PEDIATRIC PROTOCOLS
THE PEDIATRIC PATIENT
Definitions:
Newborn - birth to 30 days
Infant - 30 days to one year
Child - One year to 12 years or up to 75 pounds or 34 kilograms
Focused history - The history and physical exam for pediatric patients differs in some areas
from the adult. Areas that might get more emphasis are:
PMH - allergies, medications, prematurity, prenatal care, birth weight
Neuro - feeding well, level of activity, alertness
Cardiac - palpations, chest pain
Respiratory - retractive breathing, appearance of shortness of breath, previously on a ventilator,
wheezing, barking noises
GI - vomiting, diarrhea
GU - urine volume, (wetting diapers); urine color, smell; crying on urination
Skin - color, turgor, rash
Extremities - movement, reflexes
General - eye movement, strength, moist mucosa
.INFUSIONS
Epinephrine
Infusion
Dopamine
Infusion
0.6 X body weight (kg)
equals milligrams added
To diluent to make 100 ml
0.6 X body weight (kg) equals
milligrams added to diluent
To make 100 ml Total
1 ml/h delivers 0.1 ug/kg
per minute; titrate to effect
1 ml/h delivers 1.0 ug/kg
per minute; titrate to effect
CHART
Age
Newborn
1-6
6 Months
1 Year
3 Years
6 Years
10 Years
Weight
lbs
kgs
7
3.5
7
3.5
15
7
22
10
33
15
40
18
60
28
Systolic BP
Pulse
Respiration
50-70
70-95
80-100
80-100
80-110
80-110
90-120
100-160
100-160
90-120
90-120
80-120
70-110
60-90
30-60
30-60
25-40
20-30
20-30
18-25
15-20
Pediatric hypotension is defined as: newborn to 30 days - systolic BP < or = 60; 1 month to 1
year - SBP < or = 70; over 1 year < or = 70 + ( 2 + age in years)
Since it is difficult to measure blood pressures on children less than 1 year, other signs
of shock should be assessed. These include delayed capillary refill; rapid heart rate;
pale, cool, clammy skin; weak or absent peripheral pulses; altered level of
consciousness.
PEDIATRIC BRADYCARDIA
Criteria For Use
Pediatric patient with symptomatic bradycardia, i.e. hypotension, poor perfusion, respiratory
difficulty and/or diminished level of consciousness. Pediatric bradycardia would be a heart rate
of: <100 Newborn; <80 Infant; <60 Child; due to Sinus bradycardia, 1st. 0 , 2nd 0 or 3rd 0
heart block or ventricular escape beats.
Pediatric hypotension is defined as: Newborn to 30 days systolic blood pressure < or =60;
1 month to 1 year systolic blood pressure <or =70; over 1 year systolic blood pressure of
< or =70 +(2+age in years)
ALS Provider Guidelines:
1. Perform initial survey - resuscitate as needed
2. Secure Airway; administer appropriate oxygen
3. Perform chest compressions if bradycardia continues despite oxygenation and ventilation.
A. Heart rate < 60/minute for newborn, infant or child with associated poor systemic perfusion.
B. Infant with heart rate 60-80 per minute that does not increase despite effective positive
pressure ventilation with 100 % oxygen over 30 seconds.
4. Initiate cardiac monitoring
5. Initiate an appropriate IV
6. Utilize length based tape, Broselow tape, or other similar devices to calculate medication
dosages or for estimated weight or use the current known accurate weight of the patient.
7. Administer epinephrine 0.01 mg/kg,(1:10,000, 0.1mL/kg) IV or IO. If administered via ET,
0.1mg/kg (1:1000, 0.1 mL/mg). Repeat q 3-5 minutes.
------Contact Medical Command-----Command Physician’s Actions Might Include:
1. Order IO access
2. Second and subsequent doses epinephrine IV or IO,0.01mg/kg, (1:10,000, 0.1mL/kg) or ET,
0.1 mg/kg (1:1,000,0.1mL/kg). Repeat q 3-5 minutes.
3. Order atropine 0.02 mg/kg
minimum dose: 0.1 mg
maximum single dose: 0.5 for child; 1 mg adolescent
May be repeated x 1
4. Consider external pacing
5. Order Epinephrine infusion or Dopamine infusion to maintain blood pressure
See chart.
Expeditious transport after initial resuscitation efforts is recommended.
PEDIATRIC PULSELESS ELECTRICAL ACTIVITY
Criteria For Use
Management of a pulseless pediatric patient with presence of some type of electrical activity on the
monitor, including EMD, idioventricular rhythm, ventricular escape rhythms, bradysystolic rhythms, and
tachycardic narrow complex rhythms.
This does not include ventricular tachycardia without a pulse. Refer to protocol for pulseless ventricular
tachycardia where appropriate.
ALS Provider Guidelines:
1. Perform initial survey - resuscitate as needed
2. Secure airway; intubate
3. Hyperventilate with 100% oxygen
4. Confirm cardiac rhythm in more than 1 lead
5. Initiate appropriate IV; (limit: 2 attempts or 60 seconds. If unsuccessful,
administer first dose of Epinephrine via endotracheal tube
6. If unable to intubate or initiate and IV, and the patient is four years old or
less, initiate an intraosseous line, while enroute to the hospital. Use one leg
only for attempt.
7. Utilize length-based, Broselow tape, or other similar devices to calculate
medication dosages or to estimate weight or use current known accurate
weight of pediatric patient.
8. Administer epinephrine, first dose
IV or IO: 0.01 mg/kg (0.1 ml/kg 1:10,000)
ET: 0.1 mg/kg (0.1 ml/kg 1:1000)
9. Prepare for transport
------Contact Medical Command-----Command Physician’s Actions Might Include:
1. Order Intraosseous (IO) access
2. Order fluid challenge of 20 cc/kg
Newborn to 30 days - 10cc/kg
3. Consider earlier treatment for other causes; i.e. hypovolemia, cardiac
tamponade, tension pneumothorax, hypoxia, acidosis, pulmonary embolus,
profound hypothermia, poisoning by drug overdose
4. Second and subsequent doses of epinephrine IV, IO ET, 0.1 mg/kg,1:1,000,
(0.1ml/kg). Repeat q 3-5 minutes maximum of 1mg.
5. Order atropine 0.02 mg/kg
minimum dose: 0.1 mg
maximum single dose: 0.5 for child; 1 mg adolescent
May be repeated x 1
Expeditious transport after initial resuscitation efforts is recommended
PEDIATRIC ASYSTOLE
Criteria For Use
Management of pulseless pediatric patient with straight line EKG confirmed in 2 leads
ALS Provider Guidelines:
1. Perform initial survey - resuscitate as needed
2. Secure airway and hyperventilate
3. Initiate cardiac monitoring
4. Initiate appropriate IV; (limit: 2 attempts or 60 seconds. If unsuccessful, administer
first dose of Epinephrine via endotracheal tube.
5. If unable to intubate or initiate IV, initiate an IO line if the patient is four years old
or less, enroute to the hospital. Use one leg only for attempt.
6. Use length-based, Broselow tape or other similar devices to calculate medication
dosages or for estimated weight or use current known accurate weight of the patient
7. Administer epinephrine, first dose IV: 0.01 mg/kg,1:10,000, (0.1 ml/kg ET: 0.1
mg/kg,1:1000, (0.1 ml/kg)
8. Prepare for transport
------Contact Medical Command-----Command Physician’s Actions Might Include:
1. Order IO access
2. Order transcutaneous pacing
3. Order second and subsequent doses of IV, IO or ET epinephrine, 0.1 mg/kg (1:1000)
0.1 ml/kg, maximum of 1 mg
4. Order continuation of resuscitation efforts according to current pediatric guidelines
5. Order termination of resuscitative efforts
Expeditious transport after initial resuscitative efforts is recommended.
PEDIATRIC RAPID PULSE
NARROW COMPLEX TACHYARRHYTHMIAS
(Sinus Tachycardia)
Criteria For Use
Pediatric patient with EKG documented evidence of narrow complex ST and is symptomatic.
Heart rate of 160-220 bpm is probable ST; heart rate of > or = 220 bpm is probable SVT. Pediatric
tachycardia would be a heart rate of: newborn > or = 240; infant $ 220; child > or =180. See related
tachycardia protocol.
ALS Provider Guidelines:
1. Perform initial survey - resuscitate as needed
2. Secure airway and administer appropriate oxygen
3. Initiate cardiac monitoring
4. Obtain vital signs and focused patient history.
Pediatric hypotension is defined as: newborn to 30 days systolic BP < or = 60; 1
month - 1 year SBP < or = 70; over 1 year SBP < or =70 + (2 + age in years)
.
Pediatric symptomatic tachycardia, i.e. hypotension, poor perfusion, respiratory
difficulty, and/or diminished level of consciousness.
5. Determine if pediatric patient is stable or unstable. Go to appropriate protocol
------Contact Medical Command-----Command Physician’s Actions Might Include:
1. Order fluid challenge
2. Appropriate drug therapy
PEDIATRIC FAST PULSE
UNSTABLE SUPRAVENTRICULAR TACHYCARDIA
Narrow or Wide with Evidence of Cardiovascular Compromise SVT, VT, SVT with Aberrancy, Criteria For
Use
Pediatric patient with EKG documented evidence of narrow or wide complex
tachycardia with evidence of cardiovascular compromise: pediatric patient with
tachycardia with symptoms of hypotension (diaphoresis, pallor, cool mottled
extremities), poor perfusion, respiratory difficulty and/or diminished level of
consciousness.
Heart rate of > or = 220 bpm with symptoms for narrow complex
Heart rate of > or = 120bpm with symptoms for wide complex
Pediatric hypotension is defined as: newborn to 30 days - systolic BP < or = 60; 1 month
to 1 year - SBP < or = 70; over 1 year < or = 70 + ( 2 + age in years)
ALS Provider Guidelines:
1 Perform initial survey - resuscitate as needed
2. Secure airway; administer appropriate oxygen
3. Initiate cardiac monitoring
4. Assess vital signs; obtain focused patient history
5. Initiate appropriate IV; (limit: 2 attempts or 60 seconds.)
6. Utilize length based tape, Broselow tape, or other similar devices to calculate
medication dosages or for estimated weight or use the current known accurate
weight of the patient.
7. If stable, perform vagal maneuver:
Infant or cooperative child - stimulation of the diving reflex
Apply ice or extra cold wash cloth quickly and firmly to the patient’s
nose and mouth for five (5) seconds.
------Contact Medical Command------
Command Physician’s Actions Might Include:
1. Order Adenosine 0.1-0.2 mg/kg, maximum of 12 mg followed by 5-10 cc of fluid flush
2. Order synchronized cardioversion, 1 - 2 joules/kg. Second and subsequent
cardioversion is doubled from initial cardioversion to a maximum of 4 j/kg.
PEDIATRIC CARDIAC ARREST PULSELESS VENTRICULAR TACHYCARDIA
VENTRICULAR FIBRILLATION
Criteria For Use
Management of a pulseless pediatric patient with cardiac monitor showing ventricular fibrillation or ventricular tachycardia.
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed.
2. Administer appropriate oxygen. Begin CPR and ventilate until defibrillator is charged.
3. Initiate cardiac monitoring.
4. Utilize length based tape, Broselow tape, or other similar devices to calculate medication dosages or
to estimate weight or use current known accurate weight off patient.
5. If ventricular tachycardia or ventricular fibrillation are noted on monitor, Immediately defibrillate at 2
j/kg or 1 j/lb.
6. If no conversion, defibrillate at 4 j/kg or 2 j/lb.
7. If no conversion, defibrillate at 4 j/kg or 2 j/lb.
8. Intubate, if not already done. If not able to intubate, use BVM.
9. Initiate appropriate IV; (limit: 2 attempts or 60 seconds. If unsuccessful, administer first dose of
Epinephrine via endotracheal tube and contact medical command.
10. If unable to intubate or initiate an IV, initiate an IO, if the patient is four years old or less, while
enroute. Use one leg only for attempts
11. If vascular access is obtained, administer Epinephrine 0.01 mg/kg 1:10,000, (0.1 ml/kg). If
administered via ET, 0.1 mg/kg 1:1000, (0.1 ml/kg).
-----Contact Medical Command----Command Physician’s Actions Might Include:
1. Order intraosseous access
2. Defibrillate at 4 j/kg within 30-60 seconds if rhythm unchanged after each administration of medication.
3. Administer Lidocaine 1 mg/kg IV or IO, (maximum total dose 3 mg/kg)
4. Administer Epinephrine, second and subsequent doses IV, IO, ET at 0.1 mg/kg 1:1000, (0.1 ml/kg).
Repeat every 3-5 minutes.
5. Administer Bretylium 5 mg/kg first dose.
Expeditious transport after intubation and initiation of resuscitative efforts is recommended.
STABLE SUPRAVENTRICULAR TACHYCARDIA
IN THE PEDIATRIC PATIENT
Criteria for use
Management of the pediatric patient with ECG documentation of narrow or wide complex tachycardia who is stable.
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed
2. Administer appropriate oxygen.
3. Initiate cardiac monitoring.
4. Perform vagal maneuvers:
Infant or co-operative child - stimulate the diving reflex by applying ice or extra cold wash cloth quickly
and firmly to the patient’s nose and mouth for five (5) seconds.
5. Initiate appropriate IV. If unable to establish vascular access after 2 attempts or 60 seconds, contact
medical command immediately.
-----Contact Medical Command----Command Physician’s Actions Might Include:
1. Transport with close observation
2. Order additional IV attempts or intraosseous access.
3. Synchronized cardioversion at 1 j/kg may be ordered.
4. If no conversion, repeat synchronized cardioversion at 1 j/kg.
5. If vascular access is established, administer Adenosine 0.1-0.2 mg/kg rapid IV push, IO up to 6 mg.
6. Order repeat Adenosine at 0.2-0.4 mg/kg rapid IV push, IO up to 12 mg. (Maximum dose 12 mg.)
7. Order Lidocaine 1 mg/kg (Maximum total dose 3 mg/kg)
Expeditious transport after initiation of resuscitation efforts is recommended.
DYSPNEA/ASTHMA IN THE PEDIATRIC PATIENT
Criteria For Use
Management of the dyspneic pediatric patient with a suspected cause of bronchospasm. (Presence of
wheezes or diminished lung sounds.)
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed.
2. Administer oxygen appropriate for the condition and history.
3. Initiate cardiac monitoring.
4. Utilize length based tape or Broselow tape for estimated weight or use the current
known accurate weight of the patient.
5. Administer Albuterol (Proventil) 2.5 mg/3 cc saline aerosol inhalation, over 15
minutes for child over 12 months of age. Under 12 months, administer Albuterol
(Proventil) 1.25 mg/3cc saline aerosol inhalation over 15 minutes.
-----Contact Medical Command----Command Physician’s Actions Might Include:
1. Order initiation of appropriate IV if patient is not improving with Albuterol aerosol
inhalation
2. Order repeat Albuterol 20 minutes after first dose, 2.5 mg/3cc saline aerosol
inhalation.
3. Order Epinephrine 1:1000 0.01 mg/kg to be given subcutaneously, for severe
respiratory distress to maximum dose of 0.3 mg (0.3 ml)
Note: Severe respiratory distress in children is characterized by marked increase in respiratory effort; i.e.
severe agitation, dyspnea, tripod position, intercostal and parasternal retractions, poor feeding in an
infant, skin pallor, weakness, tachycardia.
PEDIATRIC PATIENT WITH ALTERED MENTAL STATUS
Criteria For Use
Pediatric patients who are in a coma with evolving neurological deficit, or altered mental status of
unknown etiology. Patients who are known diabetics who have an altered level of consciousness not
thought to be secondary to trauma. Maintenance of normal respiratory and circulatory function is always
the first priority. Pediatric patients with altered mental status and/or respiratory failure or arrest, shock,
trauma, near drowning or other anoxic injury should be treated under other protocols.
ALS Provider Guidelines:
1. Perform initial survey-resuscitate as needed
2. Administer appropriate oxygen
3. Initiate cardiac monitoring
4. Start an appropriate IV
5. Draw blood for sugar
6. Do a chemstrip
7. Utilize length based tape, Broselow tape, or other similar devices to calculate
medication dosages or for estimated weight or use the current known accurate
weight of the patient.
8. If the chem strip reading is 40 or below, administer D25, 0.5 g/kg; for newborns,
D12.5, 0.5g/kg
9. If the patient is12 years old or over, and the chemstrip reading is less than 60, and
no I.V. can be established, administer 1 mg Glucagon, IM. If the patient is less than
12 years old, call medical command.
------Contact Medical Command------
Command Physician's Actions Might Include:
1. Order IO line, to be performed during transport
2. Order additional 0.5 mg/kg IV or IO D25, D12.5 in newborns.)
3. If no IV access available, order Glucagon, 0.5 mg in 0.5 ml diluent, IM, for pediatric
patients weighing less than 20 kg.(20-30 Fg/kg
4. Order Narcan 1 mg IV/IO in patients greater than two years old. 0.4 mg for patients
less than 2 years old. If no IV or IO access can be established, may order 2mg
Narcan IM for patients > 2 years old, 1 mg for patients < 2 years old.
5. Order transport
Note: To make D12.5, take an amp of D25, spill ½ the volume and refill to original volume with sterile
normal saline solution.
PEDIATRIC ANAPHYLAXIS
Criteria for use :
Management of pediatric patients who are acutely symptomatic secondary to suspected exposure to an
allergen and have impending true anaphylaxis. Acutely symptomatic is defined as :
Systemic reaction: sudden onset of urticaria and/or any of the following signs - airway problems,
wheezing, throat tightness, sudden difficulty swallowing. hypotension, associated altered level of
consciousness. Urticaria by itself is not anaphylaxis but still should be closely monitored. However,
urticaria may not always be present in anaphylaxis..
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed.
2. Administer oxygen
3. Initiate cardiac monitoring.
4. Utilize length-based tape, Broselow tape, or other similar devices to calculate medication dosages or
for estimated wt., or use the current known wt. of the pediatric pt.
If acutely symptomatic,
(a) if wheezing is present, immediately administer albuterol 2.5mg/3cc saline by aerosol
inhalation.
(b) if signs of shock or severe respiratory distress are present, initiate an appropriate I.V. and give
Epinephrine 1:10,000, 0.01 mg/kg (0.1 cc/kg), up to 0.3 mg (3 ml) and give a 20 ml/kg bolus of
NSS or lactated ringers. If no I.V. access is available, give epinephrine 1:1,000, 0.01 mg/kg
(0.01 ml/kg) SQ up to 0.3 mg.
(c) administer diphenhydramine 1 mg/kg, I.V. maximum of 50 mg. Give IM if no I.V. access is
available.
(d) maintain close monitoring even if symptoms resolve, as they may recur when Epi is
metabolized.
-----Contact Medical Command----Command Physician’s Actions Might Include:
1. In patients with less severe reactions, order initial IV of NSS via a large bore IV (18-22 gauge),
or IO.
2. Order additional boluses of NSS as necessary.
3. Administer epinephrine 0.01 mg/kg (0.1cc/kg of a 1:10,000 solution) slowIV/IO bolus, or SQ.
4. Repeat IV/IO/SQ epinephrine as necessary using the same dose.
5. Administer additional Albuterol 2.5 mg. in 3 cc by aerosol inhalation.
6. Administer additional diphenhydramine1mg/kg, I.M. or I.V.
NOTE:
Examples
Epi 1:1,000:
20 kg dose = 20(0.01cc) =0.2cc =0.2mg subcutaneously
Epi 1:10,000: 20 kg dose = 20(0.1cc) = 2cc = 0.2mg intraveneously
SEIZURES IN THE PEDIATRIC PATIENT
Criteria For Use
Pediatric patient with a history of seizures or who is in a seizure state.
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed.
2. Administer appropriate oxygen.
3. Initiate cardiac monitoring.
4. Initiate appropriate IV.
5. Utilize length based tape, Broselow tape, or other similar devices to calculate medication dosages or
for estimated weight or use the current known accurate weight of the patient.
6. Check Chemstrip reading.
If the patient is not a known seizure patient or if the patient is diabetic and the Chemstrip reading is
<40, give Dextrose 25%, 0.5 - 1 g/kg IV bolus. For newborns use D12.5.
-----Contact Medical Command----Command Physician’s Actions Might Include:
1. If the patient is known to have a seizure history and has had more than one generalized seizure and
is in a seizure state upon the arrival of ALS or has been in a seizure for longer than 5 minutes, orders
may be given for the administration of Valium, 0.1-0.3 mg/kg. If no IV access has been established,
orders for rectal Valium @ 0.5 mg/kg may be given via lubricated 3 cc syringe. Be prepared to
manage the airway
2. Order intraosseous access.
3. Order additional 25% or 12.5% Dextrose IV.
Note: Bodily injury protection and airway maintenance with a nasopharyngeal airway and oxygen
administration is usually sufficient initial treatment for most seizure. Seizures are usually self
limiting. Call MedCom if unsure of aggressiveness of treatments needed.
SHOCK - TRAUMATIC or HYPOVOLEMIC
IN THE PEDIATRIC PATIENT
Criteria For Use
Management of the pediatric patient involved in a traumatic episode with hypovolemia. (Pediatric hypovolemia is defined as: Newborn to 30
days systolic BP < or = 60; 1 month to 1 year systolic BP < or = 70; over 1 year systolic BP of < or = 70 + 2 + age in years caused by
suspected or evident blood loss resulting in adequate perfusion.) Because of the difficulty in measuring BP in children less than 1 year, other
signs of shock should be assessed.
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed with spinal immobilization in place.
2. Administer appropriate oxygen, via BVM or E.T. if needed.
3. Make decision concerning hospital destination and method of transport as possible.
4. Utilize length base tape, Broselow tape or other similar devices to calculate medication dosages or to
estimate weight or use current known accurate weight of patient
5. Initiate cardiac monitoring.
6. Without delaying transport, establish one I.V. Initiate fluid challenge at 20 cc/kg, 10 cc/kg for newborn.
If unable to establish vascular access after 2 attempts, contact medical command immediately in
anticipation of an order for intraosseous access.
-----Contact Medical Command----Command Physician’s Action Might Include:
1. Alter patient destination or method of transfer.
2. Order intraosseous access.
3. Alter fluid administration.
4. Order ALS procedures as required for specific trauma assessment.
Expeditious transport after initial resuscitation efforts is recommended.
Note: Fluid boluses in children are best given by drawing up lactated ringers or normal saline solution in a 50 cc syringe and pushing via IV
line port while closing off line above port, until 20 cc/kg have been infused. Gravity bolus takes too long in a child.
TRAUMA - MECHANISM OF INJURY
IN THE PEDIATRIC PATIENT
Criteria For Use:
Management of the pediatric patient involved in a traumatic episode with vital signs within normal range (Step I - Trauma Guidelines) but
meets criteria of Step II - Anatomy/Mechanism of Injury requiring Trauma Center destination.
ALS Provider Guidelines:
1. Perform initial survey, resuscitate as needed with spinal immobilization in place.
2. Administer appropriate oxygen and intubate if necessary.
3. Make decision concerning hospital destination and method of transport as soon as possible.
4. Initiate cardiac monitoring.
5. Without delaying transport or while arranging aeromedic transport as per #3, establish one IV.
-----Contact Medical Command----Command Physician’s Actions Might Include:
1.
2.
3.
4.
Alter patient destination or method of transfer.
Alter fluid administration.
Order MAST application and inflation pressure.
Order ALS procedures as required for specific trauma assessment.
Expeditious transport after initial resuscitation efforts is recommended
PEDIATRIC BURNS
Criteria for use :
Management of pediatric burns characterized as moderate, and or critical in nature with or without associated trauma.
ALS Provider Guidelines:
1. Perform initial survey.
2. Ensure airway and breathing
3. Administer oxygen appropriate for the condition and history. (Note: pay special attention for signs and
symptoms of inhalation injury)
4. Decide hospital destination and mode of transport . Burn Center/ Trauma Center/closest hospital.
5. Without delaying transport, initiate IV appropriate for condition and infuse KVO until estimated weight
or known accurate weight is established. After weight is established, infuse 10 cc/kg/hour.
6. Utilize length based tape or Broselow tape or other available devices for estimated weight or use the
current known accurate weight of the patient.
7. Treat shock if present. Give a 20cc/kg bolus of NSS
8. Initiate cardiac monitor especially if burned by electricity.
9. Cover burns with dry sterile dressings or burn sheets. If the burn area is too large cover with regular
cotton sheet. (Not flannel, use hospital sheets)
--------Contact Medical Command-------Command Physician’s Actions Might Include:
1. Order additional airway control procedures, as necessary
2. Order additional IV’s or establish IO line if no IV established
3. Order morphine sulfate 0.1mg/kg titrated, IV
4. Order treatment for shock as per the pediatric shock protocol
5. Alter method of transport or destination facility.