Kitsap Co (WA) Protocols (2004)

INTRODUCTION
The Northwest Region Protocols have been provided to allow immediate, pre-authorized treatment of patients,
as a standardized approach in the prehospital care of sick and injured patients.
The authorization to provide prehospital care under these protocols is limited to those prehospital care providers
with current certification by the State of Washington Department of Health and approval of the Medical Program
Directors of Clallam, Jefferson, Kitsap and Mason Counties.
The prehospital care provider is expected to follow these statements:
1. It is imperative that scene safety be established prior to entering the scene. This includes body
substance isolation (BSI) as described by OSHA CFR 1910.1030.
2. The availability/use of non-latex gloves is the standard of care. Providers are unable to determine the
patient’s sensitivity prior to approaching the patient; phasing out latex gloves is recommended.
3. Perform rapid evaluation and initiate the appropriate emergency treatment as outlined in the NW
Region Patient Care Protocols.
4. It is expected that BLS procedures will be completed prior to ALS interventions. The prehospital care
provider is also given the latitude to flow between protocols as appropriate.
5. Make Base Station contact if further orders are needed. The Medical Program Director authorizes the
on-duty Emergency Department physician at the designated Base Station to provide on-line Medical
Control utilizing both the Standing and Physician Order sections as guidelines. The Base Station
physician is also available to provide advice regarding patient disposition, alternative interventions,
inter-facility medication authorization, and delegation of on-line medical control to other physicians.
6. Northwest Region EMS Providers will follow these protocol guidelines. Deviation from these guidelines
can be detrimental to optimal delivery of emergency medical services, thereby having a negative impact
on patient care. Persistent or significantly serious deviation from these guidelines therefore may result
in the loss of MPD recommendation for recertification, request provider be decertified or individual
restriction of protocols.
7. The protocols for dysrhythmias are written for Paramedics only; EMT & EMT-I do not assess rhythms.
8. Trauma banding is required for all patients meeting trauma criteria as outlined by State of Washington
Department of Health.
9. A complete set of vital signs will always be taken unless time or the patient’s condition prevents this
from being done. Documentation is required on the MIR for any deviation from this standard.
10. A copy of ECG tracing MUST be attached to all copies of the MIR when any dysrhythmia is
encountered in the field.
11. The prehospital contact report is to include:

a. Unit identification
b. Age and sex of patient
c. Severity
d. Chief complaint
e. Relevant medical history
f. Vital signs
g. Treatment given, and response to treatment
h. ETA
i. Request for additional information or treatment
2004 Northwest Region EMS Protocols -1- 2nd printing Distributed March 2004
PATIENT CONFIDENTIALITY
Patient confidentiality will be observed at all times. Individual cases will be discussed during training and quality
improvement, and will be referred to as needed. They will not be discussed with anyone else not directly
involved, and will not:
1. be the subject of casual discussion among prehospital care providers;
2. be discussed with family, or friends;
3. be discussed with other patients;
4. be specifically discussed for secondary gain, such as to defame the ability or character of another
provider.
PREHOSPITAL CARE PROVIDER CONDUCT
1. Prehospital care providers will remain courteous to the public and to the patient. If a patient is
physically threatening, the EMS provider will invoke the assistance of law enforcement.
2. Prehospital care providers will remain courteous to each other and to other healthcare providers.
3. If prehospital care providers wish to help improve the performance of an individual of lower certification,
they will instruct them in a professional and positive manner. If necessary, the incident may be
discussed with the agency’s Medical Officer, MPD, or QI Coordinator.
4. If prehospital care providers of equal certification disagree on patient diagnosis or management, the
provider who does not have on scene medical authority has an ethical obligation to discuss his/her
concern, however, in a professional manner and not in front of the patient if possible.
5. Matters of disagreement between prehospital care providers not related to the scene should not be
discussed at the scene. Providers should not threaten, degrade, insult or verbally abuse each other.
SPECIAL CIRCUMSTANCES
PHYSICIAN PRESENT AT THE SCENE
The prehospital care provider functions under the direction of the on-duty Base Station physician. Physicians,
(other than Base Station physicians), may participate in the care of a patient at the scene of any emergency in
one of the following ways:
1. Turn over control of the patient, but offer assistance, allowing the prehospital care provider to remain
under the control of the Base Station physician.
2. Take total responsibility for management of the patient(s) and accompany the patient(s) to the hospital.
In all cases, the Base Station physician must be contacted to specifically delegate authority to any on-scene
physician. Notation of such action must be included on the Medical Incident Report.
The physician on scene must supply proof of being a MD or DO prior to initiation of any patient care direction or
treatment.
In general, the physician who has the most experience in the management of prehospital emergencies will
assume control. This usually will be the Base Station physician. Access to communication with the Base
Station should be provided to any on-scene physician on request.
EMERGENCY AT A PHYSICIAN’S OFFICE
At a private Physician’s office, the individual physician maintains the responsibility for the treatment and
management decisions for the patient. During transport, the treatment rendered by the paramedic must fall
within the scope of the NW Region Standing Orders/Protocols.
PATIENT REFUSAL OF MEDICAL EVALUATION
1. Consent
a. The patient has responsibility to consent to or refuse treatment. If the patient is unable to do
so, a responsible relative or guardian has this right.
b. If waiting to obtain lawful consent from the authorized person would present a serious risk of
death, serious impairment of health, or would prolong severe pain or suffering to the patient,
treatment may be undertaken to avoid these risks without consent. In no event should legal
consent procedures be allowed to delay immediately required treatment.
c. The patient must be eighteen years of age or emancipated to legally refuse treatment.
d. If the patient is under age, consent should be from a natural parent, adopted parent, or legal
guardian only.
2. Mental competence
a. A person is mentally competent if:
1. Capable of understanding the nature and consequence of the proposed treatment.
2. Sufficient emotional control, judgment, and discretion to manage their own affairs are
present.
b. A person is not mentally competent if he/she has impaired cerebral perfusion, presents in
shock, is postictal, or under the influence of drugs or alcohol.
c. Base Station contact with the Base physician is necessary for all patients refusing transport in
those counties requiring it.
d. Nurses may speak for the Base Station physician if the physician is unable to come to the
telephone. The nurse must give the prehospital care provider the name of the Base physician
who is directing the nurse.
AIR AMBULANCE TRANSPORTS
In specific situations, patients are better served by early mobilization of air ambulance taking into consideration
site resuscitation and stabilization capabilities, as well as time variables. An air ambulance will be notified based
on the Washington State Trauma Triage Guidelines. Every attempt should be made to stabilize the patient prior
to transport, including IV, airway, chest decompression or stabilization, control of external hemorrhage, and
spine immobilization. Trauma associated cardiac arrests in asystole should not be transferred by air
ambulance.
Although it may serve as a general guide, this protocol is not intended for Search and Rescue or for Olympic
National Park, who have additional extrication variables to consider and separate protocols for invoking air
ambulance.
The on-scene provider may have dispatch contact air ambulance service for activation as soon as the need for
air transport is identified. Whenever possible, providers will contact Medical Control prior to activating an air
ambulance.
Transfer of care to air ambulance personnel will optimally occur at designated landing sites. Deviation to other
sites should be briefly discussed with Medical Control.
Patient characteristics strongly indicative of air ambulance transport:

• Head injury
• Multiple traumas
• Major burns
• Delayed ground transport time
• Multiple casualty incidents
• Spinal injury
Information to have available regarding airlift transport:

• Map coordinates - township, range and section
• Location of nearest landing zone
• Capability to transport to landing zone
• How landing zone is marked
• Any obstructions near landing zone
• Relevant weather information
ABDOMINAL PAIN
Abdominal pain is one of the most common presenting complaints in emergency medicine. In up to 42% of
patients, the etiology remains obscure. Recalling the differences between generalized types of pain can be
helpful diagnostically. Visceral abdominal pain results from stretching of the autonomic nerve fibers. The pain
may be described as cramp like, colicky or gaseous and is often intermittent. Obstruction is often the cause.
Somatic pain occurs when pain fibers located in the parietal peritoneum are irritated by chemical or bacterial
inflammation. The pain is described as sharp, more constant and more precisely located. Referred pain is any
pain felt at a distance from a diseased organ. Referred pain generally follows certain classic patterns, for
example, diaphragmatic irritation often radiates to the supraclavicular area.
SIGNIFICANT FINDINGS (*AUTOMATIC ALS)
*Distended or rigid abdomen *Pulsating abdominal mass
*Unequal/absent femoral pulses Tender abdomen
*Diaphoresis *ALOC
*Orthostatic changes
BLS TREATMENT
**Request Paramedic Evaluation If**
1. ABC, Hx, PE, Pulse Ox, Orthostatic VS PRN (a)(b) • Unconscious/not breathing
2. Administer O2 per procedure • Respiratory distress
3. NPO • Vomiting red blood
4. Treat other associated signs and symptoms • Black, tarry stools
per appropriate protocol • Upper abdominal pain
• Lower abdominal pain, women age 12-50
with dizziness, syncope or heavy vaginal
bleeding
• Abdominal/back pain with syncope or near
syncope when sitting
• Orthostatic changes >30 SBP and/or
> than 30 BPM
ILS TREATMENT
5. Obtain IV access ** Request Paramedic Intercept When **
6. Fluid bolus NS PRN • Any ILS skills performed
**Base Station Contact** • Base Station Orders
ALS TREATMENT
(Standing Orders) (Physician Orders)
7. ECG (if indicated) 1. Morphine
8. Assist respirations as needed 2. Meperidine
9. Obtain IV access
10. Fluid bolus NS PRN
11. Treat other associated signs and symptoms
per appropriate protocol
12. Toradol 30 mg IV for flank pain in
suspected kidney stone (c)(d)
**Base Station Contact**
Note:
a. Abdominal pain may be the first sign of an impending rupture of the appendix, liver, spleen, ectopic
pregnancy or aneurysm. Monitor for signs of hypovolemic shock.
b. If pulsating mass is felt, suspect an abdominal aneurysm and discontinue palpation.
c. Reduced Dose (1/2) for Elderly.
d. East Clallam County may repeat one time PRN without Physician order.
ALLERGIC REACTION / ANAPHYLAXIS
Allergic reactions can range from mild local eruptions to severe and life-threatening systemic illnesses. The most
common presenting complaints involve the dermatologic and respiratory systems, but gastrointestinal and
cardiovascular involvement also occur frequently.
*Blueness around lips Itching, hives Paleness
*Low blood pressure Anxiety *Painful, squeezing sensation in chest
*Abdominal cramps *ALOC Nausea, vomiting
Flushing around face and chest *Swelling of face and tongue *Weak, rapid pulse
Dizziness *Difficulty breathing
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox (a) • Unconscious/not breathing
2. Administer O2 per procedure • Cannot speak in full sentences
3. Administer Epinephrine auto-injector (b)(c)(g) • Swelling in throat or difficulty swallowing
4. Treat other associated signs and symptoms per • Diaphoresis
appropriate protocol • Syncope
• History of anaphylactic reactions
ILS TREATMENT
5. Obtain IV access, Fluid bolus NS PRN ** Request Paramedic Intercept When **
6. Albuterol 2.5 mg SVN PRN • Any ILS skills performed
7. Epinephrine (1:1000) 0.1– 0.3 mg SQ PRN • Base Station Orders
8. If Pt has their own allergy medicine available
provider may administer it with physician order (h)
ALS TREATMENT
9. Assist respirations as needed
10. Obtain IV access, ECG (f)
11. Diphenhydramine 25 – 50 mg PO/IM/IV
12. Albuterol 2.5 mg & Atrovent 0.5 mg SVN PRN
13. CHOOSE ONE of the following PRN:
• Methylprednisolone 125 mg IV
• Dexamethasone 20 mg IV
• Prednisone 60 mg PO
14. Epinephrine (1:10,000) 0.1 – 0.3 mg IV if
SBP < 60 mmHg (d)(e)
15. Dopamine titrated to SBP of 100 mmHg
16. Treat other associated signs and symptoms per
appropriate protocol
Note:
a. Anaphylaxis is an extreme emergency since cardiac arrest can occur. Do not delay treatment or transport.
b. Epinephrine to be given only if the patient is in extremis (respiratory distress).
c. A single dose of epinephrine may not reverse the effects of anaphylaxis. Administer the additional
epinephrine auto-injector as needed.
d. If unable to access IV and no BP, may give Epinephrine (1:1000) 0.1 – 0.3 cc SL.
e. May repeat without Physician Orders.
f. Obtain ECG tracing during all pharmacological administrations.
g. Olympic National Park providers may draw up Epinephrine (1:1000) 0.1 – 0.3 cc.
h. For example: Diphenhydramine (Benadryl), Allegra, Claritin or other per base station physician.
This page corrected on 03/11/04

ANIMAL BITES
Insect stings and animal, snake, or spider bites from a variety of species can result in serious illness and injury.
Animal bites from wild animals such as skunks, bats, raccoons, and foxes pose a special risk of rabies.
Snakebites or stings from, insects or spiders inject poisonous venom into their victims, generally affecting the
cardiovascular or neurological system. Individual reactions to venom vary greatly depending on the person’s
sensitivity. Five percent of the general population is allergic to the stings of wasps, bees, hornets, yellow jackets
and ants. Insect stings cause twice as many deaths as snakebites each year. Anaphylactic shock can occur from
any source, refer to anaphylaxis protocol as needed. Observe signs and symptoms of anaphylactic reaction. Do
not apply an ice bag or cold pack on snakebites since this can cause additional tissue damage. However, ice
bags can be applied to insect bites to reduce pain and swelling.
Hives Burning sensation at site Muscle cramps,
Chest tightness Joint pain * Abnormal pulse rate rhythm
*Weakness or collapse Headache, dizziness *Anaphylactic shock
*Constricted upper airway Localized pain or itching Swelling or blistering at site
Excessive salivation Profuse sweating *Difficulty breathing
Nausea/vomiting *ALOC
EMT TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox PRN • Unconscious/not breathing
2. Administer O2 per procedure • Uncontrolled bleeding
3. Control bleeding • Respiratory distress
4. Remove jewelry or other constricting items • Serious face and neck bites
5. Scrape away stingers or venom sacs, taking • Bite from poisonous animal
care not to pinch venom sac • Signs of shock
6. Wash area gently
7. Immobilize extremity
8. Identify and transport organism if possible
ILS TREATMENT
10. Treat other associated signs and ** Request Paramedic Intercept When **
symptoms per appropriate protocol • Any ILS skills performed
ALS TREATMENT
11. ECG PRN
13. Treat other associated signs and
symptoms per appropriate protocol
BLEEDING
Acute hemorrhage is defined as rapid blood loss and is seen with various medical and surgical conditions. Some
of the most common causes of significant hemorrhage are trauma, disorders of the gastrointestinal and
reproductive tracts, and vascular disease. The majority occur in patients with normal hemostasis. With careful
attention to the history and physical findings, patients with pathologic bleeding can often be readily identified.
Hemorrhagic (hypovolemic) shock occurs when the degree of blood loss overcomes the body’s compensatory
mechanisms and compromises tissue perfusion and oxygenation.
Diaphoresis Intense thirst
*Bloody, “coffee ground” emesis *Low blood pressure
Obvious bleeding *Decreased capillary refill (a)
*Bloody or tarry stools *ALOC
*Signs of internal bleeding, rigid abdomen *Rapid, weak pulse
Paleness
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox • Unconscious/not breathing
2. C-spine control if indicated (b) • Signs of shock
3. Control bleeding • Syncopal episodes
5. Stabilize extremity deformities • Vomiting blood
6. Maintain body temp, NPO • Black, tarry stools
7. Treat for shock (c) • Vaginal bleeding >20 weeks pregnant
• Orthostatic changes of >30 Systolic BP and/or
>30 Beats/Min
• Lower abdominal pain, women 12 – 50 years
with dizziness, syncope or heavy vaginal
bleeding
ILS TREATMENT
9. Obtain IV access PRN ** Request Paramedic Intercept When **
ALS TREATMENT
11. ECG,
Note:
a. Capillary refill time is a reliable sign typically only in infants and children less than 6 years old.
b. Simple falls may be fatal in the elderly; assume fractures until proven otherwise, consider full C-spine
precautions.
c. Consider use of MAST/PASG.
BREATHING DIFFICULTY
(Pulmonary Edema)
Left ventricular failure is the inability of the left ventricle to adequately move blood into the systemic circulation. In
left ventricular failure, an imbalance in the output of the two sides of the heart occurs. The left ventricle is unable
to move all the blood delivered to it from the right side of the heart. Left ventricular followed by left atrial pressure
rises and is transmitted back to the pulmonary veins and capillaries. When the pressure in the pulmonary vessels
becomes too high, blood serum is forced into the alveoli, resulting in pulmonary edema. Left ventricular failure
may be caused by various types of heart disease, including AMI, chronic hypertension, mitral valve disease,
certain arrhythmias and non-compliance of medication to control CHF.
*Extreme difficulty breathing *ALOC
*Audible wheezing *Pink, frothy sputum
*Rapid pulse and/or respirations *Hypotension
*Diaphoresis *Hypertension
*Chest pain *Appearing acutely ill with fever
Cough *Cyanosis
*Tripod position *Use of accessory muscles
BLS TREATMENT
1. ABC, Pulse Ox, Hx, PE, VS, blood glucose check • Unconscious/not breathing
PRN (a) • Respiratory distress
2. Administer O2 per procedure • Dyspnea with chest pain
3. Administer Pt’s MDI per prescription • Inhaled toxic substances
4. Place Pt in position of comfort (probably upright) • Unable to speak in full sentences
5. Treat other associated signs and symptoms • Recent childbirth/trauma/immobilization
per appropriate protocol (2 – 3 months) without respiratory Hx
• Drooling/difficult swallowing
ILS TREATMENT
6. Obtain IV access, ** Request Paramedic Intercept When **
7. Nitroglycerin 0.4 mg SL if SBP > 100 (b) • Any ILS skills performed
ALS TREATMENT
8. ECG, 12 lead 1. Morphine > 10 mg
10. Nitroglycerin 0.4 mg SL q 5 if SBP > 100
11. Furosemide 40mg IV (c)(d)
12. Morphine 2 mg IV PRN q 3-5 min to 10 mg max
Note:
a. Remove obstructions if any.
b. May repeat with physician order.
c. Or double patient’s single dose up to 160 mg.
d. East Clallam county may administer Furosemide 40-100mg without physician order.
BREATHING DIFFICULTY
Reactive Airway Disease
Asthma is defined as a reversible airway obstruction, associated with hyper-responsiveness of the tracheal-
bronchial tree. An early component of an asthma attack is bronchial smooth-muscle contraction, inflammation,
edema and increased mucus secretions. These become more prominent as the attack progresses. Although
bronchospasms can be reversed within minutes, mucus plugging and inflammatory changes do not decrease for
days to weeks. Direct physical examination reveals hyper-resonance to percussion, decreased intensity of breath
sounds and prolongation of the expiratory phase, usually with wheezing. Although wheezing results from
movement of air through narrowed airways, the intensity of the wheeze may not correlate with the severity of the
airflow obstruction. The quiet chest reflects very severe airflow obstruction with air movement insufficient to
promote a wheeze.
*Extreme difficulty breathing *Wheezing
*Rapid pulse and/or respirations *Diaphoresis
*Chest pain Cough
*Pink, frothy sputum *Tripod position
*Use of accessory muscles *Cyanosis
*Appearing acutely ill with fever *Hypertension
*Hypotension *ALOC
BLS TREATMENT
1. ABC, Pulse Ox, Hx, PE, VS, (a) **Request Paramedic Evaluation If**
2. Administer O2 per procedure • Unconscious/not breathing
3. Administer Pt’s MDI per prescription • Respiratory distress
4. Place in position of comfort (probably upright) • Dyspnea with chest pain
5. Treat other associated signs and symptoms • Inhaled toxic substances
per appropriate protocol • Unable to speak in full sentences
• Recent childbirth/trauma/immobilization
(2 -3 months) without respiratory Hx
• Drooling/difficult swallowing
ILS TREATMENT
7. Fluid bolus NS PRN if febrile or hypotensive • Any ILS skills performed
8. Albuterol 2.5 mg via SVN PRN • Base Station Orders
ALS TREATMENT
9. ECG, 12 lead PRN 1. Repeat epinephrine
10. Assist respirations as needed(b)
11. Albuterol 2.5 mg & Atrovent 0.5 mg SVN PRN
12. Epinephrine 1:1,000 0.1 – 0.3 ml SQ
13. CHOOSE ONE of the following Steroids PRN:
• Methylprednisolone 125 mg IV
• Dexamethasone 20 mg IV
• Prednisone 60 mg PO
14. Magnesium 2 Gm/100ml IV over 5-10min(c)
Note:
a. Remove obstructions if any.
b. Intubate COPD patients as a last resort only.
c. Do not administer Magnesium in East Clallam County only.
CHEST PAIN/HEART PROBLEMS
In the United States, coronary artery disease may cause as many as half of all deaths to patients aged 36 to 64
years. It is important to have a high index of suspicion for the presence of acute myocardial ischemia when
evaluating patients in the appropriate age group, especially when risk factors are present. Risk factors include
being male or postmenopausal female, hypertension, cigarette smoking, hypercholesterolemia, diabetes,
sedentary life-style, obesity, and family history. Chest pain or discomfort should be characterized completely,
including quality, location, radiation, duration, frequency, pattern, and onset of pain and what exacerbates and
relieves the pain. Onset of symptoms is defined as the beginning of continuous, persistent discomfort. Frequently
patients will present with a stuttering of “off & on” pattern of pain. In general, for onset time use the time of the
experience that prompted the patient to seek care. Female patients do not necessarily have classic MI symptoms.
Their symptoms may be as subtle as diaphoresis and a general feeling of “not feeling right”.
*Rapid pulse *Diaphoresis
Frightened appearance *Pale, grey skin color
*Irregular pulse *Cyanosis
*Hypotension *Difficulty breathing
Restlessness, anxiety *Nausea, vomiting
Radiation of pain *ALOC
BLS TREATMENT
2. Administer O2 per procedure • Male, age > 40 years
3. Aspirin 325 mg chewable PO • Female, age > 45 years
4. Nitroglycerin per pt’s prescription • Age, > 25 years with symptoms of SOB,
SBP >100 q 5min x 3 (a) nausea or diaphoresis
5. Treat other associated signs and symptoms • Rapid HR with CP or signs of shock
per appropriate protocol • CP with drug use
• Implanted defibrillator shock
ILS TREATMENT
7. Nitroglycerin 0.4 mg SL, repeat q 5 min if • Any ILS skills performed
SBP >100 mmHg • Base Station Orders
ALS TREATMENT
8. ECG, Obtain 12 lead (b) • Repeat Morphine > 10 mg
9. Assist respiratory status as needed • Lopressor 5mg IV over 2 min, repeat for
10. Nitroglycerin 0.4 mg SL, repeat q 5 min if total of 3 doses if time permits
SBP >100 mmHg (c) • TNK (East Clallam County)
11. Morphine 4 mg IV, may repeat 2 mg q 3 – 5min
up to 10 mg
per appropriate protocol.
Note:
a. Remember to ask patient if they have taken sildenafil (Viagra) within the last 24 hours.
b. Perform pre-hospital thrombolytic screening.
c. Exercise extreme caution in the use of nitroglycerin in patients who may have RV infarctions. Up to 40% of
patients with inferior wall injury (II, III, a VF) will have associated right ventricular wall involvement and are at
risk of hypotension secondary to the administration of vasodilators. Consider right sided ECG.
2004 Northwest Region EMS Protocols - 10 - 2nd printing Distributed March 2004
Cardiogenic Shock
10–15% of all patients with acute myocardial infarction develop cardiogenic shock. It is generally agreed that 40%
of the left ventricular myocardium must be damaged before shock develops. It has also been determined that all
patients dying of the symptoms have apical involvement of the myocardium and 84% have severe disease of the
left anterior descending coronary artery. The majority of patients who develop cardiogenic shock have had
previous infarctions. When the mean arterial blood pressure falls below 70 mmHg, coronary perfusion becomes
inadequate, further extending the area of the infarction. Although the incidence of cardiogenic shock has
decreased, mortality still remains high, averaging 50% to 70%. There are differences between patients with ST-
segment elevation and ST- segment depression. Of those who develop shock, patients without ST-segment
elevation develop shock significantly later than those with ST-segment elevation.
*Rapid pulse *Low blood pressure
*Diaphoresis *Difficulty breathing or SOB
Frightened appearance Restlessness, anxiety
*Pale, grey skin color *Nausea, vomiting
*Irregular pulse Radiation of pain
*Cyanosis
BLS TREATMENT
2. Administer O2 per procedure • Male, age >40 years
3. Aspirin 325 mg PO chewable • Female, age >45 years
4. Treat other associated signs and symptoms • Age > 25 years with symptoms of SOB,
per appropriate protocol nausea
diaphoresis
• Rapid HR with CP or signs of shock
• CP with drug use
• Implanted defibrillator shock
ILS TREATMENT
6. Fluid bolus NS PRN (a) • Any ILS skills performed
ALS TREATMENT
7. ECG, Obtain a 12 lead
8. Assist respiratory status as needed
9. Dopamine 5 – 20 mcg/kg/min titrate SBP>100 (b)
10.Treat other associated signs and symptoms
Note:
a. Be cautious of impending pulmonary edema.
b. Reference for approximate dosage with micro drip tubing: 5 – 7 mcg/kg = Weight in pounds and drop the last
digit will give approximate drops per minute. Example: 150# - 0 = 15 gtts/minute
Cardiac Arrest
Cardiac arrest occurs in approximately 360,000 people in the United States each year. Resuscitative efforts can
restore these hearts to spontaneous activity before the brain has been permanently injured. The core purpose of
emergency cardiac care is to provide effective care as soon as possible to hearts that have stopped beating. The
chain of survival relies on five principles; early recognition, early EMS activation, early CPR, early defibrillation
and early ACLS intervention. Each component of the chain of survival is crucial. Numerous clinical studies have
confirmed two simple observations; (1) almost every adult who survives sudden non-traumatic arrest was
resuscitated from ventricular fibrillation. (2) The success of defibrillation is time dependent. The probability of
defibrillating someone back to a perfusing rhythm declines about 2 – 10% per minute, starting with an estimated
probability of 70 – 80% survivability at time zero. Attempt to identify possible cause of arrest and initiate
corrective measures. A useful mnemonic for Cardiac Arrest causes is the 5 H’s & 5 T’s.
*Unresponsive
*Apneic
*Pulseless
BLS TREATMENT
1. ABC, Initiate CPR/AED (a)(b) **Request Paramedic Evaluation If**
2. Hx, PE as time permits This is an automatic ALS response
ILS TREATMENT
**Base Station Contact** • Any ILS skills performed
• Base Station Orders
ALS TREATMENT
4. ECG
per appropriate protocol and AHA guidelines
7. Consider termination of efforts if appropriate (c)
Note:
a. Do not initiate CPR if completed POLST Form, DNR documentation or EMS No CPR banding is present.
b. If valid DNR papers are presented after CPR is initiated, CPR may be discontinued. Refer to
Discontinuation of CPR.
c. Termination of efforts may be considered after the patient has been effectively ventilated with endotracheal
intubation and two rounds of ACLS pharmacology have been given.
Post-Resuscitation Management
A healthy brain is the primary goal of all cardiopulmonary-cerebral resuscitation. In the immediate post-
resuscitation period the most important action that the prehospital care provider can take to restore cerebral
function is to optimize the ABC’s oxygenation and perfusion. 1) Maintain normal body temperature; hyperthermia
increases the oxygen requirements of the brain. 2) Allow moderate hypothermia if present (93˚F). Clinical
evidence suggests that mild to moderate hypothermia increases neurological outcome. 3) Control seizures. 4)
Elevate the patient’s head 30 degrees; this increases cerebral venous drainage and decreases intracranial
pressure. 5) Avoid even mild hypotension. Consider whether the instability arises from a problem with the
cardiovascular system: a volume, pump, or rate problem. 6) Consider administration of Beta-blockers to inhibit
increased sympathetic tone and catecholamine excess in the setting of acute ischemia or infarction with recurrent
post-resuscitation VF/pulseless VT. 7) A rapid supraventricular tachycardia may develop in the immediate post
resuscitation period and is best left untreated. 8) Bradycardia is best managed by ruling out hypoxia or airway or
ventilation problems before administration of atropine or a chronotropic agent.
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox **Request Paramedic Evaluation If**
2. Administer O2 per procedure
3. Place patient in recovery position This is an automatic ALS response
4. Treat other signs and symptoms per appropriate
protocol
ILS TREATMENT
5. Obtain IV access This is an automatic ALS response
ALS TREATMENT
6. ECG, obtain 12 lead
8. Choose ONE of the following PRN:
• Midazolam 2.5 IV PRN
• Lorazepam 2 mg IV (b)
9. Consider Vecuronium 0.1 mg/kg (b)
10. Choose ONE of the following antiarrthymics PRN:
• Lidocaine 1.0-1.5 mg/kg IV (e) followed by
Lidocaine 2-4 mg/min IV drip
• Amiodarone 150mg IV infusion over 10 min
(c)(f)(g) followed by Amiodarone 1mg/kg IV
drip (d)
Note:
a. Consider post arrest sedation to avoid the removal of the ET tube, facilitate management and monitoring of
the patient.
b. Physician order in Mason County.
c. If the patient did not previously receive Amiodarone.
d. If converted from a ventricular rhythm after administration of Amiodarone and is not bradycardic or
hypotensive.
e. If patient did not previously receive and converted from a ventricular rhythm.
f. Amiodarone is for use in Kitsap County only.
Asystole
Usually asystole, the complete absence of electrical activity in the myocardium, represents extensive myocardial
ischemia from prolonged periods of inadequate perfusion. Such a status has a grim prognosis. Asystole most
often represents a confirmation of death rather than a “rhythm” to be treated.
ALS TREATMENT
1. ABC, CPR, ECG, Hx, PE (a)
2. Assist respirations as needed (b)
3. Obtain IV access
4. Consider immediate Transcutaneous Pacing
(TCP)(c)
5. Epinephrine (1:10,000) 1 mg IVP q 3–5min
6. Atropine 1 mg IVP q 3-5 min, max 0.04 mg/kg
7. Consider termination of efforts if appropriate(d)
Note:
a. Confirm asystole in two (2) or more leads.
b. Drugs given down the ETT should be 2 - 2.5 times the recommended IV dose, diluted to a total volume of 10
cc in NS.
c. TCP must be preformed early and simultaneously with drugs to be effective. Evidence does
not support the routine use of TCP for asystole.
d. Termination of efforts may be considered after the patient has been effectively ventilated with endotracheal
intubation and two rounds of ACLS pharmacology have been given.
Atrial Fibrillation / Flutter
The management of atrial fibrillation and atrial flutter warrant the prehospital care provider to consider four key
questions: 1) is the patient clinically stable? If so, treat with pharmacological therapy. If not and the duration of
the tachycardia is less than 48 hours, then electrical cardioversion is indicated. 2) Is cardiac function impaired
as evidenced by congestive heart failure or ventricular dysfunction? If so, that will affect the choice of drugs
because it is important to avoid drugs that can further impair pump function (i.e. those with negative inotropic
effect) 3) Does the patient have WPW or some other pre-excitation syndrome? If so, certain drugs are
preferred (i.e. Amiodarone) and other drugs are contraindicated. Drugs that selectively block the AV node without
also blocking coexisting accessory conduction pathways (i.e. adenosine, calcium channel blockers, -blockers)
are relatively contraindicated when pre-existing syndromes are present. 4) Has the duration of the atrial
fibrillation/flutter been less than 48 hours or more than 48 hours? The longer a patient remains in atrial
fibrillation, the greater the chances that one or more blood clots will be present within the atria. Conversion of the
rhythm by either electrical or chemical therapy can cause an embolus which may lead to CVA, MI or PE. Another
critical issue in the initial management of atrial fibrillation/flutter is whether to merely reduce the ventricular rate or
to actually terminate the arrhythmia. Termination may be unnecessary if the patient is tolerating the tachycardia.
Termination should be attempted only if the tachycardia is known to be recent onset of 48 hours or less. Drugs
used to slow ventricular rate include calcium channel blockers and -blockers. Drugs used to convert atrial
fibrillation or atrial flutter includes Amiodarone.
ALS TREATMENT
Stable Rate Control - Stable less than 48 hrs
1. ABC, Hx, PE, VS, ECG (12 lead), Pulse Ox Lopressor 5 mg IV over 2 min x 3 to max 15 mg
3. Obtain IV access Rhythm control - Stable less than 48 hrs
4. Cardizem for HR > 120/bpm 20-25 mg over 2 min Amiodarone 150 mg IV over 10 min(c)
May repeat in 15 min at (0.35mg/kg) over 2 min(a) May repeat in 10 min
5. Treat other associated sign and symptoms
per appropriate protocol WPW - Stable less than 48 hours with
**Base Station Contact** Amiodarone 150 mg IV over 10 min
• May repeat in 10 min
Unstable (a)
6. Midazolam 2.5 mg IV, IN, IM pre-cardioversion
PRN
7. Synchronized cardioversion
Note:
a. Obtain ECG tracing during all pharmacological and electrical cardioversions.
b. Serious signs & symptoms include:
Chest pain, dyspnea, ALOC, hypotension, shock, pulmonary congestion, CHF
c. Amiodarone is for use in Kitsap County only.
Bradycardia
Brady-arrhythmias can be caused by two mechanisms: depression of sinus nodal activity or conduction system
blocks. In both situations, subsidiary pacemakers take over and pace the heart, provided the pacemaker is
located above the bifurcation of the Bundle of His, and the rate is generally adequate to maintain cardiac output.
The need for emergent treatment is guided by two considerations: evidence of hypoperfusion and the potential to
degenerate into a more profound bradycardia or ventricular asystole.
ALS TREATMENT
1. ABC, Hx, PE, VS, ECG, Pulse Ox (a)
2. Administer O2, Assist respiratory status as needed
3. Obtain IV access (b)
4. Fluid bolus NS PRN if hypotensive
5. Atropine 0.5 mg IVP q 3-5 min PRN (c)(d)
Max 0.04 mg/kg
6. Choose ONE of the following PRN:
• Midazolam 2.5 mg IV
• Lorazepam 2 mg IV PRN
7. Transcutaneous pacing (e)
8. Dopamine 5-20 mcg/kg/min to maintain SBP>100
after fluid bolus
Note:
a. Inferior wall infarcts can present with hypotension, and brady-arrhythmias. Obtain 12 lead ECG.
b. TCP should be done first if delay in IV access.
nd rd
c. In symptomatic 2 and 3 degree heart block, consider pacing before atropine.
d. Serious signs and symptoms include chest pain, dyspnea, ALOC, hypotension, shock, pulmonary congestion.
e. Start at a rate of 70 BPM and an output of 80mA. Adjust upward in 5mA increments to achieve capture.
Pulseless Electrical Activity
(PEA)
The absence of a detectable pulse and the presence of some type of electrical activity other than VF or VT define
this group of arrhythmias. Research has confirmed that often a pulseless patient with electrical activity also has
associated mechanical contractions. These contractions are too weak to produce a pulse detectable by the usual
methods of palpation or blood pressure. Of utmost importance, ACLS providers must know PEA is often
associated with specific clinical states that can be reversed when identified early and treated appropriately. EMS
providers must identify possible reversible causes and institute cause-specific interventions. A useful mnemonic
for causes for PEA is 5 H’s, 5 T’s:
Hypovolemia Tablets (drug OD, accidents)
Hypoxia Tamponade, cardiac
Hydrogen ion (acidosis) Tension Pneumothorax
Hyper/Hypokalemia Thrombosis, coronary (ACS)
Hypothermia Thrombosis, pulmonary (embolism)
ALS TREATMENT
1. ABC,CPR, ECG (12 lead), Hx, PE, Pulse Ox
2. Administer O2, Assist respirations as needed (a)
3. Obtain IV access
4. Epinephrine (1:10,000) 1 mg IVP q 3-5 min
5. Use specific intervention if cause is known (b)
7. Atropine 1 mg IVP q3-5 min Max 0.04 mg/kg (c)
8. Transcutaneous pacing
9. Dopamine 5 - 20 mcg/kg/min titrated to effect
10.Consider termination of efforts if appropriate(d)
Note:
a. Drugs given down the ETT should be 2 – 2.5 times the recommended IV dose diluted with NS to a max
volume of 10 mL.
b. Consider Hyperkalemia Procedure.
c. A wide complex bradycardia may indicate a structural lesion below the Bundle of His. Atropine may not be
effective, consider going straight to TCP.
d. Termination of efforts may be considered after the patient has been effectively ventilated with endotracheal
intubation and causes have been explored. Refer to Discontinuation of CPR.
Supraventricular Tachycardia
(Narrow Complex Tachycardia)
Supraventricular tachycardia is a regular, rapid rhythm that arises from either reentry or an ectopic pacemaker in
areas above the bifurcation of the Bundle of His. The reentry variety is clinically the most common. These patients
present with acute, symptomatic episodes termed paroxysmal supraventricular tachycardia (PSVT). SVT often
causes a sensation of palpitations and light-headedness. In patients with coronary artery disease, anginal chest
pain and dyspnea may occur. Reminder: one antiarrthymic may help; however, two or more (stacking) may
worsen patient.
ALS TREATMENT
Stable (Symptomatic) 1) Junctional tachycardia:
1. ABC, Hx, PE, VS, ECG, Pulse Ox (a)(b) Preserved heart function
2. Administer O2, Assist respiratory status as needed Lopressor 5 mg IV over 2 min
3. Obtain IV access Cardizem 20-25 mg IV over 2 min
4. Vagal maneuvers Amiodarone 150 mg IV over 10 min (f)
5. Adenosine 6 mg rapid IVP (c)(d) No DC cardioversion
6. Adenosine 12 mg rapid IVP in 1-2 min 2) Junctional tachycardia: CHF
(may repeat one time) Amiodarone 150 mg IV over 10 min
7. Verapamil 2.5-5 mg slow IV, may repeat at No DC cardioversion
double dose in 15 min PRN (g) 3) PSVT: Preserved heart function
8. Treat other associated signs and symptoms Lopressor 5 mg IV over 2 min
per appropriate protocol Cardizem 20-25 mg IV over 2min
**Base Station Contact** DC Cardioversion
Amiodarone 150 mg IV over 10 min
Unstable (Critical) 4) PSVT: CHF
9. Midazolam 2.5-10 mg IV/IN PRN DC Cardioversion
10. Synchronize cardioversion (e) Amiodarone 150 mg IV over 10 min
11. Treat other associated signs and symptoms Cardizem 20-25 mg IV over 2 min
per appropriate protocol 5) Multifocal tachycardia:
**Base Station Contact** Preserved heart function
Lopressor 5 mg IV over 2 min
Cardizem 20-25 mg IV over 2 min
No DC cardioversion
6) Multifocal tachycardia: CHF
Cardizem 20-25 mg IV over 2 min
No DC cardioversion
Note:
a. Obtain 12 lead ECG.
b. Pharmacologic treatment may not be necessary. If the HR is less than 150 BPM treat the underlying cause.
c. Obtain ECG tracing during all pharmacological and electrical cardioversions.
d. Be absolutely certain that you are treating a narrow complex SVT. If any uncertainty exists, treat as VT.
e. Serious signs and symptoms include: Chest pain, dyspnea, ALOC, hypotension, shock, pulmonary
congestion, CHF, fatigue, nausea, and vomiting.
f. Amiodarone is for use in Kitsap County only.
g. Verapamil is for use in Jefferson County.
Ventricular Tachycardia
(With a Pulse)
Ventricular tachycardia is very rare in patients without underlying heart disease. The most common causes of
ventricular tachycardia are an ischemic heart and acute myocardial infarction. Ideally clinicians should attempt to
identify the specific type of wide-complex tachycardia present and treat accordingly. The challenge however, is to
distinguish between VT and SVT with aberrant conduction. AV dissociation is nearly always diagnostic for VT and
a very wide QRS interval also suggests VT. Assumptions that any wide complex tachycardia is VT until proven
otherwise will lead to 90% diagnosis accuracy in most presented cases.
ALS TREATMENT
1. ABC, Hx, PE, VS, ECG, Pulse Ox (a)(b)
2. Administer O2, assist respiratory status as needed
3. Obtain IV access
Stable:
4. Choose ONE of the following antiarrhythmics PRN:
• Lidocaine 0.5-0.75 mg/kg IVP may repeat in
3-5 min with 0.5mg/kg, Max 3.0mg/kg
• Lidocaine Drip1-4 mg min if successful
cardioversion of rhythm
• Amiodarone 150 mg IV infusion over 10 min
may repeat in 10 min 2 times (e)
• Amiodarone Drip 1 mg/minute if successful
cardioversion of rhythm
• Magnesium 1-2 Gm IV over 5-10 min
Torsades(c)
Unstable: (Critical) (d)

5. Midazolam 2.5 mg IVP pre-cardioversion PRN
6. Synchronized Cardioversion
Note:
a. Obtain 12 lead ECG if available and time permits.
b. Obtain ECG tracing during all pharmacological and electrical cardioversions.
c. For polymorphic VT.
d. Serious signs and symptoms include: Heart rate > 150 BPM, chest pain, dyspnea, ALOC,
hypotension, shock, pulmonary congestion, CHF, fatigue, nausea and vomiting.
e. Amiodarone is for use in Kitsap County only.
Ventricular Fibrillation
Pulseless Ventricular Tachycardia
Ventricular fibrillation is totally disorganized depolarization and contraction of small areas in the ventricular
myocardium. During this time, there is no effective pumping activity, pulse, or blood pressure. The ECG of
ventricular fibrillation shows a fine-to-course zigzag pattern without discernible P waves or QRS complexes.
Ventricular fibrillation is most commonly seen in patients with severe ischemic heart disease and is the most
frequently encountered rhythm in sudden cardiac death in adults. Defibrillation is required to stop ventricular
fibrillation. It constitutes the most important aspect of therapy for ventricular fibrillation. The sooner the shocks
are given, the more likely they are to be successful.
ALS TREATMENT
1. ABC, CPR, Pulse Ox, Hx, PE
2. Electrical therapy (a)
3. Continue CPR PRN
4. Administer O2, assist respirations as needed (b)
5. Obtain IV access
6. Vasopressin 40 units IV one time only or
7. Epinephrine (1:10,000) 1 mg IVP q 3-5 min
8. Electrical therapy after each drug given (c)
Choose ONE of the following antiarrhythmics PRN:

• Lidocaine 1- 1.5 mg/kg IVP May repeat q 3 –
5 min to max 3 mg/kg
• Amiodarone 300 mg IVP(e) may repeat 150
mg IVP q 3-5 min 2 times, if defibrillation
successful administer 1 mg/min IV Drip
9. Magnesium 1 – 2 Gm in 10 ml NS IVP (d)
10. Sodium Bicarbonate 50 – 100 mEq/kg IVP
(Consider)
Note:
a. Assess for and shock VF/pulseless VT, up to 3 times (200 J, 200 J – 300 J, 360 J or equivalent biphasic wave
form as recommended by manufacturer.
b. Drugs given down the ETT should be 2 – 2.5 times the recommended IV dose diluted with NS to a max
volume of 10 mL.
c. Multiple sequenced shocks (stacking) at 360 J or biphasic equivalent may be beneficial, especially when
medications are delayed.
d. For suspected hypomagnesmia or polymorphic VT.
e. Amiodarone is for use in Kitsap County only.
CHOKING
The inhalation or aspiration of foreign objects can cause symptoms ranging from none to serious life threats. The
most common scenario is one in which the patient attempts to swallow food, usually meat that is larger than the
esophagus can accept, that finds its way into the hypopharynx or trachea. Several factors may contribute to the
choking event. Patients who have been consuming alcohol may not notice that the object is larger than normal
and may attempt to swallow it anyway. In children, choking is a major cause of death, involving approximately
2,000 children in the United States, most of the victims being under the age of four. All too often, the child who is
playing or running with a mouthful of food falls, and aspirates as a result. Another probable source of aspiration is
childhood curiosity. Children explore their world through touch and taste. If the patient possibly aspirated a
foreign object but is in no distress, he or she still needs to be transported to the hospital. The only way to prove
non-aspiration is by x-ray; this needs to be done as soon as possible. Children who have possibly aspirated
anything may not be transported POV, but can be transported BLS if stable.
Universal choking sign Audible, noisy breathing
*No breath sounds *Inability to speak
*Cyanosis Labored use of accessory muscles
*Flared nostrils Strained neck and facial muscles
Progressive restlessness, anxiety and confusion *Unresponsiveness
BLS TREATMENT
1. ABC’s **Request Paramedic Evaluation If**
2. Manage airway per AHA guidelines (b) • Unconscious/not breathing
3. Administer O2 per procedure • Signs of partial or full obstruction (a)
4. PE, VS, Pulse Ox, Hx • Unable to speak normally
5. Treat other associated signs and symptoms • Turning blue
per appropriate protocol • Parent refuses transport (c)
ILS TREATMENT
• Any ILS skills performed
ALS TREATMENT
8. ECG
Note:
a. If obstruction is successfully cleared, BLS transport may be considered.
b. All choking victims need to be transported to the hospital.
c. If the parent refuses to have the child transported by your agency, an AMA form must
be signed and it is advisable to accompany POV.
DIABETIC EMERGENCIES
Diabetes mellitus is a condition caused by decreased insulin production. This condition cannot be cured, only
controlled through diet or insulin injections. The diabetic taking insulin is at risk for developing diabetic coma or
insulin shock. Both problems can be life threatening.
HYPERGLYCEMIA/DIABETIC COMA HYPOGLYCEMIA/INSULIN SHOCK
Results from a decreased insulin supply and an Occurs when there is too much insulin and there is a
excessively high blood sugar level (hyperglycemia) The seriously low blood sugar level (hypoglycemia) This
body is not producing adequate insulin or the person is can occur if the diabetic doesn’t eat enough, takes too
not taking enough insulin. much insulin, is ill, or over exercises.
SIGNIFICANT (*AUTOMATIC ALS)
FINDINGS
Dry mouth and intensive thirst Abdominal pain and vomiting
Restlessness Weak, rapid pulse
Dry, red, warm skin Dizziness and headache
Abnormal, hostile or aggressive behavior *Fainting, convulsions
Full, rapid pulse Skin pale, cold and clammy
BLS TREATMENT
1. ABC, Hx, PE, VS, blood-glucose check, pulse ox (a) **Request Paramedic Evaluation If**
3. Position in left lateral recumbent position if ALOC • ALOC
4. Glucose paste 1 tube PO (b) • Signs of shock
5. Repeat glucose check • Chest pain
6. Treat other associated signs and symptoms • Unusual behavior
per appropriate protocol • Seizures
ILS TREATMENT
7. Obtain IV access, may use D5W or NS, ** Request Paramedic Intercept When **
8. Dextrose 25 - 50 Gm IV (c)(d) • Any ILS skills performed
9. Fluid bolus PRN • Base Station Orders
ALS TREATMENT
10. ECG
11. Assist respiratory status as appropriate
12. Thiamine 100 mg IM/IV (f)
13. Glucagon 1 mg IM/IN/IV
Note:
a. Normal glucose levels are 60 – 120 mg/dl.
b. Patient must have a patent airway and gag reflex.
c. Administer only if blood glucose level is less than 60 mg/dl.
d. Or appropriate dose for weight (see pediatric appendix).
e. If a hypoglycemic patient responds to treatment, consider non-transport if left in the care
of a responsible individual and has the ability to eat. Patient must sign AMA release form.
f. To be administered if glucose paste or Dextrose 25 Gm is given to malnourished patients.

ENVIRONMENTAL EMERGENCIES
Hyperthermia
The body temperature is contingent on the balance between heat production and heat loss. Regulation of body
temperature is dependent upon the principals of conduction, convection and evaporation. Populations at risk for
hyperthermic emergencies include the elderly, the poor (who lack adequate air conditioning), those who suffer
from malnutrition and those who have chronic illnesses or substance addiction. Predisposing factors commonly
intervene over days rather than minutes or hours. Hyperthermia may occur in the presence of numerous host
factors. These factors include many that affect thermoregulation through heat loss mechanisms (lack of
acclimatization, fatigue, lack of sleep, dehydration and skin disorders), while others contribute to heat production
(obesity, lack of physical fitness, febrile illness, or sustained exercise). Changes in cognitive function appear to
occur before the development of the physical symptoms associated with heat stress. Time distortion, memory
impairment, or deterioration in attention are frequent cognitive characteristics associated with heat stress.
Weakness Dizziness/faintness
Sever muscular cramps/pain *Rapid, shallow breathing
Rapid, weak pulse *Pale, clammy skin
*ALOC *Hot, dry skin
*Seizures
BLS TREATMENT
1. ABC, Hx, PE, Pulse Ox, VS to include temperature **Request Paramedic Evaluation if**
3. Remove patient from heat source • ALOC
4. Blood glucose check PRN (a) • Signs of shock
5. Cooling measures (b) • Respiratory distress
6. Treat other associated signs and symptoms • Syncope or near syncope
per appropriate protocol • Pale, clammy skin
ILS TREATMENT
ALS TREATMENT
9. ECG
Note:
a. Normal Blood-glucose levels are 60 – 120 mg/dl.
b. Do not delay transport for procedure.
ENVIRONMENTAL EMERGENCIES
Hypothermia
Hypothermia is defined as a core temperature less than 95 Fahrenheit. While most commonly seen in cold
climates, it may develop without exposure to extreme environmental conditions. Hypothermia is not uncommon in
temperate regions and may develop indoors even during summer. Individuals at the extremes of age and those
of altered senses are susceptible to developing hypothermia. Radiation accounts for the greatest form of heat
loss (55 – 65%) Conduction normally accounts for only 2 – 3%, but increases up to five times in wet clothes and
twenty five times in cold water.
*Temperature of 90° or less *Depressed VS
*ALOC *No shivering despite being very cold
Shivering *Cold, pale skin
Rapid pulse and breathing Poor muscle coordination
BLS TREATMENT
1. ABC, Hx, PE, Pulse Ox, VS to include temp (a)(b) **Request Paramedic Evaluation if**
2. Administer O2 per procedure (c) • Unconscious/not breathing
3. Remove wet clothing and keep warm (d) • ALOC
4. Blood Glucose Check PRN • Signs of shock
5. Treat other associated signs and symptoms • Respiratory distress
per appropriate protocol • Syncope or near syncope
• Diaphoresis
• Pale, clammy skin
ILS TREATMENT
6. Obtain IV access (e) ** Request Paramedic Intercept When **
ALS TREATMENT
8. ECG (f)
10. Bretylium 5 mg/kg (g)
Note:
a. Assess pulses for a minimum of 30 seconds. If there are no pulses start CPR,
one round of the AED protocol.
b. Treat very gently. Do not rub or manipulate the extremities. Keep the patient supine.
c. Oxygen should be heated if possible.
d. Prevent further heat loss. Insulate from the ground, protect from the wind, eliminate
evaporative heat loss by removing wet clothes or by packing the patient with a vapor
barrier, cover the head and neck. Place heat packs wrapped in towels around the neck,
arm pits and groin areas.
e. Use warm fluids if possible on patients that are hypothermic and dehydrated.
f. Assess for and shock VF, pulseless VT, up to 3 times (200 J, 200 J to 300 J, 360 J or equivalent biphasic
wave form as recommended by manufacturer.
g. If available Bretylium 5mg/kg initially is recommended for any hypothermic patient manifesting
significant new ventricular ectopy or frank dysrhythmia.
GENERAL ILLNESS
Sick / Unknown / Nausea / Vomiting
The pre-hospital provider should be very careful to insure that patients who present with no specific complaints
are given due regard. The patient’s symptoms and recent history must determine the most appropriate care.
Female patients do not necessarily have classic symptoms of MI, their symptoms may be diaphoresis and “not
feeling right”
Increased/decreased BP Increased temperature
*ALOC *Non-descriptive pain
*Diaphoresis *Signs & Symptoms of Septic Shock
Nausea, vomiting Dizziness
Weakness Indigestion
*Difficulty breathing
BLS TREATMENT
1. ABC, Hx, PE, Pulse Ox, Orthostatic VS (a) **Request Paramedic Evaluation if**
2. Administer O2 per procedure • Unconsciousness/not breathing
3. Blood glucose check • ALOC
4. Perform Prehospital Cincinnati Stroke Test • Chest discomfort < 40 y/o
5. Treat other associated signs and symptoms • Diaphoresis
per appropriate protocol • Syncope or near syncope when sitting
• Pale, clammy skin
• Respiratory distress
• Orthostatic changes of > 30 SBP/BPM
ILS TREATMENT
ALS TREATMENT
8. ECG, PRN
10. Choose one of the following anti-emetics PRN:
• Promethazine 12.5 – 25 mg IV/IM (b)
• Droperidol 0.625 – 1.25 mg IV/IM (c)
• Diphenhydramine 25-50 mg IV/IM
Note:
a. It should be noted that diabetic patients, women and the elderly who present with general illness might be an
atypical presentation of myocardial infarction.
b. Not available in Mason County.
c. Obtain ECG tracing while administering Droperidol.
GYNECOLOGY / MISCARRIAGE
Spontaneous abortion is common, although it often goes unrecognized when it is mistaken for a menstrual period.
Most spontaneous abortions are indicative of some fetal abnormality incompatible with life. Threatened abortion
describes a pregnant patient who presents with vaginal bleeding and/or cramping. About 15 – 20% of all
pregnancies end in spontaneous abortion.
Heavy vaginal bleeding Patients knowledge of pregnancy
Passage of tissues *ALOC
Paleness *Rapid, weak pulse
Cramp-like pains in lower abdomen *Cool, clammy skin
*Low blood pressure
BLS TREATMENT
**Request Paramedic Evaluation if**
1. ABC, Hx, PE, Pulse Ox, Orthostatic VS (a) • Unconscious/not breathing
2. Administer O2 per procedure • ALOC
3. NPO • Vaginal bleeding with syncope
4. Treat other associated signs and symptoms • Signs of shock
per appropriate protocol • Bleeding > 20 weeks pregnant
• Abdominal injury, with contractions
• Contractions > 20 weeks pregnant
• Lower abdominal pain, women age 12-50
• with dizziness, syncope or heavy vaginal
bleeding
• Positive orthostatic changes
ILS TREATMENT
ALS TREATMENT
7. ECG (b)
Note:
a. History to include last menstrual period, number of previous pregnancies, number of live births and RH type.
b. Obtain FHT by doppler if available and time permits.
HEADACHE
Approximately 40% of all Americans have a significant headache at some time. Because many headache
patients have a normal physical exam, the most important tool for making a correct assessment is a detailed
history. Important details as to the speed of onset and relationship to other headaches are important. A
headache that recurs regularly over a number of years is most likely a tension or migraine type headache. A
severe headache with rapid onset, particularly if accompanied by ALOC or a neurological finding, is much more
likely to suggest a hemorrhage, infarct or illness such as meningitis. A violent and sudden headache, particularly
for the first time or headache accompanied with stiffness of the neck or generalized parasthesia may indicate
subarachnoid hemorrhage.
*Diaphoresis *Confusion
*ALOC Vertigo
Loss of balance/coordination *Abnormal pupil changes
*”Worst headache ever” Photophobia
*Nausea, vomiting *Slurred speech
*Blurred, double vision *Weakness, paralysis
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox **Request Paramedic Evaluation if**
3. Blood-glucose check (a) • ALOC
4. Perform Prehospital Cincinnati Stroke Test • “Worst headache ever”
5. Treat other associated signs and symptoms • Sudden onset
per appropriate protocol • Headache after physical exertion
• Headache if associated with, slurred speech,
blurred/double vision, weakness, paralysis,
diaphoresis and vomiting
• Positive Cincinnati Stroke Test
ILS TREATMENT
ALS TREATMENT
7. ECG • Diphenhydramine
8. Assist respiratory status as needed • Morphine
9 Choose one of the following anti-emetics PRN: • Demerol
• Droperidol 0.625 – 1.25 mg IV/IM (b) • Lorazepam
• Promethazine 12.5 – 25 mg IV/IM
10.Treat other associated signs and symptoms
Note:
b. Obtain ECG tracing while administering Droperidol.
MENTAL / EMOTIONAL / PSYCHOLOGICAL
EMERGENCIES
Psychiatric patients may have an illness that presents with symptoms such as delusions, hallucinations,
depression or significant trauma. The patient’s symptoms demand immediate response as they may appear
intense, raise the anxiety levels of those around the patient to an intolerable level, or create problems in the
immediate environment. The patient may perceive their life to be at immediate risk, either from suicide or their
current inability to make logical decisions. Remember that personal safety takes priority over patient
intervention!
Withdrawn Profuse sweating
Flushed appearance Hyperventilation
Rapid speech Hallucinating
Not responding to people or environment Hostile or aggressive behavior
Tries to hurt self or others Anxious and fearful
Crying or hysterical
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox, blood glucose PRN **Request Paramedic Evaluation**
3. Calm, relax and reassure patient • ALOC
4. Restrain patient PRN for safety (a) • Unusual behavior associated with diabetes
5. Treat other associated signs and symptoms • Suicidal
per appropriate protocol • GSW/stabs to head, neck, torso, thigh
ILS TREATMENT
6. Obtain IV access • Any ILS skills performed
**Base Station Contact** ** Request Paramedic Intercept When **
ALS TREATMENT
7. ECG
9. Choose one of the following PRN:
• Droperidol 2.5 – 5 mg IM/IN/IV PRN (b)
• Midazolam 2.5– 5 mg IM/IN/IV PRN (c)
• Lorazepam 1 – 2 mg IM/IN/IV PRN
Note:
a. If restraining the patient is not possible or the pre-hospital care provider feels they are in
danger, they should withdraw from patient contact until scene safety can be established.
b. Obtain ECG tracing while administering Droperidol.
c. East Clallam County only may repeat Midazolam without Physician order.
OVERDOSE / POISONINGS
The majority of poisonings occur in young children (1 – 5 years); however, adult poisoning is responsible for 80 –
90% of hospital admissions. A thorough, accurate history provides a working assessment and assists with
management decisions for most patients. Unfortunately the history of poisoning is notoriously unreliable whether
it is obtained from the patient, friends and family members or emergency service personnel. Despite the possible
inaccuracies, the important historical factors include what poison was involved, how much was taken, how it was
taken, when it was taken, why it was taken and especially what else was taken.
BLS TREATMENT
3. Blood glucose check (a) • ALOC
4. Contact base station with nature of toxic • Intentional/accidental with Rx medicines
exposure • Ingestion of household cleaners
5. Activated Charcoal 50 Gm PO (b) • Difficulty swallowing
6. Treat other associated signs and symptoms • Acute alcohol intoxication, age < 17 yrs
• Combined alcohol and drug overdose
• Cocaine/crack with chest pain
• Seizure secondary to drug overdose
ILS TREATMENT
8. Naloxone 0.4 – 2 mg IN/IV, PRN • Any ILS skills performed
9. Dextrose 25 - 50 Gm IV PRN (a) • Base Station Orders
ALS TREATMENT
10. ECG 1. Repeat Lorazepam
12. Tricyclic Anti-Depressants (symptomatic)
• Sodium Bicarbonate 100 mEq IVP followed
by 25 mEq in 250 ml NS and run 250 ml/hr
• Dopamine titrated to maintain 100 SBP
13. Calcium Channel Blockers
• Calcium Chloride 500-1000 mg IV slowly
• Consider TCP
• Glucagon 3mg-5 mg IV over 5-10 minutes
14. Beta Blockers
• Glucagon 3mg-5 mg IV over 5-10 minutes
15. Organophosphates
• Atropine 2 mg IVP q 5-15 min PRN
For excess airway secretions
16. CNS Stimulants
• Lorazepam 0.5- 4 mg IV/IM
17. Naloxone 0.4 – 2 mg IM/IN/IV PRN
Note:
a. Normal blood glucose level range is 60 – 120 mg/dl.
b. Activated Charcoal may be administered by EMT-B with base station physician order.
PAIN MANAGEMENT
The practice of pre-hospital emergency medicine requires expertise in a wide variety of pharmacological and non-
pharmacological techniques to treat acute pain resulting from a myriad of injuries and illnesses. One of the most
essential missions for all healthcare providers should be the relief or prevention of pain and suffering.
Approaches to pain relief must be designed to be safe and effective in the organized chaos of the pre-hospital
environment. The degree of pain and the hemodynamic status of the patient will determine the rapidity of care.
BLS TREATMENT
1. ABC, Hx, PE, Pulse Ox PRN (a)
2. Administer O2 per procedure PRN
3. Splint, Position of comfort PRN
4. Elevate affect body part
5. Apply ice to affected area
ILS TREATMENT
ALS TREATMENT
7. ECG PRN • Repeat Morphine
8. Assist respiratory status as needed (b) • Repeat Meperidine
9. Nitrous Oxide (if available)
10. Choose one of the following analgesics PRN (c):
• Morphine 2-4 mg IV/IM titrated 1- 3 mg q 2
min up to 20 mg PRN (d)
• Meperidine 12.5 – 25 mg IV titrated 12.5 mg
q 2 min up to 100 mg PRN or 50–75mg IM
(MS allergy)
11. Choose one of the following anti-emetics PRN:
• Droperidol 0.625 – 1.25 mg IV/IM (e)
• Promethazine 12.5 – 25 mg IV/IM
Note:
a. Obtain subjective measurement of patient’s pain using the 1 – 10 scale.
b. Patients receiving narcotic analgesics should remain on oxygen.
c. May only medicate pts with isolated injuries or burns.
d. Throughout procedure check and record VS, pulse ox, and pain scale.
e. Obtain ECG tracing while administering Droperidol.
PEDIATRIC EMERGENCIES
Cardiopulmonary Arrest
Resuscitation of the newborn can present a challenge to many EMS providers. Aside from caring for the neonate
the pre-hospital care provider must be attentive to and treat the post partum mother. The vast majority of term
newborns require no resuscitation beyond mild stimulation, suctioning of the airway and maintenance of
temperature. Only a small number of these newborns require further intervention, such as BVM ventilation and, in
severe cases, chest compression and medications. Resuscitation of the pediatric patient is challenging because
of the technical demands of vascular access and airway control. In addition, the causes of pediatric cardiac arrest
are different than those of the adult. Cardiac arrest in a child is usually the result of either respiratory failure or
shock. A child’s body is able to compensate well during the initial stages of shock. This can rapidly change
leading the pediatric patient into a state of compromise. It is very important for the EMS provider to have a high
index of suspicion for possible cardio-respiratory collapse and treat these patients as early as possible during
their emergency contact.
SIGNIFICANT FINDNGS (*AUTOMATIC ALS)
*Unresponsive
*Apneic
*Pulseless
BLS TREATMENT
1. ABC, Initiate CPR(a) **Request Paramedic Evaluation if**
2. Hx, PE, Check blood glucose as time permits 1. This is an automatic ALS response
3. Administer O2 per procedure
ILS TREATMENT
4. Obtain IV access
ALS TREATMENT
5. ECG
6. Assist respiratory status as needed (b)(c)
7. Obtain IV/IO access
8. Epinephrine (1:10,000) 0.01 mg/kg IV/IO/ET
q 3 – 5 min PRN
Note:
a. If ALS ETA delayed, consider rendezvous/transport after contact with incoming ALS unit.
b. Insert NG tube if intubation done with an uncuffed tube.
c. If meconium is present: Once baby is delivered, do not immediately dry infant. Immediately visualize the
cords. Suction vigorously through ET tube with a meconium aspirator. Re-intubate and repeat procedure as
necessary to retrieve meconium. If baby has already started breathing do not attempt deep intubation suction.
Breathing Difficulty
Acute respiratory emergencies in the pediatric patient are common. When not properly treated, respiratory
distress can result in significant morbidity and mortality. Decisive intervention is mandatory to insure the best
outcome. Appearance of the child reflects the adequacy of oxygenation and ventilation. An increased effort to
breathe may indicate an airway obstruction or lack of oxygenation. Decreased breathing effort may indicate
impending respiratory failure. If this process is not interrupted by effective treatment, deterioration to respiratory
failure will occur.
*Extreme difficulty breathing *Audible wheezing
*Rapid pulse and/or respiratory rate *Diaphoresis
*See-Saw breathing *Tripod position
*Use of accessory muscles *Cyanosis
*Appearing acutely ill with fever *ALOC
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox **Request Paramedic Evaluation if**
2. Allow child to stay in position of comfort • Unconscious/not breathing
3. Administer O2 per procedure (a) • ALOC
4. Administer Patient’s MDI per prescription • Respiratory distress
5. Treat other associated signs and symptoms • Inhaled toxic substances
per appropriate protocol • Unable to speak in full sentences
• Drooling/difficulty swallowing
ILS TREATMENT
Stable with SOB/Wheezing: ** Request Paramedic Intercept When **
6. Albuterol 2.5 mg via SVN • Any ILS skills performed
Unstable in Extremis:
7. Epinephrine 1:1,000 0.01 mg/kg SQ (0.3 mg max) (b)

ALS TREATMENT
8. ECG
9. Assist respiratory status as needed (a)
10. Epinephrine 1:1,000 5 mg/NS SVN (for extremis)
11. Albuterol 2.5 mg & Atrovent 0.5 mg SVN
12. Consider one of the following steroids PRN:
• Dexamethasone 1 mg/kg SVN
• Methylprednisolone 1 - 2 mg/kg SVN
12. Prednisone 1-2 mg/kg PO (c)
Note:
a. Use humidified O2 if available if croup suspected.
b. To be used in asthma and/or anaphylaxis in severe respiratory distress with marked bronchoconstriction and
decreased tidal volume.
c. For ease of PO administration, crush tablet and mix in jam or chocolate (per Mary Bridge ED staff).
Fever
Fever is a common chief complaint of children encountered in the pre-hospital environment. It is important to
recognize that fever represents a symptom of underlying illness and the actual illness must be determined and
treated. Febrile seizures typically occur once from a rapid rise in temperature, usually above 101.8 degrees
Fahrenheit. If more than one seizure occurs, suspect causes other than fever. The first occurrence of a seizure
warrants the most concern, because the benign nature of the illness has not been established.
Flushed, dry/hot skin Rash or stiff neck
*Dehydration Recent history of elevated temperature
Loss of appetite Rapid pulse
Restlessness *Seizures
Decreased urine output Nausea/vomiting
*ALOC
BLS TREATMENT
1. ABC, Hx, PE, VS to include temp, pulse ox, **Request Paramedic Evaluation if**
3. Remove any excess clothing (a) • ALOC
per appropriate protocol • Prolonged or multiple seizures
• Signs of shock
ILS TREATMENT
5. Obtain IV access, blood glucose check PRN ** Request Paramedic Intercept When **
ALS TREATMENT
6. ECG PRN
8. Acetaminophen 20 mg/kg PO
Note:
a. Do not delay transport for procedure.
PREGNANCY/CHILDBIRTH
Childbirth is a normal, natural process. Only in a few situations involving complications does the pre-hospital care
provider need to see that the mother reaches the hospital quickly. Care of patients in emergencies involving
reproductive organs is not a common event. EMS providers must deal with all emergencies in a professional,
effective and compassionate manner.
Abdominal pain Nausea/vomiting
Vaginal bleeding Weakness/dizziness
*Labor before 38 weeks *Urge to have a bowel movement
Bloody show *ALOC
*Seizures *Edema in face or extremities
*Signs of shock *Meconium staining
Reoccurrence of contractions after first infant born
BLS TREATMENT
3. Place in left lateral recumbent position • Vaginal bleeding with syncope
unless birth imminent • Signs of shock
4. Childbirth imminent, prepare for delivery (a) • Labor pains/contractions < 2 min apart,
5. Initiate post-partum care (b) nd
• 2 pregnancy contractions < 5 min apart
6. Treat other associated signs and symptoms • Prior delivery with labor lasting < 1 hour
• Bleeding > 20 wks pregnant
• Premature labor > 4 wks early
• Delivery
• Abdominal injury w/contractions > 20 wks
• Seizure > 20 wks pregnant
• Suspected illicit drug use
ILS TREATMENT
ALS TREATMENT
8. ECG, Doppler FHT PRN if available
Note:
a. Be aware of the possibility of multiple deliveries.
b. Warm/dry, position, suction PRN. Refer to post partum protocol.
Eclampsia
Eclampsia or pre-eclampsia is a toxic state that develops in the last trimester. It is characterized by increased
blood pressure, fluid retention and seizures (if very severe). Caution, eclampsia may occur up to 48 hours
postpartum.
rd
*3 trimester BP > 140/90 or increase of 15 mmHg above normal BP
*Seizures *ALOC
*Unresponsiveness Significant, sudden weight gain
Edema of extremities
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox, Check Blood Glucose **Request Paramedic Evaluation if**
3. Place in left lateral recumbent position • ALOC
4. Transport gently (a)(b) • Increase of SBP > 15 above normal
5. Treat other associated signs and symptoms • Seizures
ILS TREATMENT
ALS TREATMENT
7. ECG, Doppler FHT PRN if available
9. Magnesium Sulfate 4 Gm IV/IM (c)
10. Lorazepam 1 – 2mg IV
Note:
a. Sirens and flashing lights may precipitate seizures.
b. If ALS ETA delayed, consider rendezvous/transport with incoming ALS unit.
c. If patient is seizing.
This page corrected on 01/16/04.
Birth Complications
Although most babies are born without difficulty, complications may occur. Breech birth presentation is one in
which the fetal buttocks or lower extremities are low in the uterus and are the first to be delivered. Delivery may
be prolonged for these newborns, which are at great risk of delivery trauma. Limb presentation is when one arm
or leg is the first to protrude from the birth canal. The treatment necessary is the same as you would provide for a
breech presentation. Prolapsed cord may occur after the amniotic sac ruptures. The umbilical cord, rather than
the head, may be the first part presenting at the vaginal opening. In this situation the umbilical cord may get
compressed against the walls of the vagina by the pressure of the infant’s head. As a result the infant’s supply of
oxygenated blood can be cut off. This is a true emergency.
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox **Request Paramedic Evaluation**
2. Administer O2 per procedure This is an automatic ALS response
3. Place prone, knee to chest for breech (a)
prolapsed cord (b), limb presentation (c)
per appropriate protocol (d)
ILS TREATMENT
This is an automatic ALS response
ALS TREATMENT
6, ECG
Note:
a. If unable to deliver head, place gloved index and middle finger in the vagina with the palm towards the baby’s
face to maintain airway. Transport immediately.
b. Place sterile gloved index and middle finger into the vagina, pushing the infant up to relieve pressure on the
cord. Transport immediately.
c. Transport immediately.
d. If ALS ETA delayed, consider rendezvous or transport after contact with incoming ALS unit.
PREGNANCY / CHILDBIRTH
Post Partum
When caring for the healthy newborn, it is important that pre-hospital care concentrates on the basics. The
newborn’s airway should be suctioned immediately when the head presents from the birth canal. A second
suctioning should be performed immediately after the neonate is fully delivered. Suctioning should begin with the
mouth then progress to the nose. Stimulating a newborn’s breathing may be done by gently rubbing its back.
Supporting the baby’s respirations with blow by oxygen may be performed but is seldom necessary in the routine
delivery. Keeping the newborn warm is imperative. The hypothermic newborn will suffer bradycardia and
subsequent hypoperfusion. Dry the newborn immediately after clearing the airway. Use dry towels and blankets to
insure the neonate is warm. When cutting the umbilical cord, the pre-hospital care provider should place the first
umbilical clamp or tie approximately 6 inches from the neonate and the second clamp or tie approximately 3
inches from the first and cut in between. The newborn may also be laid on top of the mother to maintain warmth.
Assess the newborn every five minutes while enroute to the hospital.
BLS TREATMENT
1. ABC, Hx, PE, VS • Any unexpected birth complications
2. Administer O2 per procedure • Signs of shock
3. Massage fundus, encourage breast feeding • Uncontrolled vaginal bleeding
4. Treat other associated signs and symptoms • Newborn unconscious/not breathing
per appropriate protocol • Newborn with HR < 80 BPM
• Meconium present
ILS TREATMENT
ALS TREATMENT
6. ECG
8. Oxytocin 10 units IM, then administer
20 units/1000ml NS @ 50-1000cc/hr IV(a)
Note:
a. Only after the delivery of the placenta, titrate to control postpartum hemorrhage.
SEIZURES
A seizure is a period of altered neurologic function caused by abnormal neuronal electrical discharges.
Approximately 1% - 2% of the general population has recurrent seizures. Generalized seizures begin with abrupt
loss of consciousness. If motor activity is present, it symmetrically involves all four extremities. Episodes that
develop over minutes to hours are less likely to be seizures. Most seizures only last 1– 2 minutes. Patients with
seizure disorders tend to have stereotype, or similar, seizures with each episode and are less likely to have
inconsistent or highly variable attacks. True seizures are usually not provoked by emotional stress. Most
seizures are followed by a postictal state of lethargy and confusion.
*ALOC *Ongoing seizure activity, lasting longer than 5
minutes
Head or mouth trauma Medic alert tag
Incontinence *Pregnancy
BLS TREATMENT
2. Protect patient from injury • Seizures > 5 min
3. Administer O2 per procedure • Status seizures
4. Blood glucose check (a) • First time seizures
5. Treat other associated signs and symptoms • Diabetic
per appropriate protocol • Pregnant > 20 wks
• Secondary to illicit drugs
• Secondary to recent head injury
• Seizure, unknown Hx, age > 50 yrs
ILS TREATMENT
ALS TREATMENT
7. ECG 1. Magnesium
9. Lorazepam 0.5 – 4 mg IM/IN/IV PRN
10. Midazolam 2.5 – 5 mg IM/IN/IV PRN(b)
Note:
a. Normal glucose levels are 60 – 120 mg/dl
b. Refer to Pediatric appendix for IM dose
STROKE
Stroke is the third leading cause of death and a major cause of disability in the U.S. There are two main
mechanisms of stroke: (1) Blood vessel occlusion (85% of all strokes); and (2) Blood vessel rupture. Ischemic
strokes are most often caused by large vessel thrombosis, although embolism or hypoperfusion can cause them.
Causes of thrombosis include atherosclerosis, vessel dissection and some infectious diseases. Hemorrhagic
strokes are divided into intracerebral (IHC) and subarachnoid (SAH) hemorrhages. Risk factors for ICH include
hypertension, older age, prior stroke, and cocaine use.
Headache Impaired vision
Personality changes Loss of function to extremities on one or both sides
Mouth drawn to one side of the face Drooping on one side of the face
*ALOC Collapse
*Difficulty breathing *Coma
Paralysis of facial muscles Loss of expression on face
Confusion, dizziness
BLS TREATMENT
1. ABC, Hx, PE, VS, check Blood-glucose, • Unconscious/not breathing
Pulse Ox (a)(b) • Stroke symptoms age < 50
3. Perform Prehospital Cincinnati Stroke Test • Respiratory distress
4. Treat other associated signs and symptoms • Chest pain, age > 40
per appropriate protocol • Diabetic
• Seizure
• Severe headache
• Onset of symptoms < 3 hrs
• Positive Cincinnati Stroke Test
ILS TREATMENT
ALS TREATMENT
6. ECG
Note:
a. Determine time of onset of symptoms if possible. Time is critical for pharmacological intervention.
(onset of symptoms to pharmacological intervention < 3 hours).
b. Normal glucose levels are 60 – 120 mg/dl.
TRAUMA
Assault Trauma
Trauma is the leading cause of death and disability among Americans between the ages of one and 37. It is also
the fourth leading cause of death among all Americans. Trauma is categorized as either blunt or penetrating. In
blunt trauma, injuries are produced as the tissues are compressed, decelerated or accelerated. Penetrating
trauma is produced as the tissues are crushed and separated along the path of the penetrating object. Pre-
hospital care providers must realize and respect the fact that critical trauma is a surgical emergency. The role of
EMS in the treatment of critical trauma is recognition, insure rapid transport, and stabilize injuries while in route to
the most appropriate facility. Special attention should always be given to the trauma victim’s airway, neurological
and hemodynamic status. Patients who suffer injury as the result of an assault present the EMS provider with
several challenges. The scene of a violent attack should be secured by law enforcement prior to EMS personnel
making entry. The victim of violence should not only be treated for their physical injuries but also their emotional
injuries. Honest reassurance by the EMS provider as well as prompt referral to community support services
should be made. Consider transporting to the most appropriate facility. Trauma band the patient. If sexual
assault suspected, inform Base Hospital for possible resource activation.
Obvious bleeding
Contusions Paleness
*Signs of internal bleeding Decreased capillary refill (a)
*Deformity to head Deformity to torso, or extremities
*ALOC Alcohol or drug use
Diaphoresis Low blood pressure
BLS TREATMENT
1. Assure scene safety **Request Paramedic Evaluation if**
3. C-spine control if indicated • ALOC
4. Control bleeding • Crushing, penetrating or significant blunt
5. Administer O2 per procedure trauma to head, neck, chest, abdomen and
6. NPO thigh
7. Treat other associated signs and symptoms • Uncontrolled bleeding
per appropriate protocol • Seizures secondary to head injury
ILS TREATMENT
ALS TREATMENT
10. ECG PRN
Note:
a. Capillary refill time is a reliable sign typically only in infants and children less than 6 years old
TRAUMA
Burns
Burns are a devastating form of trauma associated with high mortality rates, lengthy rehabilitation, cosmetic
disfigurement, and permanent physical disabilities. Thermal, chemical, electrical, nuclear radiation or solar
sources may cause burns. Burns can affect more than just the skin. They can affect the body’s fluid and
chemical balance, temperature regulation, and musculoskeletal, circulatory and respiratory functions. Burns are
classified by degree, First Degree (superficial) some reddening, Second Degree (partial thickness) has blistering
and deep reddening, Third Degree (full thickness) causes damage to all skin layers and is either charred/black or
white/leathery with little or no pain at the site. The patient’s palm equals 1% of body surface area when
determining the area affected. This is sometimes more helpful than using the “rule of nines” especially with
pediatric patients. Consider transport to Trauma Center for burn management. Trauma band the patient.
st nd rd
Burned areas 1 , 2 , 3 *Singed nasal hairs or mouth
*ALOC *Low blood pressure
*Difficulty breathing *Hoarseness
Secondary trauma *Rapid, weak pulse
BLS TREATMENT
1. Remove patient from burning source (a) **Request Paramedic Evaluation if**
4. Treat burn PRN (b) • Burns to airway, nose or mouth
per appropriate protocol • Hoarseness, difficulty talking/swallowing
• Burns to neck, hands, feet or genitalia
• Burns over 20% BSA
• Electrical burns/electrocution 220 volts
ILS TREATMENT
ALS TREATMENT
8. ECG
10. Pain control, refer to pain management protocol
Note:
a. Remove electrical source if trained to do so safely. Remove patient’s clothing as appropriate. Brush off
solid/dry chemicals. Remove rings, bracelets and other constricting items.
b. Thermal Burns:
- Cover burned area with dry, sterile dressing.
st nd
- Cool or room temperature saline soaks for pain relief in 1 & 2 degree burns if < 10% of BSA
Chemical Burns:
- Continue to flush with water for 20 minutes.
- If eyes are involved, flush for 20 -25 minutes then cover with moistened pads.
Electrical Burns:
- Apply dry, sterile dressing.
- Monitor for arrhythmia.
TRAUMA
Drowning/Near Drowning
Approximately 4500 people die of submersion in the United States each year, making drowning the third leading
cause of accidental death. Drowning, like other causes of accidental death, often strikes the young or otherwise
healthy individual. Prevention is the most important step to reduce these unnecessary deaths. The patient
prognosis after near drowning depends on the speed of rescue and resuscitation, emphasizing the role of
emergency care. Treatment of near drowning begins at the scene with rapid, cautious removal of the victim from
the water. Spinal precautions should be observed if the mechanism of injury such as a high velocity impact,
diving or surfing raises suspicion of such injuries. Concern of saltwater vs. freshwater aspiration is not of
immediate importance in the pre-hospital environment. Factors that increase survivability include; (1) The
younger the person the better, (2) The colder the water the better, (3) The cleaner the water the better, and (4)
The less time submerged the better.
*Seizures Cough
*Pink, frothy sputum *ALOC
*Absent respirations or pulse *Signs of respiratory distress
BLS TREATMENT
1. ABC, O2, Hx, PE, VS, Pulse Ox, (a) **Request Paramedic Evaluation if**
2. C-spine control if indicated • Unconscious/not breathing
4. Remove wet clothing and keep warm • Respiratory distress
5. Treat other associated signs and symptoms • Submersion confirmed > 1 min
per appropriate protocol • SCUBA diving accident
ILS TREATMENT
ALS TREATMENT
7. ECG
Note:
a. All patients suspected of submersion need to be evaluated at an emergency department & transported by
ALS due to high risk of flash pulmonary edema.
TRAUMA
SCUBA Diving Related – Decompression Illness
Dysbarism is a term that encompasses all pathologic changes caused by altered environmental pressures. It
most often develops acutely because of problems caused by the mechanical effects of pressure on closed air
spaces (barotraumas) or problems caused by breathing gasses at elevated partial pressures. Most dive related
injuries occur during descent or ascent within 0-33 feet of water. Two life-threatening conditions may occur as a
result of a diving accident-air embolism and decompression sickness-grouped together as Decompression Illness.
Air emboli occur when bubbles entering the blood steam, obstruct the blood flow to an area of the brain, usually
causing unconsciousness and paralysis within minutes of surfacing. Decompression sickness is the syndrome of
joint pain, numbness, paralysis and other symptoms caused by nitrogen gas dissolved in tissue forming bubbles.
Symptoms usually occur within ten minutes upon surfacing but can be evident up to 48 hours after diving
activities. Consider suggesting ED contact the Diver’s Alert Network (DAN) (919) 684-8111 or (877) 595-0625 for
secondary transport destination advice for hyperbaric oxygen therapy.
*Seizures Cough
*Pink, frothy sputum *ALOC
*Absent respirations or pulse *Signs of respiratory distress
BLS TREATMENT
1. ABC, Hx, PE, VS, pulse ox, **Request Paramedic Evaluation if**
blood glucose check (a)(b) • Unconscious/not breathing
2. C-spine control if indicated (c) • ALOC
3. Administer O2 per procedure (d) • Respiratory distress
4. Remove wet clothing and keep warm • Submersion confirmed > 1 min
5. Treat other associated signs and symptoms • SCUBA diving accident
ILS TREATMENT
6. Obtain IV access, PRN ** Request Paramedic Intercept When **
ALS TREATMENT
7. ECG PRN
Note:
a. All patients suspected of submersion need to be evaluated at an emergency department & transported by
ALS.
b. Obtain dive plan information, including repetitive dive plans and any previous dives within the
last twenty-four hour time period.
c. Maintain patient in supine position to prevent possible emboli progression / movement.
d. Patients should have high flow oxygenation therapy regardless of respiratory status.
TRAUMA
Falls/Accidents
Falls are the most common accidental injury in patients over 75 years of age and the second most common injury
in the group 65 to 74 years. Even a short fall can be life threatening. When approaching the scene, pay particular
attention to the height of the fall, surface the patient landed on, what part of the body hit first, if they struck
anything on the way down, and if there was a loss of consciousness. Syncope has been implicated in many cases
of elderly patients who fall and may be secondary to dysrhythmias, venous pooling, medication, hypoxia, anemia,
and hypoglycemia. Consider transporting to the most appropriate facility. Trauma band the patient. Simple falls
may be fatal in the elderly, assume fractures until proven otherwise, and consider full C-spine precautions.
Pain or trauma to the head, back, neck or extremities Paleness
Obvious bleeding *ALOC
*Rapid, weak pulse *Low blood pressure
*Signs of internal bleeding *Decreased capillary refill
BLS TREATMENT
1. ABC, Hx, PE, VS, Pulse Ox, **Request Paramedic Evaluation if**
blood glucose check PRN • Unconscious/not breathing
2. C-spine control if indicated(a) • ALOC
3. Control bleeding • Uncontrolled bleeding
4. Administer O2 per procedure • Seizures, secondary to recent head injury
5. NPO • Falls associated with or preceded by
6. Stabilize extremity deformities pain/discomfort in chest, dizziness, headache
7. Treat other associated signs and symptoms or diabetic
per appropriate protocol • Accident with penetrating/crushing injury to
• head, neck, torso or thigh
• Pt is experiencing or displaying neurologic
deficit
• Falls > 10 feet
ILS TREATMENT
8. Obtain IV access, ** Request Paramedic Intercept When **
ALS TREATMENT
10. ECG PRN
Note:
a. Add necessary supportive padding for malformations and elderly.
TRAUMA
Motor Vehicle Collision
Motor vehicle collisions can be classified as frontal, rear-end, lateral, rotational, or rollover impact. Recognizing
the mechanism of injury, having a good index of suspicion and doing a complete physical exam is critical in
making priority decisions of assessment, care and transport of the patient. When considering transport to the
most appropriate facility use the trauma triage tool. Activate the trauma system and trauma band the patient.
Neck or spinal cord injuries/pain Pain or trauma to the head, back, neck or extremities
Paleness Obvious bleeding
Penetrating wounds *ALOC
Diaphoresis *Rapid, weak pulse
*Low blood pressure *Signs of internal bleeding
*Decreased capillary refill (a)
BLS TREATMENT
1. Assure scene safety **Request Paramedic Evaluation if**
2. ABC, Hx, PE, VS, Pulse Ox, • Unconscious/not breathing
blood glucose check PRN • ALOC
3. C-spine control if indicated • Respiratory distress
4. Administer O2 per procedure • Chest pain prior to accident
5. Control bleeding • Patient ejected
6. Stabilize deformed extremities • Patient trapped, extrication > 20 min
7. Treat other associated signs and symptoms • MCI criteria met
ILS TREATMENT
8. Obtain IV access, **Request Paramedic Intercept When**
ALS TREATMENT
10. ECG PRN
Note:
a. Capillary refill time is a reliable sign typically only in infants and children less than 6 years old.
UNCONSCIOUS/UNRESPONSIVE/SYNCOPE
Altered Level of Consciousness
In the usual clinical approach to a patient, the examiner first obtains a history, performs a physical examination,
and then administers treatment. However, this sequence is not correct for patients with an altered level of
consciousness. Altered LOC is such a major variance from normal neurological function that immediate
supportive efforts may be required. For patients who do not have a gag reflex, mechanical airway control is
urgently needed to prevent aspiration. If a cervical spine fracture is suspected or if the mechanism of ALOC is
unknown, the neck must be stabilized while the airway is secured. The possibility of trauma always exists in
patients with seizures and alcohol or drug intoxication. Finally, obvious hemorrhage should be stopped before a
detailed neurological exam is initiated.
Medic alert tag Breath odor
*Evidence of trauma *ALOC
Hyper/hypotension *Evidence of drug use
*Abnormal /unusual breathing *Diaphoresis, chest pain
BLS TREATMENT
1. ABC, Hx, PE, orthostatic VS, Pulse Ox **Request Paramedic Evaluation if**
2. Check blood glucose (a) • Unconscious/not breathing
3. Administer Oral Glucose if less than 60 mg/dl • Multiple syncope episodes in same day
4. Administer O2 per procedure • Combined drugs and alcohol OD
5. C-spine control if indicated • Respiratory distress
6. Perform Prehospital Cincinnati Stroke Test • Syncope associated with headache, chest,
7. Treat other associated signs and symptoms pain/
per appropriate protocol discomfort/palpitations age > 40 diabetic,
GI/vaginal bleeding, abdominal pain
• Single syncope > 50
• Alcohol intoxication < 17
• Obvious DOA, cold, stiff, age < 1
ILS TREATMENT
9. Dextrose 25 - 50 g IVP PRN • Any ILS skills performed
10. Naloxone 0.4 – 2 mg IN/IV • Base Station Orders
ALS TREATMENT
11. ECG, with 12 lead PRN
13. Thiamine 100 mg IVP (b)
14. Glucagon 1 mg IM/IN/IV PRN
15. Naloxone 0.4 – 2 mg IM/IN/IV PRN
Note:
b. Given for the malnourished patient.
12-LEAD ECG
Today the 12-Lead ECG stands at the center of decision making for the care of patients with acute coronary
syndrome (ACS). The prehospital ECG has been demonstrated to be an effective means of rapidly identifying
patients with acute myocardial infarction who might be eligible for reperfusion therapy. More importantly the 12-
lead ECG increases the paramedic’s sensitivity for the diagnosis of cardiac ischemia/infarction versus non-
specific chest wall pain. When used appropriately, the 12-lead ECG will also allow the evaluator to be more
dynamic with decision-making, differential diagnosis and specific treatment interventions.
The following list is a suggestion of patients that should be considered candidates for 12-lead
ECG evaluation:
1) Chest pain, dyspnea, syncope, near syncope, weakness, DKA, diaphoresis, palpitations
2) CVA (CVA is often associated with large anterior wall MI’s and/or dysrhythmias)
3) Pre and post cardioversion of stable patients
4) Post cardioversion of unstable patients, including post arrest
5) Suspected electrolyte disturbances
6) Overdose (unknown or suspected anti-depressants)
7) Blunt chest trauma only if patient is stable and other appropriate care given
8) Irregular pulse rates
9) Respiratory failure and/or signs of hypoxia
10) CHF
11) Nausea and vomiting in females
The clinician should place the highest priority on being able to classify patients with acute coronary syndromes
(ACS) into 1 of 3 ECG classification groups: 1) ST-segment elevation or new or presumably new Left Bundle
Branch Block: suspicious for injury; 2) ST depression or dynamic T wave inversion: strongly suspicious for
ischemia; 3) Nondiagnostic ECG: absence of changes in ST segment or T waves
The following graph illustrates anatomically contiguous lead groups used to demonstrate infarct location
recognition
I Lateral aVR V1 Septal V4 Anterior
II Inferior aVL Lateral V2 Septal V5 Lateral
III Inferior aVF Inferior V3 Anterior V6 Lateral
ANATOMICALLY CONTIGUOUS LEADS
ADVANCED AIRWAY MANAGEMENT
RSI
It is frequently necessary to gain immediate control of the airway in the critically ill patient who may be hypoxic,
hemodynamically unstable, agitated, or uncooperative and at risk of further deterioration. RSI stands for Rapid
Sequence Intubation and has gained acceptance in pre-hospital medicine in most recent years.
ALS Treatment
(Standing Orders)
1. Pre-oxygenate with 100% O2 NRB. If ventilatory assistance is necessary, bag gently while
applying cricoid pressure
2. Assemble required equipment
-BVM
-Suction with Yankauer tip
-Endotracheal tube with intact cuff, stylette, syringe, ETT securing device
-Laryngoscope and blades
-Cricothyrotomy kit and/or Eschmann catheter kit
3. Check to insure that a functioning, secure IV line is in place
4. Continuously monitor the cardiac rhythm and oxygen saturation
5. Premedicate as appropriate
Atropine 0.02 mg/kg IVP for children (minimum dose 0.1 mg)
Lidocaine 1.5 mg/kg IV to patients with suspected head injuries
Midazolam 2.5 – 10 mg IV slowly
or
Etomidate 0.1- 0.3 mg/kg IV over 15 seconds (if available)(c)
Oxymetazoline (Afrin) to facilitate Nasal Intubation
6. Succinylcholine 1.5 mg/kg IVP
or
Vecuronium 0.1 mg/kg for the head injury patient or hyperkalemia (b)
7. Apnea, jaw relaxation, and decreased resistance to BVM indicates the patient is sufficiently
relaxed to proceed with intubation
8. Intubate. If unable to intubate during the first attempt, stop and ventilate the patient with
BVM for 30 – 60 seconds (a)
9. Treat bradycardia occurring during intubation with oxygenation and hyperventilation first. If no
improvement, Atropine 0.5 mg IV (See Pediatric Appendix)
10. Once intubation is completed, inflate the cuff and confirm tube placement by auscultation of
breath sounds, checking pulse oximetry and/or CO2 detection device if available.
11. Release cricoid pressure and secure tube
12. Vecuronium 0.1 mg/kg (b)
(Physician Orders)
1. Vecuronium 0.1 mg/kg (Mason County) (b)
Note:
a. If unable to intubate, bag the patient until spontaneous respiration returns or proceed with Eschmann
catheter, consider nasal intubation or surgical cricothyrotomy
b. When Vecuronium is used, administer Lorazepam 1-2mg IV or Midazolam 2.5-5mg IV PRN.
c. Consider using Etomidate for patients with shock syndrome or possible hyperkalemia
This page corrected on 01/16/04.
APGAR
Appearance:
Extremities as well as trunk are pink =2
Trunk is pink, feet and hands are blue =1
Entire body is blue (cyanotic) or pale =0
Pulse:
Heart rate > 100 =2
Heart rate < 100 =1
No pulse =0
Grimace:
Stimulation causes grimace, sneeze,
cough, or crying =2
Only some facial grimace =1
No reflexive activity =0
Activity:
Actively moving around =2
Some flexion without active movement =1
Is limp with no extremity movement =0
Respiration:
Good respiration and strong cry =2
Slow or irregular respirations with weak cry =1
No respiratory effort =0
1. A score of 7 – 10 = active and vigorous newborn

2. A score of 4 – 6 = moderately depressed newborn
3. A score of 0 – 3 = severely depressed newborn
AUTOMATIC EXTERNAL DEFIBRILLATION
Refer to American Heart Association current guidelines.

The AED policy and procedure applies to EMTs and FRs currently certified in the use automatic external
defibrillators.
1. Rationale for early defibrillation

a. The most frequent initial rhythm in sudden cardiac arrest is ventricular fibrillation.
b. The most effective treatment for ventricular fibrillation is electrical defibrillation.
c. The probability of successful defibrillation diminishes rapidly over time.
d. Ventricular fibrillation tends to convert to asystole within a few minutes.
2. General guidelines
a. One AED series equals zero (0) to three (3) shocks depending on what the AED indicates.
b. Never shock a conscious patient.
c. The goal of EMT/FR defibrillator technicians should be to provide defibrillation within 90 seconds of their
arrival at the scene of a cardiac arrest.
d. Rapid defibrillation is the treatment of choice for ventricular fibrillation and takes precedence over other
treatment modalities, such as suctioning, IVs, oxygen administration and chest compressions.
e. An EMT or FR may not change the automatic settings if a manual override capability is available.
f. If the ALS ETA is delayed, consider rendezvous/transport after contact with the incoming ALS unit.
3. Indications
a. Unresponsive, apneic, pulseless patients who are eight (8) years or older.
4. Contraindications
a. The following patients should not be attached to an automatic or semiautomatic defibrillator:
1. Any patient who is responsive, breathing, or has a pulse.
2. Obvious “dead on scene” (decapitation, decomposition, or the presence of rigor mortis).
3. Any patient who is actively seizing.
5. Precautions
a. All persons should be clear of the patient while the machine is analyzing the rhythm and/or delivering a
shock.
AUTOMATIC EXTERNAL DEFIBRILLATION (Continued)
6. Considerations
a. Pediatric cardiac arrests are usually due to respiratory failure. Evidence suggests that ventricular fibrillation
does occur in association with congenital heart problems, drug overdoses and glue sniffing.
b. Do not use adult pads on children.
c. Hypothermia:
1. Defibrillation should not be withheld from the cold patient in ventricular fibrillation.
2. Perform one series of AED protocol only.
3. If the patient does not respond to one AED series, resume CPR and re-warming efforts.
4. Do not continue defibrillation series.
d. Trauma
1. Consider the causes of the cardiac arrest before applying AED pads.
2. Cardiac arrest secondary to major trauma seldom responds to defibrillation.
3. Remember a ventricular fibrillation arrest may have been the actual cause of the accident.
e. If the AED protocol is interrupted by the return of a normal rhythm, continue AED monitoring of the patient.
Do not turn the unit off as the machine will reset back to the initial shock status.
7. Procedure
a. Verify unresponsiveness, apnea and the absence of a pulse.
b. Start CPR while the equipment is readied for use.
c. Call for ALS if not already enroute.
d. Turn on the AED.
e. Apply the pads to the patient’s bare chest.
f. Follow all AED screen and voice prompts during the rhythm analysis.
g. Administer up to three shocks if indicated.
h. Continue CPR for one minute.
i. Repeat f, g, and h until:
1. The ALS unit arrives and takes over resuscitative efforts.
2. The Base Station Physician orders you to discontinue efforts.
8. Training and skills maintenance

a. Any AED operator must practice their skills with the device every six months. This should include reviewing
incidents of AED use in the system, studying any new protocols, and most important, practice working with
the AED.
9. Post AED usage

a. Each event requires a complete MIR to accompany incident the recording device (i.e., tape, card) to the
EMS office within 24 – 48 hours after the event for downloading and review.
b. Data cards or modules must be downloaded and erased after use to assure a clean card for future use.
Events will not record over existing data on cards or tapes.
CARDIOPULMONARY RESUSCITATION
1. Adult ( 8 years):
a. Determine unresponsiveness.
b. Open the airway using head-tilt-chin lift (jaw –thrust if trauma suspected).
c. Determine breathlessness.
d. Give 2 slow breaths using pocket mask or bag-mask in conjunction with airway adjunct PRN.
e. Determine pulselessness.
f. If the patient has a pulse, perform rescue breathing;
• Provide 12 breaths per minute (1 breath every 5 seconds). (a)
g. If no pulse and AED available, attach pads and analyze rhythm. (b)
h. If no pulse, and no AED, begin the first cycle of compressions and ventilations;
1. Find position on lower half of sternum.
2. Depress sternum 1½ to 2 inches at a rate of 100 compressions per minute.
i. Use a ratio of 2 breaths to 15 compressions with 1 and 2 rescuers CPR until the airway is secured, then
ratio of 1 breath to 5 compressions for 2 rescuer CPR;
1. Check for return of breathing and pulse after 1 minute of CPR.
2. If no pulse, resume CPR.
3. If there is a pulse but no breathing, give 1 rescue breath every 5 seconds
2. Child (1 to 8 years):
a. Determine unresponsiveness.
b. Open the airway using head tilt-chin lift (jaw-thrust if trauma suspected).
c. Determine breathlessness.
d. Give 2 rescue breaths using a pocket-mask or bag-mask.
e. Determine pulselessness.
• Provide 20 breaths per minute (1 breath every 3 seconds).
g. If no pulse, begin the first cycle of chest compressions and ventilations;
1. Find proper hand position as in adults.
2. Compress the sternum approximately 1 to 1½ inches.
3. Use only the heel of the hand.
4. Compress the chest 100 times per minute, giving 1 rescue breath for every 5 compressions.
h. Use a ratio of 1 breath to 5 compressions with 1 and 2 rescuer CPR;
1. Check for return of breathing and pulse after 1 minute of CPR.
2. If no pulse, resume CPR.
3. If there is a pulse but no breathing, give 1 rescue breath every 3 seconds.
4. After several cycles, recheck breathing and pulse.
i. If the pulse returns, check for spontaneous breathing. If there is no breathing, give 1 rescue breath
every 3 seconds.
CARDIOPULMONARY RESUSCITATION (Continued)
3. Infant (less than 1 year):

a. Determine unresponsive.
b. Position the infant on his back on a firm surface.
c. Open the airway using head tilt-chin lift (jaw-thrust if trauma suspected);
• Take care not to tilt the head to far back.
d. Determine breathlessness;
• If the patient is not breathing, give 2 gentle rescue breaths using a pocket-mask or bag-mask.
e. Determine pulselessness;
• Feel for the brachial pulse.
• Provide 20 ventilations per minute (1 breath every 3 seconds).
g. If no pulse, begin the first cycle of compressions and ventilations;
1. For one-rescuer CPR: Imagine a line drawn between the nipples, and place your index finger
below that line in the center of the chest. Place the middle and ring finger next to the index finger;
rd th
use the 3 and 4 fingers to compress the sternum.
2. For two-rescuer CPR: The “2 thumb-encircling hands” technique is preferred for
compressions.
3. Do not compress over the xyphoid process.
4. Compress the sternum approximately ½ to 1 inch at least 100 times per minute.
5. Give 1 rescue breath for every 5 compressions.
Note:
a. For continuous ventilations use smaller tidal volumes and cricoid pressure with the bag-valve-
mask.
b. See procedure use of Automatic External Defibrillation (AED).
CENTRAL LINE CATHETER ACCESS and ADJUNCTS
PHYSICIAN ORDER ONLY
1. An ALS responder may not access an A-V shunt.
2. An ALS responder may not access a central line catheter or any other permanent indwelling line
except:
a. In situation of cardiac arrest
b. Symptomatic hypovolemic shock
c. Under request of base station physician
3. ALS provider must follow written procedure for central line catheter access.
PROCEDURE:
A. Sterile technique must be maintained.

B. Use sterile gloves.
C. Clean port with Betadine swab followed by alcohol swab.
D. Unclamp catheter and inject 10cc saline.
E. Aspirate back for blood return.
F. If blood returns, clamp catheter.
G. Remove syringe and connect IV solution, unclamp.
H. Administer solution at appropriate rate.
I. Do not draw blood from catheter.
CHEST DECOMPRESSION
To be performed only in a rapidly deteriorating patient, with Medical Control concurrence whenever possible. If
two ALS providers are on scene and available agreement on the necessity of the procedure should be sought.
1. While BLS provider places high flow O2, Identify the second intercostal space midclavicular line on the affected
side.
2. Prepare the skin area using appropriate antiseptic solution. Use sterile gloves for handling and inserting
catheter or needle.
3. Prepare a flutter valve from a 10-14 gauge catheter-over needle or simple needle with a connected latex tube
(may use finger of a sterile glove).
4. TENSION PNEUMOTHORAX:
Insert needle into chest at the midclavicular line second intercostal space. Be cautious of nerves, arteries and
veins located just beneath each rib. The needle should pass just over the third rib.
HEMOTHORAX:
th th
Insert needle into chest at midaxillary line within the 5 and 6 intercostal space. The needle should pass
th
just over the 6 rib.
5. Appropriate placement of the catheter into the pleural space should be confirmed with a rush of air out
of the catheter.
6. Remove needle leaving catheter with flutter valve in place.
7. Secure catheter to the chest wall.
8. Ensure adequate respirations and air flow.
9. Intubate if needed.
10. Continually monitor and reassess the patient.
CHOKING

1. Conscious:
a. Determine if victim is able to speak or cough.
b. Perform the Heimlich maneuver (abdominal thrust) until the foreign body is
expelled or the victim becomes unconscious.
• Stand behind the victim and wrap your arms around the victim’s waist.
Press fist into abdomen with quick inward and upward thrusts.
c. Do the chest thrust for victims who are in advanced pregnancy or who are obese.
• Stand behind the victim and place your arms under the victim’s armpits
to encircle the chest. Press with quick backward thrusts
2. Unconscious:
a. Check for a foreign body.
1. Remove the foreign body only if seen. No blind finger sweep.
b. Attempt rescue breathing.
1. Open the airway.
2. Try to give 2 breaths. If needed, reposition the head and try again.
c. If the airway is obstructed, perform the Heimlich maneuver.
1. Kneel astride the victim’s thighs.
2. Place the heel of one hand on the victim’s abdomen, midline slightly
above the navel and well below the tip of the xyphoid process.
3. Place the second hand on top of the first.
4. Press into the abdomen with quick upward thrusts.
d. Repeat the sequence until successful.
1. Alternate between the finger sweep, rescue breathing attempts, and abdominal thrusts.
CINCINNATI STROKE TEST
The prehospital stroke test developed in Cincinnati effectively identifies patients with stroke. This scale evaluates
three major physical findings: facial droop, motor arm weakness and speech abnormalities. The condensed
examination can be accomplished with a series of simple tests that can help prehospital care providers to quickly
identify a stroke patient who requires rapid transport to the hospital. A more extensive examination or institution of
supportive therapies can be accomplished enroute to the hospital and in the emergency department. If possible,
prehospital care providers should establish the time of onset of stroke signs and symptoms. This timing will have
important implications for potential therapy. If the time of onset of symptoms is viewed as time zero, all
assessments and therapies can be related to that time.
1. Facial droop – Have the patient show their teeth or smile.

a. Normal – Both sides of face move equally well.
b. Abnormal – One side of the face does not move as well as the other.
2. Arm drift – The patient closes their eyes and holds both arms out.
a. Normal – Both arms move the same direction or do not move at all (pronator grip may be helpful).
b. Abnormal – One arm does not move or one arm drifts down compared to the other.
3. Speech – Have the patient say “you can’t teach an old dog new tricks”
a. Normal – The patient uses the correct words with no slurring
b. Abnormal – The patient slurs their words, uses inappropriate words or is unable to speak.
Report specific findings for example; left side facial drooping, slurred speech.
HYPERKALEMIA
Hyperkalemia can lead to sudden death from cardiac dysrhythmias, so any suggestion of hyperkalemia requires
an immediate ECG to ascertain whether signs of electrolyte imbalance are present. Hyperkalemia has been
associated with a markedly increased risk of mortality and morbidity – as high as 67% - and accordingly,
managing this blood chemistry shift is extremely important. The extremely elevated potassium level is the primary
cause of morbidity and death for these patients because of potassium’s effect on the myocardium. In order to
ensure resuscitative efforts are appropriate and effective, consider this procedure whenever severe hyperkalemia
is suspected. Beyond those with advanced diabetes mellitus and renal failure / end-stage renal disease, patients
with known or suspected rhabdomyolysis (trauma and/or burn patients, hepatic failure, military / fire recruits,
etc…), cancer patients (tumorlysis), and even elderly patients predisposed to polypharmacy can be at a
significant risk for hyperkalemia. Additionally, otherwise healthy diabetics who are (often) taking ACE-inhibitors or
angiotensin receptor blockers are at increased risk for hyperkalemia. Please keep these things in mind when
considering the best course of treatment for cardiac arrest victims (or even patients with marked QRS widening
and hypotension) that may belong to one of the above groups. Consider for VT/VF, PEA or Asystole often seen
on monitor with a “sin wave” (~) appearance.
PROCEDURE:
1. Sodium Bicarbonate 1 mEq/kg, not to exceed 50-100 mEq

2. Calcium Chloride 1 g
3. D50 1-2 amps concomitantly with 5-10 units regular insulin (Patients own Rx)
4. Follow “Central Line Access” procedure if necessary
5. Consider fluid bolus of NS
6. Albuterol 20 mg via continuous nebulizer
7. Treat associated signs and symptoms as appropriate
DIFFICULT INTUBATIONS WITH THE ENDOTRACHEAL TUBE INTRODUCER
(aka Eschmann catheter, tracheal tube introducer or Gum Elastic Bougie)
Description -60 cm long semi-rigid, resin coated, braided polyester instrument

st
-has been in clinical use for about 30 years (1 use described in 1949)
-used with endotracheal tubes larger than 6.0 mm
-first 2.5 cm angled approximately 40° to facilitate placement
Indications -any situation involving poor vocal cord visualization

-anatomic, traumatic, or pathologic conditions limiting laryngeal access
-tracheal deviation
-cervical spine immobilization
Advantages -used customary and familiar oral route

-requires no set-up
-relatively inexpensive (can be sterilized and reused 5Xs per manufacturers recommendations)
-takes 20 – 45 seconds to accomplish procedure
Technique 1. Lubricate bougie with water soluble lubricant

-Option: slide appropriately selected endotracheal tube over the bougie
2. With the tip directed anteriorly guide bougie toward the epiglottis
3. Advance the bougie posterior to the epiglottis and into the glottic opening
4. Cricoid pressure may facilitate correct placement (when the tip of the
introducer passes the cricoid cartilage and enters the trachea it also may be
palpable at the anatomic location)
5. The operator may be able to feel the bougie “click” or “bump” over the anterior
tracheal rings(“wash boarding or railroading”)
6. Use the laryngoscope to elevate the pharyngeal soft tissue
7. Subtle maneuvering may be required to traverse the vocal cords
8. Advance to the carina (resistance to passage) to verify placement
(approximately 45 cm). Once advanced to the carina, further insertion causes
the bougie to rotate on entrance into a bronchus as an additional criterion to
confirm correct placement. Failure to meet resistance after inserting nearly
the full length of the bougie indicates esophageal placement.
Withdraw and align the black “lip-line marker” with the lips (1 cm band located
40 cm (4 stripes) from proximal end)
9. Pass endotracheal tube (larger than 6.0 mm) over the bougie
10. If the endotracheal tube catches on the arytenoid or aryepiglottic folds,
withdraw the tube slightly and rotate it 90° counterclockwise and advance it
forward (allows beveled end to pass)
11. For optimal passage of the tube over the bougie into the trachea, the
laryngoscope may be left in place as the endotracheal tube is advanced with
the bevel facing posteriorly
12. Secure the tube (remove bougie) and verify tube placement
DISCONTINUATION OF CPR
Cardiopulmonary resuscitation has the same goal as all other medical interventions- to preserve life, restore
health and relieve suffering and limit disability. An additional goal unique to advanced cardiac life support (ACLS)
is the reversal of “clinical death.” However, in providing ACLS these goals are often not achieved or may not be
in the patient’s best interest. Each decision to discontinue CPR/ACLS must be individualized and made with
compassion and reason.
ALS/BLS Treatment
1. CPR may be discontinued without Base Station contact and the patient determined to be dead for the
following reasons only if:
a. Upon further examination it is determined that the patient meets the
“Determination of Death Criteria” and CPR was initiated prior to this discovery.
b. CPR was initiated but upon the arrival of the Paramedic, it is determined that the patient is in blunt trauma
arrest.
c. Endotracheal intubation and drug therapy appropriate to the presenting rhythm, according to AHA
guidelines, have been initiated and the patient remains apneic, pulseless, and in asystole or PEA.
d. DNR papers are presented after CPR was initiated.
2. Once death has been determined and resuscitation efforts discontinued, all ALS therapeutic modalities
initiated during the resuscitation must be left in place until it has been determined that the patient will not be a
Coroner’s case. This includes such equipment as endotracheal tubes, IV catheters, monitor electrodes and
personal items including clothes, jewelry etc. If the Coroner releases the body while the prehospital care
provider is still on scene, remove all medical equipment used during the resuscitation.
3. Children fourteen years and under are excluded from this policy unless ALS personnel make Base contact for
consultation with the Base Hospital Physician.
DO NOT ATTEMPT RESUSCITATION – DETERMINATION OF FIELD DEATH
1. Prehospital care providers need not initiate CPR or ALS measures when death has been determined using
the criteria outlined in this policy.
2. Prehospital care providers need not initiate CPR if:

a. POLST form or DNR papers dated and signed by the patient, are available with appropriate witnessed
signatures and there is no question they belong to the patient. The patient may be of any age.
b. Banded with the State Banding system or EMS-NO CPR Form is present.
3. Paramedics may declare apparent death but may not pronounce death. Once CPR has been initiated and
there is no favorable response, consider discontinuation of CPR as outlined in “Discontinuation of CPR”
procedure.
4. Death category criteria (a)

a. Category I – obvious death
- Decomposition of body tissue
- Total decapitation
- Total incineration
- Total separation or destruction of the heart or brain
b. Category II – (b)
- Non-breathing
- Pulselessness
- Rigor Mortis
- Asystole in two leads
c. Category III – Traumatic Arrest (c)
- Trauma deaths which do not meet the criteria in Category I or II, require resuscitation
Note:
a. Prehospital care providers desiring support in the field may contact the Base
Station Hospital at any time for Determination of Death
b. Exception – suspected hypothermia requires full resuscitation efforts
c. Non-breathing and pulseless with prolonged extrication time
EMERGENCY EPINEPHRINE ADMINISTRATION
by the EMT
Serious signs & symptoms
*Epi Needed?
Is patient in extremis?
YES NO
No
Prescription Prescription Do Not
Administer
Epi
Administer Epi
to any age < 18 yrs > 18 yrs
patient
Patient, Parent or
Guardian Request
(verbal or written) Attempt Base
Station contact
prior to
ADMINISTERING
EPINEPHRINE
YES NO
ADMINISTER Attempt Base

EPINEPHRINE Station contact
prior to
ADMINISTERING
EPINEPHRINE
*Administer Epi only if signs & symptoms include respiratory distress or hypoperfusion.
EMT-Basic MEDICATIONS
Medications that may be administered by the EMT-Basic in the prehospital setting.
POLICY
1. EMT-Basic may administer/assist the following medications if indicated
a. Patient’s metered dose inhaler (MDI) per prescription
b. Epinephrine auto-injector (a)
c. Nitroglycerin patient’s own per prescription SL tab if SBP is > 100 mmHg (b)
d. Oral glucose paste for Pt’s with glucose of 60 mg/dl or less
e. Aspirin 81 mg PO chewed to total 325 mg (4 tabs) (c)
2. The EMT-Basic may administer only after Base Station contact

a. Activated charcoal
3. Basic Life Support (BLS) units are permitted to carry the following medications
a. Activated Charcoal 50 Gm
b. Aspirin – Patients do not necessarily take Aspirin on a routine basis requiring EMTs to carry it.
d. Epinephrine auto-injector (junior and adult)
e. Oral glucose paste
NOTE:
a. A single dose may not reverse the effects of an anaphylactic reaction.
Administer additional Epinephrine auto-injections, as needed. Bring
additional auto-injectors with the patient for use during transportation, if
necessary.
b. Nitroglycerin should be used in patients with established coronary
artery chest pain, symptoms of cardiac ischemic events and who are
already taking Nitroglycerin by prescription. Patients who have taken
the medication Viagra within twenty-four (24) hours of the onset of
chest pain should not be given Nitroglycerin.
c. All patients with the complaint of cardiac chest pain should receive
aspirin unless they are allergic to it.
EMT-Intermediate MEDICATIONS (ILS)
To identify medications that may be administered by the EMT Intermediate in the prehospital setting.
POLICY
1. EMT Intermediate may administer/assist the following medications if indicated:
a. Albuterol 2.5 mg SVN for inhalation (a) Pediatric dose is ½ adult dose
b. Aspirin 325 mg PO may use 4 children’s 81 mg tablets chewed (d)
c. Dextrose 50% and 25% IV for Pt’s with glucose of 60 mg/dl or less
d. Epinephrine 1:1000 Adult 0.1-0.3 mg SQ or Pediatric 0.01mg/kg SQ (max 0.3 mg) (b)
e Naloxone: 2 mg IN/IV,
May repeat in 2 to 3 minute intervals to a maximum of 10 mg
Pediatric dose 0.1 mg/kg
f. Nitroglycerin ; one dose 0.4 mg SL tab or Spray may repeat in 3 to 5 min if SBP is > 100 mmHg
and authorized by base station up to a maximum of three doses (c)
g. Oral Glucose Paste for Pt’s with blood glucose level of 60 mg/dl or less
2. EMT Intermediate may administer only after Base Station contact

a. Activated Charcoal PO
NOTE:
a. Also known as Proventil or Ventolin
b. Epinephrine for anaphylaxis administered from a commercially preloaded measured device. A single
dose may not reverse the effects of an anaphylactic reaction. Administer additional doses as needed.
c. Nitroglycerin should be used in patients with established coronary
artery chest pain, symptoms of cardiac ischemic events and who are
already taking Nitroglycerin by prescription. Patients who have taken
the medication Viagra within twenty-four (24) hours of the onset of
chest pain should not be given Nitroglycerin
d. All patients with the complaint of cardiac chest pain should receive
aspirin unless they are allergic to it

EMT – IV THERAPY
1. The role of the EMT-IV Technician is to assist the paramedic by starting an IV or Saline lock. They must first
provide basic patient care including appropriate airway management, basic life support, and standard early
trauma treatment, including spinal immobilization and control of hemorrhage prior to the initiation of IV
therapy.
2. State law currently does not allow EMT-IV Technicians to administer medications IV.
3. In all cases, higher priority treatment should not be delayed, including times when there is a need to rush the
patient to the hospital.
4. EMT-IV Technicians may perform a glucose check as directed by protocol.
5. EMT-IV Technicians are authorized to start peripheral intravenous infusions in the upper extremities of adult
patients above the age of 12 without paramedic or Base Station Hospital contact in the following
circumstances only:
a. Cardiac Arrest. An IV of Normal Saline running at a keep-open rate should be established after initiation
of CPR provided there are sufficient personnel available to provide basic life support.
b. Traumatic Shock. A large bore IV of Normal Saline running wide open should be established when
patient who has suffered significant trauma and has no radial pulses, and a pulse rate over 100.
c. Diabetes with Altered Level of Consciousness. An IV of Normal Saline or D5W after blood glucose check
d. Suspected Anaphylaxis. A large bore IV of Normal Saline to run wide open may be started on a patient
with a blood pressure of less than 80 systolic, with hives, or an appropriate history.
e. IV Order. An IV of Normal Saline or a Saline Lock may be started at a specific rate on the direction of the
Base Station Hospital physician.
f. IV Maintenance. An IV line may be maintained during inter-facility transports provided there is no
medication being infused.
ESOPHAGEAL TRACHEAL COMBITUBE
To be used by ETC Certified prehospital care providers
INDICATIONS
1. Cardiopulmonary arrest
2. Respiratory arrest
BASIC LIFE SUPPORT

1. Verify cardiac and/or respiratory arrest
2. Initiate CPR (if indicated) and ventilate per pocket mask or BVM with supplemental O2
3. Ventilate 1 – 2 minutes prior to the ETC intubation attempt
COMBITUBE INTUBATION
1. If the patient is in cardiopulmonary arrest, and an automated or manual defibrillator is immediately

available, first proceed with AED per procedure
2. Placement of the ETC may be done at a point during the AED procedure where a shock is not
indicated, or where rhythm analysis is not being performed
3. After determining the patient' s height, place the patient's head in a neutral position
4. Insert ETC along the midline of the mouth. Advance gently until the teeth (or gums) are aligned
between the two black rings on the tube
5. For patients greater than five (5) feet in height, use the regular adult size ETC
a. Using the large syringe, inflate Line 1 through the pilot balloon with 100 cc of air
b. Using the small syringe, Inflate Line 2 through the pilot balloon with 15 cc of air
6. For patients between four (4) and five (5) feet in height, use the small adult (SA) size ETC
a. Using the large syringe, inflate Line 1 through the pilot balloon with 85 cc of air
b. Using the small syringe, inflate Line 2 through the pilot balloon with 12 cc of air
7. Attach a BVM with supplemental O2 to Tube #1 and begin ventilations
8. Using a stethoscope, listen for lung sounds in both lateral lung fields and over the epigastrium
a. If lung sounds are present, and there are no gastric sounds, continue ventilations
b. If lung sounds are absent, and gastric sounds are present, esophageal placement may have been
accomplished:
1. Remove the bag-valve device from Tube #1 and continue ventilations through Tube #2
2. Listen for lung sounds in both lateral lung fields and over the epigastrium
3. If lung sounds are absent and air exchange is heard over the epigastrium, deflate both cuffs,
remove the ETC and continue ventilations
4. If neither lung sounds or gastric sounds are heard, deflate the pharyngeal cuff and gently
withdraw the ETC approximately 2 – 3 cm and attempt to ventilate through Tube #1
9. The entire procedure should be accomplished within 30 seconds or less
10. During the first attempt, if resistance is encountered during insertion, consider the use of a water-
soluble lubricant applied to the distal shaft of the ETC
11. If unsuccessful after the second attempt to insert the ETC, discontinue the procedure and continue
ventilations using an alternative method
12. If esophageal intubation has occurred, consider attaching the mask elbow to Tube #2 to deflect the
potential flow of stomach contents
13. Periodically check for appropriate placement of the ETC and adequate ventilations
ESOPHAGEAL TRACHEAL COMBITUBE (Continued)
EXTUBATION OF THE COMBITUBE

If the patient regains consciousness or begins to fight the tube, restrain the patient if necessary and
immediately remove the ETC:
a. Turn the patient on their side
b. Deflate both the pharyngeal and esophageal cuffs through Lines 1 and 2
c. Gently remove the ETC
d. Be prepared for the patient to vomit. Suction as needed
e. Assure the patient's airway is patent and respirations are adequate assist ventilations as necessary
f. Administer O2 by NRB
IF ENDOTRACHEAL TUBE IS TO BE PLACED BY ALS PERSONNEL

1. When the ALS provider is ready to intubate, deflate the pharyngeal cuff through Line #1
2. Move the ETC to the left side of the patient'
s mouth
3. After the endotracheal tube has been successfully placed, deflate the esophageal cuff through Line #2
and gently remove the ETC
CONTRAINDICATIONS
1. An intact gag reflex
2. Airway obstruction
3. Patients under four (4) feet in height
4. Cases of known or suspected caustic ingestion
5. Known esophageal disease
6. Conscious or unconscious breathing patients
NOTE
1. For patients in cardiopulmonary arrest, early defibrillation takes precedence over placement of ETC.
2. Before releasing a patient with an ETC in place to another level of care (i.e., emergency physician,
nurse, paramedic), the certified prehospital care provider performing the procedure must be certain
that the receiving person is knowledgeable about the proper use and function of the device, and is
aware that it is in place.
3. In the event an ETC has been placed, and the ambulance that will transport the patient is not staffed
with personnel trained to use the device, the certified prehospital care provider who performed the
procedure will remain with the patient throughout transport, or until personnel with an equal or higher
level of certification can assume patient care.
4. Continuing education and skill practice with the Combitube must be completed every 90 days.
INTRAOSSEOUS ACCESS
Tibial / Sternal
This skill may be preformed by certified prehospital providers only and is only indicated for patients in
extremis.
INDICATIONS:
a. Emergency administration of fluids and/or medications, especially in the setting of circulatory collapse
where vascular access is essential.
b. Difficult, delayed or impossible venous access
c. Burns or other injuries preventing venous access at other sites.
Tibia (Anteromedial Surface)
1. Prepare insertion site with iodine and alcohol swabs. Maintain aseptic technique throughout
procedure.
2. Place index finger on tibial tuberosity and thumb on medial edge of tibia. Halfway between these
points and 1-2 cm distally, using aseptic technique, insert the needle perpendicular to the flat surface
of the bone and aim slightly away from the joint, using a boring motion back and forth. A pop or
sudden decrease in resistance signals entrance into the medullary canal. If bone marrow is aspirated,
irrigate the needle to prevent obstruction.
3. Remove stylet, slowly inject 10 ml of normal saline to verify placement, if patent stabilize with bulky
dressing for support. If signs of infiltration are present, stop the infusion, remove needle, and attempt
in the other leg.
4. Document procedure.
Sternum (Manubrium) using F.A.S.T. 1 IO System (for use by ALS providers only)
1. Expose sternum. Prepare insertion site with iodine and alcohol swabs. Maintain aseptic technique
throughout procedure.
2. Locate sternal notch with index finger held perpendicular to manubrium. Using index finger, align
notch in Patch with patient’s sternal notch. Verify Target Zone is over patient’s midline. Take
corrective action if error is greater than about 1 cm (3/8”). Secure top half of Patch to patient.
3. Remove Sharps Cap from Introducer. Place bone probe cluster in target zone. Ensure that the
Introducer axis is perpendicular (90˚) to the skin at the insertion site. Ensure the entire bone probe
cluster is within the target zone.
4. Pressing straight along the Introducer axis, with hand and elbow in line, push with firm and increasing
force until a distinct release is heard and felt. The Introducer must remain perpendicular to the skin
during insertion. After release, pull straight back to remove the Introducer, exposing the infusion Tube.
5. To dispose of sharps, push the used bone probe into the foam-filled sharps plug.
6. Attach right-angle female connector on Patch to Infusion Tube. Verify placement by attaching syringe
to straight female connector and withdrawing marrow into Infusion tube. Increase fluid flow rate by
flushing system with 10ml of saline.
7. Attach straight female connector on Patch to purged source of fluid or drugs. Fluid can now flow to the
site.
8. Place Dome over Patch and press down firmly to engage Velcro fastening.
9. Attach UNOPENED sterile remover package to the patient (arm, leg, chart) This MUST BE
TRANSPORTED WITH THE PATIENT.
Note:
a. As the insertion force required can be considerable, some users may find a two-handed grip on
the introducer allows better control during insertion of the Infusion Tube.
b. If fluid does not flow at all or if extravasation occurs, discontinue and an alternative vascular
access method should be used.
LARYNGEAL MASK AIRWAY
(LMA)
The LMA is an airway adjunct with an inflatable cuff which creates an internal mask like protection of the airway.
Use of the LMA may be preferred over endotracheal intubation in certain situations such as possible unstable
neck injuries, access to the patient is limited, or appropriate positioning of the patient for tracheal intubation is
difficult or impossible. The possibility of errors using the LMA is much lower than the risks involved with
endotracheal intubation. Blind insertion means the provider does not have to learn to use a laryngoscope or
visualize the tracheal opening.
INDICATIONS
1. Cardiopulmonary arrest
2. Respiratory arrest
3. Unprotected airway
BASIC LIFE SUPPORT
1. Verify cardiac and/or respiratory arrest

2. Initiate CPR (if indicated) and ventilate per pocket mask or BVM with supplemental O2
3. Ventilate 1 – 2 minutes prior to the LMA insertion
PROCEDURE
1. Prior to insertion check inflatable cuff for leaks and verify it is intact.
2. With the cuff deflated, blindly insert the mask like projection into the pharynx.
3. Advance until resistance is felt. The resistance indicates that the distal end of the LMA has reached the
hypopharynx.
4. Inflate the cuff. When the cuff is inflated the mask is pushed up against the tracheal opening, providing
an effective seal and a clear airway into the trachea.
5. Ventilate patient with a BVM, assess lung and epigastric region to confirm placement and respirations
are effective.
* This procedure is for use by advanced airway technicians and paramedics formally trained in its use.
MNEMONIC’S
MEDICAL
Signs and symptoms Provocation, progression
Allergies Quality
Medications Radiation
Pertinent past medical history Severity
Last oral intake Time
Events leading to injury or illness
Progression of symptoms Morphine

Associated chest pain Oxygen
Sputum production, speech, word sentences Nitrates
Temperature, tiredness Aspirin
Medications the patient is currently taking
Exercise normally tolerated
Diagnosis (previous)
TRAUMA
Deformities Burns
Contusions Tenderness
Abrasions Lacerations
Punctures Swelling
NEUROLOGICAL GLASGOW COMA SCORE

Alert Eye Opening
Verbal 4 - Spontaneous
Pain 3 – To Command
Unresponsiveness 2 – To Pain
1 – No Response
CHARTING Best Verbal Response
Subjective 5 - Oriented
Objective 4 - Confused
Assessment 3 – Inappropriate Words
Plan 2 - Incomprehensible
1 – No Response
Best Motor Response
6 – Obeys Commands
5 – Localizes Pain
4 – Withdraws from Pain
3 – Flexion (decorticate)
2 – Extension (decerebrate)
1 – No Response
MNEMONIC’S (continued)
CAUSES OF PULSELESS ELECTRICAL ACTIVITY (PEA) – The “5” H’s and “5” T’s
Hypovolemia Tablets (drug OD, accidents)
Hypoxia Tamponade, cardiac
Hydrogen ion – acidosis Tension Pneumothorax
Hyper/Hypokalemia Thrombosis, coronary (ACS)
Hypothermia Thrombosis, pulmonary (embolism)
Trauma Assessment
Scene safety
Spinal Stabilization
LOC
Airway
Breathing
Oxygen
Circulation
Arterial Bleeds
Bare the Body
T – Tracks, Tags, Tattoos

I – Instability
C – Crepitus
S - Scars
V - Vitals
O – Oxygen
M – Monitor
I – IV / Information
T – Transport decision
H – History
A – Allergies
M - Medications
NASOGASTRIC TUBE INSERTION
Paramedics may insert a nasogastric tube on pediatric patients requiring intubation with an uncuffed tube and
adults with distended abdomens in cardiac arrest. Its purpose is to relieve pressure and distention of the stomach
by removing fluid or air
PROCEDURE
1. Measure the length of the tube to be inserted by placing the tip of the tube over the approximate area of the
stomach and extending it to the patient’s ear and from the ear to the tip of the nose. Note the marks on the
tube
used for measurement
2. Lubricate distal end of the tube with a water soluble lubricant
3. Insert the NG tube into the nose and slowly pass it the distance to where the
tube was marked
a. Flexing the neck will help with tube placement as long as c-spine
precautions are maintained if indicated
4. To check for proper tube placement, connect a 10 – 20 cc syringe to the NG
tube and attempt to aspirate stomach contents. If no contents are obtained
disconnect the syringe. Fill the same syringe with air. Put a stethoscope over
the stomach area and inject air through the NG tube rapidly. If the tube is in
the stomach, a loud burping noise will be heard
a. If no stomach contents are aspirated or no burping sound is heard with the
injection of air, remove the tube and try again
b. Often the NG tube will follow the ET tube
c. If aspiration with the syringe is done too vigorously, the NG tube may
collapse and aspiration of stomach contents would not be possible
5. Secure the tube with a minimal amount of tape to the nose
6. The NG tube should be connected from low to medium suction
a. Syringe aspiration will suffice on small infants
NITROUS OXIDE (NITRONOX®)
DISCUSSION:
Inhalation of a mixture of 50% Nitrous Oxide and 50% Oxygen provides fast safe sedation and pain relief for
patients. The analgesic provides quick onset after inhalation, it last for only a short time, and has virtually no side
effects or making of symptoms. It has been proven effective in the field, in transport and in medical facilities
worldwide.
Nitrous Oxide is a self administered analgesic gas containing a mixture of 50% oxygen and 50% nitrous oxide.
NitroNox® is supplied in a carrying case containing a nitrous oxide cylinder, a mixing valve, and tubing and
utilizes a supplemental oxygen supply. These agents are mixed on administration to deliver a 50% concentration
of each to the patient. Negative pressure is required to open the valve, so the patient must have and airtight seal
at the facemask.
ACTIONS:
Anesthetic, potent analgesic:
NitroNox ® Produces rapid, reversible pain relief. A 50:50 Nitrous Oxide and oxygen mixture is equivalent to 15-
20mg of Morphine Sulfate.
1. Analgesic begins within 20 seconds of inhalation
2. Peak analgesia occurs within 40-120 seconds.
3. Duration of action is 2-5 minutes.
4. When it is discontinued, complete exhalation of the Nitrous Oxide occurs in approximately 3 minutes.
INDICATIONS:
1. Pain from musculo-skeletal trauma
2. Cardiac chest pain
3. Pain associated with non-hemorrhagic acute abdomen (especially renal stones)
4. Pain associated with burns
5. Sever pain, with physician approval
CONTRAINDICATIONS:
1. Any patient who cannot self administer NitroNox®
2. Head injuries and/or altered level of consciousness
3. Severe Maxillofacial injuries
4. COPD, respiratory distress, pneumothorax
5. Patients under 12 years of age (see “Infants and Children” below)
6. Pregnancy
7. Bowel Obstruction
8. Penetrating chest injury
9. Nitrogen narcosis (the Bends from SCUBA)
NITROUS OXIDE (NITRONOX®) continued
PRECAUTIONS:
1. NitroNox® is a patient controlled treatment. Paramedical personnel must not hold it on the patient.
2. Nitrous Oxide is not flammable but will support combustion in the same manner as oxygen.
3. If side effects occur, discontinue inhalation therapy and apply 100% oxygen for at least 5 minutes.
4. Use only in a well ventilated area.
5. May not operate properly at low temperatures.
6. Carefully monitor vital signs, ECG and oxygen saturation. O2 saturation must be >90% prior to and
during administration of NitroNox®.
7. The NitroNox® unit must be in an upright position when in use.
ADMINISTRATION:
1. Assure the Medic or Aid unit is well ventilated. (Vent fan on, window open)
2. Instruct patient to administration NitroNox® to themselves by placing the mask tightly against their face
and breathe deeply and slowly.
3. Allow mask to fall away from face spontaneously when effects are felt.
4. Paramedical personnel must not place or replace the mask on the patient face.
5. Check Blood Pressure - NitroNox® may cause BP to drop in some cases.
6. NitroNox® is a “Controlled Substance” and its use must be documented.
7. The patient should receive 100% oxygen for a minimum of 5 minutes following discontinuation of
NitroNox® administration.
8. NitroNox® may be used in conjunction with other narcotic analgesics.
ADVERSE REACTIONS:
Nausea, Vomiting and bizarre behavior
INFANTS and CHILDREN:

NitroNox® should not be administered to patients under 12 years of age without authorization from
medical control.
**NitroNox® is a standing order**
ORTHOSTATIC VITAL SIGNS
Orthostatic vital signs are used to evaluate patients with fluid loss, hemorrhage, syncope or autonomic
dysfunction. They are also used to assess the patient’s response to therapy. When shock exists, assessment of
blood volume deficit is straightforward. It is preferable that volume loss be detected before loss of physiologic
compensation and shock occurs.
Many techniques have been advocated to assess volume status. Serial vital sign measurements have been used
for assessing blood loss, but they do not reliably detect small degrees of blood loss. Up to 15% of the total blood
volume can be lost with minimal hemodynamic changes or any alteration of supine vital signs.
When the volume status of a patient is assessed by use of orthostatic vital signs, several points should be
remembered. Many factors influence orthostatic blood pressures including age, pre-existing medical conditions
including pregnancy, the use of medications and autonomic dysfunction. The pre-hospital care provider must
consider the condition of the patient as well as the orthostatic vital signs in evaluating a patient for volume
depletion.
Orthostatic vital signs are indicated as part of the evaluation of any patient with a known or suspected volume loss
or a history of syncope. The use of orthostatic vital signs is unnecessary and dangerous in a patient with supine
hypotension, shock, an altered mental status, possible spinal injuries, and in patients with lower extremity or
pelvic fractures.
Once the decision to obtain orthostatic vital signs has been made, the blood pressure and pulse are recorded
after the patient has been in the supine position for two to three minutes. No invasive procedures should be
performed during the test. The patient is then asked to stand. The pre-hospital care provider should be prepared
to assist the patient if severe symptoms develop.
If severe symptoms develop (defined as syncope or extreme dizziness requiring the patient to lie down) on
standing, the test is considered positive and should be terminated. If the patient is not symptomatic, the blood
pressure and pulse should be recorded after the patient has been standing for one to two minutes.
Criteria for positive vital sign changes are tachycardia greater than 30 BPM. Although blood pressure changes
may be seen, they are too variable to be used as an indicator for blood volume loss. Because of the lack of
agreement about the degree of postural blood pressure change that constitutes a positive test, the most
reasonable definition may be any postural fall in blood pressure that results in symptoms or cerebral
hypoperfusion.
PROCEDURE
1. Obtain baseline vital signs while the patient is lying down.
2. Obtain a second set of vital signs while the patient is standing. Allow two to three minutes then repeat.
3. A test is considered positive if the patient has dizziness, increased weakness, nausea, vomiting or the systolic
pressure drop of greater than 30 mmHg and/or an Increase in the pulse rate greater than 30 beats per/min.
OVERDOSE / POISONING
Toxic Syndromes Seen in Emergency Medicine
Anticholinergic Syndromes
Significant physical findings: *Delirium with mumbling speech, *tachycardia, dry, flushed
skin, dilated pupils, myoclonus, slightly elevated temperature, urinary retention,
decreased bowel sounds, *seizures, *dysrhythmias, widening QRS
Common causes: Antihistamines, antiparkinson’s medication, atropine, scopolamine, amantadine,
antipsychotic agents, antidepressant agents, antispasmodic agents,
mydriatic agents, skeletal muscle relaxants, many plants
Sympathomimetic Syndromes
Significant physical findings: Delusions, paranoia, *tachycardia, hypertension,
hyperoxia, *diaphoresis, piloerection, mydriasis, hyperreflexia, *seizure,
*hypotension, *dysrhythmia
Common causes: Cocaine, amphetamine, methamphetamine, over the counter
decongestants, caffeine, and theophylline
Opiates, Sedatives, or Ethanol intoxication

Significant physical findings: *Unconscious/unresponsive, *respiratory distress,
miosis, *hypotension, *bradycardia, *hypothermia, *pulmonary edema, decreased
bowel sounds, hyporeflexia, needle marks
Common causes: Narcotics, barbiturates, benzodiazepines, ethanol, clonidine
Cholinergic Syndromes
Significant physical findings: Confusion, *CNS depression, weakness, salivation,
lacrimation, urinary and fecal incontinence, gastrointestinal cramping, emesis,
*muscle fasciculations, *diaphoresis, *pulmonary edema, miosis, *bradycardia,
*tachycardia, *seizures
Common causes: Organophosphates and carbonate insecticides, physostigmine,
and some mushrooms
Common levels of toxicity

Aspirin 200 - 300 mg/kg
Acetaminophen 150 mg/kg
NSAIDS 100 - 300 mg/kg
Tricyclic Antidepressants 5 mg/kg or I.0 gm
Iron 30 - 40 mg/kg
OXYGEN THERAPY
It is important for the pre-hospital care provider to recognize signs and symptoms that indicate the necessary use
of high concentration oxygen. At times the use of oxygen is not necessary for treatment, but is administered to
“put the patient at ease”. The patient’s chief complaint and general appearance must be taken into account
regardless of the pulse oximeter reading. Treat the patient not the pulse oximeter. The correct use of oxygen is
dependent on good patient assessment skills.
POLICY
1. Patients should be allowed to assume a position of comfort if no co-
existent injuries preclude this
2. Patient assessment shall include checking for signs of shock, including
signs of central and peripheral cyanosis
3. The delivery devices that shall be carried are nasal cannulas, non-
rebreather or partial rebreather masks (adult and pediatric), and bag-
valve masks
4. In most cases patients should receive the highest concentration of oxygen available, use caution in
COPD patients and be prepared to assist ventilations with a bag-valve-mask if needed.
I. Departments with pulse oximetry

a. Pulse oximeter is a convenient tool to use if available, however it should not be the only sign used to
gauge the amount of Oxygen a patient is given.
II. Departments that do not have pulse oximetry

a. If respirations are absent or respiratory rate is < 10 or > 30 (inadequate respirations), positive pressure
ventilation should be considered
b. If the patient’s general appearance is poor (signs of shock, cyanosis, extreme pain, etc.), administer oxygen
at 15 LPM via non/partial-rebreather mask
c. Monitor the patient closely for changes in condition or appearance
d. Continue monitoring the patient’s condition and adjust the O2 delivery accordingly
e. COPD patients require minimal O2 supplementation
PREHOSPITAL SPINAL CLEARANCE
There are currently more than 200,000 spinal injury victims living in the United States, and 10,000 new cases
occur each year. Automobile and motorcycle crashes account for approximately half of all spinal injuries,
whereas falls are responsible for approximately 20% of all cases. Significant fractures or dislocations may follow
minor trauma in people with arthritic disease or osteoporosis. Accidents, as a result of participation in sporting
activities, comprise another 15% of all cases. The remaining 15% of spinal injuries are the result of intentional
acts of human violence. The median age of spinal injury victims is 25 years, with men outnumbering women four
to one.
The paramedic pre-hospital care provider may elect to forgo full spinal immobilization i.e. rigid collar,
backboard, three point restraining device and head immobilization device, if none of the following
signs/symptoms are found:
1. Midline bony spinal tenderness, crepitus, or step off

2. Painful cervical ROM
3. Physical findings with a neurologic deficit
4. Altered mental status to include substance abuse and/or loss of consciousness
5. The presence of additional painful or distracting injuries
6. The complaint of parasthesia or numbness
7. Language barrier i.e. patient not understanding the questions asked, dementia, speaks a different
language, or mentally delayed
8. Children under the age of 12
9. Significant mechanism of injury or care provider judgment
RESTRAINTS
for Aggressive or Violent Patients during Transport
PURPOSE: The use of physical restraints for patients who pose a threat to themselves or others is indicated only
as a last resort. Physical restraints should be preceded by an attempt at verbal control and the least restrictive
means of control necessary must be employed. If restraints are used, care must be taken to protect the patient
from possible injury.
1. Request assistance from law enforcement.
2. Restraint equipment applied by EMS personnel must be either padded leather restraints or soft restraints
(i.e. Posey, Velcro or seatbelt type). Either method must allow for quick release.
3. The application of any of the following forms of restraint should not be used by EMS personnel:
a. hard plastic ties or any restraint device requiring a key to remove

b. “sandwiching” patients between backboards, scoop-stretchers, or flat, as a restraint
c. restraining a patient’s hands and feet behind the patient (i.e. hog-tying)
d. methods or other material applied in a manner that could cause respiratory, vascular, or
neurological compromise
4. Restraint equipment applied by law enforcement (i.e. handcuffs, plastic ties, or “hobble” restraints) must
provide sufficient slack in the restraint device to allow the patient to straighten the abdomen and chest
and to take full tidal volume breaths. Restraint devices applied by law enforcement require the officers
continued presence to insure patient and scene safety. The officer should, if at all possible, accompany
the patient in the ambulance or follow by driving in tandem with the ambulance along a predetermined
route. A method to alert the officer of any problems that may occur during transport should be discussed
prior to leaving the scene.
5. Patients should not be transported in the prone position (on their stomach) unless necessary to provide
emergency medical stabilization. EMS personnel must ensure that the patient’s position does not
compromise the patients respiratory/circulatory systems, or does not preclude any necessary medical
intervention to protect the patient’s airway should vomiting occur.
6. Restrained extremities should be evaluated for pulse quality, capillary refill, color, nerve and motor
function every fifteen minutes. It is recognized that the evaluation of nerve and motor status requires
patient cooperation, and thus may be difficult or impossible to monitor.
7. The Medical Incident Report must document the following:
a. the reason restraints were needed

b. which agency applied the restraints
c. the periodic extremity evaluation
d. the periodic evaluation of the patient’s respiratory status
e. the time the restraints were applied
SURGICAL CRICOTHYROTOMY
Management of the airway is of paramount importance because the pre-hospital care provider has only three to
five minutes to obtain an airway and achieve effective ventilation to prevent the complication of hypoxemia.
Although intubation is the usual method of definitive airway management, situations occur in which intubation may
be difficult, contraindicated or impossible. Under these circumstances, Cricothyrotomy may be an effective
alternative for airway management. Surgical cricothyrotomy is the procedure where an opening is made in the
cricothyroid membrane to establish an airway.
ANATOMY
Knowledge of the anatomy of the neck and upper airway is essential. The anatomical landmarks include the hyoid
bone, the thyroid cartilage, the cricoid cartilage and the tracheal rings. The hyoid bone is located midway between
the mental protuberance of the mandible and the third cervical vertebra. The thyroid cartilage consists of two
quadrilateral shape laminae of hyaline cartilage that fuse anteriorly to form the laryngeal prominence. Except in
infants, the markedly obese patient of the patient with massive edema, the laryngeal prominence of the thyroid
cartilage is usually easily recognized and palpable. The cricoid cartilage is the only circumferential ring in the
larynx. The cricoid ring forms the inferior border of the cricothyroid membrane. The thyroid cartilage forms the
superior border of the cricothyroid membrane. The cricothyroid membrane is a dense fibro-elastic membrane
located between the thyroid cartilage superiorly and the cricoid cartilage inferiorly. The cricothyroid muscles bind it
laterally. The average size of the cricothyroid membrane in adults is approximately 22 to 30 mm wide and 9 - 10
mm high. The cricothyroid membrane can be identified by palpation of a notch inferiorly to the laryngeal
prominence. The cricothyroid membrane is located 2 - 3 cm below the laryngeal prominence in adults.
INDICATIONS
1. The inability to perform endotracheal intubation by a less invasive means
2. Massive oral, nasal, or pharyngeal hemorrhage, masseter spasm, clenched teeth with no response to
paralytics, or structural deformities of the upper airway.
CONTRAINDICATIONS
1. Endotracheal intubation by a less invasive means
2. Transection of the trachea with retraction of the distal end into the mediastinum
3. Fracture of the larynx or significant damage to the cricoid cartilage or larynx
4. Children < 12 years of age
5. Patients with massive neck edema
SURGICAL CRICOTHYROTOMY (Continued)
PROCEDURE
1. Assemble the required equipment
a. BVM connected to supplemental oxygen
b. Suction with Yankauer tip
c. Skin preparation solution
d. Scalpel
e. Curved hemostat
f. Appropriate sized endotracheal tube
2. Place patient in the supine position with the neck in a neutral position. Palpate the cricothyroid membrane
between the thyroid and cricoid membranes for orientation.
3. Prep the area using aseptic technique.
4. Stabilize the thyroid cartilage with non-dominant hand.
5. Use Cook Crico kit or make a 2 cm vertical incision of the skin over the cricoid membrane. NOTE: hold the
scalpel between the thumb and index finger so that only the tip of the blade can enter during the initial incision.
6. Insert the scalpel perforating the cricoid membrane and rotate 90° to the incision, use a curved hemostat, or
your index finger to open the airway.
7. Insert an appropriately sized (preferably 5 - 7 mm) cuffed ET tube or tracheotomy tube into the airway,
directing the tube distally into the trachea.
8. Inflate cuff and ventilate the patient.
9. Observe lung inflations and auscultate chest for adequate ventilation.
10. Secure tube to prevent inadvertent dislodging.
11. Document and record responses.
12. This procedure is not recommended in children under age 12.
TASER® REMOVAL/TREATMENT
This skill may be performed by EMT-B, ILS and ALS providers.
Unlike other forms of penetrating foreign bodies, Taser® barbed darts because of their shot length (1/4”) may be
safely removed by EMS personnel when requested by law enforcement. The darts should only be removed in the
field if they do not involve the eye, face, neck, breast or groin. Patients with retained darts in these areas should
be transported to a hospital for removal by a physician.
Prior to removal EMS personnel must be convinced the individual/patient must be in police custody and
adequately restrained.
1. Body substance isolation procedures must be taken.
2. Ensure that wires are disconnected from the gun or the wires have been cut.
3. Push on the body part which the barbed dart (straight #8 fish hook) is imbedded and simultaneously pull
the dart straight out.
4. Apply alcohol or iodine to the puncture area and dress wound.
5. Treat the dart as a “contaminated sharp”. The dart should be placed in a biohazard sharps container and
turned over to law enforcement.
6. Patient must be thoroughly assessed to determine if other medical problems or injuries are present.
7. If the individual does not have any other presenting injuries/illness, they may be left in the custody/care of law
enforcement.
8. If transported to the hospital, follow the Patient Care Procedure regarding restraints for aggressive or violent
patients.
9. Detailed documentation is very important as it is likely to become evidence.
THROMBOLYTIC SCREENING
Thrombolytic therapy has become the first line treatment for acute myocardial infarction or cerebral vascular
accident in most suburban and rural hospital settings. The success of this treatment depends greatly on the early
recognition of the acute myocardial infarction and rapid introduction of thrombolytics. Though the treatment has
been proven to work well in most patients receiving thrombolytics, this therapy is not for everyone. To assist in
identifying candidates for this therapy it is helpful for the screening to be performed on a prehospital basis on all
patients suspected to be having a myocardial infarction. Some agencies MIRs have a check list on the back page
or providers may use this page. Consider screening patients with suspected acute myocardial infarction in order
to advise base station physician for patient transport destination considerations.
THROMBOLYTIC CHECK SHEET
PATIENT NAME:
DATE:
TIME:
CLINICAL INFORMATION:
Active internal bleeding suspected: YES NO
Major trauma, head trauma, spinal trauma, or intracranial or YES NO

intraspinal surgery; within the previous two months:
Describe___________________________________
Previous cerebrovascular accident: YES NO

Date: ________________________
Known bleeding disorder: YES NO

Describe: __________________________________________
Aortic dissection suspected: YES NO

Explain: ___________________________________________
Suspected intracranial neoplasm, avm, or aneurysm: YES NO

Explain____________________________________
RELATIVE CONTRAINDICATIONS: Y N
CPR > 10 MINS. EXPLAIN:
HTN UNRESOLVED WITH TREATMENT, > 180/110
RECENT TIA OR CVA > 6 MONTHS AGO
DIABETIC (OR OTHER) HEMORRHAGIC RETINOPATHY
RECENT MAJOR SURGERY, NONCOMPRESSIBLE VESSEL
PUNCTURE, OR GI/GU BLEEDING 10DAYS)
SEVERE LIVER OR RENAL DISEASE SUSPECTED
SUBACUTE BACTERIAL ENDOCARDITIS SUSPECTED
ACUTE PERICARDITIS SUSPECTED
LEFT HEART THROMBUS LIKELY (MITRAL STENOSIS,
CHRONIC A-FIB)
SEPTIC THROMBOPHLEBITIS
PREGNANCY
TAKES COUMADIN
PARAMEDIC: _______________________________________ DATE: _________________
PRE-HOSPITAL INDEX
The following pre-hospital index is utilized in order to determine the need for local trauma team activation:
Systolic Blood Pressure > 100 0

86-100 1
75-85 2
0-74 5
Pulse 120 3
51-119 0
50 5
Respirations Normal 0
Labored/shallow 3
<10/min and/or intubated 5
Consciousness Normal 0
Confused/Combative 3
Unconscious/Incomprehensible Words 5
Penetrating injury to neck, chest, abdomen 4

High velocity bunt trauma with abdominal pain 4
TOTAL PHI:
MINOR TRAUMA 0-3
MAJOR TRAUMA ≥4
MEDICATION LIST
NAME SUPPLIED ROUTE

Acetaminophen (Tylenol) 1 Dropper/80 mg PO
Acetaminophen (Tylenol) 120mg Suppository Rectal
Acetylsalicylic Acid (Aspirin) 81 mg/tab PO
Activated Charcoal 50 g/240 ml PO
Amiodarone 50mg/ml IV
Adenosine (Adenocard) 6 mg/2 ml IV
Afrin (Oxymetazoline) .025%/20 ml Nasal
Albuterol (Ventolin, Proventil) 2.5 mg/3 ml SVN
Atropine Sulphate 1 mg/1 ml IV/ET
Calcium Chloride 1 g/10 ml IV
Dexamethasone (Decadron) 20mg IV/IM/PO
Dextrose 25% 25mg/10ml IV
Dextrose 50% 25 g/50 ml IV
Diltiazem (Cardizem) 25 mg/5 ml IV
Diphenhydramine (Benadryl) 50 mg/ml IV/IM/PO
Diphenhydramine (Benadryl) 25mg Tab/Capsule PO
Dopamine (Intropin) 400 mg/150 ml IV
Etomidate (Amidate) 20mg IV
Droperidol (Inapsine) 2.5 mg/2 ml IV
Epinephrine (Adrenalin) 1:1,000 1 mg/ml SQ/SL
Epinephrine (Adrenalin) 1:10,000 1 mg/10 ml IV/ET
EpiPen (Adrenalin) 1:1,000 0.3mg/0.3ml IM
EpiPen Junior (Adrenalin) 1:1,000 0.15mg/0.15ml IM
Furosemide (Lasix) 100 mg/10 ml IV
Glucagon 1 mg/ml IV/IM/IN
Glucose Paste 15Gm tube PO
Ipratropium (Atrovent) 0.02%/5 ml SVN
Ketorolac (Toradol) 30 mg/ml IV/IM
Lidocaine (Xylocaine) 100 mg/5 ml IV/ET
Lidocaine (Xylocaine) Drip 1Gm/250ml IV
Lorazepam (Ativan) 2 mg/ml IV/IM
Magnesium Sulphate 5 gm/5 ml IV
Meperidine (Demerol) 100 mg/ml IV/IM
Methylprednisolone(Solumedrol) 125 mg/2 ml IV/IM
Metoprolol (Lopressor) 5 mg/5 ml IV
Midazolam (Versed) 5 mg/5 ml IV/IM/IN
Morphine 10 mg/ml IV/IN
Naloxone (Narcan) 4 mg/10 ml IV/IM/IN
Nitrous Oxide gas Inhaled
Nitroglycerin 0.4 mg/tab/spray SL
Nitropaste Tube TD
Normal Saline 100cc/250cc/1000cc IV/Opth/Topical
Phenergan (Promethazine) 25 mg/ml IV
Prednisone 20 mg/tab PO
Oxytocin 10 units IM/IV
Sodium Bicarbonate 4.2% 5 mEq/10 ml IV
Sodium Bicarbonate 8.4% 50 mEq/50 ml IV
Succinylcholine (Anectine) 200 mg/10 ml IV
Thiamine (Vitamin B1) 100 mg/ml IV/IM
Vasopressin (Pitressin) 20 u/1 ml IV
Vecuronium (Norcuron) 10 mg/10 ml IV
ACETAMINOPHIN (Tylenol)
Classification Para-aminophenol derivative; antipyretic; analgesic
Mechanism of action The mechanism of action is unclear and may be related to

inhibition of prostaglandin synthesis in the CNS. It is believed to
exert its antipyretic effect by direct action on the hypothalamic
heat-regulating center to block the effects of endogenous
pyrogens. This results in increased heat dissipation through
sweating and vasodilatation. Its analgesic effect may be related
to an elevation of the pain threshold
Indication Fever
Contraindication Hypersensitivity, renal disease, hepatic disease
Side effects Allergic reaction, decreased renal and hepatic function
Dose to give ADULT: 500-1,000mg PO

PEDS: 20 mg/kg PO, PR
(Refer to Pediatric Appendix)
Special considerations Lethal Dose is 150 mg/kg
**Acetaminophen is a standing order**
ACETYLSALICYLIC ACID (Aspirin)
Classification Antiplatelet agent
Mechanism of action Blocks prostaglandin synthetase action, which prevents formation

of the platelet-aggregating substance thromboxane A2
Indication Acute myocardial infarction
Contraindication GI bleeding, ulcers, other bleeding disorders
Side effects Gastric irritation, GI bleeding
Dose to give ADULT: 325 mg PO (chew 4 children’s tablets)

PEDS: Not recommended
Special considerations Can be given to patients taking coumadin as a one time event in
the case of suspect myocardial infarction
**Acetylsalicylic Acid is a standing order
ACTIVATED CHARCOAL
Classification Adsorbent
Mechanism of action Binds poisons, toxins and irritants in GI tract. Bound toxins are
inactive until excreted
Indication Emergency treatment of most orally ingested poisonings
Contraindication Altered mental status with depressed gag reflex; Cyanide, mineral
acids, alkali’s, iron and carbon based products
Side effects Constipation, nausea and vomiting
Dose to give ADULT: 0.5-1.0 gm/kg PO, NG

PEDS: 0.5-1.0 gm/kg PO, NG
Special considerations Activated Charcoal is most effective if give within 30 minutes of

ingestion
**Activated Charcoal is a standing order**
ADENOSINE (Adenocard)
Classification Endogenous nucleoside
Mechanism of action Slows the conduction through AV node; interrupts reentry

pathways through AV node
Indication PSVT, PSVT and wide complex tachycardia of unknown etiology

o o
Contraindication 2 or 3 AV block, VT, sick sinus syndrome
Side effects Transient dysrhythmias, dyspnea, chest pressure, hypotension,

bronchospasm, facial flushing, headache
Dose to give ADULT: 6 mg IVP; May repeat 12 mg IVP twice at 2 minute

intervals
PEDS: 0.1-0.2 mg/kg IVP, may double the dose if no effect; Max
12 mg/kg IVP
Special considerations Adenosine is blocked by methylxanthines and potentiated by

dipyridamole and carbamazepine
**Adenosine is a standing order**
AFRIN (Oxymetazoline)
Classification Decongestant
Mechanism of action Local vasoconstriction on nasal mucosal blood vessels
Indication pre-nasal intubation
Contraindication Angle closure glaucoma
Side effects Dizziness, blurred vision, headache, hypertension, sneezing,

transient burning
Dose to give Adult 2 – 3 sprays in each nostril

Peds 2 – 3 sprays in each nostril ½ strength
Special Considerations
**Afrin is a standing order**
ALBUTEROL (Ventolin, Proventil)
Classification 2 bronchodilator
Mechanism of action Causes bronchodilation by 2-stimulation, resulting in relaxation

of bronchial smooth muscles; inhibits mast cell degranulation;
stimulates cilia to remove secretions
Indication Bronchospasms, Reactive Airway Disease, and Hyperkalemia
Contraindication Tachydysrhythmias
Side effects Tachydysrhythmias
Dose to give ADULT: 2.5 mg via SVN (may be given down ETT)
PEDS: 0.03 mg/kg via SVN
Hyperkalemia 20 mg SVN continuously
Special considerations Proper inhalation technique is extremely important for delivery of
medication
May mix with Ipratropium
** Albuterol is a standing order**
AMIODARONE (Cordarone)
Classification Alpha and Beta noncompetitive receptor blocking agent, as well

as calcium, potassium and sodium channel blocker
Mechanism of action Prolongs action potential duration and effective refractory period;
noncompetitive alpha and beta adrenergic inhibition
Indication Pulseless VT/VF, Stable wide complex tachycardia, SVT, PSVT,

Atrial fibrillation/flutter, ventricular ectopy
o o
Contraindication Cardiogenic shock, bradycardia, 2 , 3 heart block in the absence
of a functional pacemaker, do not use with drugs that prolong QT
interval
Side effects Vasodilatation, hypotension, bradycardia, AV block,

hepatotoxicity, increased QT interval, VF, VT
Dose to give ADULT: VT/VF:

300 mg IVP May repeat 150 mg IVP q 3-5 min 2 times
If defibrillation successful administer slow infusion 1 mg/min
infusion over next 6 hours
All other arrhythmias refer to the following dosing regimen:

Loading: First rapid infusion
Add 150 mg to 100 ml D5W and infuse over 10 minutes
Followed by: Slow infusion
Add 450 mg to 250 ml D5W and infuse 1 mg/min
(30 gtt/min using a 60 gtt set)
Max Dose 2 gm IV per 24 hours

Special considerations Hypotension is the most common adverse effect seen and may
be related to the rate of infusion. Hypotension should be treated
by slowing the infusion or with standard therapy: vasopressor
drugs. Avoid shaking the ampul. All ampuls are overfilled to
ensure that the presence of bubbles has no effect on the clinically
accurate dose. Fast-break ampuls are prescored for easy
opening. Filter needles are not required
Amiodarone is only available for use in Kitsap County.
**Amiodarone is a Standing Order and in some cases a
Physician Order**
ATROPINE SULFATE
Classification Anticholinergic
Mechanism of action Competitively blocks acetylcholine at muscarinic sites, thereby

increasing SA and AV node conduction velocity. It also increases
sinus node discharge rate and decreases the AV node’s effective
refractory period
Indication Unstable bradycardia, asystole, cholinergic poisoning, pediatric

RSI
Contraindication AFib/AFlutter, glaucoma
Side effects Tachycardia, myocardial ischemia VT/VF, dilated pupils, HA, dry
mouth
Dose to give ADULT: Unstable bradycardia 0.5-1.0 mg IV

q 3-5 min; up to 0.03 mg/kg
Asystole 1.0 mg IVP q 3-5 min; Up to 0.04 mg/kg
Cholinergic poisoning: 2.0-10 mg IV
q 15-30 min
PEDS: RSI 0.02 mg/kg IV (0.1 mg is the minimum dose)
Special considerations Best endpoint for medicating organophosphate poisonings is the

cessation of secretions.
**Atropine is a standing order**
BRETYLIUM
Classification Antidysrhythmic
Mechanism of action Bretylium suppresses ventricular fibrillation by direct action on the

myocardium and ventricular tachycardia by adrenergic blockade.
It suppresses ventricular tachydysrhythmias with a reentry
mechanism, elevates the fibrillation threshold and decreases
ectopic foci without changing PR, QT, and QRS intervals.
Indication Hypothermia, Cardiac Arrest
Contraindication None in the emergency setting.
Side effects Respiratory depression, Hypotension, transient Hypertension
Dose to give ADULT: 5 mg/kg IV

repeat 10 mg/kg every 15-30 min up to max 30 mg/kg
PEDS: same as adult
Special considerations Bretylium has been shown prolong cardiac irritability in

hypothermic patients there by allowing greater chance of survival.
**Bretylium is a standing order**
CALCIUM CHLORIDE
Classification Electrolyte
Mechanism of action Calcium ions are rapidly transferred to the sites of interaction
between actin and myosin filaments of the sarcromere initiating
myofibril shortening resulting in increased force of myocardial
contraction. Calcium’s positive inotropic and vasoconstriction
effects produce a predictable rise in systemic arterial pressure
Indication Calcium blocker toxicity and hyperkalemia,
Contraindication VF, digitalis toxicity, hypercalcemia
Side effects Bradycardia, asystole, hypotension, VF, extravasation causes

necrosis, coronary and cerebral artery spasm
Dose to give ADULT: 5.0-10.0 mg/kg IV

PEDS: 10.0-20.0 mg/kg IV
Special considerations Precipitates in the presence of sodium bicarbonate.
Bradycardia may be caused by rapid administration.
**Calcium Chloride is a standing order **
DEXAMETHASONE (Decadron)
Classification Steroid, Glucocorticoid, anti-inflammatory
Mechanism of action Reduces the inflammatory process

Diminishes the allergic response
Mechanism of action not completely understood
Indication Reactive Airway Disease

Anaphylactic Reaction
Reduction of elevated intracranial pressure
Croup
Pediatric Meningitis
Contraindication None in the emergency setting
Side effects Hypotension – rarely
Dose to give ADULT: 20 mg IV/PO

PEDS: 0.5 – 1 mg/kg IV/IM
croup 0.6 mg/kg IM/PO/SVN
Special considerations Steroids should be used as early as possible in refractory
exacerbation of Asthma, Chronic Bronchitis and Emphysema
**Dexamethasone is a physician order **
DEXTROSE 50%
Classification Carbohydrate
Mechanism of action Dextrose is a rapidly metabolized source of calories and fluid in

patients with inadequate oral intake.
Indication Hypoglycemia, hyperkalemia, ALOC of unknown etiology
Contraindication CVA, ICP, intracranial hemorrhage
Side effects Tissue necrosis
Dose to give ADULT: 25.0 Gm IV

PEDS: < 1 y/o. 0.25-0.5 Gm/kg D25 IV
> 2 y/o. 0.5 Gm/kg D50 IV
Special considerations Draw blood sample and perform capillary blood sugar analysis
before and after the administration of Dextrose
**Dextrose is a standing order**
DILTIAZEM (Cardizem)
Classification Calcium channel blocker
Mechanism of action Inhibits calcium ion influx across cell membranes during cardiac
depolarization; produces relaxation of coronary vascular smooth
muscle; slows SA/AV node conduction times; decreases
myocardial contractility and peripheral vascular resistance
Indication PSVT, AFib/Aflutter
Contraindication Sick sinus syndrome, high degree heart blocks, concomitant use
of IV beta blockers, wide complex tachycardia of unknown
etiology, CHF, hypotension
Side effects Hypotension, brady-dysrhythmias, pulmonary edema, dyspnea,

syncope, chest pain
Dose to give ADULT: 20 - 25 mg IV over 2 minutes

PEDS: Not recommended in the emergency setting
Special considerations Consider administration of 200.00 mg of Calcium as a

pretreatment in elderly dehydrated patients or in the case of drug
induced hypotension
**Diltiazem is a Standing order**
DIPHENHYDRAMINE (Benadryl)
Classification Antihistamine
Mechanism of action Antihistamines compete for histamine H1-receptor sites on the

smooth muscle of the bronchi, GI tract, uterus and large vessels.
By binding to cellular receptors, they prevent access of histamine
and suppress histamine induced allergic symptoms, even though
they do not prevent its release. Antihistamines are also effective
in the treatment of extra pyramidal reactions
Indication Allergic reactions, extra pyramidal symptoms (dystonic reaction),

migraine headaches
Contraindication Active asthma attacks, patients on MAOs, pregnancy or lactating

females
Side effects Sedation, hypotension, Anticholinergic effects
Dose to give ADULT: 25.0-50.0 mg IV/IM/PO

PEDS: 1.0-2.0 mg/kg IV/IM/PO
Special considerations
**Diphenhydramine is a standing order and in some cases a
physician order**
DOPAMINE (Intropin)
Classification Sympathomimetic
Mechanism of action An immediate precursor of norepinephrine, dopamine stimulates

dopaminergic and beta-adrenergic receptors of the sympathetic
nervous system. Low to moderate dosages result in
renal/mesenteric vasodilatation and increased chronotropic and
inotropic properties of the heart. High doses result in
vasoconstriction. 0.5-5mcg/kg/min: Dilatation of renal and
mesenteric blood vessels 5-10 mcg/kg/min: 1 adrenergic
receptors are primarily affected >10 mcg/kg/min: adrenergic
stimulation predominates
Indication Cardiogenic shock and vasogenic shock
Contraindication Tachydysrhythmias,
Side effects Tachydysrhythmias, VT/VF, increased myocardial ischemia, AMI,

hypertension
Dose to give ADULT: Initial 5.0 mcg/kg/min: IVD, then titrate to effect
PEDS: 5.0-20.0 mcg/kg/min IVD
Special considerations Correct hypovolemia prior to using dopamine in hypotensive

patients
Pediatric patients respond better to an epinephrine pressor drip

than dopamine drips in the emergency setting. Refer to the
Epinephrine drug profile for drip set up and maintenance
An approximate dose of 5.0 mcg/kg/min can be obtained by

determining the patients weight in pounds, take ten percent of
that weight and use that number as your initial drip rate (this
assumes that you are using a 60 gtt/min administration set and
have a solution concentration of 1600 mcg/ml)
**Dopamine is a standing order**
DROPERIDOL (Inapsine)
Classification Antiemetic, Butyrophenone derivative
Mechanism of action Produces marked sedation by directly blocking subcortical

receptors. Also blocks CNS receptors at the chemoreceptor
triggering zone, producing an antiemetic effect
Indication Chemical restraint, nausea and vomiting, migraine headache
Contraindication Renal impairment, hepatic disease
Side effects Dystonia, hypotension, tachycardia, apnea
Dose to give ADULT: 0.625-5.0 mg IV/IM

PEDS: 0.1-0.15 mg/kg IV/IM
Special considerations Use a reduced dose for elderly and debilitated patients.
Consider use of Diphenhydramine with Droperidol. These
medications can be given as a single injection
**Droperidol is a standing order and in some cases a

physician order**
EPINEPHRINE (Adrenalin)
Classification Adrenergic
Mechanism of action Acts directly by stimulating alpha and beta adrenergic receptors
in the sympathetic nervous system. Epinephrine relaxes bronchial
smooth muscles and constricts bronchial arterioles, resulting in
relief of bronchospasm, reduces congestion and edema.
Vasodilatation results form its effect on beta2 receptors. As a
vasopressor, epinephrine produces a positive chronotropic and
inotropic effect by action on beta1 receptors of the heart,
increasing cardiac output, myocardial oxygen consumption and
force of contraction; vasoconstriction results from alpha
adrenergic effect
Indication Cardiac arrest, anaphylactic shock, bronchospasm conditions,
croup, pediatric shock
Side effects Hypertension, VT/VF, Tachydysrhythmias, angina
Dose to give ADULT: Cardiac arrest 1.0 mg 1:10,000 IV q 3-5 min

2.5 mg 1:10,000 ETT q 3-5 min
Drip: mix 30 mg 1:1,000 in 250 NS run at 100 mL/hr titrate
Anaphylaxis 0.1-0.3 mg 1:1,000 SQ
Anaphylactic shock 0.1-0.3 mg 1:10,000 IV
Bronchospasm 0.1-0.3 mg 1:1,000 SQ q 20 min for a total of 3
doses
PEDS: Cardiac arrest 0.01 mg/kg 1:10,000 IV q 3-5 min
0.1mg/kg 1:1,000 ETT q 3-5 min
Anaphylaxis 0.01 mg/kg (max 0.3 mg) 1:1,000 SQ
Croup 2.5 mg 1:1000 in 2.5 ml NS nebulized SVN
Shock Dilute 0.6 mg/kg (1:1,000) to create a 100 ml solution;
Begin infusion at 1.0 mL/hr (0.1 mcg/kg/min); Adjust every 5
minutes for desired effect (0.1-1.0 mcg/kg/min)
Special considerations Use cautiously when given IV in anaphylactic shock as

myocardial ischemia and or cardiac arrest may occur
Epinephrine is the pressor of choice in the case of pediatric shock
states. Dopamine may be ineffective
**Epinephrine is a standing order**
ETOMIDATE
Classification Hypnotic
Mechanism of action An ultra short acting, nonbarbiturate hypnotic, with no analgesic

effects. It produces rapid induction of anesthesia with minimal
cardiovascular and respiratory effects. Etomidate is rapidly
distributed following IV injection or infusion and is rapidly
metabolized and excreted. Onset in 10 – 20 seconds, duration 3
– 5 minutes, and half life is 30-74 minutes.
Indication Induce sedation for facilitate Intubation
Contraindication Hypersensitivity , do not use in children under 10 years old
Side effects Myoclonic skeletal muscle movement, apnea, hyperventilation,

laryngospasm, dysrhythmias, nausea (common), vomiting, eye
movement (common) hiccups, snoring, and seizures
Dose to give ADULT: 0.1 – 0.3 mg/kg IV over 15-30 seconds
PEDS: children over 10 yr, same as adult
Special considerations Verapamil may cause prolonged respiratory depression & apnea.
An analgesic should be administered with Etomidate for painful
procedures.
Flumazenil DOES NOT reverse the effects of Etomidate.
**Etomidate is a standing order**
FUROSEMIDE (Lasix)
Classification Loop diuretic
Mechanism of action Loop diuretics inhibit sodium and chloride reabsorption in the
proximal part of the ascending loop of Henle, promoting the
excretion of sodium, water, chloride and potassium. Intravenous
doses can also reduce cardiac preload by increasing venous
capacitance
Indication Pulmonary edema
Contraindication Dehydration/hypovolemia, hypokalemia, hepatic coma, transient

hearing loss
Side effects Hypotension, electrolyte imbalance
Dose to give ADULT: 0.5-1.0 mg/kg IV (not to exceed 20.0 mg/min)

PEDS: 1.0 mg/kg IV
Special considerations Double the patient’s single oral daily dose up to
160.0 mg IV
**Furosemide is a standing order**
GLUCAGON
Classification Polypeptide hormone
Mechanism of action Accelerates liver glycogenolysis and inhibits glycogen synthetase

resulting in blood glucose elevation; stimulates hepatic
gluconeogenesis and causes an inotropic myocardial effect.
Indication Hypoglycemia, & Calcium channel blocker overdoses
Side effects Nausea and vomiting

++
Dose to give ADULT: Hypoglycemia 1.0 mg IM & Ca channel blocker
overdose 3 – 5 mg IV/IN
PEDS: 0.03 mg/kg IM (max 1.0 mg)
Special considerations Should not be considered a first-line choice for hypoglycemia
Large amounts of glucagon followed by continuous infusions may

be needed for overdose situations. Consider standard ACLS
protocols for bradycardia
**Glucagon is standing order**
GLUCOSE (Oral)
(Glucopaste, Glutose, Insta-glucose)
Classification Carbohydrate
Mechanism of action A rapidly metabolized source of calories in patients with

inadequate oral intake.
Indication Hypoglycemia,
Altered Level of Consciousness of unknown etiology
Contraindication Unconsciousness, Unable to swallow, Hyperglycemia
Side effects None when properly administered,
Dose to give ADULT: one tube PO – between the cheek and gum
PEDS: one tube PO – between the cheek an gum
Special considerations Draw blood sample and perform capillary blood sugar analysis
before and after the administration of Glucose.
**Oral Glucose is a standing order**
IPRATROPIUM BROMIDE (Atrovent)
Classification Anticholinergic bronchodilator
Mechanism of action Inhibits vagally mediated reflexes by antagonizing the action of

acetylcholine. Anticholinergic prevent the increase in intracellular
concentration of cyclic guanosine monophosphate (CGMP) that
results from the interaction of acetylcholine with the muscarinic
receptor on bronchial smooth muscle
Indication Bronchospasms secondary to COPD and reactive airway disease
Contraindication Glaucoma
Side effects Dry mouth, HA, cough
Dose to give ADULT: 0.5 mg SVN

PEDS: 0.25 mg SVN
Administered with Albuterol
**Atrovent is a standing order**
KETOROLAC (Toradol)
Classification Nonsteroidal anti-inflammatory agent
Mechanism of action Acts by inhibiting the synthesis of prostaglandins
Indication Flank pain associated with renal colic
Contraindication ASA allergies, bleeding disorders, renal failure, active peptic ulcer
Side effects Increased bleeding time, anaphylaxis, headache
Dose to give ADULT: 30 - 60 mg IV/IM

Reduce Dose (1/2) for elderly
Special considerations Ketorolac (30.0 mg) usually provides analgesia comparable to

12.0 mg of morphine or 100.00 mg of meperidine
**Ketorolac is standing order**
LIDOCAINE (Xylocaine)
Classification Amide derivative
Mechanism of action As an antiarrhythmic, it suppresses automaticity and shortens the

effective refractory period and action potential duration of His-
Purkinje fibers and suppresses spontaneous ventricular
depolarization during diastole by altering sodium permeability
through cellular fast channels membranes. The drug acts
preferentially on diseased or ischemic myocardial tissue, exerting
its effects on the conduction system, by inhibiting reentry
mechanisms and halts ventricular arrhythmias.
Indication VT/VF, VT with a pulse, symptomatic PVCs, RSI with suspected

closed head injuries
Contraindication High degree heart blocks, Stokes-Adams syndrome, hypotension
Side effects Seizures, slurred speech, altered mental status
Dose to give DOSE: VT/VF 1.5 mg/kg IV q 5-10 min, Max 3.0 mg/kg
After conversion to NSR, start drip at 2.0-4.0 mg/min VT with
pulse 1.0-1.5 mg/kg IV; then 0.5-0.75 mg/kg q 5-10 min up to 3.0
mg/kg. Start drip ASAP
PVC 0.5-1.5 mg/kg IV then 0.5-0.75 mg/kg q 5-10 min up to 3.0
mg/kg. Start drip ASAP
RSI: 1.0-1.5 mg/kg IV
RSI PEDS: 1.5-2.0 mg/kg up to 6 y/o.
DRIP: 2.0-4.0 mg/min
2.0 mg/min p 1.0 mg/kg bolus
3.0 mg/min p 1.0-2.0 mg/kg bolus
4.0 mg/min p 2.0-3.0 mg/kg bolus
Special considerations Reduce maintenance infusion by 50% if pt is > 70 y/o., has liver
disease, or is in CHF or shock
**Lidocaine is a standing order and in some cases a

physician order**
LORAZEPAM (Ativan)
Classification Benzodiazepine
Mechanism of action CNS depressant via facilitation of inhibitorythe neurotransmitter

gamma-amiobutyric acid (GABA) at benzodiazepine receptor
sites in the ascending reticular activating system; effects include
muscle relaxation, anticonvulsant activity and emotional behavior
anxiolytic effects
Indication Seizures, Anxiety
Contraindication Narrow angle glaucoma, pregnancy
Side effects Orthostatic hypotension, tachycardia, confusion, drowsiness
Dose to give ADULT: 1.0-2.0 mg IV/IM; May repeat PRN

PEDS: 0.1-0.2 mg IV/IM
**Lorazepam is a standing order**
MAGNESIUM SULFATE
Classification Electrolyte
Mechanism of action Reduces striated muscle contractions and blocks peripheral

neuromuscular transmission by reducing acetylcholine release at
the myoneural junction; slows the rate of SA node impulse
formation, prolongs conduction time
o
Indication Torsades de Pointes, VT/VF, Seizures 2 eclampsia, refractory
bronchospasm
Contraindication Renal disease, heart block, hypermagnesemia
Side effects Hypotension, respiratory depression, cardiac arrest, CNS

depression, flushing, sweating
Dose to give ADULT: Torsades de Pointes 1.0-2.0 Gm/100ml IV over 2 min

VT/VF 1.0-2.0 Gm/20ml IV over 2 min
o
Seizures 2 eclampsia 4.0 Gm/100ml IV over 2 min
Refractory bronchospasm 2.0 Gm/100ml IV over 20min
Asthma 1-2 Gm IV over 5-10 min
Special considerations Caution should be used in patients receiving digitalis
Calcium chloride should be readily available as an antidote if

respiratory depression ensues
**Magnesium sulfate is a standing order and in some cases a

physician order**
MEPERIDINE (Demerol)
Classification Opioid
Mechanism of action Narcotic agonist with activity at Mu receptors (supraspinal

analgesia, euphoria, respiratory and physical depression) Kappa
receptors (spinal analgesia, sedation and miosis) and Delta
receptors (hallucinations, and respiratory and vasomotor
stimulation); compared to morphine, equal analgesia, respiratory
depression and physical dependence
Indication Analgesia
Contraindication Patients receiving MAO inhibitors
Side effects Sedation, apnea, hypotension, tachycardia, nausea & vomiting
Dose to give ADULT: 25.0-100.00 mg IV/IM

PEDS: 1.0 mg/kg IV/IM
**Meperidine is a standing order and in some cases a
physician order**
METHYLPREDNISOLONE (Solumedrol)
Classification Synthetic glucocorticoid
Mechanism of action Decreases inflammation by depressing migration of

polymorphonuclear leukocytes and activity of endogenous
mediators of inflammation
Indication COPD, reactive airway disease, allergic reaction, spinal cord

trauma
Contraindication Premature infants, systemic fungal infections
Side effects CHF, HTN, seizures, headache, nausea & vomiting
Dose to give ADULT:

COPD & Asthma, Allergic Reaction 125.0 mg IV
PEDS:
COPD & Asthma, Allergic Reaction 1.0-2.0 mg/kg IV
Special considerations Onset of action maybe 2-6 hours and should be administered
early to be most beneficial
**Methylprednisolone is a standing order**
METOPROLOL (Lopressor)
Classification Beta-adrenergic blocking agent
Mechanism of action As a competitive -adrenergic antagonist, negative inotropic and

chronotropic responses are demonstrated by slowing of AV nodal
conduction and decreased heart rate. Decreased myocardial
oxygen consumption, antiarrhythmic effect, suppression of rennin
release and inhibition of central nervous system outflow is
observed
Indication Myocardial salvage in acute myocardial infarction

Dysrhythmias
Physician order in post resuscitation situations
Contraindication CHF, pulmonary edema, bronchospasm, heart block,
bradycardia, hypotension, history of asthma
Side effects Hypotension, CHF, bronchospasm, bradycardia, dizziness, chest

pain, headache
Dose to give ADULT: 5.0 mg IV over 5 min, repeat q 2 min to max 15.0 mg
Special considerations Use of calcium channel blockers may potentiate side effects
Vital signs including multi-lead ECG monitoring must be

continuously evaluated
**Metoprolol is a physician order**
MIDAZOLAM (Versed)
Classification Benzodiazepine
Mechanism of action CNS depressant via facilitation of inhibitory GABA at

benzodiazepine receptor sites (BZ1-associated with sleep; BZ2
associated with memory, motor, sensory and cognitive function);
effects include muscle relaxation, anticonvulsant, ataxia,
emotional behavior and anxiolytic effect
Indication Conscious sedation, RSI, seizure, chemical restraint
Contraindication Acute narrow glaucoma, shock
Side effects Respiratory depression, hypotension, bradycardia
Dose to give ADULT:

Conscious sedation 2.5-10 mg IV/IN over 2 min
RSI 5.0-10.0 mg IV/IN over 2 min
Chemical restraint 2.5-5.0 mg IV/IN/IM
Seizure 2.5-5.0 mg IM/IN
PEDS: Conscious sedation 0.1 mg/kg IV over 2 min
RSI 0.1 mg/kg IV/IN over 2 min
Seizure 0.25 mg/kg IN/IM
Special considerations Have complete complement of resuscitative equipment available

prior to administration
**Midazolam is a standing & in some cases physician order**
MORPHINE SULFATE
Classification Opioid agonist
Mechanism of action Narcotic agonist with activity at u-receptors (supraspinal analgesia,

euphoria, respiratory and physical depression), k-receptors (sedation
and myosis), and delta-receptors (dysphonia, hallucinations,
respiratory and vasomotor stimulation)
Indication Analgesia, pulmonary edema
Acute Myocardial Infarction
Contraindication Head injury, exacerbated COPD, depressed respiratory drive,
hypotension, ALOC
Side effects Respiratory depression, hypotension, ALOC, nausea & vomiting
Dose to give ADULT: Analgesia 2.0-4.0 mg IV/IN q 2-5 min up to 20.0 mg

Pulmonary edema 2.0-4.0 mg IV/IN
PEDS: Analgesia 0.1 mg/kg IV/IN
**Morphine Sulfate is a standing & in some cases physician
order**
NALOXONE (Narcan)
Classification Narcotic antagonist
Mechanism of action Prevents or reverses the effects of opiates, including respiratory

depression
o
Indication Respiratory depression 2 to opiate overdose, ALOC of unknown
etiology
Side effects Withdrawal syndrome in addicted patients, agitation, vomiting
Dose to give ADULT: 0.5-2.0 mg IV/IM/IN/ET

PEDS: 0.01 mg/kg IV/IM/IN/ET
Special considerations Naloxone is not recommended in newborn respiratory depression
Should be administered with caution to patients dependent on

narcotics as it may cause withdrawal effects
Short acting, consider augmenting every 5-10 minutes
**Naloxone is a standing order**
NITROGLYCERIN
Classification Nitrate
Mechanism of action Relaxes vascular smooth muscle of both the venous and arterial
beds, resulting in a net decrease in myocardial oxygen
consumption leading to redistribution of blood flow to ischemic
tissue. Peripheral capacitance vessel dilation decreases venous
return to heart (preload) while arterial vasodilation decreases
arterial impedance (afterload), decreasing left ventricular work
and aiding the failing heart
Indication Acute angina, AMI, CHF with pulmonary edema
Contraindication Hypotension, hypovolemia, intracranial bleeding, aortic stenosis,

recent use of Viagra (24 hrs)
Side effects Hypotension, HA, syncope, tachycardia, flushing
Dose to give ADULT: 0.4 mg SL q 3-5 min

Special considerations Minimum target systolic blood pressure is 100 mmHg

Administration of Nitro within 24 hours of Viagra ingestion can
result in a catastrophic loss of blood pressure.
**Nitroglycerin is a standing order**
NITROPASTE
Classification Organic nitrate, Vasodilator: antianginal
Mechanism of action Vascular smooth muscle relaxation; venous dilation; dilation

of post capillary vessels promotes venous pooling,
decreases venous return to the heart, reduces left
ventricular end-diastolic pressure (preload), decreases
myocardial oxygen consumption
Indication Angina, AMI, CHF with pulmonary edema
Contraindication Hypotension, hypovolemia, intracranial bleeding, aortic

stenosis, recent use of Viagra (24 hrs)
Side effects Hypotension, HA, syncope, tachycardia, flushing
Dose to give Adult: 1 – 2 inches up to 3 – 4 inches

Peds: Not Recommended
Special Considerations Minimum target systolic blood pressure is 100 mmHg,
Spread thin layer of ointment on skin using applicator or
dose-measuring papers, do not use fingers, do not rub or
massage
Administration of Nitro within 24 hours of Viagra ingestion
can result in a catastrophic loss of blood pressure.
**Nitropaste is used in Jefferson County only**
NITROUS OXIDE (NitroNox®)
Classification Inhaled dissociative anesthetic, potent analgesic
Mechanism of action When inhaled, Nitrous Oxide is rapidly absorbed through the lungs and
distributed throughout the body producing a short acting calming effect.
Nitrous Oxide is rapidly excreted by normal breathing.
Indication 1. Pain from musculo-skeletal trauma
2. Cardiac chest pain
3. Pain associated with non-hemorrhagic acute abdomen
(especially renal stones)
4. Pain associated with burns
5. Sever pain, with physician approval
Contraindication 1. Any patient who cannot self administer NitroNox®
2. Head injuries and/or altered level of consciousness
3. Severe Maxillofacial injuries
4. COPD, respiratory distress, pneumothorax
5. Patients under 12 years of age without physician order
6. Pregnancy
7. Bowel Obstruction
8. Penetrating chest injury
9. Nitrogen narcosis (the Bends from SCUBA)
Side effects Nausea, vomiting, and bizarre behavior
Dose to give ADULT: 50/50 mixture of N2O and O2 self administered PRN
PEDS: 50/50 mixture of N2O and O2 self administered PRN
Special considerations 1. NitroNox® is a patient controlled treatment. Paramedical
personnel must not hold it on the patients face. Instruct patient to
place the mask tightly against their face, breathe deeply. Allow mask
to fall away from face spontaneously when effects are felt.
2. Nitrous Oxide is not flammable but will support combustion in
the same manner as oxygen.
3. If side effects occur, discontinue inhalation therapy and apply
100% oxygen for a least 5 minutes.
4. Use only in a well ventilated area.
5. Carefully monitor vital signs, ECG and oxygen saturation. 02
saturation must be >90% prior to and during administration
6. NitroNox® unit must be in an upright position when in use.
7. Check Blood Pressure - NitroNox® may cause BP to drop in
some cases.
8. NitroNox® is a “Controlled Substance” and its use must be
documented.
9. NitroNox® may be used in conjunction with other narcotic
analgesics.
**NitroNox® is an ALS standing order for Adults**

**NitroNox® is an ALS physician order for Infants/Children**
OXYTOCIN ( Pitocin)
Classification Hormone
Mechanism of action Oxytocin is a synthetic, water soluble polypeptide identical

pharmacologically to the oxitocin secreted by the posterior
pituitary. By direct action on myofibrils it produces phasic
uterine contractions characteristic of normal delivery
Indication Control postpartum hemorrhage
Contraindication Prior to delivery of the baby
Side effects Vasoconstrictors can cause severe hypertension,

subarachnoid hemorrhage, anxiety, cardiac dysrhythmias,
titanic contractions, uterine rupture, hyponatremia
Dose to give Adult: 10 units IM following delivery of placenta

20 units in 1000 mL NS infusion titrated to the severity of the
bleeding

Special Considerations
** Oxytocin is a Standing Order**
PROMETHAZINE (Phenergan)
Classification Antiemetic
Mechanism of action Acts as antihistamine by blocking H1 receptors; produces

sedation, anti-vertigo
Indication Treatment of motion sickness, nausea and vomiting
Contraindication Narrow angle glaucoma
Side effects Hypotension, anxiety, dystonic reactions
Dose to give Adult: 12.5 – 25 mg IV IM

Special considerations Passes through breast milk, avoid prolonged exposure to sun
Diphenhydramine will reverse dystonic untoward effect
**Phenergan is a standing & in some cases a physician order
PREDNISONE
Classification Glucocorticoid
Mechanism of action Decreases inflammation by depressing migration of

polymorphonuclear leukocytes and activity of endogenous
mediators of inflammation
Indication Reactive airway disease
Contraindication Systemic fungal infections
Side effects Prolonged wound healing, nausea & vomiting
Dose to give ADULTS: 60 mg PO

PEDS: 1.0-2.0 mg/kg PO
Special considerations Attempt to administer medication with pudding or other palatable

substance
**Prednisone is a standing order**
SODIUM BICARBONATE
Classification Alkalizing agent
Mechanism of action Sodium bicarbonate is an alkalizing agent that dissociates to

provide bicarbonate ion to buffer hydrogen ions in order to raise
the ph level to reverse acidosis. It has also been found to
beneficial in the event of drug overdose in order to force urine
alkalinization/diuresis, membrane stabilization of cardiac cells as
well and electrolyte balance restoration.
o
Indication Metabolic acidosis 2 cardiac arrest, cyclic antidepressant OD,
hyperkalemia
Contraindication None in the emergency setting.

Do not administer in the same IV with calcium chloride.
Side effects Metabolic alkalosis, electrolyte imbalance, fluid overload
Dose to give ADULT: 100 mEq/kg IV

Drip - 25 mEq in 250 ml NS and run 250 ml/hr
PEDS: 1.0 mEq/kg IV
Special considerations Most catecholamines and vasopressors (dopamine, epinephrine)

can be deactivated by alkaline solutions like sodium bicarbonate.
When administered with calcium chloride, a precipitate may form
that will clog the IV line.
**Sodium Bicarbonate is a standing order**
SUCCINYLCHOLINE (Anectine)
Classification Depolarizing neuromuscular blocking agent
Mechanism of action Similar to the acetylcholine molecular structure, Succinylcholine

has an affinity for Ach receptor sites and acts by prolonging
depolarization at the motor end plate
Indication Paralysis to facilitate intubation
Contraindication Acute narrow angle glaucoma, penetrating eye injury, burns/crush

injuries greater than 8 hours old, Hyperkalemia
Side effects Apnea, malignant hyperthermia, dysrhythmias, bradycardia,

hypertension, hypotension, hyperkalemia, increased intraocular
pressure, cardiac arrest
Dose to give ADULT: 1.0-1.5 mg/kg IV

PEDS: 1.0-2.0 mg/kg IV
Special considerations Patients must be sedated.

Have alternative airway management procedures readily
available prior to administration of this drug.
Apply cricoid pressure prior to administration and continue cricoid
pressure until tube placement is verified.
A second dose should be avoided in infants and small children as
they are extremely sensitive to the vagal effects of
succinylcholine.
**Succinylcholine is a standing order**
THIAMINE (Vitamin B1)
Classification B complex vitamin
Mechanism of action Thiamine is required for carbohydrate metabolism. It combines

with adenosine triophosphate to form thiamine pyrophosphate, a
coenzyme in carbohydrate metabolism and transketolation
reactions.
Indication Co-administration with D50W in patients with suspected

malnutrition or thiamine deficiency
Contraindication Hypersensitivity
Side effects Nausea & vomiting, hypotension, restlessness
Dose to give ADULT: 100.00 mg IV/IM

PEDS: Not indicated in the emergency setting
Special considerations Rare anaphylactic reactions have been reported
**Thiamine is a standing order**
VASOPRESSIN (Pitressin)
Classification Posterior pituitary antidiuretic hormone
Mechanism of action Produces vascular smooth muscle contraction and decreased

urinary flow rate. It possesses pressor and antidiuretic (ADH)
principals. Vasopressin increases ADA activity, which increases
renal tubular reabsorption, water permeability at the renal tubule
and collecting duct, resulting in increased urine osmolality as well
as vascular smooth muscle contraction
Indication VT/VF arrested states
Contraindication Chronic nephritis
Side effects Moderate to severe skeletal weakness, which may require

artificial respiration. Malignant hyperthermia
Dose to give ADULT: 40.0 units IV

Special considerations Vasopressin during CPR increases coronary perfusion pressure,

vital organ blood flow, VF median frequency and cerebral oxygen
delivery
**Vasopressin is a standing order**
VECURONIUM (Norcuron)
Classification Nondepolarizing neuromuscular blocking agent
Mechanism of action Prevents acetylcholine from binding to receptors on the motor

end plate, thus blocking depolarization. Vecuronium exhibits
minimal cardiovascular effect and does not appear to effect heart
rate, rhythm, systolic or diastolic blood pressure, cardiac output,
systemic vascular resistance or mean arterial pressure. It has
little to no histamine releasing properties
Indication Paralysis to facilitate intubation
Contraindication Newborn infants, myasthenia gravis
Side effects Apnea, profound weakness
Dose to give ADULT: 0.1 mg/kg IV

PEDS: 0.1 mg/kg IV
Special considerations Patients must be sedated
Have alternative airway management procedures readily

available prior to administration of this drug
Apply cricoid pressure prior to administration and continue cricoid

pressure until tube placement is verified
**Vecuronium is a standing order**
PEDIATRIC FORMULARY
3 kg = 7 lbs
Age estimate = term newborn – 1 month
Vital Signs: HR: 95-145 RR: 35-45 BP: 60-70/50 mmHg
ET: 3.5 mm Suction catheter: 8 F NG tube: 8 F feeding tube
Defibrillation: 3 J repeat @ 6 J Cardioversion: 1.5 J repeat @ 3 J
Fluid challenge: 30 cc (10 cc/kg, may repeat x2)
DOSAGES ADMINISTER cc’s

Acetaminophen 20 mg/kg PO/PR 30-45 mg 0.3-0.4cc
Activated Charcoal 1 Gm/kg PO 3 Gm 14.4 cc
Adenosine 0.1-0.2 mg/kg IV 0.3-0.6 mg 0.1-0.2 cc
Albuterol 2.5 mg/3 mL NS SVN 2.5 mg 3 cc
Atropine 0.02 mg/kg IV/IO/ET 1 mg 1 cc
Calcium 10-20 mg/kg IV 30-60 mg 0.3-0.6 cc
Dextrose (D25W) 0.5 Gm/kg IV/IO 0.75-1.5 Gm 3-6 cc
Diphenhydramine 1-2 mg/kg IV/IM/PO 3-6 mg 0.06-0.12 cc
Droperidol 0.1-0.15 mg/kg IV 0.3-4.5 mg 0.12-0.18 cc
Epinephrine 1:1,000 0.01 mg/kg SQ 0.03 mg 0.03cc
Epinephrine 1:1,000 0.1 mg/kg ET 0.3 mg 0.3 cc
Epinephrine 1:10,000 0.01 mg/kg IV/IO 0.03-0.09 mg 0.3-0.9 cc
Furosemide 0.25-1.0 mg/kg IV 0.75-3 mg 0.08-0.03 cc
Ipratropium 0.25 mg SVN 0.25 mg 1.25 cc
Lidocaine 2% 1 mg/kg IV/IO/ET 3 mg 0.15 cc
Lorazepam 0.05-0.1 mg/kg IM/IV 0.3-0.6 mg 0.15-0.3cc
Methylprednisolone 1-2 mg/kg IV/IO 3-6 mg 0.05-0.09 cc
Midazolam 0.1 mg/kg IV/IO/IN 0.3 mg 0.3 cc
Morphine 0.05-0.1 mg/kg IV/IO/ET 0.15-0.3 mg 0.02-0.03 cc
Naloxone 0.1 mg/kg IV/IM/IN 0.3 mg 0.75 cc
Sodium Bicarbonate (4.2%) 1 mEq/kg IV/IO 3 mEq 6 cc
Succinylcholine 1-2 mg/kg IV/IO 4.5 mg 0.23 cc
Vecuronium > 1 year only XXX XXX
PEDIATRIC FORMULARY
6 kg = 12 lbs
Age estimate = 6 months
Vital signs: HR: 110-80 RR: 24-30 BP: 70-110/50 mm Hg
ET: 3.5 mm Suction catheter: 8 F NG tube: 8 F feeding tube
Defibrillation: 12 J repeat @ 24 J Cardioversion: 3 J repeat @ 6J
Fluid challenge: 120 ml (20 ml/kg may repeat x2)

Acetaminophen 20 mg/kg PO/PR 60-90 mg 0.6-0.9 cc
Atropine 0.02 mg/kg IV/IO/ET 0.1 mg 1 cc
Dextrose (D25W) 0.5 Gm/kg IV/IO 1.5-3 Gm 6-12 cc
Epinephrine 1:1,000 0.01 mg/kg SQ 0.06 mg 0.06 cc
Lorazepam 0.05-0.1 mg/kg IM/IV 0.6-1.2 mg 0.3-0.6 cc
Succinylcholine 1.5 mg/kg IV/IO 9 mg 0.5 cc
PEDIATRIC FORMULARY
9 kg = 18 lbs
Age estimate = 9 months
Vital signs: HR: 110-120 RR: 22-30 BP: 80-120/53 mmHg
ET: 4.0 mm Suction catheter: 8F NG tube: 10F
Fluid challenge: 180 cc (20 cc/kg, may repeat x2)

Acetaminophen 20 mg/kg PO/PR 180 mg 1.8 cc
Atropine 0.02 mg/kg IV/IO/ET 0.18 mg 1.8 cc
Dextrose (D25W) 0.5 Gm/kg IV/IO 2.25-4.5 Gm 9-18 cc
Furosemide 0.25-1.0 mg/kg IV 2.25 mg 0.3-0.9 cc
Lidocaine 2% 1 mg/kg IV/IO/ET 9 mg 0.45cc
Succinylcholine 1.5 mg/kg IV/IO 13.5 mg 0.7 cc
PEDIATRIC FORMULARY
10 kg = 22 lbs
Age estimate = 1 year
ET: 4.0 mm Suction catheter: 8 F NG tube: 10 F
Defibrillation: 20 J repeat @ 40 J Cardioversion: 5 J repeat @ 10 J
Fluid challenge: 200 cc (20 cc/kg may repeat x2)

Acetaminophen 20 mg/kg PO/PR 200 mg 2 cc
Adenosine 0.1-0.2 mg/kg IV 1-2 mg 0.33-0.67 cc
Atropine 0.02 mg/kg IV/IO/ET 0.1-0.2 mg 1-2 cc
Calcium 10-20 mg/kg IV 100-200 mg 1-2 cc
Dextrose (D25W) 0.5 Gm/kg IV/IO 2.5-5 Gm 10-20 cc
Droperidol 1-1.25 mg IV 1-1.25 mg 0.4-0.5 cc
Epinephrine 1:1,000 0.1 mg/kg ET 1 mg 1 cc
Epinephrine 1:1,0000 0.01 mg/kg IV/IO 0.1 mg 0.1 cc
Furosemide 0.25-1.0 mg/kg IV 2.5-10 mg 0.3-1 cc
Lorazepam 0.05-0.1 mg/kg IM/IV 1-2 mg 0.5-1 cc
Midazolam 0.1 mg/kg IV/IO/IN 1 mg 1 cc
Morphine 0.05-0.1 mg/kg IV/IO/ET 0.5-1 mg 0.05-0.1 cc
Naloxone 0.1 mg/kg IV/IM/IN 1 mg 2.5 cc
Vecuronium 0.1 mg/kg IV 1 mg 1 cc
PEDIATRIC FORMULARY
12 kg = 26 lbs
Age estimate = 2 years
ET: 4.5 mm Suction catheter: 8-10 F NG tube: 10 F
Fluid challenge: 240 ml (10 cc/kg may repeat x2)

Activated Charcoal 1 Gm/kg PO 12 Gm 57 cc
Atropine 0.02 mg/kg IV/IO/ET 0.12-0.24 mg 1.2-2.4 cc
Dextrose (D25W) 0.5 Gm/kg IV/IO 6 Gm 12 cc
Furosemide 0.25-1.0 mg/kg IV 3-12 mg 0.3-1.2 cc
Naloxone 0.1 mg/kg IV/IM/IN 1.2 mg 3 cc
Vecuronium 0.1 mg/kg IV 1.2 mg 1.2 cc
PEDIATRIC FORMULARY
14 kg = 31 lbs
Vital signs: HR: 100-110 RR: 20-26 BP: 90-130/55 mm Hg
Fluid challenge: 280 ml (20 cc/kg may repeat x2)

Atropine 0.02 mg/kg IV/IO/ET 0.28 mg 2.8 cc
Succinylcholine 1-2 mg/kg IV/IO 21 mg 1 cc
Vecuronium > 1 year only 0.1 mg/kg IV 1.4 mg 1.4 cc
PEDIATRIC FORMULARY
16 kg = 35 lbs
Fluid challenge: 320 ml (20 cc/kg, may repeat x2)

Adenosine 0.1-0.2 mg/kg IV 1.6-3.2 mg 0.53-1 cc
Atropine 0.02 mg/kg IV/IO/ET 0.63-0.32 mg 1.6-3.2 cc
Furosemide 0.25-1.0 mg/kg IV 4-16 mg 0.4-1.6 cc
Lidocaine 2% 1 mg/kg IV/IO/ET 16-24 mg 0.8-1.2 cc
Naloxone 0.1 mg/kg IV/IM/IN 1.6 mg 4 cc
PEDIATRIC FORMULARY
20 kg = 44 lbs
Age estimate = 5 – 6 years

Adenosine 0.1-0.2 mg/kg IV 2-4 mg 0.7-1.3 cc
Epinephrine 1:1,000 0.1 mg/kg ET 2 mg 2 cc
Furosemide 0.25-1.0 mg/kg IV 5-20 mg 0.5-2 cc
Lidocaine 2% 1 mg/kg IV/IO/ET 20 mg 1 cc
Morphine 0.05-0.1 mg/kg IV/IO/ET 1-2 mg 0.1-0.2 cc
Naloxone 0.1 mg/kg IV/IM/IN 0.4-2 mg 1-5 cc
Sodium Bicarbonate (8.4%) 1 mEq/kg IV/IO 20 mg 20 cc
Vecuronium > 1 year only 0.1 mg/kg IV 2 mg 2 cc
PEDIATRIC FORMULARY
25 kg = 55 lbs

Adenosine 0.1-0.2 mg/kg IV 2.5-5 mg 0.8-1.7 cc
Atropine 0.02 mg/kg IV/IO/ET 0.25-0.5 mg 2.5-5 cc
Calcium 10-20 mg/kg IV 250-500 mg 2.5-5 cc
Dextrose (D50W) 0.5 Gm/kg IV/IO 12.5 Gm 25 cc
Diphenhydramine 1-2 mg/kg IV/IM/PO 25-50 mg 0.5-1 cc
Furosemide 0.25-1.0 mg/kg IV 6.25 mg 0.6-2.5 cc
Succinylcholine 1-2 mg/kg IV/IO 37.5 mg 2 cc
PEDIATRIC FORMULARY
30 kg = 66 lbs
ET: 6.5 mm Suction catheter: 12-14 F NG tube: 14 F

Adenosine 0.1-0.2 mg/kg IV 6-12 mg 2-4 cc
Diphenhydramine 25-50 mg IV/IM/PO 25-50 mg 0.5-1 cc
Epinephrine 1:1,000 0.01 mg/kg SQ 0.3-0.9 mg 3-9 cc
Epinephrine 1:1,000 0.1 mg/kg ET 0.1-0.3 mg 0.1-0.3 mg
Epinephrine 1:1,0000 0.01 mg/kg IV/IO 0.3-0.9 mg 3-9 cc
Furosemide 0.25-1.0 mg/kg IV 7.5-30 mg 0.75-3 cc
Lorazepam 0.05-0.1 mg/kg IM/IV 1.5-3 mg 0.75-1.5 cc
Morphine 0.05-0.1 mg/kg IV/IO/ET 1.5-3 mg 0.15-0.3 cc
Vecuronium > 1 year only 0.1 mg/kg IV 3 mg 3 cc
ABBREVIATIONS AND CHARTING SYMBOLS
@ at
∆ change
female
L left
< less than
> greater than
male
? questionable
1° primary, first degree
2° secondary, second degree
3° tertiary, third degree
AAA Abdominal Aortic Aneurysm
Abd Abdomen
ac before meals
AC antecubital
A fib atrial fibrillation
AIDS Acquired Immune Deficiency Syndrome
ALNW Airlift Northwest
ALS advanced life support
AMA against medical advice
A & O X3 alert & oriented to person, place & time
ARDS Adult Respiratory Distress Syndrome
ASA aspirin
ASHD arteriosclerotic heart disease
b.i.d. twice daily
BLS Basic Life Support
BPM Beats per minute
CHI closed head injury
CST Cincinnati stroke test
DOS dead on scene
DT' s Delirium tremens
Dx diagnosis
EBL estimated blood loss
ECG or EKG electrocardiogram
EDC estimated date of confinement
Elix elixir
Eng. Engine Company
est. estimated
ETA estimated time of arrival
ETD estimated time of departure
ETOH ethyl alcohol
ETT or ET endotracheal tube
F° Fahrenheit
FB foreign body
FCH Forks Community Hospital
FUO fever of unknown origin
Fx fracture
Gr gravida
GCS Glasgow Coma Scale
GI gastrointestinal
gm gram
gr grain
GSW gun shot wound
gtt drops
gtt/min drops per minute
GU genitourinary
GYN gynecologic
HCVD hypertensive cardiovascular disease
HEENT head, ears, eyes, nose and throat
HIV human immunodeficiency virus
HVMC Harborview Medical Center
HMH Harrison Hospital
hr hour
HR heart rate
HTN hypertension
Hx history
IC intracardiac
ICP intracranial pressure
IDDM insulin dependent diabetes mellitus
IM intramuscular
IN intranasal
IO intraosseous
IUD intrauterine device
IV intravenous
IVP IV push
IVR idioventricular rhythm
J joules
JVD ugular vein distention
kg kilogram
KVO or TKO keep vein open, to keep open
L liter
lb pound
LLE left lower extremity
LLQ left lower quadrant
LMP last menstrual period
LOC level of consciousness
L-spine lumbar spine
LUE left upper extremity
LUQ left upper quadrant
L/min liters per minute
M meter
MAE moves all extremities
MAO monoamine oxidase
MGH Mason General Hospital
MAT multifocal atrial tachycardia
mcg microgram
MCL modified chest lead
mEq millequivalent
mg milligram
ml milliliter
min minute
mm Hg millimeter of mercury
MAST military/medical antishock trousers
M.S. morphine sulfate
MVA or MVC motor vehicle accident or collision
NA or N/A not applicable or not assessed
NAD no apparent/acute distress
NC or N/C nasal cannula
Neg negative
NG nasogastric
NKDA no known drug allergies
NPA nasopharyngeal airway
NPO nothing by mouth
NHB Naval Hospital Bremerton
NT or N/T not taken
NV or N/V nausea and vomiting
NS or N/S Normal Saline
NSAID non-steroidal anti-inflammatory drug
NSR normal sinus rhythm
NTG Nitroglycerin
OB obstetrics
OD overdose
od right eye
OMH Olympic Memorial Hospital
OPA oropharyngeal airway
O2 oxygen
os left eye
ou both eyes
oz ounce
PAC premature atrial contraction
PCN penicillin
ptoa prior to our arrival
SBP Systolic Blood Pressure
STHB said to have been
SIDS Sudden Infant Death Syndrome
SL sublingual
SNF skilled nursing facility
SOB shortness of breath
S-spine sacral spine
SQ subcutaneous
s/s signs and symptoms
SSS Sick Sinus Syndrome
ST sinus tachycardia
SVT supraventricular tachycardia
sx signs and symptoms
TB tuberculosis
TCA Tricyclic antidepressant
TGH Tacoma General Hospital
TIA transient ischemic attack
TX treatment
t.i.d. three times daily
TKO to keep open
T-spine thoracic spine
Tx treatment
URI upper respiratory infection
UTI urinary tract infection
VD venereal disease
VF ventricular fibrillation
VT ventricular tachycardia
VS or V/S vital signs
W/D warm and dry
with
without
WPW Wolff-Parkinson-White Syndrome
X multiplied by
yds yards
YO or Y/O year old
PHONE NUMBERS
HOSPITALS
Bremerton Naval Hospital (360) 475-5678 Med Reports
(360) 475-4286 ED
Children’s Hospital Medical Center (206) 987-2222 Med Reports
(206) 987- 2000 Main
Harborview Medical Center (206) 731-3074 Med Reports
(206) 731-3000 Main
Harrison Memorial Hospital-Bremerton (360) 377-9111 Med Reports
(360) 377-3911
Harrison Hospital-Silverdale (360) 337-8975 Main
Jefferson General Hospital (360) 385-7617 Med Reports

(360) 385-2200 Main
Madigan Army Medical Center (253) 968-1396 Med Reports
(253) 968-1390 Main
Mary Bridge Children’s Hospital (253) 403-1476 Med Reports
(253) 403-1418 Main
Mason General Hospital (360) 426-8171 Med Reports
Olympic Memorial Hospital (360) 452-8630 Med Reports
St. Peters Hospital (360) 493-7289
Tacoma General Hospital (253) 627-8500 Med Reports

(253) 403-1050 Main
University of Washington Medical Center (206) 598-3300
Virginia Mason Seattle (206) 583-6433 ED

(206) 624-1144 Main
Communication Centers
Airlift Northwest (800) 426-2430
Clallam County (PENCOM) (360) 452-4545
Jefferson County (360) 385-3831
Kitsap County (CENCOM) (360) 616-5800
Mason County (360) 426-5533 or (360) 426-4441(Shel-com)
Olympic Ambulance (800) 445-2257
Information
Chem Trek (800) 424-9300
Coast Guard Group Seattle (24hrs) (206) 217-6001
Diver’s Alert Network (DAN) (877) 595-0625
Dept. of Ecology (425) 649-7000
National Response & Terrorist Hot Line (800) 424-8802
Poison Control (800) 222-1222
WA State Ferries Office (206) 515-3456 (watch officer)
WA State Patrol Dispatch (360) 405-6650 (not for public use)
BIBLIOGRAPHY
The Northwest Region EMS Protocol Committee would like to acknowledge the following references for their
contribution in the development of the Regional Protocols. Materials obtained from these references were
reproduced in part or in whole in an attempt to maintain the integrity of the original author, while meeting the
requirements for pre-hospital care providers. The Northwest Region EMS Protocol Committee encourages
readers of the Protocols to refer to these references for further information regarding disease, pathophysiology
and patient care.
1. Cummins, Richard O., et al: ACLS Provider Manual 2002 edition, American Heart Association,
Texas 2002.
2. Auerbach, Paul S: Wilderness Medicine-Management of Wilderness and Environmental Emergencies
Third Ed., St. Louis, 1995, Mosby
3. Brent, Hafen Q, et. al.: Prehospital Emergency Care Fifth Ed, New Jersey,
1996, Brady-Prentice-Hall
4. Roberts, James R, et. al.: Clinical Procedures in Emergency Medicine
Third Ed., Philadelphia, 1998, Saunders
5. Rosen, Peter, et. al.: Emergency Medicine-Concepts and Clinical
Practices Fourth Ed., St. Louis, 1998, Mosby
6. Schwartz, Alan C, et. al.: Understanding Emergency Drugs Revised
1997-1998 Ed. Arizona, 1998, Emergency Physicians Professional Association
7. Tintinalli, Judith E, et. al., Emergency Medicine-A comprehensive Study
Guide Fourth Ed., New York, 1996, McGraw Hill
8. United States DOT: EMT-B for Experienced EMTs-National Standard Curriculum-Washington State
Amended Edition Revised September 1996, Washington State, 1999
The Northwest Region Emergency Medical Services Council wishes to extend a special thanks to the following Protocol
Committee members.
* Zita Wiltgen * Tammie Coulter

* George Epperly * Steve Engle
* Sherrie Shafer * Vince Stamato
* Tim Manly
These members contributed their personal time and expertise in working diligently over the past few months to ensure that
patient care within the Northwest Region will continue to be of the highest standard. As with most altruistic contributions,
appreciation of their contribution is greater than can be expressed within this printing.
INDEX
Protocol Rx Reference
12 lead EKG 52 Chest pain 8 – 20

Abbreviation and Charting Symbols 139 – 141
Abdominal pain 4 OB 26
Acetaminophen (Tylenol) 86 OD/Poisoning 76, Fever 33
Acetylsalicylic acid (Aspirin) 87 Chest pain 10, 11, OD/ Poisoning 76
EMT meds 63, ILS meds 64
Activated Charcoal 88 OD/Poisoning 29, 76, EMT meds 63,
ILS meds 64
Adenocard (Adenosine) 89 SVT 18
Adenosine (Adenocard) 89 SVT 18
Adrenalin (Epinephrine) 62 101 Allergic reaction 5, Reactive airway 9,
Asystole 14, PEA 17, VF 20,
Pediatric 31, Pediatric SOB 32,
Advanced Airway Management -RSI 48
AED 52
Afrin (Oxymetazoline) 90 Nasal intubation 48
Albuterol (Ventolin, Proventil ) 91 Allergic reaction 5, Reactive airway 9,
Pediatric SOB 32, ILS meds 64,
Hyperkalemia 58
Allergic Reaction 5
Altered Level of Consciousness 46 Spinal clearance 78
Amiodarone (Cordarone) 92 VF-VT 20, Post resuscitation 13, VT
w/pulse 19, A-Fib/A-Flutter 15, SVT 18
Anaphylaxis 5
Anectine (Succinylcholine) 124 RSI 48
Animal Bites 6
APGAR 49
Aspirin (Acetylsalicylic acid) 87 Chest pain 10, 11, OD/ Poisoning 76
Assault 40 Spinal clearance 78
Asthma, adult 9
Asthma, child 32
Asystole 14
Ativan (Lorazepam) 109 Psych 28, Headache 27, OD 76,
Eclampsia 35, Seizure 38, Sedation 16,
RSI 35
Atrial Fibrillation 15
Atropine 93 Asystole 14, PEA 17, Bradycardia 16,
OD 29, RSI 48
Atrovent (Ipratropium) 106 Reactive airway 5, 9, 32
Benadryl (Diphenhydramine) 88 Allergic reaction 5, Headache 27,
General Illness 25, Phenergan 122
Bibliography 143
Birth Complications 35
Bleeding 7
Bradycardia 16
Breathing difficulty 8
(Pulmonary Edema)
Breathing difficulty 5
(Reactive Airway Disease)
Bretylium 94 Hypothermia 24
Burns 41 Pain 30
Calcium Chloride 95 Hyperkalemia 58, OD 29
Cardiac Arrest 12, 31 AED 50

Cardiogenic Shock 11
Cardizem (Diltiazem) 97 A Fib 15, SVT 18
Chest Pain 10 11 – 20
Childbirth 34 35 – 37
Choking 24, 57
Cincinnati Stroke Test 57 Stroke 39, ALOC 46, Gen Illness 25
COPD 8
CPR 52
Croup 32 Epinephrine 102
Demerol (Meperidine) 111 Abdominal pain 4, Headache 27,Pain30
Determination of Death in the Field 60, 61
Dexamethasone 96
Dextrose 97 Hyperkalemia 58, Diabetic 22, ALOC 46
Diabetic Emergencies 22
Diltiazem (Cardizem) 97 A Fib 15, SVT 18
Diphenhydramine (Benadryl) 99 Allergic reaction 5, Headache 27,
General Illness 25, Phenergan 121
Discontinuation of CPR 60, 61
Do Not Attempt Resuscitation 60, 61
Dopamine (Intropin) 100 Allergic reaction 5, PEA 17, Cardiogenic
shock 11, Bradycardia 16, OD 29
Droperidol (Inapsine) 101 General illness 25, Headache 27,
Psychiatric Emergency 28, Pain 29
Drowning 42
Eclampsia 35 Magnesium 111, Lorazepam 110
Emergency at a Physician’s Office 2
Emotional Emergencies 28
EMT-IV Therapy 65
EMT Medications 63
Epinephrine (Adrenalin) 62 102 Allergic reaction 5, Reactive airway 9,
Asystole 14, PEA 17, VF 20,
Pediatric 31, Pediatric SOB 32,
Epinephrine Auto Injector 62 101 Allergic 5
Eschmann Catheter 59 RSI 48
Esophageal Tracheal Combitube 66 - 67
Etomidate 103 RSI 48
Falls 44 Spinal clearance 78
Fever 33
Furosemide (Lasix) 104 Pulmonary Edema 8
General Illness 25
Glucagon 105 Diabetic 22, OD 29, ALOC 46
Glucose (Oral) 106 Diabetic 22, OD 29, ALOC 46
Gum Elastic Bougie 59 RSI 48
Gynecology 26
Headache 27 Stroke 39
Heart Problems 11 – 20
Hyperkalemia 23
Hyperthermia 23
Hypothermia 24
ILS Medications 64
Inapsine (Droperidol) 100 General illness 25, Headache 27,
Psychiatric Emergency 28, Pain 29
Intropin (Dopamine) 99 Allergic reaction 5, PEA 17, Cardiogenic
shock 11, Bradycardia 16, OD 29
Ipratropium (Atrovent) 107 Reactive airway 5, 9, 32
Ketorolac (Toradol) 108 Abdominal pain 4

Lasix (Furosemide) 104 Pulmonary Edema 8
Lidocaine 109 VF 20, VT 19, RSI 48
Lopressor (Metoprolol) 114 Chest Pain 10, A Fib 15, SVT 18
Lorazepam (Ativan) 110 Psych 28, Headache 27, OD 76,
Eclampsia 35, Seizure 38, Sedation 16,
RSI 35
Magnesium Sulfate 111 Eclampsia 35
Mental Emergencies 28
Meperidine (Demerol) 112 Abdominal pain 4, Headache 27,Pain30
Metered Dose Inhaler (MDI) Pulmonary Edema 8, Reactive Airway
9, EMT meds 63, ILS Meds 64
Methylprednisolone (Solumedrol) 113 Pulmonary Edema 8, Reactive Airway 9
Metoprolol (Lopressor) 114 Chest Pain 10, A Fib 15, SVT 18
Midazolam (Versed) 115 Bradycardia 16, SVT 18, VT 19, A Fib
15, Psych 28, Seizure 38, RSI 48
Miscarriage 26
Mnemonic’s 70 – 71
Morphine 116 Abdominal pain 4, Pulmonary Edema 8,
Chest Pain 10, Headache 27, Pain 30
MVC (Trauma) 45 Spinal clearance 78
Naloxone (Narcan) 117 OD 29, ALOC 46, ILS Meds 64
Narcan (Naloxone) 117 OD 29, ALOC 46, ILS Meds 64
Nasogastric Tube Insertion 72
Near Drowning 42
Newborn Resuscitation 30
Nitroglycerin 118 Pulmonary Edema 8, Chest Pain 10,
EMT Meds 63, ILS Meds 64
Nitropaste 119
Nitrous Oxide 73 120 Pain 30
Norcuron (Vecuronium) 128 RSI 48
Orthostatic Vital Signs 75 Abdominal pain 4, Bleeding 7, General
Illness 25, Miscarriage 26, ALOC 46
Overdoses 29
Oxygen Therapy 77
Oxymetazoline (Afrin) 90 RSI 48
Oxytocin (Pitocin) 121
Pain Management 30
Patient Confidentiality 2
Patient Refusal Medical Evaluation 3
Pediatric Formulary 129-138
Pediatric Cardiac Arrest 30
Pediatric Breathing Difficulty 32
Pediatric Emergencies, Fever 33
Phenergan (Promethazine) 122 Gen illness 28, Headache 27, Pain 30
Phone Numbers 142
Physician Present at the Scene 2
Pitressin (Vasopressin) 127 VF 20
Poisoning 29, 33 76
Post Partum 37
Prednisone 123 Pediatric SOB 36 Allergic reaction 5,
Reactive airway 9, Pediatric SOB 32
Pregnancy 34 - 37
Prehospital Care Provider Conduct 2
Prehospital Spinal Clearance 78
Promethazine (Phenergan) 122 General Illness 28, Headache 27,
Pain 30
Proventil (Albuterol, Ventolin) 91 Allergic reaction 5, Reactive airway 9,

Pediatric SOB 32, Hyperkalemia 58,
ILS meds 64,
Psychological Emergencies 28
Pulmonary Edema/CHF 8
Pulseless Electrical Activity 17
Pulseless Ventricular Tachycardia 20
Rapid Sequence Intubation (RSI) 48
SCUBA related 43 Drowning 42
Seizures 38
Sick, Unknown 25 ALOC 46
Sodium Bicarbonate 124 Hyperkalemia 58, VF 20, OD 29
Solumedrol (Methylprednisolone) 113 Pulmonary Edema 8, Reactive Airway 9
Stroke 39 Cincinnati stroke test 57
Succinylcholine (Anectine) 125 RSI 48
Supraventricular Tachycardia 18
Surgical Cricothyrotomy 80, 81
Syncope 46 ALOC 46
Thiamine (Vitamin B1) 126 Diabetic 22, ALOC 46
Thrombolytic Screening 83
Toradol (Ketorolac) 107 Abdominal pain 4
Tylenol 86 OD 76, Fever 33
Unconscious 46
Unresponsive 46
Vasopressin (Pitressin) 127 VF 20
Vecuronium (Norcuron) 128 RSI 48
Ventolin (Albuterol, Proventil ) 91 Allergic reaction 5, Reactive airway 9,
Pediatric SOB 32, Hyperkalemia 58,
ILS meds 64,
Ventricular Fibrillation 20
Ventricular Tachycardia with pulse 19
Versed (Midazolam) 114 Bradycardia 16, SVT 18, VT 19, A Fib
15, Psych 28, Seizure 38, RSI 48
Vitamin B1 (Thiamine) 126 Diabetic 22, ALOC 46
January 2004 Updates/Revisions/Changes
It is the obligation of EVERY PROVIDER to read and review the protocols. This list of changes made
within the 2004 Protocols is by no means a replacement for reading the entire text.
Page #
Unspecified format changes were made throughout the text to improve continuity and
ease of reading. The protocol flow chart is laid out as BLS, ILS and ALS. For example
ALS providers are expected to perform BLS and ILS assessments/treatments also.
The protocol flow sheet steps are numbered in this way in order to avoid redundancy.
It is the duty of all providers to perform up to and within their certification level.
After an ILS provider performs skills they must contact base station and the on duty
paramedic to advise patient status and arrange possible intercept.
Intranasal medications – Midazolam, Naloxone, Glucagon, & Morphine
BLS providers may now perform Pulse oximetry & Blood Glucose testing PRN.
Training must be completed prior to performing this skill.
Generic names of medications are used for consistency and to avoid confusion
1 Added – availability/use of latex gloves is the standard of care.
3 Added – Air Ambulance Transport
4 Added – Toradol as a standing order, note c. reduce dose ½ for elderly.
5 Added – BLS - Pulse ox, ALS - Atrovent, choose one Methylprednisolone,
Dexamethasone, Prednisone
6 Added – Pulse ox & ECG PRN
7 Added – BLS - control bleeding, stabilize deformities, treat for shock
8 Added – BLS - Position of comfort, ALS -12 lead
9 Added – BLS - Pulse ox, ALS - Atrovent, choose one Methylprednisolone,
Dexamethasone, Prednisone
10 Added – note a. ask patient if they have taken sildenafil (Viagra) ALS – Clallam
County only TNK with physician order
13 Added – ALS – Lorazepam, Amiodarone standing order
15 Added - ALS – Cardizem standing order, Amiodarone, Lopressor is physician
18 Added – ALS – Verapamil is standing order, Lopressor, Cardizem, Amiodarone
Physician order
19 Added - Amiodarone
20 Added - Amiodarone
22 Added – ILS D5W
24 Added – ALS Bretylium
25 Added – ALS Diphenhydramine standing order
27 Added – ALS - Droperidol to standing orders, Lorazepam physician order
28 Added – ALS - Lorazepam standing orders
29 Added – ALS - Lorazepam standing orders
30 Added – ALS - Nitrous Oxide
32 Added – ALS – Atrovent, chose one Dexamethasone, Methylprednisolone
33 Deleted – tepid water sponging, Acetaminophen dose change
34 Added – Doppler where available
35 Added – ALS Magnesium sulfate, Lorazepam standing order
37 Added – ALS Oxytocin
42 Added – all patients must be transported ALS
44 Added – simple falls may be fatal in elderly, pad appropriately
46 Added – BLS Oral Glucose
48 Added - Etomidate
54 Added – Central Line Catheter Access physician order only
55 Added – Chest decompression
58 Added - hyperkalemia
62 Added – clarification of Nitro administration
64 Added - ILS Medications page
68 Added - Sternal IO
69 Added - LMA
71 Added – 5 Ts & Hs,
73, 74 Added – Nitrous Oxide
79 Added – Patient Restraint
82 Added - Taser Removal &Treatment
83 Added – Thrombolitic Screening
84 Added – Pre hospital index trauma score
85-128 Added – Decadron, Etomidate, Amiodarone, Glucose Paste, Lopressor, Oxytocin,
Bretylium
Deleted - Tetracaine
138 Added – various abbreviations

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INTRODUCTION

The prehospital care provider is expected to follow these statements:

11. The prehospital contact report is to include:

PREHOSPITAL CARE PROVIDER CONDUCT

PHYSICIAN PRESENT AT THE SCENE

EMERGENCY AT A PHYSICIAN’S OFFICE

AIR AMBULANCE TRANSPORTS

Patient characteristics strongly indicative of air ambulance transport:

Information to have available regarding airlift transport:

This page corrected on 03/11/04

Unstable: (Critical) (d)

Choose ONE of the following antiarrhythmics PRN:

This page corrected on 03/11/04

This page corrected on 03/11/04

**Base Station Contact**

This page corrected on 01/16/04.

I Lateral aVR V1 Septal V4 Anterior

II Inferior aVL Lateral V2 Septal V5 Lateral

III Inferior aVF Inferior V3 Anterior V6 Lateral

ANATOMICALLY CONTIGUOUS LEADS

This page corrected on 01/16/04.

1. A score of 7 – 10 = active and vigorous newborn

Refer to American Heart Association current guidelines.

1. Rationale for early defibrillation

8. Training and skills maintenance

9. Post AED usage

Refer to American Heart Association current guidelines.

3. Infant (less than 1 year):

PHYSICIAN ORDER ONLY

1. An ALS responder may not access an A-V shunt.

A. Sterile technique must be maintained.

6. Remove needle leaving catheter with flutter valve in place.

7. Secure catheter to the chest wall.

8. Ensure adequate respirations and air flow.

10. Continually monitor and reassess the patient.

Refer to American Heart Association current guidelines.

1. Facial droop – Have the patient show their teeth or smile.

1. Sodium Bicarbonate 1 mEq/kg, not to exceed 50-100 mEq

Description -60 cm long semi-rigid, resin coated, braided polyester instrument

Indications -any situation involving poor vocal cord visualization

Advantages -used customary and familiar oral route

Technique 1. Lubricate bougie with water soluble lubricant

2. Prehospital care providers need not initiate CPR if:

4. Death category criteria (a)

Serious signs & symptoms

ADMINISTER Attempt Base

Medications that may be administered by the EMT-Basic in the prehospital setting.

2. The EMT-Basic may administer only after Base Station contact

1. EMT Intermediate may administer/assist the following medications if indicated:

2. EMT Intermediate may administer only after Base Station contact

This page corrected on 03/11/04

BASIC LIFE SUPPORT

1. If the patient is in cardiopulmonary arrest, and an automated or manual defibrillator is immediately

EXTUBATION OF THE COMBITUBE

IF ENDOTRACHEAL TUBE IS TO BE PLACED BY ALS PERSONNEL

Tibia (Anteromedial Surface)

BASIC LIFE SUPPORT

1. Verify cardiac and/or respiratory arrest

Progression of symptoms Morphine

NEUROLOGICAL GLASGOW COMA SCORE

T – Tracks, Tags, Tattoos

INFANTS and CHILDREN:

**NitroNox® is a standing order**

Base Station Contact

NitroNox® is a standing order

PARAMEDIC: _______________________ DATE: _

Acetaminophen is a standing order

Activated Charcoal is a standing order

Adenosine is a standing order

Albuterol is a standing order