Redmond Emergency Medical Services
Practice Parameters
08/01/2010
1
Redmond Regional EMS
Practice Parameters
The purpose of this document is to provide:
 Medical protocols regarding permissible and appropriate medical procedures and
treatments to be performed by State of Georgia certified EMT-I’s and/or Paramedics
(medics) in the performance of their occupational duties with Redmond Regional Medical
Center.
 Communication protocols regarding which medical situations require direct voice
communication between medics and a physician (or a nurse who is in direct contact with
the physician) prior to those medics rendering specified emergency medical care.
These guidelines have been adapted from the Georgia State Office of Emergency Medical
Services Pre-Hospital Protocols with changes in the practice parameters based on current
standards of care utilized by Redmond Regional Medical Center.
Since each medical emergency must be dealt with on an individual basis and appropriate care
determined accordingly, professional judgment is mandatory in determining treatment modalities
within the practice parameters.
The Emergency Medical Services Medical Director is responsible for reviewing and approving the
practice parameters annually (or when standards of care and/or technology require a change in
the practice).
Medical Director Review and Approval:
I have reviewed the practice parameters contained within this manual and approve their usage by
EMS personnel.
Date
MD Printed Name
MD Signature
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Table of Contents
Opening Statement
7
Using These Protocols
8
Communications Failure
9
Physician On-Scene
10
Criteria for Helicopter Transport
11
IV Therapy
12
IV Therapy – EJ Venous Cannulation
14
IV Therapy – Intraosseous Infusion
15
Medication Administration
16
Thoracic Decompression
17
Medically Assisted Intubation
19
Poisoning and Overdose Information
21
Glasgow Coma Scale
26
APGAR Scale
28
AVPU Scale
29
Average Pediatric Vital Signs
30
Common Causes of Abdominal Pain
31
Cincinnati Stroke Exam
32
Common Medical Abbreviations
33
Medication Profiles
36
Nitroglycerin Drip Chart
76
Heparin Drip Chart
77
Uniform Rules of the Road
78
Reasonable Distance Guidelines
80
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Destination Selection for Pre-Hospital Patients
81
Pre-Hospital Withholding and Withdrawing Resuscitation
83
Hazardous Materials Exposure
86
Personal Property of Patient
87
EMTALA
89
Adult General Patient Care
90
Acute Respiratory Distress
92
Congestive Heart Failure/Pulmonary Edema
93
Acute Coronary Syndromes/STEMI
94
Altered Mental Status
96
Suspected Stroke/CVA
97
Seizures
98
Allergic Reactions/Anaphylaxis
99
Non-Traumatic Hypotension
100
Shock
101
Hypertensive Crisis
102
Hemodynamically Compromising Bradycardia
103
Stable Tachycardia
104
Unstable Tachycardia
105
Ventricular Fibrillation/Pulseless Ventricular Tachycardia
106
Asystole/Pulseless Electrical Activity
107
Environmental Cold Emergencies
108
Environmental Heat Emergencies
109
Sickle Cell Anemia
110
OB/GYN
111
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Pregnancy Induced Hypertension
111
Vaginal Bleeding
111
Trauma in Pregnancy
111
Emergency Childbirth
112
Newborn Care
113
Post-Partum Care
113
Childbirth Complications
114
Suspected Sexual Assault
115
Suspected Abuse/Neglect
116
Psychological/Behavioral Emergencies
117
Pediatric and Adult Trauma
118
Spinal Cord Injury
120
Selective Spinal Immobilization
123
Pediatric General Patient Care
124
Pediatric Acute Respiratory Distress
125
Pediatric Altered Mental Status
126
Pediatric Seizures
127
Pediatric Shock and Hypotension
128
Pediatric Allergic Reactions
129
Pediatric Bradycardia
130
Pediatric Tachycardia
131
Pediatric Ventricular Fibrillation/Pulseless Ventricular Tachycardia
132
Pediatric Asystole/Pulseless Electrical Activity
133
Pediatric and Adult Endotracheal Intubation
134
Pain Management for Adults and Pediatric
136
5
Refusal of Services
138
Induced Hypothermia (Post-Arrest)
139
Induced Hypothermia Inclusion Criteria
140
Induced Hypothermia Exclusion Criteria
141
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OPENING STATEMENT
The following standardized treatment protocols are intended to result in improved patient care
within the Redmond Regional Emergency Medical Service System. They are meant to aide in
expediting patient care, and give the EMT-I and the EMT-P, guidelines with which to follow, prior to
contact with Medical Control. They reflect a philosophy of patient care by which all patients should
be treated. Redmond EMS and Dr. Johnson, Medical Director, developed these protocols with the
goal of safe and efficient Pre-Hospital care.
Patients, however, do not always fit into a “cookbook treatment” approach. Therefore,
PROTOCOLS ARE NOT A SUBSTITUTE FOR GOOD CLINICAL JUDGEMENT, especially when
a situation occurs which does not fit into these guidelines.
As an Advanced Life Support Provider, your field treatment must be carefully balanced with the
knowledge of when your capabilities fall short of what the patient needs. When treating a patient
you must ask yourself, what does the patient need as opposed to what you can provide?
Advanced Life Support can benefit the patient greatly by being able to quickly deliver a
procedure or medication the patient needs at the scene. However, it can be detrimental to delay
transportation when the patient’s needs are beyond what you can provide.
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Using These Protocols
STANDING ORDERS
The following protocols have been designed for the pre-hospital professionals within Redmond
Emergency Medical Service, both EMT-I's and EMT-P's may utilize some of the modalities within
these standing orders; these are reflected on the following Protocols.
If at any time you are unclear as to what is allowed on these protocols, ESTABLISH MEDICAL
CONTROL, and the Emergency Physician will direct you.
ONCE MEDICAL CONTROL HAS BEEN ESTABLISHED, WHETHER BY PHONE OR RADIO,
THE EMERGENCY PHYSICIAN'S ORDERS SUPERCEDE THESE STANDING
ORDERS AND PROTOCOLS, AND YOU MUST FOLLOW THE DIRECTION OF MEDICAL
CONTROL AND NOT RETURN TO THESE PROTOCOLS.
When following protocols, the provider should take into consideration self-administered
medications within the previous hour.
PATIENTS WHO REMAIN UNSTABLE AFTER STANDING ORDERS HAVE BEEN CARRIED
OUT REQUIRE CONSULTATION WITH AN ON-LINE PHYSICIAN.
Unstable vital signs in an adult are defined as:
*Pulse of 55 or less and 120 or more
*Diastolic BP of 120 or more
*Systolic BP of 85 or less and 200 or more,
*Respiratory rate of 10 or less and 30 or more.
Specific examples of other "unstable patients" include, but are not limited to, the following:
*Patients with chest pain who continue to complain of chest pain after the standing order of
NITROGLYCERIN and analgesia have been administered.
*Patients with shortness of breath who continue to have shortness of breath after the
standing orders of LASIX or ALBUTEROL or ATROVENT have been administered.
*Cardiac Arrest patients with return of pulse (even transiently).
* Patients with multi-system or penetrating trauma.
While the above are examples of “defined” unstable patients, you must remember to always treat
the patient and not the equipment. If you always work in the best interest of the patient, you will
always be on solid ground if you have to defend your actions and/or treatment decisions.
PHYSICIAN OPTIONS
While every attempt has been made to list the most logical Physician's Orders, medicine changes
rapidly! A Medical Control Physician may ask you to do something different, because of a new
development. Any time an order is given which you do not understand or seems to be contrary to
established protocol, ask the physician to CONFIRM the order or to EXPLAIN it if you feel
uncomfortable carrying the order out.
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COMMUNICATIONS FAILURE
If at any point a breakdown in Medical Control Communications occurs, attempt to establish it
again by radio and/or telephone. If this is unsuccessful, begin transportation as soon as possible,
follow the appropriate patient care protocols and attempt to contact medical control again enroute.
If there is still a break in communications with Medical Control continue to follow protocol and
perform any procedures necessary which are in the best interest of the patient and within your
scope of practice. A breakdown in Medical Control Communications is defined as the inability to
contact Medical Control due to poor radio conditions and/or poor cell phone service. If you do
make contact with the receiving facility and request to speak to a Medical Control Physician and
the Physician does not come to the phone or radio within an acceptable amount of time
considering current circumstances for consultation, you may also consider this a breakdown in
Medical Control Communications.
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Physician on Scene
The control of the scene of any emergency should be the responsibility of the individual in
attendance who is the most appropriately trained in providing pre-hospital stabilization and
transport. As an agent of the Medical Director of Redmond Regional Medical Center EMS, the
paramedic represents that individual.
Occasions will arise when a physician on the scene will desire to direct pre-hospital care. A
standardized scheme for dealing with these contingencies will optimize the care given to the
patient.
1. The physician desiring to assume care of the patient must:
• Provide documentation of his status as a physician (MD or DO)
• Be licensed to practice medicine in the State of Georgia
• Document his or her assumption of care on the run report.
2. Contact with Medical Control at the receiving facility must be established as soon as
possible. The physician assuming responsibility at the scene should be placed in contact
with the Medical Control Physician and acknowledgement of his or her acceptance or
responsibility confirmed.
3. Orders provided by the physician assuming responsibility for the patient should be
followed as long as they do not, in the judgment of the paramedic, endanger patient well
being. The paramedic may request the physician to attend the patient's well being.
4. If the physician's care is judged by the paramedic to be potentially harmful to the patient,
the paramedic should:
• Politely voice his or her objections.
• IMMEDIATELY place the physician on the scene in contact with Medical Control
for resolution of the problem.
• When conflicts arise between the physician on the scene and Medical Control,
EMS personnel should follow the directives of the Medical Control Physician. Offer
no assistance in carrying out the order in question, but provide no resistance to the
physician performing this care. If the physician on scene continues to carry out the
order in question, offer no assistance and enlist aid from law enforcement.
5. All interactions with physicians on the scene must be completely documented in the run
report.
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Criteria for Helicopter Transport
1. Determine potential need for aero medical transport of the patient.
2. Criteria that suggest the need for aero medical transport may include, but are not limited to:
• Need for ALS services where none are available or will be significantly delayed.
• Mass casualty incidents.
• Prolonged extrication.
• Insufficient numbers of EMS personnel, equipment, or vehicles to manage a multiple
casualty incident or a single patient encounter.
• Traffic conditions or geographical terrain, which prohibits adequate ground access to the
victim.
• Situations in which the time differential between air and ground transport may substantially
impact the outcome of the patient.
3. The paramedic in charge of the scene is responsible for determining if aero medical transport is
warranted. He/she should notify the Communications Center of the need for aero medical
transport as soon as possible in order to minimize response and transport times. The paramedic
in charge should also request for assistance from other agencies as needed to help secure the
incident site and landing zone. The Communications Center will advise the priority channel on
which ground to air communications will occur.
4. If initial indications are that air transport may be required, the air transport should be allowed
progress towards the scene in order to decrease response times.
5. Guidelines for Landing Zone Preparation are as follows:
• Area should be at least 100 ft. X 100 ft. (day or night), on fairly solid ground, level, free of
overhead obstructions, ground obstructions, people and any material which might fly loose. If
there are obstructions, inform helicopter crew via radio. THE HELICOPTER PILOT MAKES
THE FINAL DETERMINATION FOR A SAFE LANDING ZONE, (LZ)
• Mark the four comers of the LZ with lights, flares or high visibility material. The best way to
mark the landing position in the LZ at night is to use two vehicles with low headlights ON,
shining across the LZ with the intersection of the beams at the landing point. Turn headlights
OFF after landing.
• Do not shine lights directly at the aircraft.
• Keep spectators at least 200 feet from the touchdown area and emergency personnel at
least 100 feet away. Do not allow anyone to approach the helicopter after landing.
• The individual in charge of the LZ should be clearly identified day or night with either an
orange vest or traffic control flashlight and must be wearing eye protection.
He/she should
have radio contact with the helicopter and is responsible for directional information
• Once the patient is packaged and ready to load, the helicopter crew may select 2 or 3 personnel
to assist loading. When approaching or departing the helicopter, be aware of the tail rotor.
Remain low at all times and follow the crew's directions for safety.
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Intravenous Therapy
IV THERAPY PROCEDURES TO BE USED BY ALL EMT-I’s AND EMT-P’s
INDICATIONS
1. Types of intravenous infusions used:
• Volume Replacement Infusions: The general use is to replace body electrolytes or to replace
fluid volume. NORMAL SALINE may be used with a macro drip (10gtt) administration set and
large bore IV catheters.
• Medication Line: The general use is to establish venous access in case the patient arrests or
a medication is needed. NORMAL SALINE may be used with a micro drip (60gtt)
administration set and in IV catheter of sufficient size to keep the vein open and give IV push
medications (large bore catheters are helpful during arrests when large volumes of
medications must be pushed).
2. Blood samples must be drawn on every patient prior to administration of any medications or
fluids, except those in cardiac arrest or exigent circumstances.
• Draw blood after the venipuncture.
• Fill one of each color blood tube: purple, red, green and blue top, in that order.
• After drawing hold all four tubes and gently roll them (do not shake), in order to mix
preservatives.
• Remove the tourniquet and start the infusion or flush the male adapter with at least 3cc
flush.
• Label each tube with the patients name, date and time the sample was drawn, and your
initials.
CONTRAINDICATIONS/PRECAUTIONS
1. Central venous cannulation is not approved in these protocols.
2. In adults, the veins of the upper extremities, external jugular veins, and intraosseous infusion
are the preferred sites to be used in these protocols. For pediatric patients, IV sites include the
upper and lower (below the knees) extremities, scalp, and intraosseous infusion. Only in extreme
circumstances should the EMT-P deviate from these standing protocol sites, which must be
documented on the PCR.
3. Patients with IV access in place may not be left unattended. If you have initiated IV access and
transport your patient and the receiving facility request you send your patient through triage, you
must first turn that patient over to a receiving nurse, obtain receiving signature, and then if the
nurse wants the patient to go to triage, they may send them there. Infusion rates must be watched
carefully to prevent over hydration or extravasations or infiltrations.
4. Prep the venipuncture site with both Povidone-iodine and isopropyl alcohol, if possible.
GENERAL PROCEDURES
1. Generally, distal veins should be attempted prior to attempting access to more proximal veins.
2. Avoid placing IV's in injured extremities, if possible.
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3. Always wear gloves when starting IV's.
4. In all cardiac patient's the right arm must be avoided, particularly, the right antecubital.
Frequently these patients undergo cardiac catheterizations or thrombolysis and many
Cardiologists prefer this site now, as opposed to the groin area. ("NOTE THE RIGHT
ANTECUBITAL MAY BE USED ONLY AS A LAST RESORT IN THESE PATIENTS")
5. The number of IV attempts, persons attempting, site/location, catheter size, solution, time,
started and infusion rate MUST be reported on the PCR.
6. While there is no maximum number of times an IV may be attempted, the amount of discomfort
caused the patient must be weighed against the NEEDS of the patient. After two attempts on a
patient who does not need medication "right now", consider transport. If it is a hypovolemic patient
trapped in a car, it may make more sense to make more attempts. GOOD JUDGEMENT on the
part of the EMT-P will supplant any thoughts of maximum attempt numbers.
7. The designated Redmond EMS training officer will be responsible for maintaining records and
trends in regards to each EMT-I and EMT-P's average success rate. The training officer and the
QA/QI committee will confer when it is apparent that any particular provider is presenting with a
poor success rate. If a problem is found to exist, the Training Officer will meet with that particular
provider along with the District Commander, and a course of action will be decided upon, as to
steps to re-train the provider.
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Intravenous Therapy
External Jugular Venous Cannulation
INDICATIONS
The more central external jugular (EJ) vein may be cannulated in situations where peripheral sites
lack perfusion. The external jugular vein runs from the angle of the jaw to under the first third of
the clavicle from the sternoclavicular joint, bilaterally. Redmond EMS paramedics may use
external jugular cannulation on standing protocol.
CONTRAINDICATIONS / PRECAUTIONS
1. The EJ vein is more a central (although not truly central) vein than the arm veins usually used.
Extra care must be taken during cannulation to prevent infection or air embolus injection, as these
will cause severe complications down the road.
2. Because of the location of the EJ in relation to the pleural space, care must be taken not to
cannulate the lung and produce a pneumothorax. If this happens, do not remove the catheter,
refer to the Thoracic Decompression Procedure and contact Medical Control as soon as possible.
PROCEDURE
1. Place the patient in a supine, head down position to fill the vein. Turn the patients head to the
side opposite the side you wish to cannulate.
2. Locate the vein and cleanse the overlying skin with Povidone iodine and isopropyl alcohol.
3. Hold the vein in place by applying pressure on the vein distal to the point of entry at the angle
of the jaw
4. Align the cannula in the direction of the vein with the point toward the ipsilateral nipple.
5. Tourniquet the vein lightly with one finger above the clavicle.
6. Position the catheter, bevel up, against the skin. Make the venipuncture midway between the
jaw and the clavicle on the side of the EJ.
7. Note blood return, advance the catheter and withdraw the needle. Draw blood tubes and
attach the infusion tubing. This should be done with a tamponade above the clavicle to avoid an
air embolism.
8. Cover and dress the site in an appropriate manner and secure it and the IV tubing as
necessary.
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Intravenous Therapy
Intraosseous Infusion
INDICATIONS
Obtaining rapid vascular access in children may be difficult. Intraosseous infusion of fluids and
medications has long been regarded as a safe and effective procedure. This procedure may be
performed by protocols, in extreme cases where vascular access is difficult.
CONTRAINDICATIONS / PRECAUTIONS
1. The patient must be under three years of age in order to insure that the bone marrow has
sufficient vasculature to handle fluid and medications.
2. Peripheral IV sites should be considered prior to intraosseous infusion because of the inherent
risk of bone marrow infection.
PROCEDURE
1. Select the proper IO needle.
2. Prepare the puncture with Povidone-iodine and isopropyl alcohol. IO puncture is performed on
the flat, anteriomedial surface of the tibial bone of either leg, 1-3 centimeters below the tibial
tuberosity.
3. Direct the needle perpendicular to the flat surface or with a slight angle toward the foot.
4. Advance the needle using firm pressure and a rotary motion. A sudden give of resistance
indicates the entry into the bone marrow cavity.
5. Successful cannulation is verified by:
• Give of resistance after passing through the bony cortex.
• The needle standing up without support.
• In most cases, the ability to aspirate bone marrow into a syringe attached to the needle.
• Free flow of the infusion without infiltration.
6. Attach an infusion set and infuse as per appropriate protocol. You may need to utilize a
pressure infuser if fluid does not free flow into the bone marrow cavity.
7. Secure the needle and IV tubing to the patient's leg. Monitor the puncture site frequently for
signs of infiltration.
8. Any fluid and/or medication which can be administered via IV can be administered via IO
without complications.
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Medication Administration
MEDICATION PROCEDURES TO BE USED BY PARAMEDICS
ADMINISTRATION PROCEDURES
1. Medication may be given only:
* Under one of the standing protocols listed.
* On the order of any medical control MD or receiving MD either verbally or written.
* By a Redmond EMS Paramedic or a Paramedic intern under the direct supervision of his/her
Redmond EMS preceptor.
2. The Paramedic team leader is responsible for patient presentation, confirming orders and
medication box control.
3. Medical Control will order medications in metric weight only. IF AT ANY TIME AN ORDER IS
UNCLEAR, ASK THE PHYSICIAN TO REPEAT THE ORDER OR EXPLAIN IT TO YOU!
4. Three radio transmissions are necessary to confirm an order:
* The physician will order the medication and dose.
* The Paramedic must repeat the order back.
* The Physician will acknowledge the order by giving confirmation.
5. Once the order is confirmed:
* Write the order down.
*Read the medication container to be sure it is the right one and check the expiration date.
* Administer the medication as ordered and document the time.
* Evaluate the patients' response to the medication.
* WHEN ANY MEDICATIONS ARE ADMINISTERED, THEY MUST BE DOCUMENTED ON A
PCR.
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Thoracic Decompression Protocol
Cook Emergency Pneumothorax Decompression Device
Definitions:
• Simple Pneumothorax: Air in the potential space between the visceral and parietal pleura.
• Tension Pneumothorax: A true surgical emergency, air that has leaked into the space between
the visceral and the parietal pleura, either from trauma or at times spontaneous, and is unable to
continue to escape. It continues to enlarge, with the effect of the shift of the media stinum,
creating decreased venous return, and continued respiratory compromise. Eventually left
untreated may lead to the patient’s death.
• Tension Hemothorax: A true surgical emergency, blood has leaked into the space between the
visceral and the parietal pleura, either from trauma or at times spontaneous, and is unable to
continue to escape. It continues to enlarge, with the effect of the shift of the media stinum,
creating decreased venous return, and continued respiratory compromise. Eventually left
untreated may lead to the patient’s death.
Indications:
1. Treatment of tension pneumothorax is simple, but the complications of the procedure
can
be lethal. Diagnosis must be accurate and is not always easy. Field treatment is indicated
when the life of the patient is in danger and treatment cannot be delayed until arrival at the
hospital.
2. Field relief of tension pneumothorax is indicated ONLY when the patient has progressive
severe respiratory distress with cyanosis, decreased breath sounds on the affected side, and
hypotension. In addition the patient may have distended neck veins and tracheal shift away
from the affected side. If the patient is intubated, there should be increasing difficulty
ventilating. Hypotension can be detected by noting loss of radial pulse. Usually there will be
loss of consciousness as well.
Complications:
1. Hemorrhage from vessel laceration
2. Creation of a pneumothorax if one was not already present
3. Laceration of the lung
4. Infection
The Cook Pneumothorax set consists of:
• Straight Radiopaque Catheter
• Stainless Steel Large Bore Needle
• One-way stopcock valve
• Connecting Tube
• Heimlich Valve
• 12cc Syringe
• Large Alcohol Prep Pad
• Povidone-lodine Swabstick
• Blue Rubber Occlusive Seal
If tension pneumothorax is diagnosed, and the paramedic believes the life of the patient is in
immediate danger (as demonstrated by no peripheral pulses, cyanosis, and no response to verbal
stimuli), then the procedure may be followed.
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Maintain airway and administer oxygen by non-rebreather facemask at 15 L/min.
Setting up and using the device:
Pre-assemble the set prior to the procedure, connecting the one-way stopcock to the connecting
tube and connecting it to the Heimlich Valve. Make sure you tear off enough tape, to fully secure
all invasive equipment prior to beginning the procedure.
The optimal insertion site of the pneumothorax catheter is in the 2nd anterior intercostal space,
either to the right or left of sternum at "the level of the Angle of Louis, in the mid-clavicular line,
along the superior of the 3rd rib. An alternative placement site is 4th intercostal Space, at the
Anterior or mid-axillary Line, superior of the 5th rib. Prior to insertion, the site should be prepped
with the antiseptic Povidone-iodine swabstick.
When inserting the Cook Pneumothorax Catheter, locate your landmarks on the affected side.
Insert the needle tip with the catheter as its sheath into the pleural cavity, advancing the needle
and catheter. Ensure the hub of the catheter is kept open, allowing you to hear the escape of air,
signaling you have entered the Pleural Cavity. Remove the inner needle checking for free flow of
air, and confirm placement of the catheter tip again. When certain that the catheter is well within
the Pleural Cavity, apply the blue rubber occlusive seal around the catheter, and secure it well with
tape.
Attach the one-way stopcock valve to the hub of the catheter with the valve open. If the catheter
placement is correct, and the lung is still under tension, as air is released you will hear the
Heimlich Valve make a squealing sound. Secure the entire device to the patient's thoracic area to
prevent accidental dislodgement of the needle.
Be sure to continuously reassess the patient's vital signs and breath sounds. If the patient's
condition worsens or if complications set in, follow appropriate protocol or contact Medical Control.
Warning Notes:
1. Tension pneumothorax is rare; but when present, it must be treated promptly.
2. Non-tension pneumothorax is relatively common, is not immediately life threatening and should
not be treated in the field.
3. Positive pressure ventilation may lead to the development of a pneumothorax and to rapid
progression to tension pneumothorax.
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Medically Assisted Intubation Protocol
The following protocol outlines procedures to be utilized when faced with a patient with a
compromised airway, whether the emergency is trauma or medical related. Additionally, this
protocol may only be utilized by a Redmond EMS Paramedic that has been checked off and
certified competent in advanced airway management.
A. Non Compromised Airway:
1. Administer oxygen as needed
2. Assist ventilation as needed
B. Compromised Airway:
1. Chin lift or jaw thrust - oral/nasopharyngeal airway.
2. Assist chin lift with BVM @ 100% Oxygen.
3. Consider blind nasal intubation only if there is no evidence of maxillofacial trauma.
4. Consider the need for early intubation.
C. Non-Breathing:
1. Chin lift or jaw thrust-oral/nasopharyngeal airway.
2. Hyperventilate patient 1-2 minutes prior to intubation.
3. Oral endotracheal intubation with visualization of the vocal cords.
4. Listen to breath sounds
5. Check pulse ox for significant changes.
6. Units that are equipped with Capnocheck 11 monitors shall utilize the continuous End-Tidal
CO2 monitoring for all intubated patients. Patients should maintain Continuous End-Tidal CO2
levels of 35-45mmHg.
7. Units that are not equipped with Capnocheck II monitors shall utilize the Encor CO2
detector for End tidal CO2 monitoring. The Encor CO2 detector should reflect 2-5% yellow.
8. Apply tube holder and maintain cervical stabilization using:
a. Back board
b. Head bed device
c. Spider straps
9. Confirmation of tube placement shall be done after initial intubation, after moving the patient
into transport unit and upon arrival at ED.
10. Tube placement should be confirmed whenever the patient is moved. All tube
confirmations shall be documented.
11. If ET intubation is unsuccessful utilize the combitube
D. (MAI) Medication Assisted Intubation
If unable to intubate a conscious medical or trauma patient that meets the following criteria,
you may administer MAI.
1. Patient cannot maintain their airway.
2. Patient cannot protect their airway.
3. Patient cannot be appropriately ventilated with BVM or other means.
4. Patient cannot be appropriately oxygenated with BVM or other means.
5. You must intubate patient for treatment of specific condition.
Adult: administer ETOMIDATE @ 20 mg IVP. A second dose of ETOMIDATE @ 20 mg IVP may
be administered if the first dose is ineffective. If patient has a head injury, also administer
LIDOCAINE @ 1 mg/kg IVP. Consider 5 mg VERSED for pre-sedation prior to intubation.
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Pediatric (<5 y/o): administer ATROPINE @ 0.02 mg/kg IVP. Administer ETOMIDATE @ 0.3
mg/kg IVP. A second dose of ETOMIDATE @ 0.3 mg/kg IVP may be administered if the first dose
is ineffective. If patient has a head injury, also administer LIDOCAINE @ 1 mg/kg. Consider
VERSED @ 0.05 to 0.1 mg/kg for pre-sedation prior to intubation, not to exceed 5 mg. Pediatric
patients over 12 years of age should be dosed as an adult.
E. If unable to ventilate with BVM or combitube due to massive facial trauma or obstruction:
1. Attempt digital intubation
2. Attempt needle cricothyroidotomy X 1
3. Transport
F. Consider the administration of 5 to 10 mg VERSED IVP for further sedation as needed.
NOTE: Nasopharyngeal airways should never be inserted when there is any maxillofacial trauma.
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Poisoning and Overdose Information
Tricyclic Antidepressant Poisoning
COMMON NAMES
1. AMITRIPTYLINE (ELAVIL, AMITRIL, ENDEP)
2. CLOMIPRAMINE (ANAFRANIL)
3. IMIPRAMINE (TOFRANIL, ANTIPRES)
4. TRIMIPRAMINE (SURMONTIL)
5. DOXEPIN (SINEQUAN, ADAPIN)
6. NORTRIPTYLINE (PAMELOR, AVENTYL)
7. DESIPRAMINE (NORPRAMINE)
8. PROTRIPTYLINE (VIVACTIL)
GENERAL INFORMATION
The most common lethal OD Ingestion of 15-20 mg/kg potentially fatal. Death usually occurs prehospital
TCA TOXICITY
1. Anticholinergic effects
2. Cardiac toxicity - QUINIDINE-like effect
3. Peripheral alpha receptor blockade - can cause vasodilation (hypotension)
ADVERSE EFFECTS
1. Anticholinergic Effects:
a. Dry mouth
b. Tachycardia
c. Blurred vision
d. Delirium
e. Hyperthermia
2. Neurological Toxicity
a. Confusion, agitation
b. Seizures
c. Hallucinations
d. Coma
e. Myoclonus
3. Cardiac Toxicity
a. Hypotension
b. ECG Changes, Dysrhythmias
4. ECG Changes
a. Sinus tachycardia
b. Ventricular tachycardia
c. Prolongation of PR, QRS or QT intervals
d. Ventricular fibrillation
e. Torsades de Pointes
f. Bundle branch blocks
g. Junctional dysrhythmias
h. AV blocks
i. Asystole
j. SVT
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MARKERS OF SERIOUS TOXICITY
1. Clinical signs - most useful
2. QRS Prolongation - correlates well
3. Most patients will manifest some sign of toxicity within 2 hours of ingestion
TREATMENT (FIELD MANAGEMENT)
1. Airway / IV / ECG monitor
2. Supportive care
3. Seizure treatment
4. BICARBONATE if there are signs of:
a. QRS widening over 0.10 seconds
b. Ventricular dysrhythmias
c. Hypotension unresponsive to fluid boluses
5. If VF occurs, SODIUM BICARBONATE should be administered early in the code (after
defibrillation and first round of EPINEPHRINE)
6. Hyperventilation if patient intubated
Other Poisoning & Overdoses
ANTIPSYCHOTIC DRUGS:
PHENOTHIAZINE derivatives which may cause extrapyramidal reactions including: facial muscle
twitch, full body spasm, neck muscle contraction, head deviation, occulogyrations, etc.
COMPAZINE (PROCHLORPERAZINE); HALDOL (HALOPERIDOL); LOXITANE (LOXAPINE);
MELLARIL (THIORIDAZINE); PROLIXIN (FLUPHENAZINE); SPARINE (PROMAZINE);
STELAZINE (TRIFLUOPERAZINE); TARACTAN (CHLORPROTHIXENE); THORAZINE
(CHLORPROMAZINE); TRILAFON (PERPHENAZINE); VESPRIN (TRIFLUPROMAZINE);
TRICYCLIC ANTIDEPRESSANTS:
May cause sudden onset of seizures and arrhythmias in overdose
AVENTYL (NORTRIPTYLINE); ELAVIL, TRIAVIL, LIMBITROL (AMITRIPTYLINE); LUDIOMIL
(MAPROTILINE); NORPRAMIN (DESIPRAMINE); SINEQUAN, ADAPAN (DOXEPIN); TOFRANIL
(IMIPRAMINE); VIVACTIL (PROTRIPTYLINE); ASENDIN (AMOXAPINE)
NARCOTIC ANALGESICS:
Some of these analgesics are not true opiates yet work and react similarly. NALOXONE
(NARCAN) is an effective antidote for all of these.
CODEINE; COUGH SUPPRESSANT (DEXTROMETHORPHAN); DARVOCET, DARVON
(PROPOXYPHENE); DEMEROL (MEPERIDINE); DILAUDID (HYDROMORPHIRIE); DOLOPHINE
(METHADONE); FIORINAL (BUTALBITAL); LOMOTIL (DIPHENOXYLATE); MORPHINE;
NUBAIN (NALBUPHINE); PERCODAN, PERCOCET, TYLOX (OCYCODONE); STADOL
(BUTORPHANOL); SUBLIMAZE (FENTANYL); TALWIN (PENTAZOCINE); TYLENOL/CODEINE
(ACETAMINOPHEN); VICODIN (HYDROCODONE); WYGESIC (PROPOXPHENE); PAREGORIC
(LAUDANUM)
22
ACIDS: Caustics rust remover, metal polish.
S/S: Pain, GI tract bums, lip bums, and vomiting.
Treatment: Transport patient in sitting position, if possible.
Caution: Do not induce vomiting.
ACETAMINOPHEN: ANALGESIC TYLENOL, APAP
S/S: May be no immediate s/s, but ACETAMINOPHEN is toxic to the liver, anorexia, RUQ
pain, pale color, diaphoretic.
Treatment: ABC's, 02, IV and fluids for hypotension, EKG, ACTIVATED CHARCOAL 50 gm
orally.
ALKALIS & CAUSTICS: Drano, drain & oven cleaners, bleach.
S/S: Epigastric pains, GI tract chemical burns, lip burns, vomiting.
Treatment: Prevent aspiration. Transport patient in sitting position, if possible.
Caution: Do not induce vomiting.
AMPHETAMINES & STIMULANTS: Stimulant methamphetamines, speed, crank.
S/S: Anxiety, tachycardia, diaphoresis, seizures, lethal cardiac arrhythmias, HA, palpitations,
CV A, HTN crisis, hyperthermia, dilated pupils, dry mouth.
Treatment: ABCs, 02, EKG, IV fluids for hypotension. ACTIVATED CHARCOAL 50 gm orally.
Keep patient cool. DIAZEPAM as adjunct.
ANTIDEPRESSANTS: Mood elevators ELAVIL, TRIAVIL, SINEQUAN, AMITRIPTYLINE.
S/S: Hypotension, PVC's, cardiac arrhythmias, QRS complex widening, seizures, coma, and
death.
Treatment: ABC, 02, IV, EKG, IV fluids, SODIUM BICARBONATE, intubate and
hyperventilate.
Caution: Onset of coma and seizures can be sudden.
ASPIRIN: ANALGESIC BAYER, ASA, SALICYLATES
S/S: GI bleeding, LUQ pain, pale color, diaphoresis, shock, ringing in the ears, hyperpnea.
Treatment: ABC, 02, IV, EKG, fluids for hypotension, ACTIVATED CHARCOAL 50gm orally.
BARBITURATES: Sedatives. Hypnotic Phenobarbital, barbs, downers.
S/S: Weakness, drowsiness, respiratory depression, apnea, coma, hypotension, bradycardia,
hypothermia, pulmonary edema, death.
Treatment: ABCs, 02, ventilate, IV fluids for hypotension.
Caution: protect the patient's airway.
CARBON MONOXIDE: odorless toxic gas from any source of incomplete combustion IE: car
exhaust, fire suppression, and stoves.
S/S: HA, dizziness, DOE, fatigue, tachycardia, visual disturbances, hallucinations, cherry red
skin color, decreased respirations, cyanosis, ALOC, coma, blindness, hearing loss,
convulsions, others in household with same symptoms.
Treatment: Remove patient from toxic environment, ABCs, 02, transport. Hyperbaric
treatment in severe cases.
Caution: Protect yourself from exposure.
COCAINE: Stimulant/anesthetic coke, snow, flake, crack.
S/S: HA, decreased respirations, decreased temp, agitation, tachycardia, cardiac arrhythmias,
chest pain, AMI, HTN, seizure, vomiting, hyperthermia, paralysis, coma, dilated pupils, death.
23
Acute pulmonary edema can occur with IV use.
Treatment: ABCs, 02, IV, DIAZEPAM for seizures, ET Intubation, LIDOCAINE for PVC's, cool
patient, if hyperthermic.
Note: A "speedball" is cocaine & heroin.
HALLUCINOGENS: Alter perception LSD, psilocybin mushrooms.
S/S: Anxiety, hallucinations, panic, disorientation, paranoia.
Treatment: ABC's, Supportive reassurance.
Caution: Watch for violent or unexpected behavior.
HYDROCARBONS: Fuels, gasoline, oil, and petroleum products.
S/S: Breath odor, SOB, seizures, acute pulmonary edema, coma, bronchospasm.
Treatment: ABCs, 02, gastric lavage.
Caution: Do not induce vomiting.
MUSHROOMS: Amanita Deadly mushroom Death Angel
S/S: Seizures, death.
Treatment: ABCs, 02, IV, DIAZEPAM for seizures.
Caution: Protect the patient's airway.
OPIATES: NARCOTIC ANALGESIC, DILAUDID, HEROIN, MORPHINE, CODEINE
S/S: Decreased respirations, apnea, decreased BP, coma, bradycardia, pinpoint pupils,
vomiting, and diaphoresis.
Treatment: ABC, 02, ventilate, intubate, IV fluids for hypotension, NALOXONE 2 mg IV, IM, ET,
or IO.
Caution: Consider other concurrent overdoses.
PCP - PHENCYCLIDINE: Tranquilizer Peace Pill, angel dust, horse tranquilizer
S/S: Nystagmus (constant involuntary movement of the eyeball), disorientation, HTN,
hallucinations, catatonia, sedation, paralysis, stupor, mania, tachycardia, dilated pupils, status
epilepticus.
Treatment: ABC, 02, vitals, IV, EKG.
Caution: Protect yourself against violent patient. Be aware of possible trauma due to
anesthetic effect of PCP.
TRANQUILIZERS (MAJOR): Antipsychotic HALDOL, NAVANE, THORAZINE, COMPAZINE
S/S: EPS, dystonias, painful muscle spasms, respiratory depression, hypotension, Torsades
de Pointes.
Treatment: 50 mg DIPHENHYDRAMINE for EPS. ABCs, 02, vitals, EKG. Consider
ACTIVATED CHARCOAL 50gm orally. IV fluids for hypotension. Consider intubation for the
unconscious patient.
Caution: Protect the patient's airway.
TRANQUILIZERS (MINOR): ANXIOLYTICS (anti anxiety) VALIUM, XANAX, LIBRIUM,
DIAZEPAM, MIDAZOLAM
S/S: Sedation, weakness, dizziness, tachycardia, hypotension, hypothermia.
Treatment: ABCs, monitor vitals, IV.
Caution: Coma means some other substance or cause is also involved. OD is almost always
in combination with other drugs. Protect the patient's airway.
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ECSTASY: (methylenedioxymethamphetamine): XTG, wonder drug, and X
S/S: Feelings of detachment, loss of drives such as hunger, sleep, and sexual, muscle
tension, sweating or chills, tremors, blurred vision, rapid eye movements, hypertension,
increased heart rate, dehydration, nausea, fainting, and death.
Treatment: ABC's, calm patient
GHB: Gamma-Butryolactone G, Georgia Home Boy, Liquid Ecstasy
S/S: Drowsiness, dizziness, ataxia (uncoordination), and clonic movements have been
observed during GHB induced sleep, orthostatic hypotension, high doses induce sedation, and
loss of consciousness, and can induce cardiac and respiratory depression, loss of reflexes.
Patient may need continued stimuli to remember to breath. Treatment: ABC, monitor airway,
02, assist ventilations as needed, IV, EKG, pulse oximetry
25
Glasgow Coma Scale
ADULT
Eye Opening:
Spontaneous – 4
To Voice – 3
To Pain – 2
None – 1
Verbal Response:
Oriented – 5
Confused – 4
Inappropriate – 3
Incomprehensible – 2
None – 1
Motor Response:
Obeys Commands – 6
Localizes – 5
Withdraws – 4
Flexion – 3
Extension – 2
None – 1
PEDIATRIC (AGE 4 TO ADULT)
Eye Opening:
Spontaneous – 4
Verbal Command – 3
To Pain – 2
None – 1
Verbal Response:
Oriented and Converses – 5
Disoriented and Converses – 4
Inappropriate – 3
Incomprehensible – 2
None – 1
Motor Response:
Obeys Commands – 6
Localizes – 5
Withdrawal – 4
Flexion Withdrawal – 3
Flexion Abnormal – 2
None – 1
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PEDIATRIC (BIRTH TO AGE 4)
Eye Opening:
Spontaneous – 4
Reaction to Speech – 3
Reaction to Pain – 2
None – 1
Verbal Response:
Smiles, Oriented to Sound, Interacts Appropriately – 5
Crying but Consolable, Interacts Inappropriately – 4
Crying and Inconsistently Inconsolable, Interacts Restlessly – 3
Crying and Inconsolable, Interacts Restlessly – 2
None – 1
Motor Response:
Spontaneous – 6
Localized Pain – 5
Withdraws in Response to Pain – 4
Abnormal Flexion – 3
Abnormal Extension – 2
None – 1
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APGAR Scale
A – Appearance
0 Points – Blue/Pale
1 Point – Body Pink, Extremities Blue
2 Points – Fully Pink
P – Pulse
0 Points – Absent
1 Point - <100
2 Points - >100
G – Grimace
0 Points – No Response
1 Point – Grimace
2 Points – Cough, Sneeze
A – Activity
0 Points – Limp
1 Point – Some Flex
2 Points – Active Motion
R – Respiration
0 Points – Absent
1 Point – Slow
2 Points – Strong Cry
*APGAR Score should be calculated at 1 minute and 5 minutes.
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AVPU Scale
ADULT
A – Alert
V – Responds to Verbal Stimuli
P – Responds to Painful Stimuli
U – Unresponsive
CHILD
A – Alert/Aware of Surroundings
V – Opens Eyes
P – Withdraws from Pain
U – No Response
INFANT
A – Curious/Recognizes Parents
V – Irritable/Cries
P – Cries in Response to Pain
U - Unresponsive
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Average Pediatric Vital Signs
NEONATE:
Respiratory Rate – 60
Blood Pressure – 80/46
Pulse Rate – 110 to 150
Weight – 6.6 pounds
3 MONTHS:
Respiratory Rate – 40
Blood Pressure – 89/60
Pulse Rate – 110 to 140
Weight – 11 pounds
6 MONTHS:
Respiratory Rate – 30
Blood Pressure – 89/60
Pulse Rate – 110 to 140
Weight – 16.5 pounds
1 YEAR:
Respiratory Rate – 25
Blood Pressure – 89/60
Pulse Rate – 110 to 140
Weight – 22 pounds
2 YEARS:
Respiratory Rate – 20
Blood Pressure – 96/84
Pulse Rate – 90 to 100
Weight – 27.5 pounds
3 YEARS:
Respiratory Rate – 20
Blood Pressure – 100/70
Pulse Rate – 80 to 120
Weight – 33 pounds
4 YEARS:
Respiratory Rate – 20
Blood Pressure – 100/70
Pulse Rate – 80 to 100
Weight – 39.6 pounds
6 YEARS:
Respiratory Rate – 20
Blood Pressure – 100/56
Pulse Rate – 80 to 100
Weight – 55 pounds
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Common Causes of Abdominal Pain
Epigastric: AMI, gastroenteritis, ulcer, diagram esophageal disease, heartburn.
RUQ: Liver, gall bladder, kidney large intestine. Gall stones, hepatitis, liver disease, pancreatitis,
appendicitis, perforated duodenal ulcer, AMI, pneumonia.
LUQ: Spleen, liver, kidney, pancreas, large intestine. Gastritis, pancreatitis, AMI, pneumonia.
LLQ: Small intestine, ovary uterus, large intestine. Ruptured ectopic pregnancy, diverticulitis,
ovarian cyst, PID, kidney stones, enteritis, abdominal abscess.
RLQ: Appendix, Bladder, large intestine, ovary, uterus. Appendicitis, rupture ectopic pregnancy,
enteritis, abdominal abscess, PID, diverticulitis, ovarian cyst, kidney stones, strangulated hernia.
Midline: bladder infection, aortic aneurysm, uterine disease, intestinal disease, early appendicitis.
Diffuse Pain: pancreatitis, peritonitis, appendicitis, gastroenteritis, dissecting/rupturing aortic
aneurysm, diabetes, ischemic bowel, sickle cell crisis
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Cincinnati Stroke Exam
FACIAL DROOP- Have the patient show teeth or smile.
a. Normal- both sides of the face move equally.
b. Abnormal- one side of the face does not move as well as the other side.
ARM DRIFT- Have the patient close his or her eyes and hold both arms straight out for 10
seconds.
a. Normal- both arms move the same or both arms do not move at all (other signs such as
pronator grip may be beneficial).
b. Abnormal- one arm does not move or one arm drifts down compared with the other.
ABNORMAL SPEECH - Have the patient say "you can't teach an old dog new tricks".
a. Normal- patient uses correct words with no slurring.
b. Abnormal- patient slurs words, uses the wrong words, or is unable to speak.
*Finger to nose and or heel to shin testing typically abnormal
**Decreased level of consciousness with headache and stiff neck are typical; this syndrome
without associated focal neurologic deficits is most consistent with subarachnoid hemorrhage.
With intracerebral, focal deficits may occur.
Left Hemisphere Deficits:
Arm Droop – right arm drift (weakness)
Facial Droop – right sided facial droop
Speech – aphasia, wrong or inappropriate speech
Right Hemisphere Deficits:
Arm Droop – left arm drift (weakness)
Facial Droop – left sided facial droop
Speech – says statements correctly
Brainstem:
Arm Droop – may have bilateral drift (weakness)
Facial Droop – may have bilateral facial droop
Speech – dysarthria slurring
Cerebellum:
Arm Droop – no drift
Facial Droop – no facial droop
Speech – says statements correctly
Hemorrhage:
Arm Droop – no drift
Facial Droop – no facial droop
Speech – says statements correctly but slowly (often sleepy)
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Common Medical Abbreviations
ABC: airway, breathing, circulation
ABD: abdominal
ADD: attention deficit disorder
ALS: advanced life support
AMA: against medical advice
AMI: acute myocardial infarction
Amp: ampule/one dose
A/P: anterior/posterior
APAP: acetaminophen
ASA: aspirin
AT: atrial tachycardia
AV: atrioventricular
BICARB: Sodium Bicarbonate
BID: twice a day
BIL: bilateral
BLS: basic life support
BP: blood pressure
CA: cancer
CAD: coronary artery disease
CC or c/c: chief complaint
cc: cubic centimeter
CCU: coronary care unit
CHB: complete heart block
CHF: congestive heart failure
CLR: clear
cm: centimeter
CNS: central nervous system
c/o: complains of
CO: carbon monoxide
CO2: carbon dioxide
COPD: chronic obstructive pulmonary disease
CP: chest pain
CPR: cardio-pulmonary resuscitation
CSF: cerebral spinal fluid
CSM: circulation/sensory/motor
CVA: cerebral vascular accident
cx: chest
D/C: discontinue
DL: deciliter (1/10 of a liter, 100 ml)
DOA: dead on arrival
D5W: 5% dextrose in water
Dx: diagnosis
ED: emergency department
EKG/ECG: electrocardiogram
Epi: epinephrine
EPS: extra pyramidal symptoms
ET: endotracheal
ETOH: alcohol
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fib: fibrillation
fl: fluid
FROM: full range of motion
fx: fracture
GI: gastrointestinal
gm: gram
gr: grain
gt(t): drop(s)
h, hr: hour
HA: headache
HADD: hyperactive attention deficit disorder
HTN: hypertension
hx: history
ICP: intracranial pressure
ICU: intensive care unit
IM: intramuscular
IN: intranasal
IO: intraosseous
IV: intravenous
IVP: intravenous push
Kg: kilogram
KVO: keep vein open
L: liter
LPM: liter per minute
LOC: level of consciousness/loss of consciousness (depending on context)
LR: lactated ringers
LS: lung sounds
MD: medical doctor
mEq: milliequivalents
mg: milligram
MI: myocardial infarction
min: minute
ml: milliliter
mm: millimeter
MOE: moves all extremities
MS: morphine sulfate
NaCL: sodium chloride
NaHCO3: sodium bicarbonate
NAD: no apparent distress
NG, N/G: naso gastric
NPO: nothing by mouth
NS: normal saline
NSR: normal sinus rhythm
NTG: nitroglycerine
N/V: nausea/vomiting
N/V/D: nausea/vomiting/diarrhea
O2: oxygen
OB: obstetrics
OD: overdose
OR: operating room
PAC: premature atrial contraction
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PAT: paroxysmal atrial tachycardia
PCN: penicillin
PCR: patient care report
PE: physical exam or pulmonary edema
pedi: pediatric
PERL: pupils, equal, reactive to light
PJC: premature junctional contraction
po: by mouth
prn: when necessary
PTA: prior to arrival
PVC: premature ventricular contraction
QID: four times a day
R/O: rule out
RN: registered nurse
Rx: prescription medication
SC: subcutaneous
sec: second
SL: sublingual
SIVP: slow intravenous push
SNT: soft, non-tender
SOB: shortness of breath
STAT: immediately
s/s: signs/symptoms
SVT: supraventricular tachycardia
Sx: symptoms
Sz: seizure
TB: tuberculosis
TCA: tricyclic antidepressant
TIA: transient ischemic attack
TID: three times a day
TKO: to keep open
U/A: upon arrival
UTI: urinary tract infection
VF: ventricular fibrillation
VT: ventricular tachycardia
WNL: within normal limits
W/O: wide open
X: times
y/o: years old
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Medication Profiles
Below is a list of the medications that Redmond Regional Emergency Medical Services currently
utilize. This list may be updated as medications are added or deleted from our inventory. After
the list of medications, you will find a profile for each medication.
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ACETAMINOPHEN
ADENOCARD (ADENOCARD®)
ALBUTEROL SULFATE (VENTOLIN®, PROVENTIL®)
AMIODARONE (CORDARONE®)
ASPIRIN
ATROPINE SULFATE
CALCIUM CHLORIDE
CLONIDINE HYDROCHLORIDE (CATAPRES®)
DEXTROSE (D50, D25, D10)
DIAZEPAM (VALIUM®)
DILTIAZEM (CARDIZEM®)
DIPHENHYDRAMINE (BENADRYL®)
DOPAMINE (INOTROPIN®)
EPINEPHRINE, EPI-PEN, EPI-PEN JR. (ADRENALINE®)
ETOMIDATE (AMIDATE®)
FLUMAZENIL (ROMAZICON®)
FUROSEMIDE (LASIX®)
GLUCAGON
HALOPERIDOL (HALDOL®)
HEPARIN SODIUM
IBUPROFEN
IPRATROPIUM BROMIDE (ATROVENT®)
KETOROLAC (TORADOL®)
LIDOCAINE (XYLOCAINE®)
MAGNESIUM SULFATE
MEPERIDINE (DEMEROL®)
METHYLPREDNISOLONE (SOLU-MEDROL®)
METOPROLOL (LOPRESSOR®)
MIDAZOLAM HYDROCHLORIDE (VERSED®)
MORPHINE SULFATE
NALOXONE (NARCAN®)
NITROGLYCERIN
ODANSETRON HYDROCHLORIDE (ZOFRAN®)
PHENYLEPHRINE (NEO-SYNEPHRINE®) SPRAY
PROMETHAZINE (PHENERGAN®)
SODIUM BICARBAONATE
TETRACAINE OPTHALMIC DROPS
THIAMINE (BETAXIN®)
VASOPRESSIN
36
ACETAMINOPHEN
Description/Mechanism: Acetaminophen is a synthetic, non-opiate, centrally acting analgesic
and antipyretic agent.
Indications: Treats minor pain and reduces fever.
Contraindications: Do not use in patients that have a hypersensitivity to acetaminophen.
Adverse Reactions: Allergic reaction; bloody stools or black, tarry stools; dark colored urine;
light-headedness; fainting; sweating; weakness; nausea and/or vomiting; loss of appetite; severe
stomach pain; unusual bleeding or bruising; vomiting blood or coffee-ground emesis; yellowing of
the skin or eyes.
37
ADENOSINE (ADENOCARD®)
Description/Mechanism: Adenosine is primarily formed from the breakdown product of
adenosine triphosphate (ATP). Both compounds are found in every cell of the human body, and
have a wide range of metabolic roles. Its actions in the AV node are thought to act through
stimulation of specific adenosine receptors. Adenosine slows those tachycardias associated with
the AV node (i.e. AV Node Re-entry Tachycardias) by decreasing conductivity through the node.
Specifically, activation of A1 receptors in the AV node activates an inward potassium channel
and inactivation of inward slow calcium channels that result in membrane hyperpolarization. This
decreases the speed of AV node conduction and increases the AV node refractory period.
Although there are adenosine receptors in most every cell, includes those of the sinus
pacemakers, there is no clinical effect of the drug on tachycardias originating outside the AV node
such as sinus tachycardia, atrial fibrillation or atrial flutter.
Onset: Within 30 seconds
Duration: Approximately 10 seconds
Indications: Conversion of PSVT (including those associated with WPW) to sinus rhythm
Contraindications: Hypersensitivity to adenosine; second or third degree block or sick sinus
syndrome
Adverse Reactions:
Light-headedness; hypotension; paresthesia; shortness of breath;
headache; transient periods of sinus bradycardia or ventricular ectopy; palpitations; chest pain;
nausea
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ALBUTEROL SULFATE (VENTOLIN®, PROVENTIL®)
Description/Mechanism: Primarily beta 2 -selective sympathomimetic. Relaxes smooth muscle
of the bronchial tree and peripheral vasculature.
Activates cAMP via a non-beta receptor mechanism. For this reason, it is sometimes used in betablocker overdoses. It also activates the Na-K pump by the same mechanism which is useful in
treating hyperkalemia.
Onset: 5 to 15 minutes after inhalation
Duration: 3 to 4 hours after inhalation
Indications: Relief of bronchospasm; beta-blocker overdose; hyperkalemia
Contraindications:
tachycardia
Hypersensitivity to albuterol; cardiac dysrhythmias associated with
Adverse Reactions: Adverse reactions are usually dose related; restlessness; dizziness;
apprehension; palpitations; increase in blood pressure; dysrhythmias
39
AMIODARONE (CORDARONE®)
Description/Mechanism: Prolongs duration of action potential and effective refractory period,
also provides noncompetitive a- and b- adrenergic inhibition. Decreases AV conduction velocity
and sinus node function.
Onset: Within minutes after IV administration
Duration: Days (not firmly established)
Indications: VF, unstable VT and SVT refractory to other therapy. Trials underway or recently
completed indicated amiodarone is an effective first line medication for VT/VF in cardiac arrest.
Contraindications: None in cardiac arrest with VF or VT. High degree AV blocks, sinus node
dysfunction and marked bradycardia.
Adverse Reactions: Hypotension; bradycardia
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ASPIRIN
Description/Mechanism: Powerfully inhibits platelet aggregation by inhibiting thrombonxane A2
production. Major actions appear to be associated primarily with inhibiting the formation of
prostaglandins involved in the production of inflammation, pain and fever. Lowers body
temperature by indirectly causing centrally mediated peripheral vasodilation and sweating.
Onset: Approximately 15 minutes
Duration: 2 to 4 hours
Indications: Acute myocardial infarction/injury; relieve pain of low to moderate intensity;
inflammatory conditions; reduce fever; prevent recurrence of MI or TIA
Contraindications: Hypersensitivity to salicylates; history of GI ulcerations; history of hemophilia
or other bleeding disorders; pregnancy or children under 2 years of age
Adverse Reactions: Dizziness, confusion; tinnitus; hearing loss; nausea; heartburn; stomach
pains
41
ATROPINE SULFATE
Description/Mechanism: Atropine sulfate is a potent parasympatholytic. It inhibits actions of
acetylcholine at postganglionic parasympathetic neuroeffector sites, primarily at muscarinic
receptors. Small doses inhibit salivary and bronchial secretions, moderate doses dilate pupils and
increase heart rate. Large doses decrease GI motility, inhibit gastric acid secretion. Blocked vagal
effects result in positive chronotropy and positive dromotropy (limited or no inotropic effect). In
emergency care, it is primarily used to increase the heart rate in life-threatening bradycardias. You
can think of the effects of atropine as being 'anti-SLUDGE'.
Onset: Rapid
Duration: 2 to 6 hours
Indications: Hemodynamically significant bradycardia; asystole; PEA (ventricular rate <60);
organophosphate poisoning; pre-treatment for pediatric patients receiving RSI
Contraindications: Hypersensitivity to Atropine Sulfate; tachycardia; unstable cardiovascular
status in acute hemorrhage with myocardial ischemia
Adverse Reactions:
tachycardia; palpitations; dysrhythmias; headache; dizziness;
nausea/vomiting; flushed and dry skin; dry mouth/nose; photophobia; blurred vision; urinary
retention; possible paradoxical bradycardia when pushed slowly or at doses less than 0.5 mg.
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CALCIUM CHLORIDE
Description/Mechanism: Calcium is an essential component for functional integrity of the
nervous and muscular systems, for normal cardiac contractility and the coagulation of blood.
Calcium chloride contains 27.2% elemental calcium. Calcium chloride is a hypertonic solution and
should only be administered intravenously slowly.
Onset: 5 to 15 minutes
Duration: Dose dependent but effects may last up to 4 hours after IV administration
Indications: Hyperkalemia; hypocalcemia (eg. after multiple blood transfusions, dialysis); calcium
channel blocker toxicity; hypermagnesemia; prevention of hypotensive effects of calcium channel
blocking agents (eg. Verapamil/Diltiazem via IV)
Contraindications: VF during cardiac resuscitation; hypercalcemia; digitalis toxicity
Adverse Reactions: Decreases in heart rate (may cause asystole); decrease in blood pressure;
metallic taste; severe local necrosis following IM administration or IV infiltration
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CLONIDINE HYDROCHLORIDE (CATAPRES®)
Description/Mechanism: Stimulates central alpha-adrenergic receptors to inhibit sympathetic
cardioaccelerator and vasoconstrictor centers.
Onset: 30 to 60 minutes
Duration: 8 hours to several days
Indications: Management of hypertension
Contraindications: Hypersensitivity to clonidine; patients on anticoagulant therapy; patients with
a bleeding diathesis
Adverse Reactions: Dry mouth; drowsiness; constipation; sedation; fatigue; headache; lethargy;
insomnia; dizziness, impotence; change in taste, nervousness; rash
44
DEXTROSE (D50, D25, D10)
Description/Mechanism: The term "dextrose" is used to describe the six carbon sugar dglucose, the principal form of carbohydrate utilized by the body for energy production. D50 is used
in emergency care to treat hypoglycemia, and in the management of coma of unknown origin.
Onset: Less than 1 minute
Duration: Depends on degree of hypoglycemia
Indication: Hypoglycemia; refractory cardiac arrest (controversial)
Contraindications: Intracranial bleeding; increased intracranial pressure; known or suspected
CVA in absence of hypoglycemia
Adverse Reactions: Warmth; pain; burning from medication infusion; thrombophlebitis
45
DIAZEPAM (VALIUM®)
Description/Mechanism: Diazepam is a frequently prescribed medication to treat anxiety and
stress. In emergency care, it is used to treat alcohol withdrawal and grand mal seizure activity.
Diazepam potentiates the effects of inhibitory neurotransmitters (GABA), hyperpolarizing the
membrane potential and raising the seizure threshold in the motor cortex. It may also be used in
conscious patients during cardioversion and TCP to induce amnesia and sedation. Though the
drug is still widely used as an anticonvulsant because of its fast action, it is actually a relatively
weak anticonvulsant because of its short duration. Rapid IV administration may be followed by
respiratory depression and excessive sedation.
Onset: IV - rapid; IM - 15 to 30 minutes; ET – rapid
Duration: 15 minutes to 1 hour
Indications: Acute anxiety states; acute alcohol withdrawal; sedation; seizure activity;
premedication prior to cardioversion or TCP
Contraindications: Substance abuse; coma; shock; hypersensitivity to the drug
Adverse Reactions:
Hypotension; reflex
psychomotor impairment; confusion; nausea
46
tachycardia;
respiratory
depression;
ataxia;
DILTIAZEM (CARDIZEM®)
Description/Mechanism: Diltiazem is a calcium channel blocking agent that slows conduction,
increases refractoriness in the AV node, and causes coronary vasodilation. The drug is used to
control ventricular response rates in patients with atrial fibrillation, atrial flutter, multifocal atrial
tachycardia and PSVT.
Onset: 2 to 5 minutes
Duration: 1 to 3 hours
Indications: Atrial fibrillation; atrial flutter; PSVT; multifocal atrial tachycardia
Contraindications: Sick sinus syndrome; second or third degree AV block; WPW or other preexcitation syndrome; VT or other wide complex tachycardia of unknown origin; severe
hypotension; sensitivity to diltiazem; concomitant use of IV beta blockers
Adverse Reactions: Atrial flutter; first and second degree AV block; bradycardia; chest pain;
congestive heart failure; syncope; ventricular dysrhythmias; sweating; nausea/vomiting; dizziness;
dry mouth; dyspnea; headache
47
DIPHENHYDRAMINE (BENADRYL®)
Description/Mechanism: An antihistamine with significant anticholinergic effects and a high
incidence of drowsiness. Competes for H1 receptors on effector cells thus blocking effects of
histamine release. Effects in Parkinsonism and drug-induced extrapyramidal symptoms are
apparently related to its ability to suppress central cholinergic activity and to prolong action of
dopamine by inhibiting its reuptake and storage. Diphenhydramine does not affect H2 receptors
and therefore has no effect on gastric acid secretion.
Onset: Maximal effect in 1 to 3 hours
Duration: 6 to 12 hours
Indications: Allergic reactions; anaphylaxis; acute extrapyramidal reactions
Contraindications:
Acute asthma; CNS depression; patients taking MAO inhibitors;
hypersensitivity to the drug
Adverse Reactions: Dose related drowsiness; sedation; disturbed coordination; hypotension;
palpitations; tachycardia; bradycardia; thickening of bronchial secretions; dry mouth or throat
48
DOPAMINE (INOTROPIN®)
Description/Mechanism: The essential amino acid tyrosine is converted to L-DOPA and then to
dopamine. It is then converted to norepinephrine and then to epinephrine. It acts primarily on
alpha 1, beta 1 adrenergic receptors in dose-dependent fashion. At low doses ("renal doses"),
dopamine has a dopaminergic effect that causes renal, mesenteric, and cerebral vascular dilation.
At moderate doses ("cardiac doses"), dopamine has beta 1 adrenergic effect, causing enhanced
myocardial contractility, increased cardiac output, and a rise in blood pressure. At high doses
("vasopressor doses"), dopamine has an alpha 1 adrenergic effect, producing peripheral arterial
and venous constriction. Dopamine is commonly used in the treatment of hypotension associated
with cardiogenic shock.
Onset: 2 to 4 minutes
Duration: 10 to 15 minutes after cessation of infusion
Indications: Hemodynamically significant hypotension in the absence of hypovolemia
Contraindications: VT/VF; hypovolemia; patients with pheochromocytoma
Adverse Reactions: dose related tachydysrhythmias; hypertension; increased myocardial oxygen
demand
49
EPINEPHRINE, EPI-PEN, EPI-PEN JR. (ADRENALINE®)
Description/Mechanism: Epinephrine stimulates alpha, beta 1 and beta 2 adrenergic receptors
in dose-related fashion. Rapid injection produces a rapid increase in blood pressure, ventricular
contractility, and heart rate. In addition, epinephrine causes vasoconstriction in the arterioles of the
skin and mucosa. It antagonizes the effects of histamine by decreasing its release and decreasing
membrane permeability.
Onset: IM – 5 to 10 minutes; IV or ET – 1 to 2 minutes
Duration: 5 to 10 minutes
Indications: Bronchoconstriction; anaphylaxis; all forms of cardiac arrest; profound symptomatic
bradycardia
Contraindications:
insufficiency
Hypersensitivity to the drug; hypovolemic shock; hypertension; coronary
Adverse Reactions: Headache; nausea; restlessness; weakness; dysrhythmias; hypertension;
precipitation of angina pectoris
50
ETOMIDATE (AMIDATE®)
Description/Mechanism: A hypnotic drug without analgesic properties.
Onset: Usually within 1 minute
Duration: Dose dependent but usually 3 to 5 minutes with normal dose
Indications: Induction of general anesthesia
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Hyperventilation; hypoventilation; apnea of short periods (usually 5 to 90
seconds with spontaneous recovery); laryngospasm; hiccup and snoring indicative of upper airway
obstruction; hypertension; hypotension; cardiac dysrhythmias
51
FLUMAZENIL (ROMAZICON®)
Description/Mechanism: Flumazenil antagonizes the actions of benzodiazepines on the central
nervous system. It has been shown to antagonize sedation, impairment of recall, and psychomotor
impairment produced by benzodiazepines. Flumazenil does not antagonize CNS effects of
ethanol, barbiturates or opioids.
Onset: 1 to 2 minutes
Duration: Generally less than that of the benzodiazepine
Indication: Reversal of benzodiazepine sedation
Contraindications:
Overdose of unknown substances; underlying dependence
benzodiazepines; cyclic antidepressant overdose; hypersensitivity to drug or benzodiazepines
of
Adverse Reactions:
Nausea/Vomiting; dizziness; agitation; injection-site pain; cutaneous
vasodilation; abnormal vision; seizures
52
FUROSEMIDE (LASIX®)
Description/Mechanism: Furosemide is a potent diuretic that inhibits the reabsorption of sodium
and chloride in the proximal tubule and loop of Henle.
Onset: Diuretic effects within 15 to 20 minutes and vasodilatory effects within 5 minutes when
given IV
Duration: 4 to 6 hours
Indications: Cardiogenic pulmonary edema; congestive heart failure
Contraindications:
Anuria; hypersensitivity to the drug; hypovolemia/dehydration; known
hypersensitivity to sulfonamides; states of severe electrolyte depletion
Adverse Reactions: Hypotension; dry mouth; hypochloremia; hypokalemia; hyponatremia;
hyperglycemia; tinnitus if given too rapidly
53
GLUCAGON
Description/Mechanism: Glucagon is a protein secreted by the alpha cells of the pancreas.
When released, it results in blood glucose elevation by increasing the breakdown of glycogen to
glucose and inhibiting glycogen synthesis. The drug is only effective in treating hypoglycemia
when the patient has adequate stored glycogen.
In addition, glucagon exerts positive inotropic action on the heart and decreases renal vascular
resistance. It is, therefore, also used in managing patients with beta-blocker cardiotoxicity.
Onset: Within 1 minute
Duration: 9 to 17 minutes
Indications: Hypoglycemia with altered level of consciousness; beta blocker overdose
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Tachycardia; hypertension; nausea/vomiting
54
HALOPERIDOL (HALDOL®)
Description/Mechanism: Potent, long-acting butyrophenone derivative with pharmacologic
actions similar to those of phenothiazines but with higher incidence of extrapyramidal effects and
less hypotensive and relatively low sedative activity. Exerts strong antiemetic effect and impairs
central thermoregulation. Produces weak central anticholinergic effects and transient orthostatic
hypotension.
Onset: IV – 10 to 20 minutes; IM – 30 to 60 minutes
Duration: 12 to 24 hours
Indications: Acute psychotic episode
Contraindications: CNS depression; coma; pregnancy; hypersensitivity to the drug
Adverse Reactions: Orthostatic hypotension; nausea/vomiting; allergic reactions; blurred vision;
dose related pseudoparkinsonism; dose related akathisia; dose related dystonias
55
HEPARIN SODIUM
Description/Mechanism: Exerts a direct effect on blood coagulation by binding with and
enhancing the actions of antithrombin III (heparin cofactor). Antithrombin III binds with and
inactivates excess thrombin in order to limit the spread of regionalized clotting activity. By
decreasing the amount of available thrombin, fibrinogen is prevented from converting to fibrin and
new clots are not made. The antithrombin III-heparin complex is ~1000 X as effective as
antithrombin III alone. Heparin does not lyse already existing thrombi (and is therefore NOT a
thrombolytic) but may prevent their extension and propagation.
Onset: Less than 1 minute via IV
Duration: 4 to 8 hours
Indication: Acute myocardial infarctions; unstable angina
Contraindications: Hypersensitivity to the drug; active bleeding; recent intracranial, intraspinal,
or eye surgery; severe hypertension; bleeding tendencies
Adverse Reactions: Allergic reaction; hemorrhage; thrombocytopenia
56
IBUPROFEN
Description/Mechanism: Ibuprofen tablets contain Ibuprofen which possesses analgesic and
antipyretic activities. Its mode of action, like that of other NSAIDs, is not completely understood,
but may be related to prostaglandin synthetase inhibition
Onset: 15 to 30 minutes
Duration: 4 to 6 hours
Indications: Used for mild to moderate pain relief; patients with fever
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Nausea/vomiting; epigastric pain; diarrhea; abdominal distress; heartburn;
dizziness; headache; nervousness; rash; tinnitus; decreased appetite
57
IPRATROPIUM BROMIDE (ATROVENT®)
Description/Mechanism: Atrovent is an anticholinergic. It works by relaxing and opening
bronchial tubes (air passages in the lungs), making it easier to breath.
Onset: Up to 1 hour
Duration: 4 to 6 hours
Indications: Treating and preventing bronchospasm (wheezing or difficulty breathing) associated
with chronic obstructive pulmonary disease, including chronic bronchitis and emphysema. It can
be used alone or with certain other medications.
Contraindications: Hypersensitivity to Atrovent; hypersensitivity to soy lethicin or related
products (eg. Soybeans, peanuts); hypersensitivity to Atropine or similar medications
Adverse Reactions: Dizziness; dry nose or nose irritations; dry mouth; flu-like symptoms;
headache; nausea; nervousness; pain; runny nose; sinus congestion; sore throat; upper
respiratory tract infection; blurred vision; nosebleeds; eye pain; trouble urinating; visual halos or
colored rings
58
KETOROLAC (TORADOL®)
Description/Mechanism: Ketorolac is an anti-inflammatory drug that also exhibits peripherally
acting, non-narcotic analgesic activity by inhibiting prostaglandin synthesis.
Onset: Within 10 minutes
Duration: 2 to 6 hours
Indication: Short term management of moderate to severe pain
Contraindications: Hypersensitivity to the drug; patients with history of asthma; patients with
allergies to aspirin or other NSAIDS; bleeding disorders; renal failure; hypotension
Adverse Reactions:
Anaphylaxis; edema; sedation; hypertension; hypotension; bleeding
disorders; rash, nausea; headache
59
LIDOCAINE (XYLOCAINE®)
Description/Mechanism: Suppresses automaticity in His-Purkinje system and by elevating
electrical stimulation (fibrillation) threshold of ventricles during diastole. This occurs by blocking
fast sodium channels and depressing pathogenic phase 4 diastolic depolarization.
Onset: 30 to 90 seconds
Duration: 2 to 4 hours
Indications: VF/VT; wide complex tachycardia of unknown origin; significant ventricular ectopy in
the setting of myocardial ischemia/infarction; pre-medication prior to RSI in patients with closed
head injury
Contraindications: Hypersensitivity to other amide type anesthetics (NOT ester anesthetics like
NOVACAINE®); Stokes - Adams syndrome; second or third degree AV block without an artificial
pacemaker
Adverse Reactions: Lightheadedness; confusion; CNS depression; muscle twitching; seizures;
blurred vision; hypotension; bradycardia; cardiovascular collapse
60
MAGNESIUM SULFATE
Description/Mechanism: Magnesium sulfate reduces striated muscle contractions and blocks
peripheral neuromuscular transmission by reducing acetylcholine release at the myoneural
junction. In emergency care, magnesium sulfate is used in the management of seizures
associated with toxemia of pregnancy.
Other uses of magnesium sulfate include uterine relaxation (to inhibit contractions of premature
labor), as a bronchodilator after beta agonist and anticholinergic agents have been used,
replacement therapy for magnesium deficiency, as a cathartic to reduce the absorption of poisons
from the GI tract, and in the initial therapy for convulsions. Magnesium sulfate is frequently used
as an initial treatment in the management of Torsades de pointes, and dyrhythmias secondary to
TCA overdose or digitalis toxicity. The drug is also considered as a class IIa agent (probably
helpful) for refractory VF/VT after administration of other antidysrhythmics. Some success has
also been found in patients suffering with respiratory distress from asthma or COPD.
Onset: Less than 1 minute
Duration: 3 to 4 hours
Indications:
Seizures of eclampsia; Torsades de Pointes; refractory VF; suspected
hypomagnesemic state; respiratory distress secondary to asthma or COPD
Contraindications: Heart Blocks
Adverse Reactions: Diaphoresis; facial flushing; hypotension; depressed reflexes; bradycardia;
respiratory depression
61
MEPERIDINE (DEMEROL®)
Description/Mechanism: Meperidine is a synthetic opioid agonist that works on opioid receptors
to produce analgesia, euphoria, and respiratory and physical depression. It has a tendency for
physical dependence and abuse, and is classified as a Schedule II drug.
Onset: Less than a minute via IV
Duration: 2 to 4 hours
Indications: Moderate to severe pain; OB analgesia
Contraindications: Hypersensitivity to narcotics; patients taking MAO inhibitors; during labor or
delivery of a premature infant; undiagnosed abdominal pain or head injury
Adverse Reactions:
respiratory depression; nausea and vomiting; euphoria; delirium;
agitation/hallucination; seizures; headache; visual disturbances; coma; facial flushing; circulatory
collapse; dysrhythmias; allergic reaction
62
METHYLPREDNISOLONE (SOLU-MEDROL®)
Description/Mechanism: Methylprednisolone is a synthetic steroid that suppresses acute and
chronic inflammation. In addition, it potentiates vascular smooth muscle relaxation by beta
adrenergic agonists, and may alter airway hyperactivity. A newer usage is for reduction of posttraumatic spinal cord edema
Onset: 1 to 2 hours
Duration: 8 to 24 hours
Indications: Anaphylaxis; acute spinal cord injury; bronchodilator-unresponsive asthma
Contraindications: Use with caution in patients with GI bleeding and diabetes mellitus
Adverse Reactions:
alkalosis
Headache; hypertension; sodium and water retention; hypokalemia;
63
METOPROLOL (LOPRESSOR®)
Description/Mechanism: Clinical pharmacology studies have confirmed the beta-blocking activity
of metoprolol in man, as shown by (1) reduction in heart rate and cardiac output at rest and upon
exercise, (2) reduction of systolic blood pressure upon exercise, (3) inhibition of isoproterenolinduced tachycardia, and (4) reduction of reflex orthostatic tachycardia.
Onset: Within 1 hour
Duration: Dose dependent but from 3 to 12 hours
Indications: Hypertension; angina pectoris; myocardial infarction
Contraindications: Hypersensitivity to the drug; bradycardia; sick sinus syndrome; second and
third degree heart blocks; cardiogenic shock; severe peripheral arterial circulatory disorders
Adverse Reactions:
Tiredness; dizziness; mental confusion; short-term memory loss;
headaches; insomnia; diarrhea; nausea/vomiting; heartburn; abdominal pain; rash; hypotension;
bradycardia; CHF; peripheral edema; palpitations
64
MIDAZOLAM HYDROCHLORIDE (VERSED®)
Description/Mechanism: Like all benzodiazepines, enhances the inhibitory effects of GABA
receptors on chloride channels in central nervous system, hyperpolarizing membrane. Induces
sleep, decreases anxiety, and impairs memory retention.
Onset: 1 to 3 minutes (dose dependent)
Duration: 2 to 6 hours (dose dependent)
Indications: Pre-medication for tracheal intubation or cardioversion; anxiety; status epilepticus
(off-label)
Contraindications: Hypersensitivity to the drug; depressed vital signs; concomitant use of
barbiturates, alcohol, narcotics, other CNS depressants
Adverse Reactions: Hiccough; cough; oversedation; pain at the injection site; headache;
nausea/vomiting; blurred vision; hypotension; respiratory depression or arrest (especially when
given rapidly)
65
MORPHINE SULFATE
Description/Mechanism: Morphine sulfate is a natural opium alkaloid that increases peripheral
venous capacitance and decreases venous return ("chemical phlebotomy"). It promotes analgesia,
euphoria, and respiratory and physical depression.
Secondary pharmacologic effects of morphine include depressed responsiveness of alpha
adrenergic receptors (producing peripheral vasodilation) and baroreceptor inhibition. In addition,
because morphine decreases both preload and afterload, it may decrease myocardial oxygen
demand. The properties of this medication make it extremely useful in emergency care.
Onset: Less than 1 minute
Duration: 2 to 7 hours
Indication: Chest pain associated with myocardial infarction/ischemia; congestive heart failure
(with or without pain); moderate to severe acute and chronic pain
Contraindications: Hypersensitivity to the drug; hypovolemia; hypotension; head injury or
undiagnosed abdominal pain; patients who have taken MAO inhibitors within past 14 days
Adverse Reactions: Hypotension; tachycardia or bradycardia; palpitations; syncope; facial
flushing; respiratory depression; euphoria; bronchospasm; allergic reaction
66
NALOXONE (NARCAN®)
Description/Mechanism: Naloxone is a competitive narcotic antagonist that is used in the
management and reversal of overdoses caused by narcotics and synthetic narcotic agents.
Compared with other narcotic antagonists which do not completely inhibit the analgesic properties
of opiates, naloxone antagonizes all actions of morphine.
Onset: Within 2 minutes
Duration: 30 to 60 minutes
Indications: Complete or partial reversal of CNS and respiratory depression induced by opioids;
coma of unknown origin; decreased level of consciousness
Contraindications: Hypersensitivity to the drug; use with caution in narcotic-dependent patients
who may experience withdrawal syndrome (including neonates of narcotic-dependent mothers)
Adverse Reactions: Tachycardia; hypertension; dysrhythmias; nausea/vomiting; diaphoresis
67
NITROGLYCERIN
Description/Mechanism: It was originally believed that nitrates and nitrites dilated coronary
blood vessels, thereby increasing blood flow to the heart. It is now believed that atherosclerosis
limits coronary dilation and that the benefits of nitrates and nitrites are due to dilation of arterioles
and veins in the periphery. The resultant reduction in preload, and to a lesser extent in afterload,
decreases the workload of the heart and lowers myocardial oxygen demand. Nitroglycerin is very
lipid soluble and is thought to enter the body from the GI tract through the lymphatics, rather than
the portal blood.
Onset: 1 to 3 minutes
Duration: 20 to 30 minutes
Indications: Ischemic chest pain; hypertension; congestive heart failure
Contraindications: Hypersensitivity to the drug; use of erectile dysfunction medications within
past 24 hours; hypotension; head injury; cerebral hemorrhage
Adverse Reactions: Transient headache; postural syncope; reflex tachycardia; hypotension;
nausea/vomiting; diaphoresis
68
ODANSETRON HYDROCHLORIDE (ZOFRAN®)
Description/Mechanism:
Ondansetron is a selective 5-HT3 receptor antagonist. While
ondansetron’s mechanism of action has not been fully characterized, it is not a dopamine-receptor
antagonist. Serotonin receptors of the 5-HT3 type are present both peripherally on vagal nerve
terminals and centrally in the chemoreceptor trigger zone of the area postrema. It is not certain
whether ondansetron's antiemetic action in chemotherapy-induced nausea and vomiting is
mediated centrally, peripherally, or in both sites. However, cytotoxic chemotherapy appears to be
associated with release of serotonin from the enterochromaffin cells of the small intestine. In
humans, urinary 5-HIAA (5-hydroxyindoleacetic acid) excretion increases after cisplatin
administration in parallel with the onset of vomiting. The released serotonin may stimulate the
vagal afferents through the 5-HT3 receptors and initiate the vomiting reflex.
Onset: Up to 15 minutes
Duration: Up to 4 hours
Indications: Prevention of nausea and vomiting.
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Constipation; angina; hypotension; tachycardia
69
PHENYLEPHRINE (NEO-SYNEPHRINE®) SPRAY
Description/Mechanism:
A decongestant that shrinks blood vessels in the nasal passages.
Onset: 3 to 5 minutes
Duration: Up to 4 hours
Indications: Temporary relief of congestion or stuffiness in the nose caused by common hayfever or other allergies, colds, or sinus trouble. It may also be used in ear infections to relieve
congestion.
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Fast, irregular, or pounding heartbeat; headache or dizziness; increased
sweating; nervousness; paleness; trembling; trouble sleeping; increase in runny or stuffy nose
70
PROMETHAZINE (PHENERGAN®)
Description/Mechanism: Long acting derivative of phenothiazine with marked antihistaminic
activity and prominent sedative, amnesic, antiemetic, and anti-motion sickness actions. Unlike
other phenothiazine derivatives, it is relatively free of extrapyramidal side effects; however, in high
doses it carries same potential for toxicity. In common with other antihistamines, exerts
antiserotonin, anticholinergic, and local anesthetic action. Anti-emetic action thought to be due to
the depression of the CTZ in medulla.
Onset: Less than 1 minute
Duration: 4 to 6 hours
Indications: Nausea and vomiting due to stimulation of CTZ (not from GI bleed, CHI, etc); to
potentiate the effects of analgesics; motion sickness; pre-and postoperative, obstetric (during
labor) sedation
Contraindications: Hypersensitivity to the drug; coma; CNS depressed patients; when signs of
Reye’s syndrome are present
Adverse Reactions: Hypotension; sedation; dizziness; may impair physical and mental ability;
allergic reactions; dysrhythmias; nausea/vomiting; hyperexcitability; EPS
71
SODIUM BICARBONATE
Description/Mechanism: Sodium bicarbonate reacts with hydrogen ions to form water and
carbon dioxide and thereby can act to buffer metabolic acidosis. By increasing the plasma
concentration of bicarbonate, blood pH rises.
Onset: 2 to 10 minutes
Duration: 30 to 60 minutes
Indications: Known pre-existing bicarbonate responsive acidosis; intubated patient with
continued long arrest interval; upon return of spontaneous circulation after long arrest interval;
tricyclic antidepressant overdose; alkalinization for treatment of specific intoxications
Contraindications: Patients with chloride loss from vomiting and GI suction; metabolic and
respiratory alkalosis; hypocalcemia; hypokalemia
Adverse Reactions: Metabolic alkalosis; hypoxia; electrolyte imbalance; seizures; tissue
sloughing at injection site; rise in intracellular PCO2 and increased tissue acidosis
72
TETRACAINE OPTHALMIC DROPS
Description/Mechanism: Tetracaine Drops are an anesthetic. It works by blocking nerve
impulses, which results in loss of feeling.
Onset: Less than 1 minute
Duration: 10 to 15 minutes
Indications: To numb the eye during certain procedures
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Temporary burning, stinging, or redness
73
THIAMINE (BETAXIN®)
Description/Mechanism: Thiamine combines with adenosine triphosphate (ATP) to form
thiamine pyrophosphate (TPP) coenzyme, a necessary component for carbohydrate metabolism.
Most vitamins required by the body are obtained through diet, however, certain states such as
alcoholism and malnourishment may affect the intake, absorption, and utilization of thiamine. The
brain is extremely sensitive to thiamine deficiency.
Onset: Less than 1 minute
Duration: Depends on degree of deficiency
Indications: Prior to the administration of D50 in hypoglycemia when alcohol abuse and/or
malnourishment is suspected; delirium tremens
Contraindications: None significant
Adverse Reactions: Hypotension (from rapid injection or large dose); anxiety; diaphoresis;
nausea/vomiting; allergic reaction (usually from IV injection, very rare)
74
VASOPRESSIN
Description/Mechanism: Vasopressin is a peptide hormone that controls the re-absorption of
molecules in the tubules of the kidneys by affecting the tissue's permeability. It also increases
peripheral vascular resistance, which in turn increases arterial blood pressure.
Onset: IV – Less than 1 minute
Duration: Approximately 3 hours
Indication: Asystole; diabetes insipidus; esophageal varices
Contraindications: Hypersensitivity to the drug
Adverse Reactions: Angina; abdominal cramps; nausea/vomiting; gas; gangrene; ischemic
colitis; tissue necrosis (with extravasation); allergic reaction
75
Nitroglycerin Drip Chart
Drug Amount: 50 mg pre-mixed
Final Volume: 250 ml
Final Concentration: 200 mcg/ml
Usual Dose: 1 – 20 mcg/min
Maximum Dose: 200 mcg/min
Instructions: Find the desired dosage in mcg/min on the chart and locate the rate in ml/hr below it.
Dose
mcg/min
Rate
ml/hr
1
2
3
4
5
6
0.3
0.6
0.9
1.2
1.5
1.8
7
8
9
10
15
20
2.1
2.4
2.7
3
4.5
6
Dose
mcg/min
Rate
ml/hr
30
40
50
60
70
80
9
12
15
18
21
24
Dose
mcg/min
Rate
ml/hr
90
100
110
120
130
140
27
30
33
36
39
42
Dose
mcg/min
Rate
ml/hr
150
160
170
180
190
200
45
48
51
54
57
60
Dose
mcg/min
Rate
ml/hr
76
Heparin Drip Instructions and Chart
Drug Amount: 25,000 units
Final Volume: 500 ml
Final Concentration: 50 units/ml
Procedure:
 Administer Heparin Bolus 5000 units via IV

Administer Heparin Drip IV-weight adjusted @ 60 units/kg, not to exceed 4000 units.

Use the following formula to determine drip rate:
Initial Drip Rate: 12 units/kg multiplied by weight in kg then divide by 50 units/ml to equal
dosage in ml/hr. Max dose is 20 ml/hr.
Chart Instructions: Find weight on chart and locate drip rate below it.
Weight in kg
40
45
50
55
60
Drip Rate
ml/hr
9.6
10.8
12
13.2
14.4
Weight in kg
65
70
75
80
85
15.6
16.8
18
19.2
20
Drip Rate
ml/hr
*For all weights over 85 kg, the drip rate is 20 ml/hr.
77
THE LAW
UNIFORM RULES OF THE ROAD
OCGA 40-6-6. Authorized emergency vehicles.
(a) The driver of an authorized emergency vehicle, when responding to an emergency call, or
when in the pursuit of an actual or suspected violator of the law, or when responding to but not
upon returning from a fire alarm, may exercise the privileges set forth in this Code section.
(b) The driver of an authorized emergency vehicle may:
(1) Park or stand, irrespective of the provisions of this chapter;
(2) Proceed past a red or stop signal or stop sign, but only after slowing down as may be
necessary for safe operation;
(3) Exceed the maximum speed limits so long as he does not endanger life or property;
(4) Disregard regulations governing direction of movement or turning in specified directions.
(c) The exceptions granted by this Code section to an authorized emergency vehicle shall apply
only when such vehicle is making use of an audible signal and use of a flashing or revolving red
light visible under normal atmospheric condition s from a distance of 500 feet to the front of such
vehicle, except that a vehicle belonging to a federal, state, or local law enforcement agency and
operated as such shall be making use of a flashing or revolving blue light with the same visibility to
the front of the vehicle.
(d) The foregoing provisions shall not relieve the driver of an authorized emergency vehicle from
the duty to drive with due regard for the safety of all persons.
No emergency response is so urgent that we cannot respond in a safe manner so as to protect the
lives of the public and ourselves. To do otherwise could compound an already urgent situation and
result in additional emergency patients. The safety of individuals proceeding to the scene as well
as the public through which they are traveling is of high priority.
LIGHTS & SIREN
DEFINITIONS
"Hot" Response - This type of response includes use of the ambulances warning lights and siren.
"Cold" Response - This type of response, while it may be deemed to be an emergency response,
does not dictate the use of lights and siren by the ambulance service personnel. During a "cold"
response the ambulance will be operated in compliance with the "Rules of the Road" and all traffic
laws will be obeyed.
Emergency or Emergent - any circumstance calling for immediate action in which medical
attention is indicated. Rules and Regulations for Ambulance Services 290-5-30.02 (bb).
Note: An emergency or emergent call can be considered a "hot" or "cold" response.
Non-Emergency - means any circumstances in which a delayed action is appropriate and in
which transport to a medical facility is indicated.
Note: A non-emergency is always considered a "cold" response.
GUIDING PRINCIPLES
The driver of the ambulance should be advised by the attending medic, as outlined by ambulance
protocol, whether it is necessary to respond under "hot" conditions. If a question arises concerning
the transport of any patient, medical control should be contacted.
The driver should be advised by the attending medic if the patient's condition changes during
transport, and the method of operating as an authorized emergency vehicle can be altered as
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appropriate.
When operating a vehicle as "an authorized emergency vehicle", both the warning lights and
audible signal must be in use. Operating a vehicle with only one of these warning devices in use
does not satisfy the requirements of OCGA 40 -6-6.
There are certain medical conditions that may require the rapid transport of the patient, but without
the use of an audible warning device due to the patient's condition (i.e. acute MI, pre -eclampsia,
etc.). In circumstances where lights only are used for transport, the driver should be advised that
the vehicle cannot proceed as "an authorized emergency vehicle" under the conditions set forth in
OCGA 40-6-6. The operator of the ambulance using lights only without the use of an audible
warning device must proceed in complete compliance with the "Rules of the Road".
Despite the existence of an emergency situation, there are times when it may be more appropriate
to approach a scene or transport the patient t o a medical facility silently or "cold". Similarly, there
may be environmental conditions (i.e. traffic, weather, etc.) in which operating as an emergency
vehicle or "hot" introduces unreasonable risk and/or disruption and provides minimal opportunity to
arrive at the scene early. In any case, remember ambulance charges and third party payment
rates do not correspond directly with the use of warning lights and siren.
When transporting a patient, either "hot" or "cold", the driver of the ambulance should be
especially aware of the physical danger inherent and the operation of an emergency vehicle, and
drive in a manner to minimize turbulence to passengers resulting from quick and/or sudden stops,
acceleration, and turning movements.
Realizing all contingency cannot be considered and a hard and fast rule established, the practice
of returning to a station or quarters "hot" for any reason other than an emergency is discouraged.
Proper use of backup personnel and vehicles and the use of common sense should all but
eliminate returning to station "hot".
Any 911 call received should be considered an emergency call and lights and sirens should be
used when responding unless otherwise advised by 911 or another agency.
*** NOTE***
The paramedic may make the decision not to respond emergency to a 911 call emergency.
The Paramedic should always take all precautions into consideration while making this
decision. If call is an “unknown problem” call you should consider this an emergency until
otherwise advised.
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Reasonable Distances for Rendition of Pre-Hospital Emergency Care for EMS
Reasonable distances have been determined based on the patient’s medical or:
(1) Trauma related emergency
(2) Resources at the local and surrounding facilities
(3) Geographic location of the various facilities
(4) Ambulance service resources
(5) Obligation to provide emergency services in the assigned ambulance zone
(6) Availability of mutual aid
With due consideration of normal workloads and/or extraordinary circumstances at the time of the
request for service (i.e. medics, ambulances, and resources of intended receiving facility).
A distance of 25 miles (or closest appropriate medical facility) shall be within reasonable distance
for rendition of pre-hospital emergency care. The patient shall be transported by the ambulance
service to the hospital of his/her choice providing that the hospital chosen is within reasonable
distance of the patient's location and is capable of meeting the patient's immediate needs. The
ambulance service medical director has established reasonable distances for rendition of prehospital emergency care for EMS. (See below) In the event of exigent circumstances on-line
medical control may override the established reasonable distances.
1. If the patient's choice of hospital is not within a reasonable distance, medical control will
determine the closest hospital capable of meeting the patient's immediate needs.
2. If the patient's choice of hospital is within a reasonable distance but medical control (or the
medic, if the medic is unable to communicate with medical control) determines that
A) The patient's condition is too critical to risk excessive time necessary to reach the hospital
chosen and a nearer hospital is capable of meeting the patient's immediate needs, or
B) The hospital chosen is unable to meet the patient's immediate needs, or
C) The hospital chosen by the patient has notified the medic that it is unable to receive the
patient, THEN medical control and/or the medic should make a reasonable effort to convince
the patient that a hospital other than the one chosen is more capable of meeting the patient's
immediate needs. If the patient continues to insist on being transported to the hospital he/she
has chosen then the patient shall be transported to that hospital.
If the patient does not, cannot, or will not express a choice of hospitals, the ambulance service
shall transport the patient to the nearest hospital believed capable of meeting the patient's
immediate medical needs without regard to other factors, (e.g., patient's ability to pay, hospital
charges, county or city limits, etc.).
Reference: DHR Public Health Rule 290-5-30-.05(8)(k) Destination of Pre-hospital Patients.
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DESTINATION SELECTION FOR PREHOSPITAL PATIENTS
Use the following criteria to help determine if air transportation is needed:
GENERAL
Land transport time greater than 30 minutes for critically ill/injured patients whose condition is
likely to worsen in transport and air transport will significantly reduce that time.
TRAUMA
Physiologic Status
 Glasgow Coma Scale <14
 Systolic blood pressure <90
 Respiratory rate <10 or >29
 Revised Trauma Score <11
Anatomy of Injury
 All penetrating injuries to head, neck, torso, and extremities proximal to elbow and knee
 Flail chest
 Combination trauma with burns
 Two or more proximal long-bone fractures
 Pelvic fractures
 Open and depressed skull fracture
 Paralysis of extremities, new onset
 Amputation or near amputation, excluding digits
 Major burns >10% of body surface of face, hands, feet or perineum, or burns with
significant respiratory involvement or major electrical or chemical burns
Mechanism of Injury
 Ejection from automobile
 Death in same passenger compartment
 Extrication time >20 minutes
 Falls >20 feet
 Rollover
 High-speed auto crash: Initial speed >40 mph
 Major auto deformity >20 inches
 Intrusion into passenger compartment >12 inches
 Auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact
 Pedestrian thrown or run over
 Motorcycle crash >20 mph or with separation of rider from bike
Other Factors
 Age <5 or >55 years
 Cardiac disease, respiratory disease
 Insulin-dependent diabetes, cirrhosis, or morbid obesity
 Pregnancy
 Immunosuppressed patients
 Patient with bleeding disorder or patient on anticoagulants
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**NOTE**
EACH PATIENT AND SITUATION IS DIFFERENT AND VARIATIONS FROM THESE
GUIDELINES MAY BE NECESSARY. CRITERIA FOR TRANSPORT BY HELICOPTER SHOULD
NOT REPLACE DECISIONS BASED ON SOUND MEDICAL JUDGEMENT. TRANSPORT TO
LOCAL FACILITY FOR STABILIZATION AND TRANSFER TO TERTIARY CARE IN CRITICAL
SITUATIONS WHERE AIR TRANSPORT IS NOT FEASIBLE.
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Pre-Hospital Withholding and Withdrawing Resuscitation
General Comments
1. Emergency medical services provide rapid evaluation and treatment of potentially life threatening illnesses and injuries in the out of hospital environment. The first obligation is to the
patient(s) in distress. The receipt of a 911 call establishes an implied contract to perform a patient
assessment and give appropriate treatment.
2. Patient assessment should always occur promptly and without delay. NEVER withhold or put off
patient assessment to take time to read a document. Vital moments in a patient's life may be spent
in such an effort. In the absence of a valid DNR, requests by family members to withhold
assessment and lifesaving treatment should be set aside initially except in the setting of a patient
who is obviously dead.
3. EMS personnel are not trained in making legal opinions and should not attempt to decide if
DNR orders or living wills are valid or not while on the scene of a patient in distress. Instead,
verbal communication from (1) the patient, (2) the immediate family (authorized person), or (3)
medical personnel specifically assigned to and familiar with the patient should be used to make
decision.
4. CPR can be stopped in the field in the proper setting (OCGA 31-39-4). Patients experiencing
asystole in the field almost always die. Even if they respond initially, almost no studies show
survival of any of these patients to hospital discharge.
must be
warm (95°) before they are pronounced dead. The exception is in the obviously dead patient.
terminally ill cancer patients will still have terminal cancer when resuscitated.
have many more years of quality life when resuscitated.
5. Patients that have died or for whom it is later determined did NOT want intubation (or the
individuals who legally may substitute their judgment for them did NOT want intubation) can be
extubated in the emergency department. Endotracheal extubation should not be performed in the
field.
6. Since each DNR situation must be dealt with on an individual basis and appropriate care and
decision -making determined accordingly, professional judgment is mandatory in determining
treatment modalities within the parameters of this protocol.
7. Emergency medical providers must always remember the primary goal of this profession:
Render aid and comfort to the suffering. The application of this protocol in no way diminishes this
responsibility. All patients whether they are dying, are near death, or have some other clinical
problem deserve the provider's utmost compassion and concern.
Withholding of Resuscitation
1. It is proper that resuscitation should not be attempted on certain patients. Any victim meeting
one or more of the criteria of "obvious death" should have resuscitative attempts withheld. You
must be familiar with the signs of obvious death. A patient, who is in rigor mortis, has dependent
lividity (pooling of blood due to gravity), has decomposition, or has experienced decapitation or
obviously fatal trauma should have resuscitation withheld. If there is EVER any doubt, attempt
resuscitation.
2. "Down time", while not a nebulous concept is fraught with too many variables to permit a
specific period of time being used in this protocol to determine whether or not to withhold
resuscitation. The medic must exercise professional judgment in determining if "down time", say,
15 -minutes in a particular set of circumstances, would clearly indicate withholding resuscitation. If
there is any doubt the medic will initiate a resuscitative attempt and proceed to URGENT
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HISTORY.
3. Living Will - In recognition of the dignity and privacy which patients have a right to expect, the
Georgia General Assembly allows a competent adult person to make a written directive, known as
a living will, instructing his physician and others to withhold or withdraw life-sustaining procedures
in the event of a terminal condition, a persistent coma, or persistent vegetative state. SEE OCGA
31 -32. Each medic should be familiar with this statute which includes a sample living will and goes
into the execution and revocation of a living will, including the immunity of participants from liability.
: If you elect to ignore a living will and resuscitate the patient, you are protected
from liability.
REMEMBER: If you elect to follow a living will's instructions, you are protected from liability.
4. DNR Order - This is an order in writing by the attending physician using the term "do not
resuscitate", "DNR", "order not to resuscitate", "no code", or substantially similar language in the
patient's chart. This constitutes a legally sufficient order and authorizes a physician, health care
professional, emergency medical technician, cardiac technician, or paramedic to withhold or
withdraw cardiopulmonary resuscitation whether or not the patient is receiving treatment from or is
a resident of a health care facility. SEE OCGA 31 -39. Each medic should be familiar with this
statute.
Urgent History
1. Obtain the urgent history only after the appropriate medical measures have been initiated. The
resuscitation measures should not be interrupted while the urgent history is obtained.
2. Determine the most legitimate person present from whom the history should be taken, for
example the spouse, next of kin, and so on. This is the "authorized person". Know what durable
power of attorney for health care means.
3. Determine the following:
a. Is there a terminal illness involved?
b. Is there an advance treatment directive such as a living will or DNR order?
c. Did the patient express to an authorized person any desires regarding resuscitative measures,
e.g. proxy directive through durable power of attorney for health care? If so, what?
4. REMEMBER: Just because a living will exists does NOT mean that the patient wants NO
resuscitative effort. Even a terminal cancer patient would likely want to have an airway suctioned,
oxygen given, and proper aid and comfort administered.
Endotracheal Intubation
1. The field patient who is experiencing an arrest state should be evaluated where possible to
determine if the patient may or may not have wanted
to be intubated. This should not delay the medic's efforts to do so if, in the judgment of the medic,
that intubation is the proper course to follow.
2. The unresponsive field patient in asystole, PEA, or in ventricular fibrillation or unstable
tachycardia refractory to initial care needs to be intubated.
If the patient's family or authorized medical agent states that they and/or the patient did not wish to
have endotracheal intubation even for a short period, this wish should be followed. When in doubt,
intubate. The tube can always be removed in the emergency department.
Medical Control
Generally speaking medical control should always be contacted prior to withholding or withdrawing
resuscitative efforts.
DEATH SCENE
The Cardiac Arrest Protocol is to be initiated on all patients except under the following situations:
1. The patient is displaying obvious and accepted signs of irreversible death such a rigor mortis,
dependent lividity, decapitation, decomposition, or incineration.
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2. Blunt trauma victims who have no respirations, no pulse, show asystole confirmed in 2 leads on
the cardiac monitor and have obvious signs of trauma.
3. A Georgia Licensed Physician, Medical Examiner, Coroner or other person legally authorized in
Georgia to pronounce death.
4. The physician (patient’s physician, medical director, or Emergency Room physician) states to at
least two (2) EMS personnel, (Paramedics and/or EMTs), that resuscitation is not to be attempted
on this patient and the physician agrees to accept responsibility for pronouncing the patient dead.
5. The patient’s family has a “Do Not Resuscitate” Order present on the scene that has been
signed by a Licensed Physician.
The Paramedic’s/EMTs responsibility is to the patient.
1. Neither the family nor Law Enforcement Officers have the right to refuse resuscitation attempts
for the patient.
2. The Paramedic/EMT is responsible for the medical judgment as to whether a patient is
obviously dead or dismembered.
3. Document absence of vital signs and attach the EKG strip to the EMS record.
In possible crime cases, do not remove or cut clothing, remove penetrating objects, or cut through
penetrating holes in clothing unless absolutely necessary for patient evaluation/care.
If the Paramedic/EMT has any doubt as to how to handle a situation, notify medical control
and give an assessment of the situation.
WITHDRAWING RESUSCITATION
Cardiac Arrest
APPROPRIATE PROTOCOL
Continue CPR if it is in progress upon arrival, or clear airway and start rescue breathing and chest
compressions
OBTAIN URGENT HISTORY
Identify authorized person giving information
id DNR orders present?
Notify proper authorities
Protect the dignity of the patient
Provide support for the family
Watch for emergent medical problems in family members
Protect the crime scene (if appropriate)
Stay until proper authorities arrive
IF Asystole, V-Fib, Pulseless V-Tach, or PEA is present go to appropriate protocol THEN
Contact Medical Control AND consider termination unless hypothermia and/or short (<15 min)
down time
Resuscitate as ordered
Terminate resuscitation as ordered
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HAZARDOUS MATERIAL EXPOSURE
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Arrive at Scene
Signs of hazardous materials present
Proceed to appropriate protocol
Haz Mat Team on scene
Keep patients isolated to avoid contaminating EMS crew & equipment
Report to scene commander
Contact Medical Control and notify receiving facility (or facilities)
Implement Haz Mat Response
Move patients to safe area out of the hazardous environment and emergency personnel
should wear appropriate PPE
Is medical treatment necessary?
Decontaminate by thorough cleansing
Medical attention or surveillance required
Report to supervisor for instructions
Transport to appropriate facility
Do patients require transport by EMS?
If yes, package patients appropriately and transport
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Personal Property of Patient
A medic’s first responsibility is to treat the patient. Handling a patient’s valuables or personal
property is secondary to proper pre-hospital emergency care. However, special attention needs to
be paid to how a patient’s personal property is handled by the medic (when handling it cannot be
avoided) to minimize potential problems for the medic and the EMS later on. In “load-and-go”
situations, do not waste time handling patient’s valuables.
In Georgia case law, Bricks v. Metro Ambulance Service, Inc., et.al. 70517,177 Ga. App. 62 (1985)
the court ruled that an ambulance service is a common carrier under Georgia law and therefore it
owes duty to passengers not only to protect their lives and persons from insult and injury but to
also protect their personal effects from loss.
The common carrier (ambulance service) is liable for willful and wanton acts of its own servants in
its employment, so proper handling of a patient’s valuables is very important.
Proper procedure under this protocol is determined by location of the patient (at home, accident
scene, etc.) whether family members or friends of the patient are present, whether law
enforcement personnel are present and several other factors. Every situation cannot be described
here, but the following is to serve as a guideline.
Patient’s personal property could include but not be limited to: glasses, dentures, wallets, money,
watches, jewelry, expensive clothing, medications, and keys.
PATIENT AT HOME OR A RESIDENCE
 Advise and encourage the patient to leave all unnecessary personal items and valuables at
home or with a family member or friend.
 A patient’s medication in most cases would need to go to the hospital either with the patient
or be carried by a family member. If it is necessary for the medic to handle these
medications they should be treated like any other patient valuables.
 Do not remove a watch, jewelry, or wallet from a patient unless it is necessary to treat the
patient, e.g., start an I.V. If it is necessary to do so tell the patient you are removing the
item. Then try to give it to the patient if conscious and alert or to a family member if present
and document this on the ambulance trip report. If possible have another medic or law
enforcement officer witness what you did with the patient’s personal property.
 If the patient insists on taking personal items with him, the patient must be alert enough to
keep possession of the items. If you are uncomfortable about the security of the premises
you are leaving, notify law enforcement.
PATIENT AT ACCIDENT SCENE OR NOT AT HOME
 If the patient is conscious encourage the patient to give personal property and valuables to
a responsible person of his choice. If you have to remove any item from the patient (e.g.,
watch, jewelry, etc.) to treat the patient, return the items to the patient, and if possible, have
someone witness this and document it on the trip report.
 If law enforcement presents you with a patient’s personal items, request that they (law
enforcement) present the items to the patient (if conscious and alert) or to the patient’s
family, or present them to the hospital staff.
 If personal items or valuables are handled by first responders or bystanders before they
were presented to you, document this on the trip report.
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If personal items or valuables are destroyed in order to gain access to the patient, this
should be documented and the items kept.
If patient is disoriented or unconscious give the patient’s personal items to a family member
or law enforcement officer if possible. Document any incident involving valuables on the trip
report and obtain signature from the person receiving valuables. If family or law
enforcement are unavailable, transport valuables with patient.
TAKING CHARGE OF PATIENT’S PERSONAL ITEMS
When the medic finds himself in possession of a patient’s personal items and valuables, he/she
should carefully document what he/she did with the items. Place the items in a container provided
for that purpose – zip lock bags for small items and plastic garbage bags for larger items. Make a
list of the items placed in each bag and place the list on the bag or in the bag. Medications should
be listed separately. Currency should be listed by amount. Have your partner or law enforcement
officer verify (sign) the list of items included in the bag. When you arrive at the hospital, turn the
bag(s) over to the appropriate hospital staff (depending on hospital protocol) and have them sign
for the items. Retain a copy of this signed list to be attached to the EMS copy of the trip report.
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Practice Parameter
Emergency Medical Treatment and Active Labor Act
The purpose of this practice parameter is to provide guidance as to EMS’ role in meeting
the guidelines concerning the Emergency Medical Treatment and Active Labor Act
regulations.
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a. When patient contact is made, the patient is considered to be “in the emergency
department” and the obligation to provide an appropriate medical screening exists.
b. The Paramedic should perform an assessment of the patient to include general
appearance, vital signs, and symptoms related to the chief complaint.
c. Care rendered will be performed based on the Practice Parameters established for
EMS.
d. The Emergency Department physician at RRMC is responsible for performing the
medical screening exam except when the following conditions apply:
I.
The patient is in active labor (RRMC does not provide obstetrical services);
II.
The patient or family requests that the patient be transported to another
facilities’ emergency department;
III.
The following trauma related injuries are apparent:
Multi-system trauma with cardiovascular compromise
Combination trauma with burns
Open and depressed skull fractures OR
IV.
The following mechanism of injury occurs:
Ejection from automobile
Death in same passenger compartment
Extrication time >20 minutes
Falls>20 feet
Rollover
Intrusion into passenger compartment > 12 inches
Major auto deformity > 20 inches
Auto-pedestrian/auto-bicycle injury with significant (>5 mph) impact
Pedestrian thrown or run over
e. In the event the patient or family does not have a preference for facility or is unable to
voice a preference, the patient will be transported to Redmond Regional for the MSE to
be completed.
**In certain situations, the requirement to complete Initial Medical Care, as written, may be
altered or waived in favor of rapidly transporting the patient for definitive care. Document
the patient's condition or behaviors which interfered with the performance of any needed
assessments and / or interventions. If no response to Practice Parameters, contact Medical
Control for consult.
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ADULT GENERAL PATIENT CARE
INDICATIONS: Any adult patient requiring pre-hospital medical evaluation by a pre-hospital health
care provider with Redmond Regional Medical Center EMS. The Adult General Patient Care
protocol will be followed in conjunction with all other applicable protocols.
 Perform scene survey.
 Observe universal precautions.
*Follow Infection Control Directive
 Consider the need for additional resources.
 Determine responsiveness using AVPU.
 Evaluate Airway, Breathing, Circulation, and Disability, Exposing the patient as necessary.
 Secure a patent airway appropriately.
 Manage cervical spine appropriately.
 Treat life-threatening conditions as necessary per specific treatment protocols.
 Assess body systems as appropriate.
 Monitor patient via the use of pulse oximetry and/or capnography, as appropriate.
 Administer OXYGEN as appropriate. (Maintain a SaO2 of at least 92%)
 Obtain medical history (HPI, PMH, allergies, and medications).
 Evaluate blood pressure, pulses, respiratory rate, pulse oximetry and tactile temperature.
Reassess with a frequency indicated by patient condition (ideally q 5 to 10 minutes) and prior
to each ALS intervention.
 Monitor cardiac rhythm and/or 12 lead ECG as appropriate.
 Assess blood glucose level as necessary per PMH or S/S.
 Assign treatment priority and make transport decision.
 Establish intravenous access with normal saline infused as appropriate or with a saline flush as
appropriate. Limit 2 attempts unless situation dictates further attempts. Inability to establish
IV does not preclude other interventions for definitive therapy.
 Obtain appropriate blood tubes.
 Consider intraosseous access, if IV access cannot readily be obtained for patients in extremis
that are in need of medication or fluid resuscitation.
*Administer 20 – 40 mg LIDOCAINE IO over 1 minute in the conscious patient if not
contraindicated
*Administer 10 ml NSS rapid IO push
*All IV medications can be administered IO
 Consider the administration of ZOFRAN 4mg undiluted over
2-5 minutes or the administration
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of 12.5 mg to 25 mg PROMETHAZINE (PHENERGAN ) IV or IM for nausea and vomiting
(must be diluted with 9 ml Bacteriostatic solution). ZOFRAN IS PREFERRED.
 If
tactile temperature indicates possible fever in an adult, perform
*Obtain temperature - oral or axillary
*Passive cooling of patient with removal/loosening of clothing and change of
environmental conditions. Note: Do not cool to point of shivering.
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following:
*For temperatures of 101.5° f (38.5° C) or greater and no ACETAMINOPHEN in last 4
hours, consider administering ACETAMINOPHEN 650 mg PO in absence of nausea
and vomiting and any allergies to medication.
*If ACETAMINOPHEN has been administered within the last 4 hours and temperature is
still 101.5° F, then consider administering IBUPROFEN 600mg PO if no allergies,
contraindications and without nausea and vomiting.
For animal bites or stings:
o Irrigate and cleanse wound with normal saline.
o Assess degree of bite or sting by measuring bite/sting marks. Outline edematous,
erythemic and ecchymotic areas with pen and mark the time. Try to confirm size,
type and length of any snakes. (Do not bring LIVE snakes to the ER)
o Apply constricting band IF your ETA to receiving facility is <20 minutes or if the bite
or sting shows signs of increasing reaction. Apply constricting band proximal to
wound and ensure constricting band does not impede arterial blood flow.
o Remove stingers as necessary and take care to avoid compression of the area.
o Immobilize affected part and keep it below the level of the heart. Remove any distal
jewelry on the affected part.
o Monitor ABC’s, apply cardiac monitor, obtain IV access, apply O2 as needed.
o Frequently reassess patient for airway patency.
o Do not apply ice or cold pack to any bite or sting.
In certain situations, the requirement to complete Initial Medical Care, as written, may be
altered or waived in favor of rapidly transporting the patient for definitive care. Document
the patient's condition or behaviors which interfered with the performance of any needed
assessments and / or interventions. If no response to Practice Parameters, contact Medical
Control for consult.
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ACUTE RESPIRATORY DISTRESS
INDICATIONS: Acute exacerbation of asthma, emphysema, and reactive airway disease; cough,
shortness of breath, air hunger, wheezing, diminished breath sounds, retractions, and tachypnea.
Contact medical control prior to medication administration if the patient's heart rate is greater than
150 beats per minute (BPM).
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Consider capnography.
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Consider CPAP for an alert patient who is able to maintain a patent airway but is, or continues
to be, in moderate to severe respiratory distress.
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If the patient who is short of breath has a history of asthma, emphysema, or is actively
wheezing, administer up to 5 mg of ALBUTEROL via nebulized aerosol.
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Consider the administration of 0.5 mg nebulized IPRATROPIUM BROMIDE (ATROVENT )
with ALBUTEROL.
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If wheezing continues after first nebulized aerosol treatment is completed, you may repeat
ALBUTEROL or ALBUTEROL with ATROVENT treatment up to 3 times IF the patient’s heart
rate remains less than 150 BPM.
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Consider the administration of 0.3 to 0.5 mg SC EPINEPHRINE 1:1000 for asthma only.
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Consider the administration of 125 mg METHYLPREDNISOLONE (SOLU-MEDROL ) IV for
moderate to severe respiratory distress secondary to asthma or COPD.
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Contact medical control for consideration of administration of 1-2 g MAGNESIUM
SULFATE IV diluted in 250 ml Normal Saline over 10 minutes for continuing severe
respiratory distress secondary to asthma or COPD.
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If suspected severe Carbon Monoxide Poisoning, contact Medical Control for possible
transport to closest Hyperbaric Chamber.
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Congestive Heart Failure/Pulmonary Edema
Indications: Shortness of breath, air hunger, tachypnea, tachycardia, elevated blood pressure,
rales, neck vein distention, and diaphoresis.
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If patient presents with CHF symptoms BUT is febrile, consider treating with the Acute
Respiratory Distress protocol secondary to possible Pneumonia.
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Allow patient to maintain position of comfort (usually sitting).
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Consider use of capnography.
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Consider CPAP for an alert patient who is able to maintain a patent airway but is, or
continues to be, in moderate to severe respiratory distress.
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Administer 0.4 mg NITROGLYCERIN (NTG) SL. Repeat 0.4 mg NTG every 3-5 minutes. If
systolic blood pressure (SBP) is less than 90 mmHg, discontinue NTG administration until
SBP recovers to greater than 90 mmHg. IV must be established prior to NTG
administration for patients not currently prescribed and taking NTG.
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If the patient is on FUROSEMIDE (LASIX ), administer FUROSEMIDE IV in a dose
equivalent to the patient's total daily dose. Give FUROSEMIDE doses up to 100 mg.
Withhold if systolic blood pressure is less than 90 mmHg.
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1. If the daily dose is unknown, administer 40 mg FUROSEMIDE IV.
2. Contact Medical Control to administer doses in excess of 100 mg IV.

If wheezing present and heart rate is <150, consider ALBUTEROL 2.5 mg via nebulizer

Consider MORPHINE via IV (2-10mg)

If heart rate <60 AND systolic BP <90 mm Hg, consider ATROPINE 0.5 mg IV.

If heart rate >60 AND systolic BP <90 mm Hg, consider fluid challenge. If no response,
administer DOPAMINE 5-20 mcg/kg/min.

Perform and interpret 12 lead ECG.

Contact Medical Control for consideration of NITROGLYCERIN Drip at 3mcg/minute
via IV pump IF systolic BP is above 110 mmHg.
Assessment and management of airway and breathing precedes the performance of a 12 lead
ECG. Withhold nitrates and contact medical control if the patient relates taking SILDENAFIL
®
®
®
(VIAGRA ) or VARDENAFIL (LEVITRA ) within the last 24 hours or TADALAFIL (CIALIS ) within
the last 48 hours.
93
Acute Coronary Syndrome (ACS) and/or ST Elevation MI (STEMI)
Suspect ACS and or STEMI for the following presentations: classic anginal chest pain, atypical
chest pain, or anginal equivalents such as dyspnea, palpitations, syncope or pre-syncope, general
malaise, or DKA. All of these patients should have a 12 lead EKG performed and interpreted.
Indications for ACS: Classic anginal chest pain OR patients whose 12 lead is suspicious for
ischemia.
Indications for STEMI: Suspicion of ACS and a pre-hospital12 lead diagnosis of STEMI.

Administer OXYGEN via nasal cannula @ 4 lpm. Obtain Pulse Ox, IV access, and labs

Cardiac Monitor, obtain and transmit 12 lead EKG to ER. Follow chest pain flow sheet.

Administer BABY ASPIRIN 324 mg, chewed, if no allergies to ASA exist.

If systolic BP is above 110 mm Hg:
1. Administer NITROGLYCERIN 0.4 mg SL spray. Repeat at 5 minute intervals for 3
doses. Do not give NTG if patient is on an erectile dysfunction drug. Document
BP before and after NTG administration.
2. Consider MORPHINE SULFATE 1 to 4 mg IVP, then 1 to 2 mg IV every 5 minutes
PRN for continued chest pain until stable (unless allergy to MORPHINE SULFATE
exists).
3. If patient allergic to MORPHINE SULFATE, administer DEMEROL 12.5 to 25 mg IV
for chest pain, then 12.5 mg every 5 minutes until stable (unless allergy to
DEMEROL exists).

If patient vomiting or severe nausea, administer ZOFRAN 4 mg undiluted over 2 to 5
minutes or PROMETHAZINE 12.5 mg slow IVP diluted with 9cc NORMAL SALINE.
ZOFRAN is preferred.

If systolic BP below 90 mmHg, elevate lower extremities and administer 200 to 300 ml
NORMAL SALINE bolus.

If systolic BP above 90 mmHg, place patient in semi-fowlers position for transport or in
position of comfort.

If heart rate less than 75 bpm and systolic BP above 100 mmHg, administer LOPRESSOR
5 mg slow IVP; may repeat times 2 every 5 minutes PRN.

Repeat 12 lead ECG throughout transport as necessary.

Contact Medical Control for consideration of NITROGLYCERIN Drip at 3 mcg/minute
via IV pump. Titrate and increase NTG Drip at 2 mcg/minute increments every 3 to 5
minutes until relief of discomfort. Monitor and document BP q 5 minutes.

IF STEMI is present, perform above treatments AND:
1. Notify Medical Control immediately
2. Contact Medical Control for consideration of administration of HEPARIN Bolus
(units) 5000 IV.
3. Contact Medical Control for consideration of administration of HEPARIN Drip
IV-weight adjusted: 60 units/kg not to exceed 4000 units.
94

If NTG or HEPARIN IV drip medications are initiated, obtain 2nd IV with NORMAL SALINE
at KVO rate prior to administration. Both IV’s should be in the left upper extremity. Avoid
putting IV in right arm if possible.
Early notification to receiving hospital is paramount in the treatment of ACS.
The 12 lead ECG may be deferred initially in order to stabilize the hemodynamically unstable
patient.
Contact medical control for consideration of the administration of VERSED in the presence of
suspected cocaine usage within the past 72 hours.
®
Withhold nitrates and contact medical control if the patient relates taking SILDENAFIL (VIAGRA )
®
®
or VARDENAFIL (LEVITRA ) within the last 24 hours or TADALAFIL (CIALIS ) within the last 48
hours.
Observe the following precautions for administration of LOPRESSOR: Early aggressive beta
blockade may be hazardous in hemodynamically unstable patients; Do not give to patient with
STEMI if there are signs of heart failure, low cardiac output, or increased risk for cardiogenic
shock; Relative contraindications include PR interval >0.24 second, second or third degree heart
block, active asthma, reactive airway disease, severe bradycardia, or systolic BP <100 mm Hg;
Concurrent IV administration with calcium channel clocking agents like VERAPAMIL or
DILTIAZEM can cause severe hypotension; and Monitor cardiac and pulmonary status during
administration.
95
Altered Mental Status
Indications: Incomprehensible speech, inappropriate verbal responses, inability to follow verbal
commands, decreased responsiveness, or unresponsiveness.

Consider C-spine precautions if necessary

Obtain blood sugar reading via glucometer

If blood sugar less than 60 mg/dl, administer 25 g DEXTROSE 50% via IVP. Monitor for IV
patency and protect against tissue necrosis secondary to infiltration. For pediatric
administration dilute DEXTROSE 50% to DEXTROSE 25% or DEXTROSE 10% and refer
to Broselow tape.

If hypotensive, place patient in Trendelenburg position and administer fluid bolus.

If ethanol or malnourishment suspected, administer THIAMINE 100 mg IVP.

Consider the administration of NARCAN to provide for patent, self maintained airway and
adequate respirations:
1. If patient’s weight is <50 kg, administer NARCAN 2 mg IVP q 3 minutes PRN but not
to exceed 6 mg until airway and respiratory status improve. If unable to establish IV
line, utilize MAD device.
2. If patient’s weight is >50 kg, administer NARCAN 2 mg IVP q 3 minutes but not to
exceed 10 mg until airway and respiratory status improve. If unable to establish IV
line, utilize MAD device.
3. Refer to Broselow tape for pediatric administration of NARCAN.

If benzodiazepine overdose suspected, contact Medical Control for consideration of
administration of FLUMAZENIL 0.2 mg increments rapid IVP q 5 minutes if transient
response observed, not to exceed 1 mg.

If tricyclic antidepressant overdose suspected, contact Medical Control for
consideration of administration of SODIUM BICARBONATE.

If beta blocker overdose suspected, contact Medical Control for consideration of
administration of GLUCAGON.

If calcium channel blocker overdose suspected, contact Medical Control for
consideration of administration of CALCIUM CHLORIDE.
96
Suspected Stroke / CVA
Indications: Altered mental status, seizure, headache, parasthesia, hemiparesis in the absence
of trauma, weakness, ataxia, visual disturbances, dysarthria, nausea, vomiting, general malaise,
positive pronator drift, facial droop, abnormal papillary function, or other symptoms of suspected
cerebral ischemia or hemorrhage.

Administer OXYGEN via nasal cannula at a quantity sufficient to maintain the oxygen
saturation level equal or greater than 95%.

Maintain head and neck in neutral alignment without flexing the neck. Elevate head of
stretcher 15 to 30 degrees if systolic BP is above 90 mmHg.

Obtain IV access

Obtain blood sugar level via glucometer. If reading is below 60 mg/dl, administer 25 g
DEXTROSE 50% via IVP and THIAMINE 100 mg IVP. Patient is to remain NPO.

Administer 1 mg GLUCAGON if IV access cannot be established and blood sugar reading
is below 60 mg/dl.

Obtain and interpret 12 lead EKG

If seizures are present and lasting >2 minutes, consider the administration of VERSED 2.5
to 10 mg IVP or DIAZEPAM 2 to 20 mg slow IVP titrated to control seizure activity. If no IV
access obtained, consider same doses VERSED or VALIUM IM up to total of 2 ml per large
muscle injection site and 1 ml per small muscle injection site. VERSED is preferred.

Monitor and record neurological status and any changes. Protect paralyzed limbs from
injury.

If patient is vomiting or has severe nausea, administer ZOFRAN 4 mg IV with 9cc flush or
PROMETHAZINE 12.5 mg slow IVP (diluted with 9cc of NORMAL SALINE). ZOFRAN is
preferred.

Transport to nearest appropriate CT-capable hospital without delay.

Notify Emergency Room of Stroke Alert if verified onset is less than 3 hours.

Maintain on scene time of less than 20 minutes.
97
Seizures
Indications: EMS witnessed active seizure activity.

Administer OXYGEN at rate sufficient enough to maintain SpO2 at/or above 95%.

Protect airway and protect patient from injury. Do not place anything inside patient’s mouth.
Observe type, location, and duration of seizure activity.

Obtain IV access if possible.

Obtain blood glucose reading. If blood sugar level below 60 mg/dl, administer 25 g of
DEXTROSE IV. If unable to obtain IV access, administer 1 mg GLUCAGON IM.

Administer up to 5 mg VERSED slow IVP, if patient has witnessed generalized seizure
activity. If unable to obtain IV access, VERSED may be administered IM or IN. This may
be repeated times 1 as needed.

May consider administering up to 5 mg VALIUM slow IVP for seizure activity if patient does
not have a history of epilepsy or does not respond appropriately to VERSED. This may be
repeated times 1 as needed. (VERSED is preferred)

Administer 1 g MAGNESIUM SULFATE diluted in 250 ml Normal Saline via IV infused over
10 minutes for seizures secondary to eclampsia.
Contact Medical Control for consideration of additional VERSED if the patient continues to
have seizure activity after the second dose. Be prepared to maintain control of airway after
administering VERSED should severe respiratory depression or respiratory arrest occur.
98
Allergic Reactions/Anaphylaxis
Moderate Allergic Reaction
Indications: Allergic manifestations without airway compromise or shock. Hives (urticaria) and/or
history of systemic reaction in the past.
 Maintain airway and administer OXYGEN at level to maintain SpO2 levels above 95%.
 Establish IV access
 Consider the administration of 25 to 50 mg DIPHENHYDRAMINE (BENADRYL) IV, IM, or
PO
 If wheezing and heart rate <150, consider the administration of 2.5 mg ALBUTEROL via
nebulizer
 Apply cardiac monitor, obtain labs if possible.
Severe Allergic Reaction
Indications: Allergic manifestations with urticaria and/or history of an allergic exposure with:
1. Airway obstruction (partial or complete) OR
2. Systolic blood pressure less than 80 mmHg with clinical evidence of shock

Maintain airway and administer OXYGEN at level to maintain SpO2 levels above 95%

Establish IV access using NORMAL SALINE and administer a fluid bolus of 500 ml.

Administer 0.25 mg EPINEPHRINE (1:10,000) IV over a one minute interval. If unable to
establish IV access, administer 0.3 to 0.5 mg EPINEPHRINE (1:1,000) IM or SC.

Reassess patient, if acute respiratory obstruction persists or systolic BP is less than 80
mmHg with clinical evidence of shock present, repeat 0.25 mg EPINEPHRINE (1:10,000) IV
over a one minute period, or repeat 0.3 to 0.5 mg EPINEPHRINE (1:1,000) IM or SC, if no
IV access established.

May repeat IV fluid bolus of 500 ml if systolic BP remains below 80 mmHg with continued
evidence of clinical shock.

Consider administration of 50 mg DIPHENHYDRAMINE (BENADRYL) IV or IM.

Consider administration of 125 mg METHYLPREDNISOLONE (SOLU-MEDROL) IV.

Consider administration of 2.5 to 5.0 mg ALBUTEROL via nebulizer if wheezing is present
and heart rate is below 150.
99
Non-Traumatic Hypotension
Indications: Systolic blood pressure less than 80 mmHg and heart rate greater than 60 beats per
minute.

Infuse up to 500 ml bolus of NORMAL SALINE via IV if clinical signs of CHF are not present

Reassess vital signs and lung sounds

Infuse an additional 500 ml bolus of NORMAL SALINE via IV if clinical signs of CHF are
note present.

Reassess vital signs and lung sounds

Contact Medical Control for consideration of a 5 to 20 mcg/kg/min DOPAMINE
infusion for continued hypotension not due to hypovolemia.
100
Shock
Indications: Systolic blood pressure less than 80 mmHg and heart rate greater than 60 beats per
minutes with signs of decreased tissue perfusion secondary to HYPOVOLEMIA.

Administer OXYGEN necessary to maintain SpO2 at/or above 95%

Place patient in Trendelenburg position.

Control external hemorrhage if necessary.

Apply cardiac monitor

Establish IV access via 2 large bore IV lines. Administer fluid boluses of LACTATED
RINGERS in increments of 20 ml/kg, to titrate systolic BP >80 mmHg. Monitor for
signs of fluid overload.

If known hemorrhagic shock, infuse fluid rapidly until systolic BP >80 mmHg. Monitor
patient for signs of fluid overload.

Administration of DOPAMINE for patients with hypovolemia is contraindicated.
101
Hypertensive Crisis
Indications: Systolic BP >230 mmHg and/or Diastolic BP >120 mmHg.
Consider medical etiology for hypertensive crisis and refer to appropriate protocol:
Congestive Heart Failure/Pulmonary Edema, Acute Coronary Syndrome/STEMI, and/or
Suspected Stroke/CVA.

Administer OXYGEN at levels sufficient to maintain SpO2 levels at or above 95%.

Apply cardiac monitor and establish IV access

Draw labs, if possible

Administer 0.1 to 0.2 mg CATAPRES (CLONIDINE) PO

Continue to monitor and document BP q 5 min

If patient exhibits signs of severe nausea or vomiting, administer ZOFRAN 4 mg undiluted
over 2 to 5 minutes or PROMETHAZINE 12.5 mg slow IVP diluted with 9cc NORMAL
SALINE. ZOFRAN is preferred.

Contact Medical Control for consideration of NITROGLYCERIN 0.4 mg SL, repeat q 5
min or until NITROGLYCERIN Drip is established at 3 mcg/minute via IV pump. DO
NOT GIVE NITRO IF PATIENT IS ON VIAGRA, CIALIS, or LEVITRA. Discontinue
NITROGLYCERIN therapy when systolic BP <200 mmHg and/or diastolic BP <110
mmHg.

Contact Medical Control for consideration of administration of 5 mg VALIUM slow IVP
over 1 to 2 minutes (excluded for patients that exhibit any CVA like signs and/or
symptoms.)
102
Hemodynamically Compromising Bradycardia
Indications: Pulse less than 60 bpm AND systolic blood pressure less than 80 mmHg OR
absence of radial pulses bilaterally, with clinical evidence of shock. Patients with altered mentation
and clinical evidence of shock are hemodynamically compromised, even if the systolic blood
pressure is greater than 80 mmHg.

Administer 0.5 mg ATROPINE IV. Repeat 0.5 mg ATROPINE IV every 3-5 minutes until a
maximum of 3 mg of ATROPINE is administered or the pulse rate is 60 bpm or greater.
ATROPINE in 2 mg doses may be given via ET every 3-5 minutes to a total of 6 mg.

Consider initiating transcutaneous cardiac pacing (TCP) if patient does not respond to
ATROPINE. Set rate at 80 per minute. Rapidly increase the output (MA) until capture
occurs, or the maximum MA is reached.
o If electrical or mechanical capture is achieved, do not give ATROPINE,
unless capture is lost, and bradycardia recurs.
o If the patient is experiencing discomfort due to pacing and the systolic blood
pressure is greater than
or equal to 100 mmHg, administer up to 5 mg
®
MIDAZOLAM (VERSED ) IV for sedation..

Administer an intravenous bolus of up to 500 ml NSS if clinical signs of CHF are not
present.

Contact medical control for consideration of a 5-20 mcg/kg/min DOPAMINE infusion
for continued hypotension not due to hypovolemia.
Contact medical control for consideration of GLUCAGON IV if a beta-blocker overdose is
suspected.
Contact medical control for orders to administer CALCIUM CHLORIDE and possibly
SODIUM BICARBONATE, if the patient has a history of chronic renal failure and either
hemodialysis or peritoneal dialysis.
103
Stable Tachycardia
Indications: A wide complex tachycardia (QRS ≥ 0.12 seconds) presumed to be ventricular
tachycardia (VT), with a rate exceeding 100 bpm, or a narrow complex tachycardia (QRS < 0.12
seconds) other than sinus tachycardia, with a rate exceeding 150 bpm. There should be no
evidence of trauma.
** For purposes of these Protocols, STABLE is defined as a patient with a systolic blood pressure
greater than 80 mmHg.

Consider Valsalva maneuver. (Carotid massage may not be performed.)

If the rhythm is a wide complex tachycardia
at a rate exceeding 100 bpm, administer 150
®
mg AMIODARONE (CORDARONE ) IV infused over 10 minutes.

If the rhythm is a narrow complex tachycardia, other than sinus tachycardia, atrial
fibrillation or atrial
flutter, at a rate exceeding 150 bpm, administer 6 mg ADENOSINE
®
(ADENOCARD ) IV rapidly.
o If there is no response to the initial 6 mg dose, administer 12 mg ADENOSINE.
o If there is no response to the second dose, administer 12 mg ADENOSINE.

If the rhythm is a narrow complex atrial fibrillation, atrial flutter, or SVT refractory to
ADENOSINE, at a rate exceeding 150 bpm, and the patient is without
signs or symptoms of
®
congestive heart failure, administer 20 mg DILTIAZEM (CARDIZEM ) IV over 2 minutes.

After administering DILTIAZEM (CARDIZEM®) bolus, hang a maintenance drip with
remaining DILTIAZEM (CARDIZEM®) at rate of 5 mg/hr.

May repeat DILTIAZEM (CARDIZEM®) bolus if desired effects not achieved after 15
minutes at dose of 25 mg via IV, then continue with the maintenance drip at 5mg/hr.
Contact medical control for orders to administer CALCIUM CHLORIDE and possibly
SODIUM BICARBONATE, if the patient has a history of chronic renal failure and either
hemodialysis or peritoneal dialysis.
DILTIAZEM (CARDIZEM) use with caution, contact medical control when patients are on
DIGOXIN.
ADENOSINE: potentiated by DIPYRIDAMOLE (PERSANTINE), use half (1/2) doses. Use with
caution with patients on CARBEMAZEPINE (TEGRETOL), DIGOXIN and VERAPAMIL.
104
Unstable Tachycardia
Indications: A wide complex tachycardia (QRS ≥ 0.12 seconds) presumed to be ventricular
tachycardia (VT), with a rate exceeding 100 bpm, or a narrow complex tachycardia (QRS < 0.12
seconds) other than sinus tachycardia, with a rate exceeding 150 bpm. There should be no
evidence of trauma.
**For purposes of these Protocols, UNSTABLE is defined as systolic blood pressure less than 80
mmHg OR radial pulses are absent bilaterally, with clinical evidence of shock. Patients with altered
mentation and clinical evidence of shock are UNSTABLE, even if the systolic blood pressure is
greater than 80 mmHg.

If appropriate, consider ADENOSINE administration for narrow complex tachycardia if IV is
established.

Consider the administration of up to 20 mg ETOMIDATE (AMIDATE ) IV prior to
cardioversion of an alert patient. This is in consideration of the weight for a normal size
adult. Otherwise, ETOMIDATE dose is 0.2 mg/kg IV.

Perform synchronized cardioversion using 100 joules.

Perform synchronized cardioversion using 200 joules.

Perform synchronized cardioversion using 300 joules.

Perform synchronized cardioversion using 360 joules.

Administer intravenous fluid bolus up to 500 ml.

Upon successful conversion, perform and interpret 12 lead ECG.

For wide complex tachycardia, administer 150 mg AMIODARONE (CORDARONE ) IV
infused over 10 minutes:
®
®
o If there is no response to cardioversion,
o OR upon successful conversion,
o AND if needed for a recurrence.
Contact medical control for consideration to administer CALCIUM CHLORIDE and possibly
SODIUM BICARBONATE, if the patient has a history of chronic renal failure and either
hemodialysis or peritoneal dialysis.
Biphasic devices may use FDA approved/recommended energy settings.
105
Ventricular Fibrillation/Pulseless Ventricular Tachycardia

In the absence of effective CPR on arrival and when response time is greater than four (4)
minutes, perform 2 minutes of chest compressions prior to first defibrillation or intubation.

Defibrillate using 360 joules every 2 minutes.
If an IV/IO can be established:

Administer 1 mg EPINEPHRINE (1:10,000) IV. Repeat 1 mg EPINEPHRINE (1:10,000) IV
every 3-5 minutes if VF or pulseless VT persists.

Consider administration of 2 g MAGNESIUM SULFATE via IV if Torsade de Pointes is
identified (withhold for renal dialysis patients).

Administer 300 mg AMIODARONE (CORDARONE ) IV, with a repeat dose of 150 mg after
10 minutes. (Do not administer if LIDOCAINE has already been given).
®
If an IV/IO cannot be established:

Administer 2 mg EPINEPHRINE 1:10,000 ET every 3–5 minutes until IV access is obtained.

Administer 3 mg/kg LIDOCAINE via ET once. If an IV is established, continue with 0.75
mg/kg LIDOCAINE IV every 5-10 minutes until a max dose is given of 4.5 mg/kg.
With return of
antiarrhythmic:
spontaneous
circulation
(ROSC)
prior
to
administration
of
any
®
 Administer 150 mg AMIODARONE (CORDARONE ) IV infused over 10 minutes or 3 mg/kg
LIDOCAINE ET if no IV access is available.
Guidelines
• Biphasic devices may use FDA approved/recommended energy settings
• Ventilations
o ventilate at 8-10 breaths per minute to decrease intrathoracic pressure
o patients should be bagged using a one-hand squeeze
• Compressions
o perform 2 minutes of chest compressions between each defibrillation attempt
o CPR should be adjusted to provide for an EtCO 2 reading of greater than 10 mmHg,
with greater than 20 mmHg preferred to improve chance of return of spontaneous
circulation (ROSC)
o ensure proper depth and rate of compressions and minimize hands-off time
o frequently switch providers performing chest compressions to maintain peak
performance
o ensure complete recoil of the chest wall prior to the next compression
106
Asystole/Pulseless Electrical Activity
 Consider early transcutaneous pacing for heart rates less than 60 bpm.
 Administer 1 dose of VASOPRESSIN 40 U IV/IO.
administering EPINEPHRINE.
This should be completed prior to
 Administer 1 mg EPINEPHRINE (1:10,000) IV. Repeat 1 mg EPINEPHRINE (1:10,000) IV
every 3 to 5 minutes if asystole or PEA continues
 For asystole or PEA at a ventricular rate less than 60 bpm, administer ATROPINE 1 mg IV.
ATROPINE 1 mg IV may be repeated every 5 minutes until ventricular rate is greater than
60 bpm or a total of 3 mg of ATROPINE has been given.
 Administer intravenous bolus of NORMAL SALINE up to 500 ml.
Guidelines
• Ventilations
o ventilate at 8-10 breaths per minute to decrease intrathoracic pressure
o patients should be bagged using a one-hand squeeze
• Compressions
o CPR should be adjusted to provide for an EtCO 2 reading of greater than 10 mmHg,
with greater than 20 mmHg preferred to improve chance of return of spontaneous
circulation (ROSC)
o ensure proper depth and rate of compressions and minimize hands-off time
o frequently switch providers performing chest compressions to maintain peak
performance
o ensure complete recoil of the chest wall prior to the next compression
107
Environmental Cold Emergencies
Note: All patients should have their temperature assessed.
Frostbite

Initiate medical care.

Remove wet garments and move patient to a warm environment ASAP.

Elevate affected part and cover with loosely applied, dry, sterile dressings.
Systemic Hypothermia
Mild / Moderate 95 to 90 degree Fahrenheit. Conscious or altered sensorium with shivering.

Initiate medical care
o OXYGEN via NC @ 4 lpm, EKG, and obtain IV access
o Warm IV packs using hot packs

Remove wet clothing and protect patient against heat loss and wind chill.

Place patient in horizontal position avoiding rough movement and excess activity

Completely dry patient and cover with insulating blanket.
Severe Systemic Hypothermia
Temperature of 90 degrees Fahrenheit or less. Patient may appear uncoordinated with poor
muscle control or stiff, simulating rigor mortis. There will be NO shivering. Sensorium:
confused, withdrawn, disoriented, comatose.

Initiate medical care
o OXYGEN 4 lpm via NC. Do not intubate unless patient is apneic.
o Warm IV tubing, fluids, and oxygen tubing with hot packs.

Refer to Systemic Hypothermia and Contact Medical Control.

For Ventricular Fibrillation and Pulseless Ventricular Tachycardia: do not administer any
medications unless core body temperature is above 90 degrees Fahrenheit and do not
defibrillate more than 3 times until patient is re-warmed.
108
Environmental Heat Emergencies
Note: All patients should have their temperature assessed.
Heat Cramps

Initiate medical care

Move patient to a cool environment and transport.
Heat Exhaustion

Initiate medical care and administer OXYGEN via NC at 4 lpm

If Systolic BP <90 mm Hg then administer NORMAL SALINE boluses in 200 to 300 ml
increments to titrate systolic BP >90 mm Hg

Move patient to cool environment

Lay patient in supine position with feet elevated

Remove as much clothing as possible to facilitate cooling

Sponge with cool water or cover with wet sheet and fan patient’s body
Heat Stroke

Initial Medical Care - OXYGEN 4 lpm via Nasal Cannula. Pulse ox / cardiac monitor / IV
access / labs

If systolic BP < 90 mm Hg, Fluid boluses in increments of 200 - 300 ml, to titrate systolic BP
> 90 mm Hg.

Move patient to cool environment

Semi-reclining position with head elevated 15 - 30 degrees if systolic BP > 90 mm Hg.
Evaluate and take precautions for increased intracranial pressure

Initiate rapid cooling. Remove as much clothing as possible to facilitate cooling; place cold
packs on lateral chest wall, groin, axilla, carotid arteries, temples, and/or behind knees;
sponge with cool water or cover with wet sheet and fan patient’s body.
109
Sickle Cell Anemia
Signs and Symptoms include: severe dyspnea, severe pain secondary to hypoxia or vasoocclusive disease process and pain may include any large muscle mass.

Initiate medical care, pulse oximeter, OXYGEN via NC @ 4 lpm

Cardiac monitor, IV access, and draw labs

Keep patient as calm as possible to minimize oxygen needs

Administer a NS fluid bolus of 200 to 300 ml then continue IV infusion KVO

If wheezing is present and HR <150 bpm, administer 2.5 mg ALBUTEROL via nebulizer

If the patient is exhibiting severe altered mental status, consider endotracheal intubation
and ventilate with OXYGEN at 100% via BVM.

Consider the administration of pain management to include MORPHINE SULFATE and/or
TORADOL. Refer to the Pain Management protocol.
110
OB/GYN
Pregnancy Induced Hypertension

Initiate Medical Care. Provide OXYGEN via NRM or assist with BVM as indicated.

Apply cardiac monitor, obtain IV access, draw labs, obtain blood glucose level, and be
prepared for seizures.

Handle patient gently. Maintain minimal CNS stimulation.

Patient should be positioned on left side or raise the right side of the backboard
approximately 30 degrees.

If seizure occurs, administer MAGNESIUM SULFATE 1 gm IV diluted in 250 ml Normal
Saline over 10 minutes.

If seizures last longer than 2 minutes, administer VERSED 5 mg IV or IM for adults and
titrate to control seizure activity. If patient does not respond appropriately, consider
administering VALIUM 2 to 20 mg slow IVP and titrate to control seizure activity. VERSED
is the safer medication for the unborn fetus.
Vaginal Bleeding

Initiate Medical Care. Administer OXYGEN via nasal cannula at 4 lpm, apply pulse
oximeter, apply cardiac monitor.

Determine LMP, note if there is a passage of clots or tissue and if present then save them
for analysis. Examine perineum and do not perform vaginal examination. Determine if
there is any possibility of trauma.

If unknown pregnancy status and/or LMP and/or if it is a known pregnancy in the first 6
months then place patient in left lateral position and treat for Shock as indicated.

If Third Trimester Bleeding then establish 2 large bore IV lines, place patient in left lateral
recumbent position for transport, and mark fundal height and time of measurement with a
pen then reassess fundal height every 20 minutes as needed. If hypotensive then treat for
Shock as indicated.
Trauma in Pregnancy

Initiate Medical Care. Apply pulse oximeter and administer OXYGEN via NRM or assist
ventilations with BVM as needed.

Check for uterine contractions, vaginal bleeding and/or leaking amniotic fluid. Assess for
fetal movements. Apply cardiac monitor, obtain IV access, draw labs, and check blood
glucose level.
111

Raise right side of backboard approximately 30 degrees.

If hypotension is present, treat for Shock as indicated.
Emergency Childbirth
PHASE 1 – LABOR

Obtain history and determine if there is adequate time to transport. If time allows have
mother remove all clothing and place a hospital gown on patient.

Inspect for bulging perineum, crowning or whether patient is involuntarily pushing with
contractions. If contractions are two minutes apart or less, or if any of the above is present,
prepare for delivery. Do not attempt to restrain or delay delivery unless there is a prolapsed
cord present.

Initiate medical care. Apply pulse ox, cardiac monitor, and IV as time allows. Administer
OXYGEN as necessary. If mother is hyperventilating, encourage eye contact and coach
her to take slow, deep breaths. If mother becomes hypotensive or lightheaded at any time,
administer fluid boluses in increments of 200-300 ml, to titrate BP >90 mm Hg and apply
OXYGEN via NRM or assist with BVM as needed.

Place mother supine on flat surface if possible. If time permits, put on full blood and body
secretion barriers.

Open OB pack. Place drapes over mother’s abdomen and beneath perineum. Prepare
bulb syringe, cord clamps, and tux to receive the infant.
PHASE 2 – DELIVERY

If amniotic sac is not punctured you must puncture it with a gloved hand and pull away from
the face.

Allow head to deliver passively. Control rate of delivery by placing palm of one hand gently
over occiput. Protect perineum with pressure from other hand.

Gently suction infant’s mouth then nose as soon as head delivers if time allows.

Once the head is delivered, allow it to passively turn to one side. This is necessary for the
shoulders to deliver.

Feel around the infant’s neck for the umbilical cord (nuchal cord). If present, attempt to
gently lift it over the baby’s head. If unsuccessful, double clamp and cut the cord between
the clamps.

To facilitate delivery of the upper shoulder, gently guide the head downwards. Support and
lift the head and neck slightly to deliver the lower shoulder.

The rest of the infant should deliver quickly with one contraction. Firmly grasp the infant as
112
it emerges. Baby will be wet and slippery.

Keep newborn level with perineum until the cord stops pulsating and is double clamped.

Check blood sugar and rectal temp. If blood sugar is <60 mg/dl, then follow the
hypoglycemic protocol. If patient is hypothermic, keep warm and dry. Turn heat on in unit
no matter the weather outside the unit.

If able, mother may hold infant on chest/abdomen during transport. Remember the mother
may be very tired or lethargic from blood loss after delivery.
Newborn care
 Record APGAR score at 1 minute and 5 minutes.
 Continue to suction mouth first then nose of infant with bulb syringe. For meconium-stained
infants: suction only upon delivery of the head prior to delivery of the body; after delivery,
intubate the infant and apply suction to the lumen of the ETT while withdrawing from the
trachea.
 After establishing airway, dry, warm and stimulate the infant, clamp and cut cord provided
pulsations have ceased.
 Assess respiratory rate
 If respirations are adequate or patient crying: place infant in Trendelenburg position; assess
color and provide OXYGEN via NRM if central cyanosis is present; if respirations improve
then administer “blow-by” OXYGEN; keep warm and check rectal temp.
 If respirations are shallow, slow or absent: assist ventilations with BVM and OXYGEN at
100%; If respirations improve, provide OXYGEN via NRM; if apneic after OXYGEN and
BVM then consider intubation; keep warm and check rectal temp.
 Assess heart rate. If rate is below 100, deliver high flow OXYGEN. If below 60, begin
compressions.
 If no response, administer EPINEPHRINE 0.01 mg/kg (0.1 ml/kg of 1:10,000 solution)
IV/IO.
 Contact Med Control for further orders.
Post-Partum Care
 Placenta should deliver in 20 to 30 minutes. If delivered, collect in plastic bag. Do not pull
on cord to facilitate delivery of the placenta. Gently massage the fundus in order to
facilitate delivery of the placenta. Note the time placenta was delivered. Do not discard
the placenta. The placenta must be taken with mother and released to the RN in labor
and delivery.
 Do not delay transport if placenta has not delivered.
113
 If perineum is torn and bleeding apply direct pressure with sanitary pads and have patient
bring her legs together.
 If significant blood loss or signs of hypoperfusion: administer high flow OXYGEN, apply
pulse ox, and cardiac monitor; administer fluid boluses in increments of 200-300 ml, to
titrate BP > 90 mm Hg; gently massage abdomen over the uterus until the uterus is firm.
 If altered sensorium, and signs of hypoperfusion persist after treatment, then follow the
Shock protocol.
Childbirth Complications
Breech Birth
 Initiate medical care. Apply oxygen via NRM or assist ventilations with BVM as needed.
 Never attempt to pull the infant from the vagina.
 As soon as legs are delivered, support the baby’s body wrapped in a towel.
 After the shoulders are delivered, if face down, gently elevate the legs and trunk to facilitate
delivery of the head.
 Head should deliver within 30 seconds. If not, reach two sterile gloved fingers into vagina to
locate baby’s mouth. Push vaginal wall away from baby’s mouth to form an airway. If
possible suction the mouth then the nose.
 Apply gentle pressure to the fundus. If head does not deliver in two minutes, keep your
fingers in place to maintain the airway.
Prolapsed Cord
 Initiate medical care. Administer OXYGEN via NRM or assist ventilations with BVM as
needed.
 Elevate mother’s hips.
 Place sterile gloved hand into vagina between pubic bone and presenting part with cord
between two fingers to monitor cord pulsations and exert counter-pressure on presenting
part.
 Cover exposed cord with moist dressing and keep warm.
NOTE: All the above described patients in the OB/GYN section should be transported to the
nearest facility that provides comprehensive obstetrical care.
114
Suspected Sexual Assault

Perform generalized evaluation.

Attempt to calm patient as needed, protect patient’s privacy and suspected crime scene.

Refer to appropriate medical or trauma protocols as needed.

Do not remove clothing unless medically necessary for treatment. If clothing is already
removed, place clothing in a paper bag to preserve evidence.

Contact law enforcement

Transport to closest appropriate facility

At the conclusion of the call, wrap and leave stretcher sheets in the patient’s room for
evidence.

If possible, female EMS personnel should accompany patient during transport and perform
the majority of the evaluation.
115
Suspected Abuse / Neglect

Initiate medical or trauma care as indicated.

Note environment, patient’s interaction with care-givers, discrepancies in the history
obtained from patient and care-givers, and any signs of obvious injury.

If parents / guardians refuse to let you transport the patient, leave scene, remain in safe
location and contact law enforcement for assistance.

Transport. It is mandatory that you report your suspicions to the ER Physician upon arrival
at the ED. EMS personnel are considered ‘mandatory reporters’ and are legally bound to
report all suspicions concerning possible abuse and/or neglect to the ER Physician.

It is the Emergency Department Physician’s responsibility to contact DFACS or ensure
DFACS is contacted in all suspected abuse and neglect cases.

Carefully document history and physical exam findings as well as environmental /
circumstantial data on the patient care report.
116
Psychological / Behavioral Emergencies

Consider medical etiology of psychological / behavioral disorder and treat accordingly.

Establish scene safety and maintain personal safety. Call law enforcement to scene if
needed. Do nothing to jeopardize your safety.

Determine and document if the patient is a threat to self or others and if the patient is
unable to care or provide for self. Protect patient from harm to self or others.

Attempt to calm patient verbally as able and encourage patient to leave current
environment.

Physically restrain as necessary. Document use, type, time applied, and reason for
restraints. Document distal circulation, sensory, and motor assessments every 5 minutes.
Notify medical control that physical restraints were necessary.

If physical restraints are necessary, every attempt should be made to contact law
enforcement for assistance.

Consider the administration of HALDOL 5mg IV/IM if patient is violent and is a potential
harm to self or others. Use caution in IM usage due to delayed onset of medication action.
If patient then remains violent and a danger to self or others, you may repeat HALDOL 5mg
IV/IM times 1. After administration of HALDOL, continually monitor patient for any
complications with respirations and level of consciousness.

Initiate medical care after mechanical or chemical restraint.

Consult medical control in ALL instances where a refusal of transport of a patient
with a psychological / behavioral emergency is being considered due to patient being
conscious, alert and oriented times 4. If patient appears to have any degree of
confusion or appears to be a potential harm to themselves or others, the patient
should be transported against his will. Law enforcement should be involved in this
instance.
117
Pediatric and Adult Trauma
Indications: This trauma protocol applies to patients with any of the following field triage criteria:
Mechanism:
Ejection from vehicle
Death of passenger in same vehicle
Extrication > 20 minutes
Falls 2 ½ times patient’s height
Obvious Injury:
Penetrating injury to the chest, abdomen, head, neck, proximal injuries or groin
Major burns, inhalation injury, or trauma with burns
More than one proximal long bone fracture
Suspected spinal column or cord injury or limb paralysis
Pelvic fracture (suspected on clinical grounds)
Flail chest, multiple rib fractures, or subcutaneous emphysema
Major external bleeding
Amputated limb
Vital Sign Abnormalities:
Adults: Glasgow Coma Scale <13; Systolic BP <90 mmHg; Respiratory rate <10 or >30;
Heart rate <50 or >120 bpm
Pediatrics: Pediatric Glasgow Coma Scale <13; Refer to abnormal Vital Signs section of
Broselow Tape
Extenuating Circumstances (Not stand alone criteria for initiation of trauma protocol or
helicopter transport):
Pregnancy
Age <15 or >65 yoa
Known significant cardiac or respiratory disease
Rollovers
High-speed crash
Pedestrian >5 mph impact
Motorcycle >20 mph or rider thrown
 Consider helicopter transport if ground transport to appropriate hospital is expected
to exceed 20 minutes
 Consider medication assisted intubation as needed.
 If unable to intubate, maintain cricoids pressure and resume ventilations via BVM
pending placement of an appropriate airway device
 Consider needle chest decompression for patients with severe respiratory
compromise due to tension pneumothorax or for patients in trauma arrest with
possible chest involvement.
 For clinical shock, initiate bilateral IV with fluid resuscitation of 20 ml/kg of NORMAL
SALINE or LACTATED RINGERS as indicated. If unable to obtain IV access, IO
access is permissible.
 For suspected unstable pelvic fractures, apply pelvic compression device.
 Initiate transport to an appropriate trauma facility without delay
118
 If head or spinal trauma, consider direct transport to a medical facility with immediate
neurosurgical capabilities
 If isolated burns, consider direct transport to the nearest appropriate specialty burn
facility via helicopter or ground without delay for patients with 2 nd or 3rd degree burns
greater than or equal to:
o 20% BSA in adults
o 10% BSA in ages less than 10 and over 50 years of age
o 5% BSA in infants
o 5% BSA of third degree in any patient
o Circumferential burns or burns of the airway, neck, face, head, hands, feet,
major joints or perineum
o Patients with severe underlying medical conditions
o Chemical burns with serious threat to functional or cosmetic impairment
o Bandage burn areas using a dry or wet sterile dressing for burns <10% BSA.
For burns greater than or equal to 10% BSA, use dry sterile dressing only.
Cover the patient and provide for a warm environment to prevent heat loss.
*Trauma scene times should be less than 10 minutes unless there are extenuating circumstances.
Reasons for scene times greater than 10 minutes should be documented on the patient care
report. Appropriate reasons for prolonged trauma scene times include extrication, securing scene
safety, presence of multiple patients, necessary stabilizing patient treatment, etc.
119
Spinal Cord Injury
THERAPEUTIC GOAL: The patient with a suspected or known spinal cord injury will be
recognized and all resources will be utilized to prevent further injury or deficit to the patient. The
patient’s entire spine will be adequately immobilized and maintained throughout transport.
PATHOPHYSIOLOGY: All trauma patients must be assumed to have a spinal cord injury until
proven otherwise. Traffic accidents are the most frequent cause of spinal cord injuries in all age
groups, and falls amount for over half of all work-related spinal injuries. Approximately seven
percent of spinal injuries are the result of sports and recreational activities. Five percent of
patients with a known vertebral fracture have a second fracture along their vertical vertebral axis.
The majority of injuries to the bony spine and cord are closed injuries and are usually the result of
indirect forces, as opposed to a direct blow. Areas of the spine with great mobility are the most
susceptible to injury such as the lower cervical spine, thoracolumbar junction, and lumbar sacral
junction. Injury may involve the bony skeleton, the cord itself or both. There may or may not be a
neurological deficit.
Hyperextension, hyperflexion, vertical loading, or rotational forces may cause blunt spinal injury.
Hyperextension injuries often occur as the occupant of a car is thrown forward, striking his chin on
the dash or windshield. Similarly, a victim involved in a motor vehicle collision may incur a
hyperflexion injury when the top of his head strikes an object, forcefully flexing the head forward.
Diving accidents and falls result in direct axial forces being applied to the spine and frequently lead
to crush injuries of the vertebrae.
Ligamentous injuries (rupture or tearing of ligaments) can cause subluxation of a vertebral body
over another, increasing the risk of spinal cord damage. Spinous process fractures are painful but
are considered stable fractures. Comminuted fractures of the vertebral body may produce
teardrop fractures. Any bony fragments that penetrate the spinal canal have potential to damage
the cord. Herniated tissue from disc rupture may result in nerve damage and/or cord compression.
Fractures of intervertebral articulations may be associated with subluxation. Damage to the spinal
cord at or about the level of the fifth cervical vertebral may result in paralysis of the diaphragm that
may compromise the ability to ventilate. Thoracic spine injuries are frequently the result of acute
flexion, rotational, and/or axial load forces. Rotational forces are usually associated with
thoracolumbar injuries. Edema and contusions are serious complications of a spinal cord injury at
any level and may lead to ischemia and necrosis.
Neurogenic shock may accompany a low cervical or high thoracic spine injury and is defined as a
transient distal areflexia which can last from hours to weeks. Due to loss of sympathetic tone
below the level of the injury, hypotension and a paradoxic bradycardia occur, resulting in
inadequate perfusion of tissues. Skin below the level of injury is warm and dry due to vasodilation,
and urinary output is adequate. The patient may have symptoms of autonomic nerve dysfunction
evidenced by acute urinary retention and gastric dilation. The patient in neurogenic shock loses
the ability to regulate body temperature and may become hypo or hyperthermic.
120
ASSESSMENT:
 Conduct a primary survey for assessment of airway, breathing and circulation with
simultaneous C-spine control.
 Immobilize the entire spine if indicated by potential mechanism of injury.
 If the patient is an interfacility transport trauma patient and the immobilization devices have
been removed the patient should be re-immobilized for transport UNLESS ALL OF THE
FOLLOWING ARE TRUE:
o No neck pain exists.
o At least three adequate radiographic views of the C-spine rule out fracture (lateral,
AP, and odontoid) or lateral C-spine and complete C-spine CT rules out fracture.
o The patient is neurologically intact with a GCS of 15.
o There is no potentially distracting injury.
o The patient is not under the influence of alcohol or drugs.
o The mechanism of injury was not highly suspicious of neck injury (i.e. high speed,
head-on MVC).
o Medical Control is aware and agrees that re-immobilization is not necessary.
 If any doubt exists, the patient should be completely immobilized for transfer.
 Assess vital signs.
shock.
Hypotension associated with bradycardia may indicate neurogenic
 Assess for soft tissue injury, swelling, bony crepitus, pain, deformity, and/or muscle spasm.
 Assess movement, sensation, and strength of extremities.
 Assess for abdominal breathing, use of accessory muscles, indicating injury at or above the
cervical three, four, or five level.
 Assess patient’s body temperature (poikilothermy is possible).
 Assess for bladder distention, lack of bowel control, and/or priapism.
TREATMENT:
 Assess and manage airway, breathing, and circulation.

Initiate full spinal precautions.

Protect patient from hypothermia.

Consider anti-emetic medications as needed.

Assess blood glucose level.

Be prepared to treat patient according to the “Shock” protocol as needed.
121

If the patient has a potential non-penetrating spinal cord injury with motor/sensory
deficits and the injury has occurred within the prior eight hours, consider contacting
Medical Control for orders to administer METHYLPREDNISOLONE (SOLU-MEDROL®)
at rate of 30 mg/kg diluted in 250 ml Normal Saline over 15 minutes.

Patient should be transported to nearest medical facility equipped to adequately manage a
spinal injury patient.
High-dose steroids are not indicated for patients with a spinal injury that is older than eight hours
and will have no therapeutic effect on those patients.
If you are over 45 minutes away from a facility that can adequately
consider transport via aviation.
The patient should have
METHYLPREDNISOLONE (SOLU-MEDROL®) initiated 45 minutes
high-dose steroidal bolus. The maintenance infusion will run at a
next 23 hours.
handle a spinal injury patient,
a maintenance infusion of
after the administration of the
rate of 5.4 mg/kg/hr over the
High dose steroidal treatment for a spinal injury is a twenty-four hour process and requires the
adequate and timely recognition of a spinal injury. Proper pre-hospital treatment is an important
key to the patient survivability and being able to have an opportunity to resume a normal or near
normal lifestyle after a spinal injury.
122
Selective Spinal Immobilization
Apply this guideline to all patients in known or suspected blunt trauma
Implement spinal immobilization in the following circumstances:
 Significant multiple system trauma

Severe head or face trauma

Any penetrating trauma such as GSW or stabbing

If altered mental status (including drugs, alcohol, and trauma) AND: no history available;
patient found in setting of possible trauma (lying at bottom of stairs, in street, etc.); or near
drowning with a history or probability of diving.

Loss of consciousness after trauma

Spinal pain or tenderness, including any neck pain with a history of trauma

Numbness or weakness in any extremity after trauma

Patient with significantly painful distracting injury
High Risk (should be immobilized):
 Age >64 years

Dangerous mechanism (fall >5 stairs, axial load, high speed MVC with ejection and/or
rollover)

Motorized recreational vehicles

Bicycle collisions
Low Risk (may be cleared)
 Simple low speed rear-end MVC without being pushed into oncoming traffic, without
rollover, without being struck by a large vehicle or high speed vehicle

Ambulatory at any time after traumatic incident
123
Pediatric General Patient Care
Indications: Any patient that is 12 years of age or less requiring pre-hospital medical evaluation
by a pre-hospital health care provider. The Pediatric General Patient Care protocol should be
followed in conjunction with all other applicable protocols.

Perform scene survey

Observe universal precautions

Consider the need for additional resources

Determine responsiveness using AVPU

Evaluate airway, breathing, circulation, and disability exposing the patient as necessary

Secure a patent airway as needed

Manage cervical spine as needed

Treat life-threatening conditions as necessary per specific treatment protocols

Assess body systems as appropriate

Monitor patient via the use of pulse-oximetry as appropriate

Administer OXYGEN as necessary to maintain SpO2 at 92% or greater

Obtain medical history (HPI, PMH, allergies, and medications)

Evaluate blood pressure, pulses, respiratory rate, and tactile temperature. Reassess as
needed.

Monitor cardiac rhythm and/or 12 lead EKG as appropriate

Establish IV access with NORMAL SALINE as needed and appropriate

Consider IBUPROFEN or ACETAMINOPHEN via rectal suppository for pediatric temps
above 101.5 F or may be given PO at ACETAMINOPHEN 15 mg/kg or IBUPROFEN 10
mg/kg. Alternate medications if already administered <4 hrs prior EMS contact.

Use Broselow Tape to estimate drug dosages

Consider IO access, if IV access cannot be readily obtained for critically ill and/or injured
pediatric patients in extremis that are in urgent need of medication or fluid resuscitation.
Contact medical control for consideration of obtaining IO access in all other pediatric
patients in extremis that you cannot readily obtain IV accessibility.

Consider transport to an appropriate pediatric capable facility
124
Pediatric Acute Respiratory Distress
Indications: Acute exacerbation of asthma and reactive airway disease; cough, shortness of
breath, air hunger, wheezing, diminished breath sounds, retractions, and tachypnea. Contact
medical control prior to medication administration if patient’s heart rate is greater than 180 beats
per minute.

If patient has history of asthma or is actively wheezing and is less than 2 years of age:
administer one dose of ALBUTEROL (2.5 mg) via nebulized aerosol by face mask or blow
by. Contact medical control for additional doses.

If patient has history of asthma or is actively wheezing and is 2 years of age or older:
administer one dose of ALBUTEROL (2.5 mg) via nebulized aerosol.

In children 2 years of age or greater, who continue to exhibit respiratory distress, consider
the administration of 0.5 mg IPRATROPIUM BROMIDE (ATROVENT) via nebulizer with
additional dose of ALBUTEROL 2.5 mg. In children less than 2 years of age, contact
medical control for orders and dosage of IPRATROPIUM BROMIDE.

Consider the administration of 0.01 mg/kg EPINEPHRINE 1:1,000 IM/SC for patients in
severe respiratory distress (maximum dose of IM/SC EPINEPHRINE 1:1,000 is 0.3 mg).

For patients suspected of having croup, consider administration of nebulized SALINE for
inhalation. For continued distress, contact medical control for consideration of the
administration of 2 mg of EPINEPHRINE 1:1,000 via nebulizer.

Patient who present with acute respiratory distress of sudden onset accompanied by fever,
drooling, hoarseness, stridor, and sitting forward in the tripod position should be suspected
of having a partial airway obstruction. Do nothing to upset the child. Perform critical
assessments only and have parent administer blow-by OXYGEN. Transport immediately.
If patient’s airway becomes obstructed, in the setting of potential epiglottis. Attempt airway
management primarily with a BVM.

Contact medical control for consideration of administration of 2 mg/kg SOLUMEDROL IV (up to total dose of 125 mg) for children in moderate to severe
respiratory distress and a history of asthma in which an IV/IO has been started.

Contact medical control for consideration of administration of 25 mg/kg MAGNESIUM
SULFATE (up to a max dose of 2 g) diluted in 250 ml NS via IV infused over 10
minutes for continued severe respiratory distress.
125
Pediatric Altered Mental Status
Indications: Incomprehensible speech, inappropriate verbal responses, inability to follow verbal
commands, decreased responsiveness, or unresponsiveness.

If blood sugar less than 60 mg/dl via glucometer, administer 0.5 mg/kg DEXTROSE IV at
the following dilutions (max dose 25 g): DEXTROSE 25% (D25) at 2 ml/kg; or DEXTROSE
10% (D10) at 5 ml/kg for neonates.

Administer GLUCAGON 1 mg IM if unable to obtain IV access.

Consider the administration of up to 0.1 mg/kg NALOXONE (NARCAN) IV, ETT, IN, or IM
(max dose is 2 mg) for suspected drug overdose.
Contact medical control for consideration of SODIUM BICARBONATE for tricyclic
antidepressant overdose, glucagon for beta blocker overdose, and CALCIUM CHLORIDE for
calcium channel blocker overdose.
126
Pediatric Seizures (active)

If blood sugar less than 60 mg/dl via glucometer, administer 0.5 mg/kg DEXTROSE IV at
the following dilutions (max dose 25 g): DEXTROSE 25% (D25) at 2 ml/kg; or DEXTROSE
10% (D10) at 5 ml/kg for neonates.

Administer GLUCAGON 1 mg IM if unable to obtain IV access.

Administer 0.2 mg/kg MIDAZOLAM (VERSED) up to max dose of 5 mg IV, IN, or IM for
seizure activity greater than 5 minutes in duration.
127
Pediatric Shock and Hypotension
Indications: Altered mental status, tachycardia, absent peripheral pulses, or cool, clammy, or
mottled skin with a capillary refill greater than 2 seconds. Heart rate is greater than 60 bpm.

Infuse a 20 ml/kg fluid bolus of NORMAL SALINE via IV.

If signs of hypovolemic shock persist, boluses may be repeated at the same volume up to a
maximum of 60 ml/kg.
128
Pediatric Allergic Reactions
Moderate Allergic Reaction
Indications: Allergic manifestations such as urticaria or history with allergic exposure without
airway compromise or shock.

In patients over the age of two (2) years, consider the administration of 12.5 to 25 mg
DIPHENHYDRAMINE (BENADRYL) PO without the necessity of IV access.
Severe Allergic Reaction
Indications: Generalized allergic manifestations such as urticaria or history of an allergic exposure
with airway obstruction (partial or complete) OR clinical evidence of shock including altered mental
status, confusion, delayed capillary refill, and cool, clammy, or mottled skin.

Administer 0.01 mg/kg (0.1 mL/kg) EPINEPHRINE (1:10,000) IV over a one-minute interval.
If unable to establish IV access, administer 0.01 mg/kg EPINEPHRINE 1:1,000 (max 0.3
mg) IM/SC.

If respiratory distress and clinical shock are still present and there is no evidence of SVT,
ventricular ectopy, or ventricular tachycardia: repeat 0.01 mg/kg EPINEPHRINE 1:10,000
(max 0.25 mg) IV over a one-minute interval.

Administer 1 mg/kg DIPHENHYDRAMINE (BENADRYL) IV or IM (max dose is 50 mg).

Administer an IV bolus of 20 ml/kg NORMAL SALINE if shock persists. If signs of shock
persist, bolus may be repeated at the same volume up to 2 additional times for a max dose
of 60 ml/kg.

Contact medical control for consideration of administration of 2 mg/kg
METHYLPREDNISOLONE (SOLU-MEDROL) up to a max dose of 125 mg IV for
children which an IV has been initiated.
129
Pediatric Bradycardia
Indications: Pulse less than 60 bpm, systolic blood pressure less than 80 mmHg, patient not in
cardiac arrest, and any of the following signs or symptoms: chest pain, dyspnea, altered mental
status, dizziness, diaphoresis, slow capillary refill, shock, or pulmonary edema.

If severe cardio-respiratory compromise is present as evidenced by poor perfusion,
hypotension, or respiratory difficulty continues: Begin CPR if heart rate is less than 60 bpm
despite adequate ventilation and oxygenation.

Administer 0.01 mg/kg EPINEPHRINE (1:10,000) via IV; or 0.1 mg/kg EPINEPHRINE
(1:1,000) via ETT if no IV present. May repeat every 3 to 5 minutes as needed.

Administer 0.02 mg/kg ATROPINE via IV; or 0.04 mg/kg via ET is no IV present. Max
single dose is 0.5 mg IV or 1 mg via ET. May repeat once in 3 to 5 minutes.

Consider cardiac pacing

Search for and treat possible contributing factors: hypovolemia, hypoxia, hydrogen ion
(acidosis), hypo-hyperkalemia, hypoglycemia, hypothermia, toxins, cardiac tamponade,
tension pneumothorax, thrombosis, and trauma.
130
Pediatric Tachycardia
Indications: A wide complex tachycardia (QRS ≥ 0.08 seconds) presumed to be ventricular
tachycardia (VT), with a rate > 180 bpm in children more than 1 year old or > 220 bpm in children
less than 1 year of age OR a narrow complex tachycardia (QRS ≤ 0.08 seconds) other than sinus
tachycardia, with a rate >180 bpm in children > 1 year old or > 220 bpm in children less than 1
year old. There should be no evidence of trauma.
Stable: patients with signs of adequate tissue perfusion, not in cardiac arrest, and not displaying
signs or symptoms of slow capillary refill, altered mental status, shock, or pulmonary edema.
 Consider vagal maneuvers (valsalva, ice packs applied to face). Carotid massage may not
be performed.
 Administer fluid bolus of 20 ml/kg of NORMAL SALINE if no signs of pulmonary edema.
 Obtain 12 lead EKG on all patients
 Contact medical control for consideration of:
o If rhythm is a wide complex tachycardia at a rate exceeding 180 in children >1
year old or 220 in children less than 1 year old, administer 5 mg/kg
AMIODARONE IV (up to max dose of 150 mg) infused over 10 minutes.
o If rhythm is narrow complex tachycardia (SVT) at a rate exceeding 180 bpm in
children > 1 year of age or 220 bpm in children less than 1 year of age,
administer ADENOSINE (ADENOCARD) 0.1 mg/kg IV to max dose of 6 mg.
May repeat at 0.2 mg/kg IV to max dose of 12 mg one time.
Unstable: patient with signs of poor tissue perfusion, delayed capillary refill, altered level of
consciousness, shock, or pulmonary edema.

Synchronized cardioversion: 0.5 to 1 J/kg, if this is not effective may repeat once at 2 J/kg.

Consider sedation but do not delay cardioversion. May sedate with 0.2 mg/kg ETOMIDATE
(AMIDATE) via IV to max dose of 20 mg.
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Pediatric Ventricular Fibrillation (VF) and/or
Pulseless Ventricular Tachycardia (VT)

In the absence of effective CPR on arrival and when response time is greater than four (4)
minutes, perform 2 minutes of chest compressions prior to first defibrillation or intubation.

Defibrillate at 2 joules/kg

Perform 2 minutes of chest compression while attempting IV and/or intubation

Defibrillate using 4 joules/kg every 2 minutes

If IV/IO can be established:
o Administer 0.01 mg/kg EPINEPHRINE (1:10,000) IV. Repeat every 3 to 5 minutes
for the duration of the resuscitation.
o Administer 5 mg/kg AMIODARONE (CORDARONE) bolus IV. (Do not administer if
LIDOCAINE has already been given).
o Follow each medication administration with a single shock of 4 joules/kg and 2
minutes of chest compressions.

If IV/IO cannot be established:
o Administer EPINEPHRINE 0.1 mg/kg (0.1 mL/kg) of 1:1,000 via ET. Repeat every 3
to 5 minutes for duration of resuscitation.
o Administer 1 mg/kg LIDOCAINE via ET once (diluted in 10 ml of NORMAL SALINE).
If an IV/IO is established, continue with 0.5 mg/kg LIDOCAINE every 5 to 10 minutes
until a max dose of 3 mg/kg is given.
o Follow each medication administration with a single shock of 4 joules/kg and 2
minutes of chest compressions.

With return of spontaneous circulation prior to administration of any antiarrhythmic:
o Administer 2.5 mg/kg AMIODARONE (CORDARONE) IV infused over 10 minutes or
1 mg/kg LIDOCAINE via ET if no IV access is available.
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Pediatric Asystole / Pulseless Electrical Activity (PEA)

Ensure adequate oxygenation and ventilation

Administer 0.01 mg/kg EPINEPHRINE (1:10,000) via IV/IO or 0.1 mg/kg EPINEPHRINE
(1:1,000) via ET. May repeat every 3 to 5 minutes.

Administer IV bolus of up to 20 ml/kg NORMAL SALINE. Boluses may be repeated at the
same volume up to max dose of 60 ml/kg.
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Pediatric and Adult Endotracheal Intubation
Indications: Respiratory failure, inadequate ventilatory effort with minimal air exchange, severe
dyspnea with an increased or decreased respiratory rate, retractions, difficulty speaking, extreme
agitation, anxiousness, altered mental status or situations where airway protective reflexes are lost
(loss of gag reflex). Central cyanosis may be noted.

Consider the administration of up to 0.4 mg/kg ETOMIDATE (AMIDATE) IV/IO as needed
prior to intubation.

Perform endotracheal intubation and ventilate with 100% OXYGEN.

If unable to intubate or ventilate, maintain cricoid pressure and resume ventilations via BVM
pending insertion of an approved rescue airway device.

Cricothyrotomy (Quick-Trach) is authorized for the difficult airway when unable to ventilate
and oxygenate a patient.

Verify proper endotracheal placement via the following methods:
o Visualization of tube passing through the vocal cords or the substitution of a whistle
device (e.g. BAAM) for nasotracheal intubation
o Visualization of chest rising and falling with ventilations
o Presence of bilateral breath sounds and absence of air sounds over the epigastrium
o Clearing of the ET tube with lung inflation and misting of the tube with lung deflation
o SaO2 reading
o Capnography with waveform reading. Every effort should be made to continuously
monitor waveform on intubated patients. A printout of the capnography with the
waveform should be obtained upon transfer of patient to receiving facility for
documentation purposes.
o A printout of the trend report with the patient’s heart rate, pulse oximetry and
capnography readings will be presented to the receiving physician and copied for the
agency’s medical director, regardless of intubation success.

Ventilator management (device dependent):
o Tidal volume should be set to 8 ml/kg of body weight
o Rate should be set to:
 8 to 10 for cardiac arrest
 To titrate as close to 35-45 mmHg via digital capnography for perfusing
patients
 To titrate as close to 30-35 mmHg via digital capnography for patients with a
head injury and signs of impending herniation
o FiO2 should be set to:
 100% OXYGEN for cardiac arrest patients
 Titrate to maintain SpO2 of at least 95% for perfusing patients.

Consider the administration of up to 5 mg MIDAZOLAM (VERSED) IV/IO as needed
following intubation and placement confirmation in adults if the systolic blood pressure is
greater than 100 mmHg. For children 12 years of age and under, contact medical
control for a sedation order.
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Oral endotracheal intubation is the preferred route of intubation. If unable to perform oral
intubation, nasotracheal intubation should be attempted using an endotracheal tube with a
directional control tip along with a whistle device (e.g. BAAM).
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Pain Management for Adults and Pediatrics
Indications: Moderate to severe pain
Contraindications: Altered mental status, head injury, multi-system trauma, SaO2 less than
95%, or systolic blood pressure less than 100 mmHg (80 mmHg in the pediatric patient)

Contact medical control for pain management for all pediatric patients

Angina / Myocardial Infarction
o MORPHINE SULFATE 2 to 10 mg IVP as needed for pain
o May consider 25 mg IV DEMEROL if patient has allergy to MORPHINE SULFATE. If
DEMEROL is administered, consider 4 mg IV ZOFRAN to prevent nausea from
euphoria. If ZOFRAN is ineffective, consider administering 12.5 mg PHENERGAN
via slow IV diluted in 9 cc of Normal Saline. ZOFRAN is preferred.

Acute Abdominal Pain
o MORPHINE SULFATE IV 2 to 5 mg, up to max dose of 5 mg.
o May consider administration of 30 mg TORADOL via IV as a substitute for
MORPHINE SULFATE
o Renal Colic (Kidney Stones) may respond better to DEMEROL at 25 to 50 mg IV. If
DEMEROL is administered, consider 4 mg IV ZOFRAN to prevent nausea from
euphoria. If ZOFRAN is ineffective, consider administering 12.5 mg PHENERGAN
via slow IV diluted in 9 cc of Normal Saline. ZOFRAN is preferred.

Combative Post Resuscitation
o DIAZEPAM 2 to 20 mg slow IVP titrated to effect. Monitor respirations.

Environmental Frostbite
o DIAZEPAM 2 to 20 mg slow IVP titrated to effect. Monitor respirations.
o May consider 0.1 mg/kg MORPHINE SULFATE IV up to 5 mg as a substitute for
DIAZEPAM.

Sickle Cell Anemia Crisis
o Consider MORPHINE SULFATE IV 2 to 5 mg, up to max dose of 5 mg IV
o May consider use of 30 mg TORADOL IV as a substitute for MORPHINE SULFATE.

Combative Head Injury
o Contact medical control for consideration of administration of 2 to 20 mg
DIAZEPAM (VALIUM) slow IVP titrated to effect. Monitor respirations. May
also consider 5 mg MIDAZOLAM IV or up to 5 mg MORPHINE SULFATE IV.

Extremity Injuries
o MORPHINE SULFATE 2 to 5 mg IV
o May consider 25 to 50 mg DEMEROL IV as a substitute for MORPHINE SULFATE.
If DEMEROL is administered, consider 4 mg IV ZOFRAN to prevent nausea from
euphoria. If ZOFRAN is ineffective, consider administering 12.5 mg PHENERGAN
via slow IV diluted in 9 cc of Normal Saline. ZOFRAN is preferred. May consider
30 mg TORADOL IV/IM as a substitute for MORPHINE SULFATE and Demerol.

Burns
o MORPHINE SULFATE 2 to 5 mg IV
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Use caution when administering any medications for pain management. Always monitor patient’s
respiratory efforts when administering any pain medications and be prepared to utilize BVM to
assist patient’s respiratory efforts if needed. Never give more than one type of pain medication
unless medical control has been contacted and orders have been given. This protocol should not
prevent you from contacting medical control should you have any concerns over the correct
dosage/type of medication to be administered. Use proper judgment when utilizing any portion of
this protocol and remember to monitor patient closely after the administration of any medication.
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Refusal of Service
Indications: EMS often responds to scenes where the patient wishes to decline service. It is
important that the EMS provider obtains the patient’s informed consent before leaving the scene;
otherwise the EMS provider might be exposed to legal liability for abandonment of the patient.

Assess the patient fully and document all finding on the PCR.

Inform the patient about needed treatment and possible outcomes if patient refuses
treatment and transport. If the patient is felt to need treatment, every effort should be made
to persuade the patient to consent to needed health care. Consider involving family,
medical control, and law enforcement.

Document the informed consent process, and, if applicable, the medical control physician
on your PCR.

Medical control is not needed for patient refusals if patient is alert and oriented to normal
mentation and not inhibited by alcohol or drugs. If you suspect the patient is being coerced
or is a victim of domestic violence or abuse, etc. then law enforcement should be contacted
immediately.

You should consider contacting medical control if patient is wishing to refuse treatment
and/or transport and any of the following are present:
 Intoxication by drugs or alcohol
 Acute mental disease or suicidal or homicidal ideations
 Significant head injury
 Respiratory distress
 Abnormal vital signs (normal vital signs are defined as heart rate between 60 and
100 bpm, systolic blood pressure > 100 mmHg, respiratory rate of 12 to 20 bpm, and
SaO2 reading > 95% on room air)
 Altered mental status
 Age less than 18, unless parents are on scene and consent to the refusal
 Patient who suffer from same mechanism of injury that could be classified as
something that could cause serious medical problems that would normally require
direct transport to a trauma center under a possible trauma alert designation

Refusals of service account for many instances of litigation every year and caution should
be taken on all refusals and documentation should include every detail so that you are
covered in your actions should you have to appear in court. Any time you have doubts or
concerns, contact medical control, they are there to help you make this important decision.
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Induced Hypothermia (POST-ARREST)
“Iceman”

Complete inclusion and exclusion worksheet

Perform a baseline patient assessment

Perform a neurological exam

Intubate as needed

Obtain 12 lead EKG

Draw blood for labs

Decrease temperature to lowest setting in back of ambulance

Induce hypothermia procedures
o Apply ice packs to axial, groin and neck areas
o Establish chilled 0.9% NORMAL SALINE IV and administer 1000 ml bolus. Consider
the establishment of a second IV line in order to administer the fluid bolus. (This is
the preferred method except in fluid overload.)

Evaluate and treat for first signs of shivering
o Administer VERSED 2.5 mg (may repeat times 1)
o Administer 5 mg MORPHINE (may repeat times 1)
o Prepare for DOPAMINE administration if systolic BP ≤ 90

Properly document the inducement of hypothermia on PCR

Transport to closest appropriate facility, preferably a facility that participates in the “Iceman”
program (i.e. Redmond Regional Medical Center)

Advise Medical Control that you have initiated the Induced Hypothermia protocol

Monitor and document vital signs every 15 minutes
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Induced Hypothermia INCLUSION Criteria

Age 18 or older

Women must be over 50 or not be pregnant

Cardiac arrest, asystole, with return of normal rhythm (initial rhythm outside of hospital of
ventricular fibrillation, pulseless ventricular tachycardia or PEA can be considered if
returned to normal rhythm and other criteria is met)

Persistent coma as evidenced by no eye opening to pain after resuscitation (no waiting
period required)

Blood pressure can be maintained at a minimum of 90 mmHg systolic either spontaneously
or with fluid and pressors (not aortic balloon pump)

Known time of cardiac arrest within 6 hours (excludes “found down” of unknown duration.

All witnessed cardiac arrest: consider all patients who survived the cardiac arrest as
candidates if return of circulation was quick and/or effective circulation was maintained
during resuscitation

Resuscitation started within 5 to 15 minutes of arrest

Restoration of systemic circulation within 60 minutes of initiation of ACLS (if onset outside
of the hospital) and systolic BP ≥ 90 mmHg

Enrollment and initiation of hypothermia within 90 minutes of initiation of ACLS

Informed consent obtained from family
NOTE: If post-arrest intervention is needed, that takes precedence over therapeutic hypothermia.
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Induced Hypothermia EXCLUSION Criteria

Evidence of another reason to be comatose (e.g., drug overdose, status epilepticus)

Pregnancy

A known terminal illness preceding the arrest

Known, pre-existing coagulopathy or bleeding disorder

Pre-existing DO NOT INTUBATE code status and patient not intubated as part of the
resuscitation efforts

Arrest < 5 minutes or > 15 minutes prior to resuscitation being initiated

CPR failed to achieve spontaneous circulation within 1 hour (as evidenced by palatable
pulse for > 5 minutes)

Unfavorable cerebral performance prior to arrest

Arrest > 15 minutes prior to initiation of ACLS, hypotension, prolonged hypoxia (O2 sat < 85
for > 15 minutes)

Failure to achieve favorable cardiac status

EKG evidence of ischemia, due to increased risk for malignant ventricular dysrhythmia

Failure to obtain informed consent

Significant cardiac dysrhythmia or cardiac instability

Evidence of sepsis

Cardiogenic shock (systolic BP < 90 mmHg)

Coagulopathy or thrombocytopenia QT interval > 40 milliseconds
141