Document ETCO2 waveform and reading continuously at time of EACH patient movement,
including waveform and reading at time of transfer of care at the emergency department.
Procedure 3.2
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207
Procedure
Clinical Indications:
P
Paramedic
Respiratory or Cardiac Arrest
Inadequate ventilation with Bag Valve Mask
Impending respiratory failure:
□ Decreased level of consciousness with hypoxia unimproved by 100% oxygen, apnea, and/or
respiratory rate <8
□ OR poor ventilatory effort (with hypoxia unresponsive to 100% Oxygen)
□ OR unable to maintain patent airway
Airway obstruction
P
Equipment:
Video Assisted Laryngoscope (VAL) with appropriate size blade.
Proper size endotracheal tube (ETT) and back up ETT 0.5-1.0 mm smaller
Water-soluble lubrication gel, (lubricate distal end of tube at cuff)
10cc syringe (larger syringe if low pressure cuff)
Stylet if compatible with VAL device (insert into ET tube and do not let stylet extend beyond tip of ET
tube)
Tape or ETT securing device
Proper size oral pharyngeal airway
BVM
Oxygen source
Suction device
Stethoscope
Capnography
Oxygen saturation monitor
Procedure:
Patient/equipment preparation:
□ Maintain cervical alignment and immobilization, as necessary
□ Attach proper blade to VAL device and ensure function of video screen
□ Check endotracheal tube cuff
□ Raise gurney so that patient's nose is at intubator’s xiphoid (if possible)
□ Confirm patient attached to cardiac monitor and oxygen saturation monitor
□ Ready ETCO2 detection device
□ Specify personnel to:
~apply cricoid pressure
~maintain cervical alignment and immobilization during procedure
~watch cardiac and oxygen saturation monitors
Continued on page 2
Service MD Approval:______
Procedure 4.1
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208
Procedure
P
Paramedic
P
Intubation:
□ Preoxygenate patient with 100% Oxygen (BVM or NRB) before intubation attempt to achieve O2
saturation >93% for 5 minutes or 8 vital capacity breaths. Have assistant apply cricoid pressure
(Sellicks’s maneuver) during entire procedure.
□ Remove all foreign objects, such as dentures, oral pharyngeal airways, etc. and suction the
patient’s airway if needed. (Do not remove an esophageal located ETT if in place from prior
attempt)
□ Load ET tube into VAL device as per manufacturer recommendations
□ Grasp VAL device in left hand.
□ Insert the VAL device midline in the patient’s mouth
□ Visualize the vocal cords while avoiding any pressure on the teeth
□ Visualize the endotracheal tube passing the vocal cords until cuff is beyond the cords.
□ Typical depth = tube size (ID) x3 (example would be tube depth of 24 for a 8.0mm tube)
□ Remove the VAL device
□ Inflate the endotracheal cuff with the syringe with 5-10cc of air (low pressure cuff may require
larger volume) and remove the syringe from inflation valve
□ Confirm tube placement
□ Ventilate with BVM and:
~observe immediate (within 6 breaths) ETCO2 waveform and number with capnography
~watch for chest rise AND
~listen to abdomen to ensure tube is not esophageal
□ Then, listen for bilateral breath sounds
□ Observe oxygen saturation
Note: regardless of the apparent presence of lung sounds, tube misting and chest rise, or lack of gastric
sounds, if ETCO2 does not indicate proper tube location (alveolar waveform), ETT must be removed.
If unilateral right sided breath sounds are heard, then consider:
□ Right mainstem intubation
□ If present, deflate the cuff and withdraw tube 1-2cm
□ Repeat auscultation procedure as above for breath sounds
If bowel sounds heard with bagging or ETCO2 device does not indicate proper ETT placement, deflate
cuff, remove tube and ventilate with BVM for two minutes
If intubation attempt unsuccessful, refer to the next step in the Airway, Adult Protocol
If successful tube placement:
□ Secure tube using an endotracheal securing device
□ Document depth of tube
□ Reassess lung sounds and patient clinical status
□ Insert oral pharyngeal airway, or use ET tube holder with built in bite block (if available)
□ Ensure c-spine is immobilized
□ Continue ventilations
□ Document ETCO2 waveform and reading continuously at time of EACH patient movement,
including waveform and reading at time of transfer of care at the emergency department.
Procedure 4.2
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209
Procedure
Clinical Indications:
Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient who
cannot maintain or keep the airway clear.
EMT
Procedure:
A
P
A‐EMT
A
P
1)
Ensure suction device is in proper working order with suction tip in place
2)
Preoxygenate the patient.
3)
Explain the procedure to the patient if they are coherent.
4)
Examine the oropharynx and remove any potential foreign bodies or material that may occlude the
airway if dislodged by the suction device.
5)
If applicable, remove ventilation devices (ie. BVM) from the airway.
6)
Use the suction device to remove any secretions, blood, or other substances
The alert patient may assist with this procedure.
7)
Reattach ventilation device (ie. BVM) and ventilate or assist the patient.
8)
Record the time and result of the suctioning procedure in the patient care report (PCR)
Paramedic
Service MD Approval:______
Procedure 5
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210
Procedure
Clinical Indications:
Obstruction of the airway (secondary to secretions, blood, or any other substance) in a patient
currently being assisted with an airway adjunct such as a LTA/LMA, endotracheal tube, tracheostomy
tube, or a cricothyrotomy tube.
Procedure:
1)
Ensure suction device is in proper working order with suction tip in place
2)
Preoxygenate the patient.
3)
Attach suction catheter to suction device, keeping sterile plastic covering over catheter.
4)
For all devices, use the suprasternal notch as the end of the airway. Measure the depth desired
for the catheter (judgment must be used regarding the depth of suctioning with cricothyrotomy and
tracheostomy tubes).
5)
If applicable, remove ventilation devices(ie. BVM) from the airway.
6)
With the thumb port of the catheter uncovered, insert the catheter through the airway device.
7)
Once the desired depth (measured in #4 above) has been reached, occlude the thumb port and
remove the suction catheter slowly.
8)
Small volume (<10ml) of normal saline lavage may be used as needed.
9)
Reattach ventilation device (ie. BVM) and ventilate or assist the patient.
10)
Record the time and result of the suctioning procedure in the patient care report (PCR)
P
Paramedic
P
Service MD Approval:______
Procedure 6
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211
Procedure
Clinical Indications:
Patients with suspected hypoglycemia (diabetic emergencies, altered/change in mental status, bizarre
behavior, etc.).
EMT
A
P
Procedure:
A‐EMT
1)
Gather and prepare equipment
2)
Blood samples for performing glucose analysis should be obtained simultaneously with
intravenous access when possible
3)
Place correct amount of blood on reagent strip or site on glucometer per the manufacturer’s
instructions.
4)
Time the analysis as instructed by the manufacturer.
5)
Document the glucometer reading and treat the patient as indicated by the appropriate protocol
6)
If reading appears incorrect, redraw and repeat analysis.
7)
Repeat glucose analysis as indicated for reassessment after treatment and as per protocol.
Paramedic
A
P
Service MD Approval:______
Procedure 7
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212
Procedure
EMT
Clinical Indications:
Persons with suspected or known exposure to carbon monoxide
Procedure:
A
P
A‐EMT
Paramedic
A
P
1)
Apply probe to patient’s middle finger or any other digit as recommended by the manufacturer. If
near strobe lights, cover the finger to avoid interference and/or move away from lights if possible.
Where the manufacturer provides a light shield it should be used.
2)
Allow machine to register percent circulating carboxyhemoglobin values
3)
Verify pulse rate on machine with actual palpable pulse of the patient.
4)
Record levels in patient care report or on the scene rehabilitation form.
▪ If CO <5%, assess for other possible illness or injury
▪ If CO >5% to <15% and symptomatic from Carbon Monoxide – treat per Carbon Monoxide
Exposure Protocol
Signs and Symptoms ‐ Altered mental status / dizziness, headache, nausea/vomiting, chest pain/respiratory
distress, neurological impairments, vision problems/reddened eyes, tachycardia/tachypnea, arrhythmias, seizures,
coma
▪ If CO >15% = Treat per Overdose and Poisoning: Carbon Monoxide Protocol and Transport.
5)
Monitor critical patients continuously with pulseox and SpCO until arrival at the hospital.
6)
Document percent of carboxyhemoglobin values every time vital signs are recorded during therapy
for exposed patients.
7)
Use the pulse oximetry feature of the device as an added tool for patient evaluation. Treat the
patient, not the data provided by the device. Utilize the relevant protocol for guidance.
8)
The pulse oximeter reading should never be used to withhold Oxygen from a patient in respiratory
distress
9)
Factors which may reduce the reliability of the reading include:
□ Poor peripheral circulation (blood volume, hypotension, hypothermia)
□ Excessive external lighting, particularly strobe/flashing lights
□ Excessive sensor motion
□ Fingernail polish (may be removed with acetone pad)
□ Irregular heart rhythms (atrial fibrillation, SVT, etc.)
□ Jaundice
□ Placement of BP cuff on same extremity as pulse ox probe
Service MD Approval:______
Procedure 8
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213
Procedure
P
Clinical Indications:
Paramedic
P
Unstable patient with tachydysrhythmia (rapid atrial fibrillation, supraventricular tachycardia,
ventricular tachycardia)
Patient is not pulseless (pulseless patient requires unsynchronized cardioversion, ie. defibrillation).
Procedure:
1)
Ensure the patient is attached properly to a monitor/defibrillator capable of synchronized
cardioversion.
2)
Have all equipment prepared for unsynchronized cardioversion/defibrillation, if the patient fails
synchronized cardioversion and the condition worsens.
3)
Consider the use of pain medication or sedatives per protocol.
4)
Set energy selection to the appropriate setting
5)
Set monitor/defibrillator to synchronized cardioversion mode
6)
Make certain all personnel are clear of patient.
7)
Press and hold the shock button to cardiovert. Stay clear of the patient until you are certain the
energy has been delivered. NOTE: It may take the monitor/defibrillator several cardiac cycles to
“synchronize”, so there may be a delay between activating the cardioversion and the actual
delivery of energy.
8)
Note patient response and perform immediate unsynchronized cardioversion/defibrillation if the
patient's rhythm has deteriorated into pulseless ventricular tachycardia/ventricular fibrillation.
Follow the procedure for Defibrillation-Manual
9)
If the patient’s condition is unchanged, repeat steps 2-8 above, using escalating energy settings
per protocol.
10)
Repeat per protocol until maximum setting or until efforts succeed.
11)
Note procedure, response, and times in the PCR.
Service MD Approval:______
Procedure 9
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214
Procedure
Clinical Indications:
Age > 18 years of age ( CCR causes worse outcomes in the pediatric population)
Suspected cardiac cause of arrest (not respiratory-OD, drowning, etc.)
EMT
A
P
A‐EMT
Paramedic
A
P
It occurs with Ventricular Fibrillation or Pulseless Ventricular Tachycardia, with PEA and with Asystole. You must
assume there is no blood perfusing the brain and heart….which is bad for survival. Your patient needs both a pump (chest
compressions) and diastolic pressure support (to perfuse the coronary arteries). Time spend doing other things (such as
prolonged airway management) at the expense of not delivering pump support is not good for the patient.
Determine as close as possible when the patient collapsed, and document this. Also look for any signs of patient
gasping prior to and/or during resuscitation, and document this. If gasping is present, note pupil reaction and document also.
It is also important to remember that not all Pulseless patients are the result of cardiac related events. Other
mechanisms such as trauma, drowning, hypothermia, choking and other respiratory problems, etc. must be considered as a
possible cause for the arrest and should be addressed with immediate, appropriate airway intervention.
Key points in the Cardio Cerebral Resuscitation (CCR) approach:
Survival is determined by a functional recovery of two organs: the heart and the brain
□ without adequate blood flow neither organ will survive
□ that makes properly performed chest compressions (CC) the single most important determinant of
survival.
□ Anything that interrupts or otherwise decreases the quality of CC contributes to the death of your
patient.
□ This concept – continuous maximal quality CC – must become the foundation of all you think and
do during resuscitation.
All patients are treated the same during the first two minutes of the code.
□ They get uninterrupted continuous CC (CCC) while other interventions are performed.
□ The cardiac rhythm is irrelevant during this period.
The cardiac rhythm determines subsequent management.
□ It is analyzed (using manual interpretation) briefly AFTER each set of 200 CCC
□ It is either shockable or non-shockable - don’t make it more complicated than that.
CCCs are to be resumed immediately following a rhythm assessment + shock.
□ The rhythm observed after a shock is not – meaning NOT – to be treated.
□ Otherwise deadly pauses in CCC will be introduced in an attempt to gather information that is
irrelevant to survival!
The initial rhythm (after 200 CCC) determines subsequent treatments:
□ When to initiate invasive airway insertion and positive pressure ventilation.
□ Need for anti-arrhythmic medications
□ How long to remain on scene.
Success depends on:
□ Leadership
□ Delegation of a limited set of specific tasks
□ Timely focused completion of these specific tasks by rescuers
Service MD Approval:______
Procedure 10-1
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215
Procedure
Interventions that are critical to survival MUST whenever possible be performed by two persons solely
dedicated to that task.
□ One to perform it and a second person to assure quality performance.
□ This applies especially to chest compressions and it is also important in the management of an
invasive airway + ventilations.
Code Commander:
Someone must assume the role of code commander. This person is responsible for delegating tasks,
is the only person interpreting the rhythm, and is responsible for monitoring/critiquing the overall
performance of the team.
Other members must work as a team and take direction from the code commander. They must focus
on their assigned tasks and let the code commander manage the overall response (in other words,
keep their noses out of other rescuers business)
Critical First Tasks: (delegated and performed in first two minutes if at all possible)
MCMAID – a prioritized sequence consisting of:
□ M = Metronome (100/min)
□ C = Chest compressions (focus on rate, recoil and depth)
□ M = Monitor (turn on in defib mode, pads on, joules set at maximum)
□ A = Airway (OPA, ensure patency, NRB @ 15/lpm)
□ I = Intravenous or Intraosseous access
□ D = Drugs (Epi, Vasopressin, Amiodarone) (be ready to administer when needed and monitor
timing for repeat doses)
Chest Compressions: MCMAID
Metronome should be turned on to assure a rate of 100/minute.
CCC should be started ASAP after arrival.
A two-person task if at all possible
□ Switch compressors rapidly/frequently (every 1-2 minutes)
□ The non-compressor continuously monitors the quality of CCC: rate, depth and recoil
CCC should be continuous = not interrupted
□ The only valid reasons for interrupting compressions are for analyzing the rhythm and shocking.
□ All other requests to pause CCC must be cleared by the code commander, and the reason and
duration documented in the run report.
Monitor/Defibrillator: MCMAID
Initial:
□ Turn unit on when compressions are started and set mode to defib.
□ Ensure joules are set to maximum allowed
▪ Place pads in sternum/apex position without interruption of chest compressions.
Service MD Approval:______
Procedure 10-2
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216
Procedure
Defibrillation Process:
□ Charge defibrillator during the last 10 seconds of 200 CCC.
□ Ensure all rescuers will be clear if a shock is needed.
□ Pause a few seconds only for analysis – determine if it is shockable or not.
▪ If indicated, immediately deliver a single (not stacked) shock at maximum joules.
▪ If no shock is indicated, dump the charge by either decreasing the energy level and
immediately returning back to maximum energy setting (200J or 360J), OR switching the
mode to monitor and then quickly back to defib mode.
□ Immediately resume CCC after analysis + shock.
▪The pause from stopping CCC to resumption of CCC should be less than 5 seconds.
Airway: MCMAID
Initially:
□ Insert OPA, apply NRB @15 lpm (look for misting), ensure patency (listen for exhausted air with
compressions. If unsure, give one single breath with BVM, looking for chest rise and fall for
compliance).
When to insert invasive airway depends on the initial rhythm:
□ If non-shockable, initiate immediately after first rhythm analysis.
□ If shockable – ONLY after three cycles (2 min. of CCC + analysis + shock). NOT earlier, even if
second rhythm is non-shockable.
Once the invasive airway is in place, the airway persons sole task is to perform/monitor that task and
no other.
Invasive airway monitoring includes attention to:
□ Proper placement
□ Apply Capnography and verify waveform/presence of ETCO2.
□ Avoidance of any interruption of CCC
□ Ventilation rate of 6 per minute. Each breath must be timed – aim for 10 seconds between each
breath. Excessive ventilation rates are deadly!
□ Volume should be ~500cc.
□ Delivery of breath should be over one second.
Use an LTA if placing an endotracheal tube is met with any problems or delays.
If the initial rhythm is shockable, seriously consider using the LTA instead of an ETT because these
patient’s cannot tolerate even brief periods of less than optimal CCC.
Assure that oxygen is attached.
Intravenous/Intraosseous access: MCMAID
Consider intraosseous route whenever there are any delays in IV insertion.
Consider spiking a bag en route and having it ready on arrival.
Service MD Approval:______
Procedure 10-3
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217
Procedure
Drugs: MCMAID
The individual assigned to the Drug “Task”:
□ Initially ensures medications are available and ready to administer.
□ Is responsible for:
▪ The rapid administration when indicated.
▪ Re-dosing at appropriate intervals.
▪ Detecting when V-Fib is persistent or recurrent, and therefore indicating the use of
Amiodarone.
▪ Accurate timing of when meds are to be given (to the second – using elapsed time since
defibrillator was turned on.)
Vasopressors should be given ASAP after analysis + shock, so their effect will be seen after the next
200 chest compressions.
Epinephrine first!
□ **The one exception is the patient who you suspect may get return of spontaneous circulation with
the first shock. Such patients may include those with short down times or those who have had
excellent chest compression generated perfusion. A clue to this is the presence of regular agonal
respirations (gasping). In these patients consider giving Vasopressin initially, and reserving
Epinephrine until the Code Commander observes persistent pulseless V-fib/Tach after the first
shock – or until another 200 CCC cycle has been completed.
□ Epi dose is 1mg IV/IO. Endotracheal administration is not to be utilized – start an IO instead
□ If repeating doses, administer every other cycle of 200 compressions. (equivalent to every 4 min)
Vasopressin: administer with first or second Epi dose as per protocol
□ Dose is 40 units (two vials of 20 U each)
□ Same dose is used for IV or intraosseous (IO) routes.
Amiodarone is administered for persistent or recurrent pulseless V-fib/Tach. This should be
administered immediately during the next 200 chest compression cycle if a second shock was indicated
and delivered at the time of analysis. The Code Commander may visualize return of fibrillation during
the 200 CCC and as such may order Amiodarone earlier since it has recurred.
□ Dose is 300mg IV/IO
□ Repeat doses are 150mg IV/IO
Additional Treatments to consider:
Consider possible renal failure (hyperkalemia) or suspected Tricyclic antidepressant overdose. If
suspected, administer Sodium Bicarbonate 1mEq/Kg. If renal failure is suspected, also administer
Calcium Chloride 1g IVP.
If rhythm is persistent shockable V-fib or Pulseless V-Tach, consider the possible use of Magnesium
Sulfate 2g IVP.
Service MD Approval:______
Procedure 10-4
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218
Procedure
Additional Treatments to consider (continued):
If the patient is successfully converted from V-Fib/Pulseless V-tach to a perfusing sustainable rhythm,
consider post resuscitation Amiodarone boluses.
□ Amiodarone bolus: 150mg
If rhythm is a non-shockable Asystole or PEA, seek out and treat any possible contributing factors.
Also consider external pacing: for PEA. Apply the pads in (or move them to) the anterior/posterior
position, attach the 4-Lead cable, and set the pacer at the maximum milliamps at a rate of 80/min. Do
NOT interrupt compressions while attempting pacing.
When to stop CCC:
If the patient shows signs of cerebral activity and the rhythm is non-shockable.
Use end-tidal CO2 as a marker for possible ROSC. Look for a dramatic increase.
Pulse checks are ONLY performed during brief rhythm analysis with location of carotid pulse
ascertained during chest compressions.
□ This may be modified by the Code Commander if cerebral function signs of life appear
□ The Code Commander is the only individual who can order a pulse check other than that
done during rhythm analysis.
□ The Code Commander must ensure the pulse checker is clear if a shock is indicated.
When to move the patient:
Remember that moving the patient inevitably results in compromised quality of compressions. If crew
safety is compromised or inadequate resuscitation space is available, patient should be quickly moved
to a safe or larger area. This should be done initially and not after resuscitation efforts have begun.
Initially shockable patients will live or die in the field!
□ Move is allowed after 3 cycles are completed and a non-shockable rhythm is identified at the 3rd
analysis
▪ If 3rd analysis is still shockable, continue resuscitation at the scene until a non-shockable
rhythm is encountered.
Initially non-shockable rhythms
□ Medical Control must make this determination, but these patients may deserve at least 3 cycles of
treatment with optimal quality compressions.
Avoid Excessive Pauses:
Rhythm analysis – ONLY the Code Commander pays attention to the rhythm (not everyone)
Resume CCC immediately after analysis + shock. The Code Commander must assure this happens
Charging – perform during last 10 seconds of 200 chest compressions
During Intubation – It is responsibility of both the Code Commander and the second airway person to
avoid pauses in CCC. This MUST be able to be performed without any interruption of compressions!
Consider using the LTA if unable to intubate effectively.
Pulse Checks – only performed during the rhythm analysis pause; must be correlated with rhythm
Service MD Approval:______
Procedure 10-5
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219
Procedure
P
Clinical Indications:
Paramedic
P
Tension pneumothorax should be suspected in patients who exhibit:
□ Severe respiratory distress with hypoxia
□ Unilateral decreased or absent lung sounds
□ Evidence of hemodynamic compromise (Shock, Hypotension, Tachycardia, Altered Mental
Status)
□ Tracheal deviation away from the collapsed lung field (less reliable than the above)
Pleural decompression for tension pneumothorax should only be preformed when at least 3 of the
above criteria are present.
Equipment:
14 gauge 2 inch – 2.5 inch over the needle catheter
Tape
Sterile gauze pads
Antiseptic swabs
Occlusive dressing
Procedure:
Locate decompression site
□ Identify the 2nd intercostal space in the mid-clavicular line on the same side as the
pneumothorax
Prepare the site with an antiseptic swab:
□ Firmly introduce catheter immediately above distal rib of selected site.
Insert the catheter into the thorax until air exits
Advance catheter and remove needle.
Secure the catheter taking care not to allow it to kink
Reassess lung sounds and patient condition
Dress area with occlusive dressing then cover with sterile gauze pad
Assess breath sounds and respiratory status.
Service MD Approval:______
Procedure 11
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220
Procedure
EMT
Clinical Indications:
A
P
A‐EMT
Paramedic
Active labor with perineal crowning
Apply personal protective equipment and prepare for childbirth
Allow head to deliver passively and control delivery by placing palm of hand over occiput.
Protect perineum with pressure from other hand
If amniotic sac is still intact, gently pinch and twist to manually rupture.
Note presence or absence of meconium.
If meconium is present, see Complication of Childbirth
Once the head is delivered and passively turns to one side, suction mouth and nose
If nuchal cord present, gently lift cord from around infant’s neck
Gently apply downward pressure to infant to facilitate delivery of upper shoulder
Once upper shoulder has delivered, apply gentle upward pressure to deliver lower shoulder
Grasp the infant as it emerges from birth canal
Keep infant at level of perineum until cord stops pulsating and cord is clamped.
A
P
Care of the Newborn:
Double clamp cord 10-12 inches from abdomen, once it stops pulsating cut cord.
Suction mouth and nose
Dry and warm the neonate. Wrap in blankets
Stimulate infant by rubbing back or soles of feet
Refer to Neonatal Resuscitation Protocol if infant is hypoxic, not breathing properly or heart rate
<100.
0
1
2
Obtain APGAR Score
Appearance
Pulse
Grimace
Activity
Respiratory Effort
Blue
Absent
No response
Limp
Absent
Peripheral Cyanosis
Pink
<100/minute
>100/minute
Grimace
Cough/Sneeze
Minimal Movement Active Motion
Weak Cry
Strong Cry
Post Partum Care:
Allow placenta to deliver spontaneously while transporting patient to hospital. Do not pull on cord.
Apply direct pressure to any actively bleeding areas on the perineum
If blood loss significant or vaginal bleeding continues
□ Fluid bolus as needed
□ Massage top of uterus
□ Allow newborn to nurse / breast feed if stable
Service MD Approval:______
Procedure 13
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221
Procedure
Shoulder Dystocia:
Place mother in knee-chest position and reattempt delivery
If delivery fails, support child’s airway, provide supplemental oxygen.
EMT
A
P
A‐EMT
A
P
Breech Birth:
Paramedic
Do not attempt to pull infant by trunk or legs.
Place mother in knee-chest position
If head does not deliver, push baby’s mouth and nose away from vaginal wall with two gloved fingers.
Provide supplemental oxygen to infant.
Prolapsed Cord:
Place mother in knee-chest position
Do not push cord back into birth canal
Insert gloved fingers into birth canal and keep pressure off prolapsed cord
Cover exposed cord with warm moist dressing
Meconium-Stained Amniotic Fluid:
Suction mouth and nose after delivery
If baby is vigorous (normal respiratory effort, muscle tone, and heart rate >100), provide supportive
care
If baby is not vigorous (depressed respirations, poor muscle tone, or heart rate <100) – REQUEST
ALS
Meconium-Stained Amniotic Fluid:
P Paramedic P
Suction mouth and nose after delivery
If baby is vigorous (normal respiratory effort, muscle tone, and heart rate >100), provide supportive
care
If baby is not vigorous (depressed respirations, poor muscle tone, or heart rate <100), perform
endotracheal intubation and suction trachea while removing ET tube, may repeat one additional time.
Support ventilation and re-intubate with a clean tube
Service MD Approval:______
Procedure 12
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222
Procedure
Clinical Indications:
For patients with Acute Bronchospastic Disorders (acute or chronic bronchitis, emphysema, or asthma)
or Acute Pulmonary Edema, who have hypoxemia and/or respiratory distress that does not quickly
improve with pharmaceutical treatment.
Consider CPAP protocol if 2 or more are present:
Retraction of intercostals or accessory muscles
Bronchospasm
Rales
Respiratory Rate >25 per minute
Oxygen saturation <93% on high flow Oxygen
EMT
A
P
A‐EMT
Paramedic
A
P
Contraindications:
Respiratory arrest
Agonal respirations
Unconsciousness or obtundation
Shock associated with cardiac insufficiency
Trauma
Persistent nausea and vomiting
Facial anomalies
Inability to cooperate with the procedure
Current tracheostomy
Equipment:
Medical Director approved Continuous Positive Airway Pressure (CPAP) device
Procedure:
Perform primary and secondary survey
Attach cardiac monitor, capnography if available, and pulse oximetry
Service MD Approval:______
Verbally instruct patient (this is a critical item)
□ Patient requires verbal sedation to use this device effectively
□ Setup CPAP device as per manufacturer’s instructions
□ Instruct patient to slowly breathe in through the nose and exhale through the mouth (exhalation
phase should be about 4 seconds)
Continue treatment throughout transport to ED - document CPAP level used and FiO2 level used
Record and monitor vital signs, ETCO2, and O2 saturation as needed/available
In the event of progressive respiratory failure:
□ Offer reassurance
□ Stop treatment if necessary
□ Institute BLS and ALS care per appropriate protocol
□ Document adverse reactions, and reasons why CPAP was discontinued, in PCR
Procedure 15
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223
Procedure
Clinical Indications:
Pediatric Arrest
Suspected non-cardiac arrest/respiratory arrest in adult patients
(ie. overdose, drowning)
EMT
A
P
A‐EMT
Paramedic
A
P
Procedure:
1) Assess the patient’s level of responsiveness (signs of life)
2) If no response, open the patient’s airway with the head-tilt, chin-lift. Look, listen and feel for
respiratory effort. If the patient may have sustained c-spine trauma, use the modified jaw thrust while
maintaining immobilization of the c-spine. For infants, positioning the head in the sniffing position is the
most effective method for opening the airway.
3) If patient is an adult, go to step 4. If no respiratory effort in the pediatric patient, give two ventilations.
If air moves successfully, go to step 4. If air movement fails, proceed per AHA obstructed airway
guidelines.
4) Check for pulse (carotid for adults and older children, brachial or femoral for infants) for at least 10
seconds. If no pulse, begin chest compressions as directed below.
Age
Infant
Child
Adult
Location
Over sternum, between
nipples (inter‐mammary
line), 2‐3 fingers
Depth
Rate
1.5 inches (1/3 the
anterior‐posterior chest
dimension
At least 100/minute
2 inches (1/3 the anterior‐
Over sternum, between posterior chest
nipples, heel of one hand dimension
At least 100/minute
Over sternum, just above
the xyphoid process,
At least 2 inches (1/3 the
hadns with interlocked
anterior‐posterior chest
fingers
dimension
At least 100/minute
5) Go to Cardiac Arrest protocol
6) Chest compressions should be provided in an uninterrupted manner. Only brief interruptions are
allowed for rhythm analysis and defibrillation
7) Document the time and procedure in the PCR.
Service MD Approval:______
Procedure 16
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224
Procedure
If Possible Contact Medical Control Before Proceeding!
P
Paramedic
P
Clinical Indications:
When all airway management measures have failed and the patient needs an advanced airway
immediately, consider performing cricothyrotomy. The percutaneous approach is preferred.
If, in the paramedics judgment, the time necessary to contact medial control will compromise the
patient's chance of survival AND it is not possible to ventilate the patient with a bag-valve-mask
during transport, cricothyrotomy may be performed without Medical Control.
Relative Contraindications:
Ability to ventilate patient with an oral-pharyngeal/nasal-pharyngeal airway, BVM, LTA/LMA, or
endotracheal tube.
Procedure:
1)
Cleanse anterior neck.
2)
Identify and mark cricothyroid membrane
3)
Fill a 10cc syringe with 5cc’s of 0.9% normal saline
4)
Remove dilator from the package and sheath and advance into the tracheostomy tube
5)
Penetrate the skin and cricothyroid membrane with the splitting needle perpendicular to the skin
while gently aspirating with the syringe. Air aspiration as evidenced by bubbles into syringe
should flow easily confirming tracheal airspace. Incline needle more than 45 degrees toward
carina and complete insertion of needle aspirating to ensure continued proper placement
6)
Disconnect needle from syringe and advance tip of dilator into the hub of the splitting needle until
resistance is met.
7)
Squeeze wings of needle together then, open them out completely to split the needle. Remove
needle, continuing to pull it apart in opposite directions, while leaving the dilator in the trachea.
8)
Place thumb on dilator knob while first and second fingers are curved under flange of trachea
tube. By exerting pressure, advanced dilator and tracheostomy tube into position until flange is
against skin.
9)
Remove dilator and inflate cuff until you have control of the airway (max 5cc’s). Attach ETCO2
and BVM. Secure tube around patient’s neck with twill tape.
10)
Confirm placement with gentle ventilation via BVM, continuous capnography and physical means.
Be sure air movement is fluid with bilateral symmetric chest rise and that no visible neck softtissue distortion is noted.
11)
If tracheal placement is unclear, remove and transport immediately to the closest ER
12)
Secure tube and consider sedation protocol
13)
If not previously done, immediately notify Medical Control.
Service MD Approval:______
Procedure 17
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225
Procedure
EMT
A
P
A‐EMT
Paramedic
A
P
Clinical Indications:
Any patient who may have been exposed to significant hazardous materials, including chemical, biological,
or radiological weapons.
Procedure:
In coordination with HazMat and other Emergency Management personnel, establish hot, warm, and
cold zones of operation.
Ensure that personnel assigned to operate within each zone have proper personal protective
equipment.
In coordination with other public safety personnel, assure each patient from the hot zone undergoes
appropriate initial decontamination. This is specific to each incident; such decontamination may
include:
□ Removal of patient from hot zone
□ Simple removal of clothes
□ Irrigation of eyes
□ Passage through high-volume water bath (ie. Between two fire apparatus) for patients
contaminated with liquids or certain solids. Patients exposed to gases, vapors, and powders often
will not require this stop as it may unnecessarily delay treatment and/or increase dermal
absorption of the agent(s).
Initial triage of patients should occur after step #3. Immediate life threats should be addressed prior to
technical decontamination.
Assist patients with technical decontamination (unless contraindicated based on #3 above). This may
include removal of all clothing and gentle cleaning with soap and water. All body areas should be
thoroughly cleansed, although overly harsh scrubbing which could break the skin should be avoided.
Place triage identification on each patient Match triage information with each patient’s personal
belongings, which were removed during technical decontamination. Preserve these personnel affects
for law enforcement.
Service MD Approval:______
Monitor all patients for environmental illness.
Transport patients per local protocol.
Procedure 18
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226
Procedure
EMT
Clinical Indications:
Patients in cardiac arrest (pulseless, non-breathing)
Age <8 years, use pediatric pads if available
A
P
A‐EMT
Paramedic
A
P
Contraindications:
Pediatric patients whose body size is such that the pads cannot be placed without touching one
another.
Procedure:
1)
If multiple rescuers available, one rescuer should provide uninterrupted chest compression while
the AED is being prepared for use.
2)
Apply defibrillator pads per manufacturer recommendations. Use alternate placement when
implanted devices (pacemakers, AICD’s) occupy preferred pad positions.
3)
Remove any medication patches on the chest and wipe off any residue
4)
If necessary, connect defibrillator leads: per manufacturer recommendations.
5)
Activate AED for analysis of rhythm
6)
Stop chest compressions and clear the patient for rhythm analysis. Keep interruption in chest
compressions as brief as possible
7)
Defibrillate if appropriate by depressing the “shock” button. Assertively state “CLEAR” and
visualize that no one, including yourself, is in contact with the patient prior to defibrillation. The
sequence of defibrillation charges is preprogrammed for monophasic defibrillators. Biphasic
defibrillators will determine the correct joules accordingly.
8)
Begin CPR/CCR immediately after the delivery of the shock beginning with chest compressions.
9)
After 2 minutes of CPR/CCR, analyze rhythm and defibrillate if indicated. Repeat this step
every 2 minutes.
10)
If “no shock advised” appears, perform CPR/CCR for two minutes and then reanalyze.
11)
Transport and continue treatment as indicated.
12)
Keep interruption of compressions as brief as possible. Adequate CPR/CCR is a key to
successful resuscitation.
Service MD Approval:______
If pulse returns: See Post-Resuscitation Protocol
Procedure 19
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227
Procedure
EMT
Clinical Indications:
Cardiac arrest with ventricular fibrillation or pulseless ventricular tachycardia
A
P
A‐EMT
Paramedic
A
P
Procedure:
1)
Ensure chest compressions are adequate and interrupted only when necessary
2)
Clinically confirm the diagnosis of cardiac arrest and identify the need for defibrillation
3)
Apply hands-free pads to the patient’s chest in the proper position
4)
Charge the defibrillator to the maximum energy level. Continue chest compressions while the
defibrillator is charging.
5)
Pause compressions, assertively state, “CLEAR” and visualize that no one, including yourself, is in
contact with the patient.
6)
Deliver the shock by depressing the shock button for hands-free operation.
7)
Immediately resume chest compressions and ventilations for 2 minutes. After 2 minutes of CPR/
CCR, analyze rhythm and check for pulse only if organized rhythm.
8)
Repeat the procedure every two minutes as indicated by patient response and EKG rhythm.
9)
Keep interruption of compressions as brief as possible. Adequate compressions are the key to
successful resuscitation.
If pulse returns: See Post-Resuscitation Protocol
Service MD Approval:______
Procedure 20
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228
Procedure
Clinical Indications:
Patients meet clinical indications for oral intubation
Initial intubation attempt for medical indication unsuccessful
Predicted difficult intubation
P
Paramedic
P
Contraindications:
ETT size less than 6.5mm.
Already failed twice on medical indicated intubation attempts or failed on one trauma intubation
attempt DO NOT UTILIZE BOUGIE.
Procedure:
1)
Prepare, position, and oxygenate the patient with 100% Oxygen
2)
Select proper ET tube without stylette, test cuff and prepare suction
3)
Lubricate the distal end and cuff of the endotracheal tube (ETT) and the distal ½ of the
endotracheal tube introducer (Bougie) (note: failure to lubricate the Bougie and the ETT may
result in being unable to pass the ETT)
4)
Using laryngoscopic techniques, visualize the vocal cords if possible using Sellick’s/BURP as
needed.
5)
Introduce the Bougie with curved tip anteriorly and visualize the tip passing the vocal cords or
above the arytenoids if the cords cannot be visualized
6)
Once inserted, gently advance the Bougie until you meet resistance or “hold-up” (if you do not
meet resistance you have a probable esophageal intubation and insertion should be re-attempted
or the failed airway protocol implemented as indicated.
7)
Withdraw the Bougie ONLY to a depth sufficient to allow loading of the ETT while maintaining
proximal control of the Bougie
8)
Gently advance the Bougie and loaded ET tube until you have hold-up again, thereby assuring
tracheal placement and minimizing the risk of accidental displacement of the Bougie.
9)
While maintaining a firm grasp on the proximal Bougie, introduce the ET tube over the Bougie
passing the tube to its appropriate depth
10)
If you are unable to advance the ETT into the trachea and the Bougie and ETT are adequately
lubricated, withdraw the ETT slightly and rotate the ETT 90 degrees COUNTER clockwise to turn
the bevel of the ETT posteriorly. If this technique fails, to facilitate passing of the ETT you may
attempt direct laryngoscopy while advancing the ETT (this will require an assistant to maintain the
position of the Bougie and , if so desired, advance the ETT)
11)
Once the ETT is correctly placed, hold the ET tube securely and remove the Bougie
12)
Confirm tracheal placement with capnography according to the intubation protocol. Inflate the cuff,
auscultate for equal breath sounds and reposition accordingly.
13)
When final position is determined secure the ET tube, continuously record and monitor
capnography, reassess breath sounds and monitor patient to assure continued tracheal intubation.
14)
If there is any question regarding placement of ETT (Esophageal vs. Tracheal) remove
immediately and ventilate with BVM.
Service MD Approval:______
Procedure 21
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229
Procedure
Clinical Indications:
Monitored heart rate less than 60 per minute with signs and symptoms of inadequate cerebral or
cardiac perfusion such as:
□ Severe chest pain
P Paramedic
□ Hypotension
□ Pulmonary edema
□ ALOC, disorientation, confusion, etc
PEA, where the underlying rhythm is bradycardic and reversible causes have been treated
P
Procedure:
1)
Attach standard four-lead monitor
2)
Apply defibrillation/pacing pads to chest and back:
□ One pad to left mid chest next to sternum, one pad to left mid posterior back next to spine
3)
Choose pacing option
4)
Adjust heart rate to 70 BPM for an adult, 100 BPM for pediatric patients
5)
Note pacer spikes on EKG screen
6)
Slowly increase output until capture of electrical rhythm on the monitor
7)
If unable to capture while at maximum current output, stop pacing immediately
8)
If capture observed on monitor, check for corresponding pulse and assess vital signs
9)
Mechanical capture occurs when paced electrical spikes on the monitor correspond with palpable
pulse
10)
Consider the use of sedation or analgesia if patient is uncomfortable, per protocol
11)
Document the dysrhythmia and the response to external pacing with EKG strips in the PCR.
Service MD Approval:______
Procedure 22
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230
Procedure
Clinical Indications:
Inability to BVM ventilate
When an alternative airway device is needed in the management of respiratory failure
P
Contraindications:
Pharyngeal pathology (abscess or hematoma)
Obstructive lesions below the glottis
Limited mouth opening
Intact gag reflex
Paramedic
P
Equipment:
Correctly sized laryngeal mask airway (see chart below)
Bag valve mask or automatic ventilator
Oxygen reservoir
Suction device
Bite block and/or endotracheal tube holder (if available)
25 and/or 35ml syringes for expanding cuff
End Tidal CO2 and oxygen saturation monitoring devices
Laryngeal Mask Airway Sizes
Mask Size
1
1.5
2
2.5
3
4
5
Patient weight
(kg)
<5kg
5‐10
10‐20
20‐30
30‐60
60‐80
>80
Age (years)
<0.5yrs
Length (cm)
10cm
10
11.5
12.5
19
19
19
.5‐5
5‐10
10‐15
>15
>15
Cuff volume (ml)
4
5‐7
7‐10
14
15‐20
25‐30
30‐40
Largest
ETT*
3.5mm
4.5
5
6
6.5
7
*Appropriately sized endotracheal tube (internal diameter) that can be passed through LMA for blind
intubation if intubating LMA is inserted.
Service MD Approval:______
Procedure 23-1
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231
Procedure
Procedure – Laryngeal Mask Airway Placement:
Pre-oxygenate patient with 100% Oxygen via bag valve mask to achieve O2 saturation of >93% if
possible
Remove the red tag from the balloon port
P Paramedic P
Check the integrity of the cuff and pilot balloon
Tightly deflate the cuff with the syringe
□ The deflated cuff should appear BOAT shaped
Lubricate the posterior surface
Place patient in neutral sniffing position (if no c-spine/spinal injury suspected)
□ For patients with suspected c-spine injury, perform two person insertion technique:
•One person maintains manual in-line cervical spine stabilization while the other person
proceeds with procedure as below:
Pull mandible down to open mouth
Insert uninflated LMA into oral cavity with cuff facing away from hard palate
Guide LMA around curvature of the posterior pharynx into the hypopharynx until resistance is felt.
Resistance is due to the tip of the LMA stopping at the upper esophageal sphincter
If uninflated LMA insertion is difficult:
□ If the curvature of the posterior/hypopharynx is too acute, perform a jaw thrust, pulling the
tongue
forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate
insertion.
□ A slight inflation of the cuff to 1/3 – ½ of typical inflation volume may also increase ease of
insertion
□ Insert LMA with cuff facing hard palate, then rotate 180 degrees into the proper position after the
angel around the posterior aspect of the tongue has been cleared.
Inflate cuff without holding the tube
Ensure that the black line running the length of the LMA shaft is in the midline of the upper lip and
between the two central incisors (this will help maintain a seal)
Administer gentle positive pressure ventilation
Obtain end-tidal CO2 (waveform), listen for breath sounds bilaterally, look for chest excursion, and
check oxygen saturation.
Secure in the midline to help maintain a good seal over the Larynx
Place bite block, gauze or endotracheal tube holder (if available) between teeth to prevent biting tube.
Ensure c-spine is still immobilized
If repeated attempts are made, oxygenate with 100% O2 for 2 minutes between attempts
Endotracheal intubation using Intubating Laryngeal Mask Airway (ILMA):
Select correct size ILMA
Insert endotracheal tube into oropharynx at 90 degree angle (from corner of mouth)
During insertion and passage through the ILMA rotate ET tube 90 degrees so that the tip of the ET
tube will pass through the bars that traverse the distal opening of the ILMA.
Confirm placement as per endotracheal intubation procedure.
Service MD Approval:______
Procedure 23-2
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232
Procedure
P
Paramedic
P
Service MD Approval:______
Procedure 23-3
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233
Procedure
History:
Number of patients
Cause of Incident
Chemical, Biological, Radiological
contamination
Secondary Devices
Signs and Symptoms:
SLUDGE for chemical exposure
Respiratory Distress for Narcotic Exposure
Nausea Vomiting for radiation
Differential:
Blast Response
MCI penetrating trauma
MCI blunt trauma/MVC
Scene Safety –
If blast, wear N95 mask and full turnout gear
until advised to remove
Provide scene size‐up on radio; activate MCI plan
if more than 5 patients
EMT
A
P
A‐EMT
Paramedic
A
P
If not already accomplished, establish
Incident Command, Staging and Triage
Move all ambulatory patients to
safe area in cold zone
Move non‐ambulatory patients to
transportation as rapidly as possible.
Establish treatment areas only if there are
insufficient transport resources available
for rapid transport.
Consider public transportation
to alternative receiving facility
for ambulatory patients
Service MD Approval:______
Pearls
Task cards and job vest should be utilized by all personnel involved in a MCI
If blast injury with more than 5 patients, patient with SBP<90 and/or obvious external trauma to 4 or more body surface areas should go to the Level
1 Trauma Center. Other may be considered for transport to the other area hospitals.
Multiple patients may be transported in the same EMS unit if needed. When possible, patients of similar acuity should be transported in the same
unit to assist with appropriate transport destination.
Utilize state/local approved triage system.
Procedure 24
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234
Procedure
Purpose:
Administration of medication via a non-invasive route
Clinical Indications:
Altered mental status, presumed or possible opiate overdose
Seizures
Pain management
EMT
A
P
A‐EMT
Paramedic
A
P
Contraindications:
DO NOT USE on patient if:
Severe nasal/facial trauma
Active nasal bleeding or discharge
Procedure for medication administration via the MAD®:
1)
2)
3)
4)
5)
6)
7)
8)
Determine appropriate dose of medication per protocol
Draw medication into syringe and dispose of the sharps (add an additional 0.1 ml of medication
due to dead space), do not administer more than 1 ml per nostril.
Attach Mucosal Atomizer Device (MAD) to syringe
With one hand, control the patient’s head
Gently introduce MAD into nare, stop when resistance is met.
Aim slightly upwards and toward the ear on the same side.
Briskly compress the syringe to administer one-half of the medication, repeat the procedure with
the remaining medication on the other nare.
Document the results in the PCR.
Service MD Approval:______
Procedure 25
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235
Procedure
Clinical Indications:
Gastric decompression in adult intubated patients
After successful placement of an LTA or BIAD
Contraindications:
History of alkali ingestion, or esophageal disease (ie. stricture or cancer)
Comatose state with unprotected airway (as procedure will induce vomiting)
Penetrating cervical injuries in the awake trauma patient.
EMT
A
P
A‐EMT
Paramedic
A
P
Procedure:
1)
2)
3)
4)
5)
6)
7)
8)
Measure the length of the tube from the umbilicus to ear lobe to corner of the mouth.
Lubricate the tube with a water based lubricant prior to insertion
Insert lubricated tube through the gastric port of the LTA or lift tongue/jaw anteriorly while passing
tip lateral to endotracheal tube.
Continue to advance the tube gently until the appropriate distance is reached.
Confirm placement by injecting 20cc of air and auscultate for the whoosh or bubbling of the air
over the stomach. If any doubt about placement, remove and repeat the insertion.
Secure the tube.
Decompress the stomach of air and food by connecting the tube to low continuous suction (green).
Document the procedure, time, and result (success) on/with the PCR.
EMT-B and EMT-A must have State approval to perform this skill
Service MD Approval:______
Procedure 26
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236
Standards Procedure
Purpose:
To establish control of the patient's airway and to facilitate
ventilation for the listed indications.
EMT
A
P
A‐EMT
Paramedic
Indications:
When an alternative airway device is needed in the management of respiratory failure in patients 4
feet tall or greater
Contraindications:
Intact gag reflex
Patients with known esophageal disease
Patients who have ingested caustic substances
Patient with known tracheal obstruction
Patient with a tracheostomy or laryngectomy
Patients less than 4 feet tall.
Equipment:
Correctly sized LTA (see chart below)
Bag valve mask
Oxygen reservoir
Suction device
Bite block and/or endotracheal tube holder (if available)
Appropriately sized syringes for expanding cuff
End Tidal CO2 and oxygen saturation monitoring devices
Airway Size Connector Color
3
Yellow
4
Red
5
Purple
King LTS-D Airway Sizes
Patient
Height
OD/ID (mm)
4‐5 feet
18/10mm
5‐6 feet
18/10
>6 feet
18/10
Cuff Volume
(ml)
45‐60 ml
60‐90
70‐90
Gastric Tube
(Fr.)
Up to 18
Up to 18
Up to 18
Procedure:
1)
Pre-oxygenate patient with 100% Oxygen via Bag Valve Mask or spontaneous ventilation to
achieve O2 saturation of >93% if possible
2)
Check the integrity of the cuff inflation system and pilot balloon
3)
Tightly deflate the cuff with the syringe
4)
Lubricate the posterior distal tip of the LTA with a water soluble lubricant
5)
Place patient in neutral sniffing position (if no c-spine/spinal injury suspected)
□ For patients with suspected c-spine injury, perform two-person insertion technique
• One person maintains manual in-line cervical spine stabilization while the other
person proceeds with procedure
Service MD Approval:______
Procedure 27-1
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237
A
P
Procedure
EMT
Procedure (Continued):
A‐EMT
A
A
6)
Pull mandible down to open mouth
P
7)
Insert uninflated LTA into oral cavity with midline or a lateral technique P Paramedic
8)
Advance the tip behind the base of the tongue while rotating tube back to midline so that the blue
orientation line faces the chin of the patient.
9)
Without exerting excessive force, advance tube until base of the colored connector is aligned with
teeth or gums
10)
Inflate the King with the appropriate volume:
□ If uninflated King Airway insertion is difficult, perform a jaw thrust, pulling the tongue
forward. Alternately, a laryngoscope may be used to lift the jaw/mandible to facilitate
insertion.
11)
Attach the BVM to the King LTSD
12)
While bagging the patient, gently withdraw the tube until ventilation becomes easy and free flowing
(large tidal volume with minimal airway pressure)
13)
Adjust cuff inflation if necessary to obtain a seal of the airway at the peak ventilatory pressure
employed.
14)
Obtain end-tidal CO2 (waveform), listen for breath sounds bilaterally, look for chest excursion, and
check oxygen saturation
15)
Secure in the midline to help maintain a good seal over the Larynx
16)
Place bite block, oral airway or endotracheal tube holder (if available) between teeth to prevent
biting tube.
17)
Place orogastric tube and attach to low continuous suction as directed in the applicable procedure
to assist in gastric decompression.
18)
Ensure c-spine is still immobilized
19)
If repeated attempts are made, oxygenate
with 100% O2 for 2 minutes between attempts
20)
**Follow manufacturers suggested
guidelines at all times**
Service MD Approval:______
Procedure 27-2
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238
Procedure
EMT
A
P
A‐EMT
Paramedic
A
P
Service MD Approval:______
Procedure 27-3
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239
Procedure
EMT
A
P
A‐EMT
Paramedic
A
P
Service MD Approval:______
Procedure 27-4
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240
Procedure
Indications:
Patients with suspected hypoxemia, altered level of consciousness
respiratory issues, or as specified in protocol.
EMT
A
P
A‐EMT
Paramedic
A
P
Procedure:
1)
Apply probe to patient’s finger or any other digit as recommended by the device manufacturer.
2)
Allow machine to register saturation level.
3)
Record time and initial saturation percent on room air if possible on/with the PCR
4)
Verify pulse rate on machine or with actual manual pulse check of the patient
5)
Monitor critical patients continuously until arrival at the hospital. If recording a one-time reading,
monitor patients for a few minutes as oxygen saturation can vary.
6)
Document percent of oxygen saturation every time vial signs are recorded and in response to
therapy to correct hypoxemia
7)
In general, normal saturation is 97-99%. Below 93% suspect a respiratory compromise
8)
Use the pulse oximetry as an added tool for patient evaluation. Treat the patient, not the data
provided by the device
9)
The pulse oximeter reading should never be used to withhold oxygen from a patient in respiratory
distress or when it is the standard of care to apply oxygen despite good pulse oximetry readings,
such as chest pain.
10)
Factors which may reduce the reliability of the pulse oximetry reading include:
□ Poor peripheral circulation (blood volume, hypotension, hypothermia)
□ Excessive pulse oximeter sensor motion
□ Fingernail polish (may be removed with acetone pad)
□ Carbon monoxide bound to hemoglobin
□ Irregular heart rhythms (atrial fibrillation, SVT, etc.)
□ Jaundice
□ Placement of BP cuff on same extremity as pulse ox probe
Service MD Approval:______
Procedure 29
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241
Procedure
Indications:
Age >18 unless specific permission given prior to procedure by Medical Control
Need for invasive airway management in the setting of an intact gag reflex or
inadequate sedation to perform non‐pharmacologically assisted airway
management
□ Apnea
□ Decreased LOC with respiratory failure (ie. Hypoxia [O2 sat <90%] not
improved by 100% Oxygen, and/or respiratory rate <8)
□ Poor ventilatory effort (with hypoxia not improved by 100% Oxygen)
□ Unable to maintain patent airway by other means
□ Burns with suspected significant inhalation injury
Contraindications:
Sensitivity to Succinylcholine or other RSA drugs
Inability to ventilate via BVM
Suspected Hyperkalemia
Myopathy or neuromuscular disease
History of Malignant Hyperthermia
Recent crush injury or major burn (>48 hours after injury)
End Stage Renal Disease
Recent Spinal Cord Injury (72 hours – 6 months)
TWO PARAMEDICS REQUIRED FOR THIS PROCEDURE
PREPERATION (T-8 minutes)
Monitoring (continuous EKG, SPO2, Blood Pressure)
Double
P Paramedic
2 patent IV’s
Functioning Laryngoscope and BVM with highflow O2
Endotracheal tube(s), stylet, syringe(s)
LTA(s) and appropriate syringe(s)
Alternative/Rescue Airway (LMA and surgical airway kit) immediately available
All medications drawn up and labeled (including post-procedure sedation)
Suction – turned on and functioning
End Tidal CO2 device on and operational (colometric immediately available as backup only)
Assess for difficult airway – LEMON
PREOXYGENATE
100% O2 x5 minutes (NRB) or 8 vital capacity breaths with 100% O2 (BVM/NRB)
PRETREATMENT (T-3 minutes)
Evidence of head injury or stroke
Lidocaine 1.5mg/kg IV/IO (max 150mg)
Begin cricoid pressure / Sellick’s maneuver
PARALYSIS and INDUCTION (T=0)
Etomidate 0.3mg/kg (max 20mg)
Succinylcholine 2 mg/kg (max 200mg)
PLACEMENT with PROOF (T+30 seconds)
Place LTA/ETT
Confirm with:
□ End Tidal CO2 Waveform
□ Auscultation
□ Physical findings
Secure device, note position
POST-PLACEMENT MANAGEMENT (T+1 minute)
Sedation: Morphine 3mg IV/IO AND Midazolam 3mg IV/IO, repeat x2 as needed
If additional needed and transport time >10 minutes: Rocuronium 1mg/kg IV/IO Service MD Approval:______
Procedure 30
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242
P
Procedure
Clinical Indications:
Any patient who may harm himself, herself, or others may be gently restrained to prevent injury to the
patient or crew. This restrain must be in a humane manner and used only as a last resort. Other means
to prevent injury to the patient or crew must be attempted first. These efforts could include reality
orientation, distraction techniques, or other less restrictive therapeutic means. Physical or chemical
restraint should be a last resort technique.
EMT
A
P
A‐EMT
Paramedic
Procedure:
1)
Attempt less restrictive means of managing the patient.
2)
Ensure that there are sufficient personnel available to physically restrain the patient safely
3)
A
P
Restrain the patient in a lateral or supine position. No devices such as
backboards, splints, or other devices will be on top of the patient.
The patient will never be restrained in the prone position
4)
5)
9)
The patient must be under constant observation by the EMS crew at all times. This includes direct
visualization of the patient as well as cardiac, pulse oximetry and capnography monitoring as
indicated.
The extremities that are restrained will have a circulation check at least every 15 minutes. The first
of these checks should occur as soon after placement of the restraints as possible. This MUST be
documented on the PCR.
If the above actions are unsuccessful, or if the patient is resisting the restraints, consider chemical
restraint per protocol.
If a patient is restrained by law enforcement personnel with handcuffs or other devices EMS
personnel cannot remove, a law enforcement officer must accompany the patient to the hospital in
the transporting EMS vehicle.
Consider Behavioral protocol.
10)
Restraining a patient in the prone position is never authorized.
6)
7)
8)
Service MD Approval:______
Procedure 31
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243
Procedure
EMT
Clinical Indications:
Need for spinal immobilization as determined by protocol
Procedure:
A
P
A‐EMT
Paramedic
A
P
1)
Gather a backboard, straps, c-collar appropriate for patient’s size, tape, and head rolls or similar
device to secure the head.
2)
Explain the procedure to the patient.
3)
Apply an appropriately sized c-collar while maintaining in-line stabilization of the c-spine.
This stabilization, to be provided by a second rescuer, should not involve traction or tension but
rather simply maintaining the head in a neutral, midline position while the first rescuer applies the
collar. This may be performed by any credentialed responder if indicated by protocol.
4)
Once the collar is secure, the second rescuer should still maintain their position to ensure
stabilization (the collar is helpful, but will not do the job by itself).
5)
If the patient is supine or prone, consider the log roll technique. For the patient in a vehicle or
otherwise unable to be placed prone or supine, place them on a backboard by the safest method
available that maximizes maintenance of in-line spinal stability.
6)
Stabilize the patient with straps and head rolls/tape or other similar device. Once the head is
secured to the backboard, the second rescuer may release manual in-line stabilization.
7)
NOTE: Some patients, due to size or age, will not be able to be immobilized through in-line
stabilization with standard backboards and C-collars. Never force a patient into a non-neutral
position to immobilize them. Such situation may require a second rescuer to maintain manual
stabilization throughout the transport to the hospital.
8)
Document the time of the procedure in the PCR.
Service MD Approval:______
Procedure 32
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244
Procedure
EMS providers must use extreme caution when evaluating and treating an injured football player, especially when
the extent of the injury remains unknown. Suspect any unconscious football player to have an accompanying
spinal injury until proven otherwise. If the football player isn’t breathing or the possibility of respiratory arrest
exists, its essential that certified athletic trainers and EMS providers work quickly and effectively to remove the
face mask and administer care. In most situations, the helmet should not be removed in the field. Proper
management of head and neck injuries includes leaving the helmet and shoulder pads in place whenever possible,
removing only the face mask from the helmet and developing a plan to manage head-and-neck injured football
players using well-trained sports medicine and EMS providers.
EMT
Guidelines and Recommendations:
The following guidelines and recommendations were developed by the
Inter-Association Task Force for the Appropriate Care of the Spine-Injured Athlete:
A
P
A‐EMT
Paramedic
A
P
General Guidelines for Care Prior to Arrival of EMS
□ The Emergency Medical Services system should be activated.
□ Any athlete suspected of having a spinal injury should not be moved and should be managed as
though a spinal injury exists.
□ The athlete’s airway, breathing and circulation, neurological status and level of consciousness
should be assessed.
□ The athlete should NOT be moved unless absolutely essential to maintain airway, breathing and
circulation
□ If the athlete must be moved to maintain airway, breathing and circulation, the athlete should be
placed in a supine position while maintaining spinal immobilization
□ When moving a suspected spine injured athlete, the head and trunk should be moved as a unit.
one accepted technique is to manually splint the head to the trunk.
Face Mask Removal
□ The face mask should be removed prior to transpiration, regardless of current respiratory status
(see figure 1)
□ Those involved in the pre-hospital care of injured football players must have the tools for face
mask removal readily available.
Indications for Football Helmet Removal:
The athletic helmet and chin straps should only be removed if:
□ The helmet and chin strap do not hold the head securely, such that immobilization of the helmet
does not also immobilize the head
□ The design of the helmet and chin strap is such that even after removal of the face mask the
airway cannot be controlled, or ventilation be provided.
□ The face mask cannot be removed after a reasonable period of time
□ The helmet prevents immobilization fro transportation in an appropriate position.
Service MD Approval:______
Procedure 33-1
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245
Procedure
EMT
A
P
A‐EMT
A
P
Paramedic
Helmet Removal:
If it becomes absolutely necessary, spinal immobilization must be maintained while removing the
helmet.
□ Helmet removal should be frequently practiced under proper supervision by an EMS supervisor
or Training Division.
□ Due to the varying types of helmets encountered, the helmet should be removed with close
oversight by the team athletic trainers and/or sports medicine staff
□ In most circumstances, it may be helpful to remove cheek padding and/or deflate air padding
prior to helmet removal.
Spinal Alignment:
Appropriate spinal alignment must be maintained during care and transport using backboard, straps,
tape, head blocks or other necessary equipment.
□ Be aware that the helmet and shoulder pads elevate an athlete’s trunk when in the supine
position
□ Should either be removed, or if only one is present, appropriate spinal alignment must be
maintained.
□ The front of the shoulder pads can be opened to allow access for CPR and defibrillation.
Service MD Approval:______
Procedure 33-2
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246
Procedure
EMT
A
P
A‐EMT
Paramedic
A
P
Clinical Indications:
Immobilization of an extremity for transport, either due to suspected fracture, sprain or injury.
Immobilization of an extremity for transport to secure medically necessary devices such as
intravenous catheters.
Procedure:
1)
Assess and document pulses, sensation, and motor function prior to placement of the splint. If no
pulses are present and a fracture is suspected, consider reduction of the fracture prior to
placement of the splint.
2)
Remove all clothing from the extremity
3)
Select a site to secure the splint both proximal and distal to the area of suspected injury, or the
area where the medical device will be placed.
4)
Do not secure the splint directly over the injury or device
5)
Place the splint and secure with Velcro, straps or bandage material (ie. Kling, kerlex, cloth
bandage, etc.) depending on the splint manufacturer and design
6)
Document pulses, sensation and motor function after placement of the splint. If there has been a
deterioration in any of these 3 parameters, reposition the splint and reassess. If no improvement,
remove splint.
7)
If a femur fracture is suspected and there is no evidence of pelvic fracture or instability, place a
traction splint
8)
Consider pain management per protocol
9)
Document the time, type of splint, and the pre and post assessment of pulse, sensation and motor
function in the PCR.
Service MD Approval:______
Procedure 34
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247
Procedure
Clinical Indications:
EMT
Suspected stroke patient.
A
P
Procedure:
A‐EMT
Paramedic
A
P
1)
Assess and treat suspected stroke patients as per protocol
2)
The Cincinnati Stroke Screen should be completed for all suspected stroke patients
3)
Establish the “time last normal” for the patient. This will be the presumed time of onset.
4)
Perform the screen through physical exam:
□ Look for facial droop by asking the patient to smile
□ Have patient, while sitting upright or standing, extend both arms parallel to floor, close eyes, and
turn their palms upward. Assess for unilateral drift of an arm.
□ Have the person say, "You can't teach an old dog new tricks," or some other simple, familiar
saying. Assess for the person to slur the words, get some words wrong, or inability to speak.
5)
One of these exam components must be positive to answer “yes”
6)
Evaluate Blood Glucose level results
7)
If the “time last normal” is less than 24 hours, blood glucose is between 60 and 400, and at least
one of the physical exam elements is positive, follow the Suspected Stroke Protocol, alerting the
receiving hospital of a possible stroke patient as early as possible.
8)
All sections of the Cincinnati screen must be completed.
9)
The complete screening should be documented in the PCR.
Service MD Approval:______
Procedure 35
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248
Procedure
EMT
A
P
A‐EMT
Paramedic
Clinical Indications:
Monitoring body temperature in a patient with suspected infection, hypothermia, hyperthermia, or to
assist in evaluating resuscitation.
Procedure:
1)
If clinically appropriate, allow the patient to reach equilibrium with the surrounding environment.
2)
Leave the device in place until there is indication of an accurate temperature acquisition (per the
“beep” or other indicator specific to the device)
3)
Record time, temperature, method (tympanic, rectal or oral), and scale (C° or F°) in PCR
Service MD Approval:______
Procedure 36
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249
A
P
Procedure
(CAT‐Combat Application Tourniquet)
EMT
A
P
A‐EMT
Paramedic
A
P
Clinical Indications:
Extremity injury/amputation with uncontrollable hemorrhage despite aggressive direct pressure.
Procedure:
Apply tourniquet device as proximal on extremity as possible, minimum of 2" proximal to hemorrhage
site. (see procedure below)
Secure in place and expedite transport to Level 1 Trauma Center
Document time placed in patient care report and on device (if possible)
Notify receiving center of presence, time placed, and location of tourniquet
1) Route the Self-Adhering Band around the extremity and pass the free-running end of the band through
the inside slit of the friction adaptor buckle
2) Pass the band through the outside slit of the buckle, utilizing the friction adaptor buckle which will lock
the band in place.
Service MD Approval:______
Procedure 14-1
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250
Procedure
(CAT‐Combat Application Tourniquet)
3) Pull the Self-Adhering Band tight and securely fasten the band back on itself.
EMT
A
P
A‐EMT
Paramedic
A
P
4) Twist the rod until bright red bleeding has stopped.
5) Lock the rod in place with the Windlass Clip™
6) Hemorrhaging is now controlled.
Secure the rod with the strap: Grasp the
Windlass Strap™, pull it tight and adhere it
to the opposite hook on the Windlass Clip™
**IF needed a second tourniquet can be
added more proximal
Service MD Approval:______
Procedure 14-2
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251
Procedure
EMT
A
P
A‐EMT
Paramedic
A
P
Patients with major trauma (one or more of the following) should be transported to UW Hospital:
Patient unresponsive to voice and/or GCS <12
Adult unstable vital signs (BP<90mmHg, HR >120 or <60, Respirations <10 or >30)
Pediatric unstable vital signs
Heart Rate
Less than 1 year <90 or >205
1 to 5 years
<70 or >140
5 to 12 years
<60 or >140
Systolic BP
<60
<70
<80
Respirations
<20 or >80
<16 or >30
<12 or >30
Clinical signs of shock
Penetrating injuries to head, neck, torso, groin or extremity with signs of distal vascular compromise
Flail chest or pelvic fracture
Burns >15% TBSA and/or airway involvement
Two or more proximal long bone fractures (humerus, femur)
Signs of spinal cord injury
Amputation injuries proximal to the wrist or ankle
Significant mechanism of injury in a pregnant patient
Consider transport to UW ED for patients with the following mechanisms of injury and medical
conditions:
Ejection from an automobile during a motor vehicle crash
Death of another patient in the same auto
Extrication time of greater than 20 minutes
Falls:
□ Children >10 feet (2-3x’s patient height)
□ Adults >20 feet
Victim of a high speed auto crash (impact speed of greater than 40 mph, major auto deformity, intrusion
of auto damage into the passenger compartment)
Auto-pedestrian or auto-bicycle injury with significant (>20mph) speed
Pedestrian thrown or run over
Motorcycle crash of greater than 20 mph, or separation of rider from bike
Age of less than 5 or greater than 55 years old
Patient with cardiac or respiratory disease
Major trauma patient with immune system problems
Major trauma patient with bleeding disorder, or currently taking an anticoagulant medication.
Note: Above reference is from the Wisconsin Trauma Field Triage Protocol
Service MD Approval:______
Procedure 37
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252
Procedure
P
Paramedic
P
Clinical Indications:
Access of an existing venous catheter for medication or fluid administration in a life threatening
situation when no other access is available
Central venous access in a patient in cardiac arrest
Contraindications:
Non-externalized ports (subcutaneous or tunneled ports)
Procedure:
1)
Clean the port of the catheter with alcohol wipe
2)
Using sterile technique, withdraw 5-10cc of blood and place syringe in sharps box
3)
Using 5cc normal saline, access the port with sterile technique and gently attempt to flush the
saline
4)
If there is no resistance, no evidence of infiltration (ie. no subcutaneous, collection of fluid), and no
pain experienced by the patient, then proceed to step 5. If there is resistance, evidence of
infiltration, pain experienced by the patient, or any concern that the catheter may be clotted or
dislodged, do not use the catheter.
5)
Begin administration of medications or IV fluids slowly. Observe for any signs of infiltration. If
difficulties are encountered, stop the infusion and reassess.
6)
Record procedure, any complications, and fluids/medications administered in the PCR.
Service MD Approval:______
Procedure 38
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253
Procedure
A
A‐EMT
Clinical Indications:
P Paramedic
Patients requiring IV medications or fluids
Patients with any potential for deterioration (ie. seizures, altered mentation, trauma, chest pain,
difficulty)
A
P
Contraindications:
Child with partial airway obstruction (ie. Suspected epiglotitis) – when agitation from performing
procedure may worsen respiratory difficulty.
Equipment:
Appropriate tubing or IV lock
#14-#24 catheter over the needle, or butterfly needle
Venous tourniquet
Antiseptic swab
Gauze pad or adhesive bandage
Tape or other securing device
Procedure:
1)
Saline locks may be used as an alternative to IV tubing and fluid at the discretion of the paramedic
2)
Paramedics and A-EMT can use intraosseous access where threat to life exists as provided for in
the Venous Access – Intraosseous procedure.
3)
Use the largest catheter bore necessary based upon the patient’s condition and size of veins
4)
Fluid and setup choice is preferably:
□ Normal Saline with a macro drip (10-gtt/cc) for medical/trauma conditions.
□ Normal Saline with a micro drip (60gtt/cc) for medication infusions or for patients where fluid
overload is of concern.
5)
Assemble IV solution and tubing:
□ Open IV bag and check for clarity, expiration date, etc.
□ Verify correct solution
□ Open IV tubing
□ Assemble IV tubing according to manufacturer's guidelines
6)
Insertion
□ Explain to the patient that an IV is going to be started.
□ Place the tourniquet around the patient's arm proximal to the IV site, if appropriate
□ Palpate veins for resilience
□ Clean the skin with the antiseptic swab in an increasing sized concentric circle and follow it with
an alcohol swab
□ Stabilize the vein distally with the thumb/fingers
□ Enter the skin with the bevel of the needle facing upward
□ Enter the vein, obtain a flash, and advance the catheter into the vein while stabilizing the
needle.
□ Remove the needle while compressing the proximal tip of the catheter to minimize blood loss
Continued on next pageService MD Approval:______
Procedure 39-1
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254
Procedure
6)
7)
A
A
A‐EMT
Insertion (continued)
P Paramedic P
□ Remove the tourniquet
□ Connect IV tubing to the catheter, or secure the IV lock to the catheter and flush with appropriate
solution (normal saline)
□ Open the IV clamp to assure free flow
□ Set IV infusion rate.
Secure the IV:
□ Secure the IV catheter and tubing
□ Recheck IV drip rate to make sure it is flowing at appropriate rate.
□ Troubleshooting the IV, (if the IV is not working well):
• Make sure the tourniquet is off
• Check the IV insertion site for swelling
• Check the IV tubing clamp to make sure it is open
• Check the drip chamber to make sure it is half full
• Lower the IV bag below IV site and watch for blood to return into the tubing
External Jugular IV Access:
Contraindications:
● Anterior neck hematoma
● Anterior neck mass
● Medical appliance in place covering anterior neck
● Previous Surgical Procedure of anterior neck
P
Paramedic
P
□ If extremity IV attempts are unsuccessful, reconsider need for IV access.
□ If patient hypotensive, but alert and responsive to pain – consider external jugular vein IV access.
If patient unstable, go directly to Intraosseous access.
□ Monitor for complications
▪ Expanding hematoma
▪ Tracheal shift
▪ Difficulty breathing
▪ Increase in pain
Service MD Approval:______
Procedure 39-2
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255
Procedure
Clinical Indications:
Patients where rapid, regular IV access if unavailable with any of the following:
Cardiac Arrest
CCR – IO is preferable
Multisystem trauma with severe hypovolemia
Severe dehydration with vascular collapse and/or loss of consciousness
Respiratory failure/respiratory arrest
A
P
A‐EMT
Paramedic
A
P
Contraindications:
Fracture proximal to proposed intraosseous site.
History of Osteogenesis Imperfecta
Current or prior infection at proposed intraosseous site
Previous intraosseous insertion or joint replacement at the selected site.
Procedure:
1)
Identify anteromedial aspect of the proximal tibia (bony prominence below the knee cap). The
insertion location will be 1-2 cm (2 finger widths) below this.
2)
Cleanse the site
3)
For manual pediatric devices, hold the intraosseous needle at a 60-90° angle, aimed away form
the nearby joint and epiphyseal plate, twist the needle handle with a rotating grinding motion
applying controlled downward force until a “pop” or “give” is felt indicating loss of resistance. Do
not advance the needle any further
4)
For the EZ-IO intraosseous device, hold the intraosseous needle at a 60-90° angle, aimed away
from the nearby joint and epiphyseal plate, power the driver until a “pop” or “give” is felt indicating
loss of resistance. Do not advance the needle any further.
5)
Remove the stylette and place in an approved sharps container
6)
Attach a 12cc syringe filled with 5cc NS; aspirate bone marrow to verify correct placement, then
inject 5cc of NS to clear the lumen of the needle.
7)
Attach the IV line. Use a pressure bag
8)
Stabilize and secure the needle with dressings and tape
9)
Paramedics may administer 10-20mg (1-2cc) of 2% Lidocaine in adult patients who experience
infusion related pain.
10)
Following the administration of IO medications, flush the IO line with 10cc of IV fluid to expedite
medication absorption.
11)
Document the procedure, time, and result (success) on/with the PCR.
Service MD Approval:______
Procedure 40
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
256
Procedure
Clinical Indications:
Protection of open wounds prior to and during transport
EMT
A
P
A‐EMT
Paramedic
A
P
Procedure:
1)
If active bleeding, elevate the affected area if possible and hold direct pressure. Do not rely on
compression bandage to control bleeding. Direct pressure is much more effective.
2)
Once bleeding is controlled, irrigate contaminated wounds with saline as appropriate (this may
have to be avoided if bleeding was difficult to control).
3)
Cover wounds with sterile gauze/dressings. Check distal pulses, sensation, and motor function to
ensure the bandage is not too tight.
4)
Monitor wounds and/or dressing throughout transport for bleeding
5)
Consider tourniquet use as indicated in protocol/procedure
6)
Document the wound assessment and care in the PCR
Service MD Approval:______
Procedure 41
Any local EMS Agency changes to this document must follow the DCEMS Protocol Change Policy and be approved by WI EMS
257
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Table of Contents: Authorized Pharmaceuticals
Overview...................................................................................................... D-3
Adenosine (Adenocard®) ............................................................................. D-4
Albuterol Sulfate (Proventil, Ventolin ) ........................................................ D-5
Amiodarone (Cordarone®) ........................................................................... D-6
Acetylsalicylic Acid (Aspirin®)....................................................................... D-8
Atropine Sulfate (As a Cardiac Agent) ......................................................... D-9
Atropine Sulfate (As an Antidote for Poisonings) ......................................... D-11
Calcium Chloride.......................................................................................... D-13
Dextrose ...................................................................................................... D-14
Diazepam..................................................................................................... D-15
Diltiazem (Cardizem®).................................................................................. D-16
Diphenhydramine Hydrochloride (Benadryl®) .............................................. D-18
Dopamine Hydrochloride (Intropin ®)............................................................ D-20
DuoDote Kit (see Mark 1 Kit) ....................................................................... D-43
Epinephrine Hydrochloride (1:1,000) ........................................................... D-23
Epinephrine Hydrochloride (1:10,000) ....................................................... D-25
Adult Epinephrine Dosing Summary ............................................................ D-27
Pediatric Epinephrine Dosing Summary ...................................................... D-27
Etomidate..................................................................................................... D-28
Famotidine (Pepcid®) ................................................................................... D-29
Fentanyl ....................................................................................................... D-30
Glucagon ..................................................................................................... D-32
Glucose (Oral).............................................................................................. D-33
Haloperidol (Haldol ®)................................................................................... D-34
Hydroxocobalamin (Cyanokit®) ................................................................... D-36
Ipratropium bromide (Atrovent®) .................................................................. D-37
Ketamine...................................................................................................... D-38
Lidocaine Hydrochloride (Xylocaine®).......................................................... D-39
Lorazepam (Ativan ®) ................................................................................... D-40
Magnesium Sulfate ...................................................................................... D-41
Mark 1 Kit..................................................................................................... D-43
Methylprednisolone (Solumedrol®)............................................................... D-44
Midazolam (Versed®) ................................................................................... D-45
Morphine Sulfate.......................................................................................... D-47
Naloxone (Narcan ®) .................................................................................... D-49
Nitroglycerin (Nitrostat ®).............................................................................. D-51
Ondansetron Hydrochloride (Zofran®).......................................................... D-53
Rocuronium ................................................................................................. D-54
Sodium Bicarbonate..................................................................................... D-55
Succinylcholine ............................................................................................ D-56
Vasopressin ................................................................................................. D-59
260
Overview
The purpose of this document is to serve as a drug information supplement and to provide a brief
description of the prehospital drugs used. This document in no way represents the comprehensive
drug knowledge required for use of these medications by paramedic practitioners. The
comprehensive information about use of these medications by practicing paramedics, requires
reference to other sources, including, but not limited to, pharmacological textbooks, the DOT
curriculum, the Physician’s Desk Reference, paramedic text book (e.g. Prehospital Emergency
Care, Paramedic Care: Principles and Practice, BTLS, PHTLS), American Heart Association
publications (e.g., ACLS, PALS, NALS), etc.
Drugs are listed alphabetically, based on their generic names (brand names are shown in
parenthesis).
Michael T. Lohmeier, MD, FACEP
Medical Director
Dane County EMS
261
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278
279
280
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282
283
284
285
286
287
288
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292
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295
296
297
298
299
300
301
302
303
304
305
306
307
308
309
310
311
312
313
314
315
A&Ox3
A&Ox4
A‐FIB
AAA
ABC
ABD
ACLS
AKA
ALS
AMA
AMS
AMT
APPROX
ASA
ASSOC
Alert and Oriented to Person, Place and Time
Alert and Oriented to Person, Place, Time and Event
Atrial Fibrillation
Abdominal Aortic Aneurysm
Airway, Breathing, Circulation
Abdomen
Advanced Cardiac Life Support
Above the Knee Amputation
Advanced Life Support
Against Medical Advice
Altereed Mental Status
Amount
Approximately
Aspirin
Associated
BG
BILAT
BKA
BLS
BM
BP
BS
BVM
Blood Glucose
Bilateral
Below the Knee Amputation
Basic Life Support
Bowel Movement
Blood Pressure
Breath Sounds
Bag‐Valve‐Mask
C‐SECTION
C‐SPINE
C/O
CA
CABG
CAD
CATH
CC
CEPH
CHF
CNS
COPD
CP
CPR
CSF
CT
CVA
Caesarean Section
Cervical Spine
Complains Of
Cancer
Coronary Artery Bypass Graft
Coronary Artery Disease
Catheter
Chief Complaint
Cephalic
Congestive Heart Failure
Central Nervous System
Chronic Obstructive Pulmonary Disease
Chest Pain
Cardiopulmonary Resuscitation
Cerebrospinal Fluid
Cat Scan
Cerebrovascular Accident (stroke)
316
D5W
DKA
DNR
DOA
DT
Dx
5% Dextrose in Water
Diabetic Ketoacidosis
Do Not Resuscitate
Dead on Arrival
Delirium Tremens
Diagnosis
EKG
EEG
ET
ETOH
ETT
EXT
Electrocardiogram
Electroencephelogram
Endotracheal
Ethanol (alcohol)
Endotracheal Tube
External (extension)
FB
FLEX
Fx
Foreign Body
Flexion
Fracture
g
GI
GSW
gtts
GU
GYN
gram(s)
Gastrointestinal
Gunshot Wound
drops
Gastrourinary
gynecology (gynecological)
H/A
HEENT
HR
HTN
Hx
Headache
Head, Eyes, Ears, Nose, Throat
Heart Rate (hour)
Hypertension
History
ICP
ICU
IM
IV
JVD
kg
KVO
Intracranial Pressure
Intensive Care Unit
Intramuscular
Intraveneous
Jugular Vein Distension
kilogram
Keep Vein Open
L‐SPINE
L/S‐SPINE
L&D
LAT
lb
LLQ
LMP
LOC
LR
LUQ
MAST
mcg
MED
mg
MI
min
MS
MVC
MVA
Lumbar Spine
Lumbarsacral spine
Labor and Delivery
Lateral
pound
Left Lower Quadrant
Last Menstrual Period
Level of Consciousness (loss of consciousness)
Lactated Ringers
Left Upper Quadrant
Military anti‐shock trousers
microgram(s)
Medicine
miligram(s)
Myocardial Infarction (heart attack)
minimum/minute
Mental Status
Motor Vehicle Crash
Motor Vehicle Accident
N/V
N/V/D
NAD
NC
NEB
NKDA
NRB
NS
NSR
OB/GYN
PALP
PAC
PE
PERRL
PMHx
PO
PRN
PT
PVC
Nausea/Vomiting
Nausea/Vomiting/Diarrhea
No Apparent Distress
Nasal Cannula
Nebulizer
No Known Drug Allergies
Non‐Rebreather
Normal Saline
Normal Sinus Rhythm
Obstetrics/Gynecology
Palpation
Premature Atrial Contraction
Pulmonary Embolus
Pupils Equal. Round, Reactive to Light
Past Medical History
Orally
as needed
Patient
Premature Ventricular Contraction
317
RLQ
RUQ
Rx
Right Lower Quadrant
Right Upper Quadrant
Medicine
S/P
SOB
SQ
ST
SVT
Sx
SZ
Status Post
Shortness of Breath
Subcutaneous
Sinus Tachycardia
Supraventricular Tachycardia
Symptom
Seizure
T‐SPINE
Temp
TIA
TKO
Tx
Thoracic Spine
Temperature
Transient Ischemic Attack
To keep Open
Treatment
UOA
URI
UTI
Upon our Arrival
Upper Respiratory Infection
Urinatry Tract Infection
VF
VS
VT
Ventricular Fibrillation
Vital Signs
Ventricular Tachycardia
WAP
WNL
Wandering Atrial Pacemaker
Within Normal Limits
YO (YOA)
Years Old (Years of Age)
+
‐
?
~
>
<
=
Positive
Negative
Questionable
Approximately
Greater Than
Less Than
Equal
318
319
12‐Lead EKG
204
Abdominal Pain
23
Acute Dystonic
108
Decontamination
226
Defibrillation ‐ Automated
227
Defibrillation ‐ Manual
228
Adult ‐ Airway Management
30
Destination
11
Adult ‐ Dyspnea
25
DNR
18
Airway Obstruction
205
Endotracheal Tube Indroducer
229
Airway Orotracheal Intubation
206
Envenomations
48
Airway Suctioning ‐ Advanced
211
Excited Delirium
46
Airway Suctioning ‐ Basic
210
External Cardiac Pacing
230
Airway Video Laryngoscopy
208
Extremity Trauma
148
Allergic Reaction
40
Eye Trauma
147
Altered Mental Status
43
GI Bleeding
23
81
Antidepressants
106
Hazardous Material
Antipsychotics
108
Head Trauma
144
Asystole
52
Hypertensive
89
Atrial Fibrillation
65
Hyperthermia
91
Atrial Flutter
65
Hypothermia
93
Behavioral
46
Induced Hypothermia
60
Beta Blocker
Bites
Blood Glucose Analysis
Bradycardia
109
48
212
67
Intercept
10
Interfacility
14
Intravenous Access
95, 253, 254, 256
King LTS‐D
237
Burns
140
Labor
102
Calcium Channel Blockers
110
LMA ‐ Laryngeal Mask Airway
231
Carbon Monoxide
111
MAD ‐ Mucosal Atomizer Device
235
Carboxyhemoglobin SpCO Monitoring
213
MCI ‐ Mass Casualty Incident
234
Cardiac Arrest
Nerve Agent
87
Cardiac Arrest ‐ Traumatic
151
50
Obstetrics
96
Cardioversion
214
Opiate
114
CCR ‐ Cardiocerebral Resuscitation
215
Organophosphates
107
Chest Decompression
220
Orogastric Tube Insertion
236
Chest Trauma
143
Overdose
104
Pain
115
Chest Pain
77
Childbirth
102
Paramedic
Childbirth Complications
222
Pediatric ‐ Burns
196
Childbirth Procedure
221
Pediatric ‐ Airway Management
163
Cholinergic
107
Pediatric ‐ Allergic Reactions
166
Cocaine
113
Pediatric ‐ Altered Mental Status
168
10
CPAP
223
Pediatric ‐ ALTE
170
CPR ‐ Cardiopulmonary Resuscitation
224
Pediatric ‐ Bradycardia
176
Cricothyrotomoy
225
Pediatric ‐ Cardiac Arrest
171
Pediatric ‐ Dyspnea
160
Cyanide
84
Pediatric‐ General
159
Pediatric ‐ Head Injuries
200
Tricyclic
106
Pediatric ‐ Narrow Complex Tachycardia (SV
180
Venous Access ‐ Existing
253
Pediatric ‐ Newborn Resuscitation
183
Venous Access ‐ Extremity
254
Pediatric ‐ Overdose, Poisoning, Or Ingestion
186
Venous Access ‐ Intraosseous
256
Pediatric ‐ Pain Management
188
Ventricular Fibrillation
56
Pediatric ‐ Seizure
191
Wide‐Complex Tachycardia
72
Pediatric ‐ Trauma
194
WMD
87
Pediatric ‐ Wide Complex Tachycardia
179
Wound Care
Perinatal Emergencies
Pharmaceuticals
96
259
Physician
12
Poisonings
104
Policy Custody
118
Polymorphous Ventricular Tachycardia
75
Post‐Resuscitation
58
Pulse Oximetry
Pulseless Electrical Activity (PEA)
Radio Report
Rapid Sequence Airway
Refusal
241
54
15
33, 242
120, 122, 123
Restraints
243
Sedation
124
Seizure
125
Sexual Assault
153
Shock (Non‐Trauma)
128
Spinal Immobilization ‐ Protocol
154, 244
Spinal Immobilization ‐ Football Players
245
Splinting
247
Stroke
Supraventricular Tachycardia
131, 248
70
Sympathomimetic
113
Syncope
134
Taser
119
Temperature Measurement
249
Termination of Resuscitation
63
Tetracyclic
106
Tourniquet
250
Trauma
137
Trauma Guidelines
252
257