Rapid City (Pennington Co) (SD) Protocols (2008)

RAPID CITY
PENNINGTON COUNTY
ADVANCED LIFE SUPPORT

PROTOCOLS
These protocols are effective as of January 2007

Pre-hospital Emergency Medical Services in the Rapid City metro and
Pennington County area have evolved dramatically in the past decade.
Since the first major revision of these Advanced Life Support (Paramedic)
Protocols, what were once a few pages in a notebook have mushroomed into a
formidable volume. The current revision of these protocols is a compilation of
input from multiple sources – local, national and international.
Our practice of pre-hospital emergency medicine is second-to-none. In an
increasingly sophisticated and technology–based environment, a special thanks
goes to those dedicated individuals who take the knowledge condensed herein and
provide a critical service for our community. It should always be remembered that
protocols define process, people provide care.
As always, these protocols are an evolving project. We invite your
comments and suggestions.
Sincerely,
John M. Rud, M.D., F.A.C.E.P
Rapid City and Pennington County
Pre-hospital Advanced Life Support Protocols
RECEIPT OF PROTOCOL ACKNOWLEDGEMENT
This is to certify that the undersigned has received the Rapid City and Pennington
County Pre-hospital Advanced Life Support Protocols, and accepts the responsibility for
knowing and practicing in accordance with these protocols.
Name (please print) Date
Signature
Rapid City Department of Fire and Emergency Services Paramedics

Rapid City and Pennington County
Pre-hospital Advanced Life Support Protocols
INTRODUCTION
This protocol manual represents the foundation for the clinical standards of the
Pre-hospital Emergency Medical Services system in Rapid City and Pennington County.
The process which resulted in the construction of this set of protocols will remain in
place and these protocols will continue to be edited and revised to reflect the dynamic
role of Pre-hospital Emergency Medical Services within the medical care community.
Section 1. contains the Patient Assessment Protocols.
Section 2. contains the Medical Treatment Protocols.
Section 3. contains the Trauma Treatment Protocols.
Section 4. contains the Environmental Injury Treatment Protocols.
The Treatment Protocols are divided into adult and pediatric sections, each with two
parts:
I. Level I. treatment is an intervention that can performed without contacting

medical control. (Designated by Roman numeral I.)
II. Level II. treatment is an intervention that requires contact with Medical
Control prior to performing. (Designated by red Roman numeral II.)
Section 5. contains the Procedure Protocols. The Procedure protocols where

applicable, include a description of Indications, Precautions, Techniques, and
Complications for procedures approved for use in the Rapid City/Pennington County
EMS System. Procedure Protocols will in some instances include Level I. and Level II.
interventions.
Section 6. contains the Operational Protocols required for effective clinical and tactical
EMS operations in the Rapid City/Pennington County EMS system.
Section 7. contains Drug Summaries. The Drug Summaries include a description of

Actions, Indications, Contraindications, Side Effects, Dosages (adult and pediatric if
applicable) and available forms of those drugs approved for use in the Rapid
City/Pennington County EMS System.
Section 8. contains a full list of tables and illustrations.
Rapid City Department of Fire and Emergency Services Paramedics

INDEX
ADVANCED LIFE SUPPORT PROTOCOLS
Page
Definitions .................................................................................................................... 1-1
1. Patient Assessment
Assessment-Trauma Patient, Primary Survey................................................... 1-3
Assessment-Trauma Patient, Secondary Survey.............................................. 1-5
Assessment-Medical Patient ............................................................................. 1-8
Assessment-Pediatric Patient ........................................................................... 1-9
Assessment-Neurologic .................................................................................. 1-11
Patient History................................................................................................. 1-14
2. Treatment Protocols - Medical

Protocol 2.1: General Supportive Care............................................................ 2-1
Protocol 2.2: Abdominal Pain .......................................................................... 2-6
ACLS core protocols
Protocol 2.3: Asystole .................................................................................... 2-7
Protocol 2.4: Bradycardia ............................................................................ 2-10
Protocol 2.5: Narrow-Complex Tachycardia ................................................ 2-12
Protocol 2.6: Neonatal Resuscitation .......................................................... 2-15
Protocol 2.7: Premature Ventricular Ectopy................................................. 2-17
Protocol 2.8: Pulseless Electrical Activity, (PEA) ........................................ 2-19
Protocol 2.9: Ventricular Fibrillation / Pulseless Ventricular Tachycardia .... 2-22
Protocol 2.10: Wide-Complex Tachycardia with Pulse .................................. 2-25
Protocol 2.11: Airway Obstruction ................................................................... 2-28

Protocol 2.12: Allergic Reaction / Anaphylaxis ................................................ 2-30
Protocol 2.13: Asthma ..................................................................................... 2-32
Protocol 2.14: Behavioral / Psychiatric ............................................................ 2-33
Protocol 2.15: Cardiogenic Shock ................................................................... 2-35
Protocol 2.16: Chest Pain................................................................................ 2-36
Protocol 2.17: Coma / Altered Mental Status .................................................. 2-38
Protocol 2.18: COPD....................................................................................... 2-40
Protocol 2.19: Diabetic Emergencies .............................................................. 2-42
Protocol 2.20: Drug Overdose / Ingestion / Poisoning..................................... 2-44
Protocol 2.21: Hypertensive Emergencies ...................................................... 2-49
Protocol 2.22: OB / GYN ................................................................................. 2-51
Protocol 2.23: Pulmonary Edema.................................................................... 2-55
Protocol 2.24: Seizures and Status Epilepticus ............................................... 2-56
Protocol 2.25: Sudden Infant Death Syndrome (SIDS) ................................... 2-58
Protocol 2.26: Syncopal Episode..................................................................... 2-59
INDEX (CONT.)
Page
3. Treatment Protocols - Trauma
Protocol 3.1: Trauma and Hypovolemic Supportive Care................................. 3-1
Protocol 3.2: Abdominal / Pelvic Trauma ......................................................... 3-6
Protocol 3.3: Amputation .................................................................................. 3-8
Protocol 3.4: Burns......................................................................................... 3-10
Protocol 3.5: Chest Trauma ........................................................................... 3-17
Protocol 3.6: Extremity Injuries....................................................................... 3-20
Protocol 3.7: Eye Injuries ............................................................................... 3-22
Protocol 3.8: Head Trauma ............................................................................ 3-24
Protocol 3.9: Spinal Trauma........................................................................... 3-27
Protocol 3.10:Trauma Cardiac Arrest .............................................................. 3-29
4. Treatment Protocols – Environmental Injury

Protocol 4.1: Bites and Stings .......................................................................... 4-1
Protocol 4.2: Drowning / Near Drowning .......................................................... 4-3
Protocol 4.3: Hyperthermia............................................................................... 4-6
Protocol 4.4: Hypothermia and Frostbite .......................................................... 4-8
5. Procedure Protocols
Protocol 5.1: Airway Management: General Principles ................................... 5-1
Protocol 5.2: Airway Management: Assisting Ventilation................................. 5-4
Protocol 5.3: Airway Management: Clearing and Suctioning the Airway ......... 5-6
Protocol 5.4: Airway Management: Obstructed Airway ................................... 5-9
Protocol 5.5: Airway Management: Opening the Airway ............................... 5-12
Protocol 5.6: Advanced Airway Management: Combitube ............................ 5-15
Protocol 5.7: Advanced Airway Management: Orotracheal Intubation .......... 5-19
Protocol 5.8: Advanced Airway Management: Nasotracheal Intubation ........ 5-24
Protocol 5.9: Advanced Airway Management: Rapid-Sequence Induction.... 5-28
Protocol 5.10: Advanced Airway Management: Needle Cricothyrotomy ......... 5-33
Protocol 5.11: Advanced Airway Management: Surgical Cricothyrotomy........ 5-37
Protocol 5.12: CPAP ....................................................................................... 5-41
Protocol 5.13: Defibrillation ............................................................................. 5-44
Protocol 5.14: Endotracheal Drug Administration............................................ 5-47
Protocol 5.15: External (Transcutaneous) Cardiac Pacing.............................. 5-49
Protocol 5.16: Glucose Level Determination ................................................... 5-53
Protocol 5.17: Intraosseous Infusion (Jamshidi & EZ-IO)................................ 5-56
Protocol 5.18: Medication Administration ........................................................ 5-64
Protocol 5.19: Nebulized Bronchodilators ....................................................... 5-68
Protocol 5.20: Pain Management .................................................................... 5-70
Protocol 5.21: Peripheral IV Line Insertion ...................................................... 5-72
Protocol 5.22: Restraint (Physical and Chemical) ........................................... 5-75
Protocol 5.23: Saline Lock Insertion ................................................................ 5-79
INDEX (CONT.)
Page
5. Procedure Protocols (Cont.)
Protocol 5.24: Spinal Immobilization ............................................................... 5-80
Protocol 5.25: Splinting, Extremity................................................................... 5-84
Protocol 5.26: Stroke (CVA) “Stroke Alert” ...................................................... 5-87
Protocol 5.27: Tension Pneumothorax Decompression .................................. 5-89
Protocol 5.28: Trauma Alert ............................................................................ 5-93
Protocol 5.29: 12 Lead ECG ........................................................................... 5-95
6. Operational Protocols
Protocol 6.1: Advanced Directives / DNR Orders............................................ 6-1
Protocol 6.2: Confidentiality............................................................................. 6-4
Protocol 6.3: Controlled Substance Documentation ........................................ 6-6
Protocol 6.4: Crime Scene Operations .......................................................... 6-13
Protocol 6.5: Field Determination of Death.................................................... 6-17
Protocol 6.6: Hazardous Materials / WMD Incidents ..................................... 6-21
Protocol 6.7: Helicopter Utilization................................................................. 6-67
Protocol 6.8: Infectious / Communicable Disease ......................................... 6-76
Protocol 6.9: Inter-facility Transport (Critical Care) ....................................... 6-83
Protocol 6.10: Multiple Casualty Incidents (MCI)............................................. 6-85
Protocol 6.11: No-Transport (Refusal, Cancel) ............................................... 6-99
Protocol 6.12: Patient Care Report (PCR) Requirements ............................. 6-106
Protocol 6.13: Public Inebriate Disposition .................................................... 6-109
Protocol 6.14: Radio Reports ........................................................................ 6-112
Protocol 6.15: Rules of Engagement............................................................. 6-115
7. Drug Summaries
Approved Drug List ...................................................................................................... 7-1
Adenocard (Adenosine) ............................................................................................... 7-3
Albuterol (Proventil) ..................................................................................................... 7-5
Amiodarone (Cordarone) ............................................................................................. 7-7
Aspirin (Acetylsalicylic Acid)......................................................................................... 7-9
Ativan (Lorazepam).................................................................................................... 7-10
Atropine Sulfate (as a cardiac agent)......................................................................... 7-11
Atropine Sulfate (as an antidote for poisoning) .......................................................... 7-13
Benadryl (Diphenhydramine) ..................................................................................... 7-15
Calcium Gluconate..................................................................................................... 7-17
Cyanokit ..................................................................................................................... 7-19
Dextrose 50% (D50) .................................................................................................. 7-21
Dextrose 25% (D25) .................................................................................................. 7-22
Dopamine Infusion (Intropin)...................................................................................... 7-23
Epinephrine (1:10,000) .............................................................................................. 7-25
Epinephrine (1:1000) ................................................................................................. 7-27
Etomidate (Amidate) .................................................................................................. 7-29
INDEX (CONT.)
Page
7. Drug Summaries (Cont.)
Fentanyl (Sublimaze) ................................................................................................. 7-31
Glucagon.................................................................................................................... 7-33
Haldol (Haloperidol) ................................................................................................... 7-34
Haz-Mat / WMD drugs (Mark I Kit, not stocked)
• Pralidoxime (2 Pam) Chloride ......................................................................... 7-36
• Atropine Sulfate............................................................................................... 7-38
Inter-facility Transport drugs (not stocked)
• Heparin Infusion .............................................................................................. 7-40
• Nitroglycerin Infusion....................................................................................... 7-42
• Integrilin........................................................................................................... 7-44
Lasix (Furosemide) .................................................................................................... 7-46
Lidocaine (Xylocaine)................................................................................................. 7-48
Lidocaine 2% Viscous Gel (Xylocaine)....................................................................... 7-50
Morphine Sulfate........................................................................................................ 7-51
Narcan (Naloxone) ..................................................................................................... 7-53
Neo-Synephrine ......................................................................................................... 7-55
Nitroglycerin Spray /Tablet......................................................................................... 7-56
Procainamide (Pronestyl)........................................................................................... 7-58
Sodium Bicarbonate................................................................................................... 7-59
Succinylcholine (Anectine) ......................................................................................... 7-61
Thiamine Hydrochloride ............................................................................................. 7-63
Valium (Diazepam) .................................................................................................... 7-64
Zemuron (Rocuronium) .............................................................................................. 7-66
Zofran (Ondansetron) ................................................................................................ 7-68
Infusion Charts (Adult, Pediatric, Critical Care)............................................... 7-70 – 7-72
8. Tables and Illustrations
Table 1.A. Normal Vital Signs in the Pediatric Age Group ........................................ 1-10
Table 1.B. Glasgow Coma Scale – Adult / Child ....................................................... 1-11
Table 1.C. Glasgow Coma Scale – Infant / Small Child ............................................ 1-13
Table 2.A. APGAR Score................................................................................. 2-16, 2-52
Illustration 3.A. Rule of Nines Chart .......................................................................... 3-15

Table 3.A. Parkland Burn Formula............................................................................ 3-14
Table 3.B. Burn Classifications ................................................................................. 3-16
INDEX (CONT.)
8. Tables and Illustrations (Cont.) Page

Illustration 5.A. Combitube Placement ...................................................................... 5-16
Illustration 5.B. Combitube Anatomy......................................................................... 5-17
Illustration 5.C. Combitube Anatomy......................................................................... 5-18
Illustration 5.D. Mallampati Classification.................................................................. 5-31
Illustration 5.E. Thyromental Distance ...................................................................... 5-32
Illustration 5.F. PTLV O2 Delivery Device ................................................................ 5-36
Illustration 5.G. Laryngeal Anatomy .......................................................................... 5-40
Illustration 5.H. Intraosseous Needle Placement ...................................................... 5-59
Illustration 5.I. Cook Emergency Pneumothorax Kit................................................ 5-92
Illustration 5.J. 12-Lead Precordial Lead Placement................................................ 5-98
Table 5.A. ETT Size By Age ..................................................................................... 5-23
Illustration 6.A. RCRH Controlled Drug Administration Record................................. 6-10

Illustration 6.B. Ambulance Controlled Substance Log ............................................. 6-11
Illustration 6.C. Controlled Substance Usage Log..................................................... 6-12
Illustration 6.D. HazMat Zones.................................................................................. 6-66
Illustration 6.E. 20-Minute Ground Travel Zone ........................................................ 6-75
Illustration 6.F. MCI IC Flowchart.............................................................................. 6-96
Illustration 6.G. START Triage .................................................................................. 6-97
Illustration 6.H. METTAG Triage Tag........................................................................ 6-98
Table 7.A. Dopamine Drip......................................................................................... 7-70

Table 7.B. Epinephrine Drip ...................................................................................... 7-70
Table 7.C. Lidocaine Drip.......................................................................................... 7-70
Table 7.D. Procainamide Drip ................................................................................... 7-71
Table 7.E. Pediatric Infusions ................................................................................... 7-71
Table 7.F. Heparin Drip............................................................................................. 7-72
Table 7.G. Nitroglycerin Drip..................................................................................... 7-72
Rapid City and Pennington County Section 1
Pre-hospital Advanced Life Support Protocols Patient Assessment
Definitions
Level I Treatment:
Level I treatment is denoted by a Roman numeral I. It is defined as an

intervention that can be performed under “standing orders” and does not
require contact with medical control to perform (within protocol parameters).
Level II Treatment:
Level II treatment is denoted by a red Roman numeral II. It is defined as an

intervention that requires contact with medical control to perform.
Clinical Definitions:
It is necessary to make a differentiation between neonatal, infant and adult

patients to select appropriate protocols.
A. Neonate:
The difference between neonates and infants, for the purposes of these
protocols, is based on age. A neonate is in a physiological transition from
mechanisms used in utero to those that are used after delivery and
severance of the umbilical cord. Thus, a patient less than six weeks old will
be considered as a neonate.
B. Infant:
Infants have functional differences from older children, which relate to their
developing physiology and their poorly developed intellect. Ability to
communicate and understand are limited. This is a distinction based on age,
not size. A patient less than one (1) year of age will be considered as an
infant.
C. Pediatric and Adult:
The term “pediatric” is used in these protocols as a collective term, including

neonates, infants, children and adolescents. Any patient less than 18 years
old is considered pediatric, from a legal standpoint (except emancipated or
married minor). The legal standpoint must be considered in decisions about
patient rights in regard to treatment refusals, choice of hospitals, etc.
Rapid City Department of Fire and Emergency Services Paramedics, PAGE 1-1
Definitions (cont.)
For medical purposes, differences between neonates, infants and children

may appear in protocols such as dysrhythmia and arrest protocols. Without
specific notations, all these groups are treated similarly. Age in these young
patients may still be an important factor in the history, influencing the
probability for accidental ingestion of poisons or the occurrence of certain
types of accidents.
A more subtle distinction, from a medical perspective, is made between

adolescents and adults. Adolescents are nearly equal physiologically to
adults, aside from age and size. Most significantly, drug dosages for
adults assume a body size between 50 and 200 kg (100 - 400lbs.). From
a medication dosage standpoint, pediatric patients weigh less than 50 kg
(100 lbs.).
Reference:
Thomas, CL (Ed.): Taber’s Cyclopedic Medical Dictionary, F.A. Davis

Co., Philadelphia, 1985. pgs. 43, 839, 1105, 1244
ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY
Environmental Assessment:
A. Recognize environmental hazards to rescuers, and secure area for

treatment.
B. Recognize hazard to patient, and protect from further injury.
C. Identify number of patients. Initiate a triage system if appropriate.
D. Observe position of patient, mechanism of injury, surroundings.
E. Initiate communications if hospital resources require mobilization; call for

backup if needed.
F. Identify self. Consider TRAUMA ALERT.
Primary Survey:
Note initial level of responsiveness (awake, verbal, pain, unresponsive).
A. Airway:
1. Observe the mouth and upper airway for air movement.

2. Protect cervical spine from movement in trauma victims. Use
assistant to provide continuous in-line cervical immobilization.
3. Look for evidence of upper airway problems such as vomitus,
bleeding, and facial trauma.
B. Breathing:
1. Look for jugular venous distention and tracheal deviation.

2. Expose chest and observe chest wall movement.
3. Note respiratory rate (qualitative), noise, and effort.
4. Look for life-threatening respiratory problems and briefly stabilize:
a. Open or sucking chest wound - Seal.

b. Large flail segment - Stabilize.
c. Tension pneumothorax: transport rapidly and consider
decompression.
5. Auscultate for crackles (wet sounds), wheezes, or decreased

breath sounds.
6. Palpate for tenderness, wounds, fractures, crepitus, or unequal rise
of chest.
ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY (cont.)
C. Circulation:
1. Palpate for radial and carotid pulses. Note pulse quality (strong,
weak), and general rate (slow, fast, moderate). Where a pulse is
able to be palpated can be indicative of an approximate systolic BP.
The following are general guidelines, they should not be considered
absolutes:
a. Radial pulse - systolic BP > 90

b. Femoral pulse - systolic BP > 80
c. Carotid pulse - systolic BP > 70
2. Check capillary refill time in fingertips: ≤ 2 sec is typically normal.

3. Check skin color and condition.
4. Control hemorrhage by direct pressure with clean dressing to
wound.
D. Responsiveness:
1. Reassess level (awake, responsive to voice or pain, no response).

2. Briefly note body position and extremity movement.
3. Check movement and sensation in all four extremities prior to
moving patient.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY
Secondary survey is the systematic assessment of the entire patient. The

purpose of the secondary survey is to uncover problems which are not life-
threatening but which could be injurious or could become life-threatening to
the patient. It should be performed after:
1. Primary survey.
2. Stabilization and initial treatment of life-threatening airway,
breathing, or circulatory difficulties.
A. Initial Vital signs.
B. Additional History.
C. Head and Face:
1. Observe for deformities, asymmetry, bleeding.

2. Palpate for deformities, tenderness, or crepitus.
3. Re-check airway for potential obstruction: dentures, bleeding, loose
or avulsed teeth, vomitus, abnormal tooth position from mandibular
fracture, and absent gag reflex.
4. Eyes: pupils (equal or unequal, responsiveness to light), foreign
bodies, contact lenses, periorbital ecchymosis (raccoon eyes).
5. Nose: deformity, bleeding, discharge.
6. Ears: bleeding, discharge, bruising behind ears. (Battles sign)
D. Neck:
1. Re-check for deformity or tenderness if not already immobilized.

2. Observe for penetrating wounds, neck vein distention and use of
neck muscles for respiratory effort. Also note altered voice, and
medical alert tags.
3. Palpate for crepitus, tracheal shift, sub-q air.
E. Chest:
1. Observe for wounds, symmetry of chest wall movement

2 Have patient take deep breath: observe for pain, symmetry, air
leak from wounds.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).
3. Re-auscultate for crackles (wet sounds), wheezes, and decreased

or absent breath sounds.
4. Palpate for tenderness, wounds, fractures, crepitus, or un-equal
rise of chest.
F. Abdomen:
1. Observe for wounds, bruising, distention.

2. Palpate all 4 quadrants for tenderness, rigidity.
G. Pelvis:
1. Palpate and compress lateral pelvic rims and symphysis pubis for
tenderness or instability.
H. Shoulders/Upper Extremities:
1. Observe for angulation, protruding bone ends, symmetry.

2. Palpate for tenderness, crepitus.
3. Note distal pulses, color, medical alert tags.
4. Check sensation.
5. Test for weakness if no obvious fracture present (have patient
squeeze your hands).
6. If no obvious fracture, gently move arms to check overall function.
I. Lower Extremities:
1. Observe for angulation, protruding bone ends, symmetry.

2. Palpate for tenderness, crepitus.
3. Note distal pulses, color.
4. Check sensation.
5. Test for weakness if no obvious fracture present (have patient push
feet against your hands).
6. If no obvious fracture, gently move legs to check overall function.
J. *Back:
1. If patient is stable, logroll, observe and palpate for wounds,

fractures, tenderness, bruising.
2. Recheck motor and sensory function as appropriate.
ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).
* Examination of the back may take place after the primary survey and
prior to placing patient on backboard if rapid transport is indicated (see
Trauma and Hypovolemic Supportive Care Protocol).
Special Notes:
A. Be systematic. If you jump from one obvious injury to another, the

subtle injury that is most dangerous to the patient is easily missed.
B. Obtain and record two or more sets of vital signs and neurologic
observations on every patient. A patient cannot be called “Stable”
without sets of vital sign’s giving similar normal readings. Serial vital
signs are an important parameter of the patient’s physiologic status.
Vital signs should be repeated as necessary to document changes in
abnormal findings.
C. Use your judgment. Weigh benefits vs risks to patient in considering a

prolonged field evaluation vs rapid transport to medical facility.
ASSESSMENT - MEDICAL PATIENT
A primary survey is done on all medical and trauma patients. In the awake
medical patient, this may consist only of identifying yourself and noting the
patient’s responsiveness and general appearance. The formal secondary
survey may not need to be done on patients with a specific complaint, such
as “chest pain”. Assessment must be no less thorough, but it may be limited
to the body systems that are pertinent to the presenting problem.
A. Vital signs: quantitative vital signs (including oxygen saturation) usually

precede the rest of the exam.
B. Head/Face:
1. Note airway patency, oral swelling, and hydration.

2. Eyes: note pupil symmetry, reaction to light, movement.
3. Note symmetry of facial movements.
C. Neck:
1. Observe for neck vein distention in the upright position and use of
accessory muscles for breathing.
D. Chest:
1. Observe chest wall for symmetry of air movement.

2. Auscultate:
a. Breath sounds for symmetry, crackles (wet sounds),

wheezing, or evidence of obstruction.
b. Heart for regularity (if irregular, is it intermittently or
consistently irregular?).
E. Abdomen:
1. Observe for distention, bruising

2. Palpate for tenderness, rigidity, masses.
F. Extremities:
1. Observe: presence of edema, color of skin.

2 Palpate for warmth, tenderness, presence of pulses.
G. See Neurologic Assessment
ASSESSMENT - PEDIATRIC PATIENT
Children can be examined easily from head to toe, but lack of understanding
by the patient, poor cooperation, and fright often limit the ability to assess
completely in the field. Children often cannot verbalize what is bothering
them, so it is important in trauma victims to do a systematic primary and
secondary survey, which covers areas that the patient may not be able to tell
you about. Any observations about spontaneous movements of the patient
and areas that the child protects are very important. In the patient with a
medical problem, the more limited set of observations listed below should
pick up potentially serious problems.
A. General:
1. Level of alertness, eye contact, attention to surroundings.

2. Muscle tone: Normal, increased or weak and flaccid.
3. Responsiveness to parents, caregivers; is the patient playful or
inconsolable?
B. Head:
1. Signs of trauma.
2. Fontanelle, if open: abnormal depression or bulging.
C. Face:
1. Pupils: size, symmetry, reaction to light.

2. Hydration: brightness of eyes, is child making tears, are the mouth
and lips moist or dry?
D. Neck: note stiffness.
E. Chest:
1. Note presence of stridor, retractions (depressions between ribs on

inspiration), grunting, increased respiratory effort, or rapid/overly
slow respiratory rate.
2. Breath sounds: symmetrical, wet, wheezing.
3. Heart rate, obvious murmur?
F. Abdomen: distention, rigidity, bruising, tenderness.
ASSESSMENT - PEDIATRIC PATIENT (cont.)
G. Extremities:
1. Brachial pulse.
2. Signs of trauma.
3. Muscle tone, symmetry of movement.
4. Areas of tenderness, guarding or limited movement.
H. Skin:
1. Skin temperature and color, capillary refill.

2. Unusual rashes, i.e., petechia, urticaria.
3. Skin turgor.
I. See Neurologic Assessment
TABLE 1.A.
NORMAL VITAL SIGNS IN THE PEDIATRIC AGE GROUP
AGE PULSE RESPIRATIONS BLOOD PRESSURE

beats/min. rate/min. Systolic + or - 20
(mean)
Premature 144 20-38 N/A
Newborn 140 20-38 N/A
6 months 130 20-30 80 palp
1 year 130 20-24 90 palp
3 years 100 20-24 95 palp
5 years 100 20-24 95 palp
8 years 90 12-20 100 palp
ASSESSMENT - NEUROLOGIC
Management of patients with head injury or neurologic illness depends on

careful assessment of neurologic function. Changes are particularly
important. The first observations of neurologic status in the field provide the
basis for monitoring sequential changes. It is therefore important that the
first responder accurately observe and record neurologic assessment using
measures which will be followed throughout the patient’s hospital course.
A. Vital Signs: Observe particularly for adequacy of ventilation, also depth,

frequency, and regularity of respirations.
B. Level of consciousness: Use Glasgow Come scale.
TABLE 1.B.
GLASGOW COMA SCALE – ADULT / CHILD
EYE OPENING:
None 1
To pain 2
To speech 3
Spontaneously 4
BEST VERBAL RESPONSE:

None 1
Garbled sounds 2
Inappropriate words 3
Disoriented sentences 4
Oriented 5
BEST MOTOR RESPONSES:

None 1
Abnormal extension 2
Abnormal flexion 3
Withdrawal to pain 4
Localizes pain 5
Obeys commands 6
Score = Sum of scores in 3 categories: (15 points possible)
ASSESSMENT - NEUROLOGIC (cont.)
C. Eyes:
1. Direction of gaze.
2. Size and reactivity of pupils.
D. Movement: Observe whether all four extremities move equally well.
E. Sensation (if patient awake): Observe for absent, abnormal, or normal

sensation at different levels if cord injury is suspected.
Special Notes:
A. The Glasgow Coma Scale (GCS) used above has gained acceptance as
one method of scoring and monitoring patients with head injury. It is
readily learned, has little observer-to-observer variability, and accurately
reflects cerebral function. Always record specific responses rather than
just the score (sum of observations). Remember that a patient who is
totally without response will have score of 3, not 0.
B. Use a flow sheet to follow and identify changes rapidly.
C. Sensory and motor exam must be documented before moving patient

with suspected spinal injury.
D. Note what stimulus is being used when recording responses. Applied

noxious stimuli must be adequate to the task but not excessive. Initial
mild stimuli can include light pinch, dull pinprick - if these are
unsuccessful at eliciting a pain response, pressure with a dull object to
base of nailbed, stronger pinch (particularly in axilla) may be necessary
to demonstrate the patient’s best motor response.
Note: The “sternal rub” shall not be used to test pain response.
E. When responses are not symmetrical, use motor response of the best
side for scoring GCS and note asymmetry as part of neurologic
evaluation.
F. Use of restraints or intubation of patient will obviously make some

observations less accurate. Be sure to note on chart if
circumstances do not permit full verbal or motor evaluation.
ASSESSMENT - NEUROLOGIC (cont.)
Special Notes (cont.):
G. Glasgow Coma Scale of 13 or less-observe closely for deterioration.

Glasgow Coma Scale of 8 or less will probably require airway
intervention at some point.
H. In infants and small children, the GCS may be difficult to evaluate.

Children who are alert and appropriate should focus their eyes and
follow your actions, respond to parents or caregivers, and use language
and behavior appropriate to their age level. In addition, they should
have normal muscle tone and a normal cry. Several observers should
attempt to elicit a “best verbal response”, to avoid over or
underestimation of level of consciousness.
TABLE 1.C.
GLASGOW COMA SCALE – INFANT / SMALL CHILD
EYE OPENING:
None 1
To pain 2
To speech 3
Spontaneously 4
BEST VERBAL RESPONSE:

None 1
Moans, grunts 2
Cries to pain 3
Irritable cries 4
Coos, babbles 5
BEST MOTOR RESPONSES:

None 1
Abnormal extension 2
Abnormal flexion 3
Withdrawal to pain 4
Localizes pain 5
Spontaneous movement 6
Score = Sum of scores in 3 categories: (15 points possible)
PATIENT HISTORY
Medical:
A. Chief complaint:
1. When did it start? How long has it been going on? Is it changing?
2. How intense is the problem? Very severe, mild?
3. What caused or brought on the condition?
4. Does anything make it better or worse?
5. For pain: describe the location, type of pain, severity, radiation.
6. What caused the patient or family to seek help at this time?
7. Has the patient experienced or been treated before for this
problem? When?
B. Associated complaints: Are there any other symptom bothering the

patient at this time?
C. Pertinent past medical history.
D. Allergies.
E. Medications and drugs.
F. Survey of surroundings for evidence of drug abuse, mental function,

family, problems.
Trauma:
A. Chief complaints: areas of tenderness, pain.
B. Associated complaints.
C. Mechanism of injury:
1. What were the implements involved-weapons, autos, etc?

2. How did the injury happen: cause, precipitating factors?
3. What trajectories were involved. Bullets, cars, people?
4. How forceful was the mechanism: speed of vehicles, force of the
blow, etc.?
PATIENT HISTORY (cont.)
Trauma (cont.):
4. With a vehicle: What is the condition of windshield, steering wheel,

and vehicle body? Was there significant intrusion into the
passenger compartment? Were the passengers wearing
seatbelts? Was the patient ejected from the vehicle? Type:
rollover, head-on, rear-end, T-bone?
D. Mental status and pertinent findings since accident according to

witnesses or bystanders. Patient getting worse? Better?
E. Treatment since accident: movement of patient by bystanders, etc.

Patient ambulatory at scene?
Special Notes:
A. Do not let the gathering of information distract from management of life-

threatening problems.
B. Appropriate questioning can provide valuable information while

establishing authority, competence, and rapport with patient.
C. In medical situations, history is commonly obtained before or during

physical assessment. In trauma cases it may be simultaneous or
following the primary survey. An assistant is often used for gathering
information from family or bystanders.
D. USE BYSTANDERS to confirm information obtained from the patient

and to provide facts when the patient cannot. History from the scene is
invaluable.
E. Over-the counter medications (including aspirin and birth control pills)

are frequently overlooked by patient and EMS, but may be important to
emergency problems.
Pre-hospital Advanced Life Support Protocols Treatment Protocols - Medical
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE
Note: This protocol provides guidelines for the initial care and packaging of
medical patients. Because patients with hypovolemia and/or traumatic
complaints may require different treatment and transport priorities, a
separate Trauma and Hypovolemia Supportive Care Protocol has been
created.
The General Supportive Care Protocol is meant to be the foundation of

care for all medical patients, and may be the only protocol invoked for
any particular patient. If there is a question as to whether a patient
requires a particular intervention, contact with Medical Control is advised.
Medical Control contact is not required if only this protocol is
implemented. Contact may be required if other protocols need to be
implemented.
ADULT CARE
I.1. Patient assessment and history-taking. Include charting of at least two

sets of vital signs.
I.2. Airway management:
A. Initial management includes patient positioning and manual

maneuvers to assure a patent airway.
B. Patients with obvious signs and symptoms of hypoxia (e.g.

tachypnea, cyanosis, tachycardia, altered mental status,) should
initially be treated with 10-15 L/min via non-rebreather mask
(Exception: Patients with COPD may initially be started on 2-4L/min
via nasal cannula – See 2.18: COPD Protocol) Respiratory
suppression from oxygen administration should be closely monitored
and managed by assisted ventilation.
C. If the patient has continued difficulty with oxygenation and ventilation

after simple airway maneuvers, airway adjuncts and/or advanced
airway procedures may be used.
D. Endotracheal tube placement must be verified by three (3)

different methods immediately following intubation (see 5.7-9:
Advanced Airway Management Protocols). Tube placement must
also be re-verified after securing tube, after moving the patient, and
at any other time of concern or change in the patient’s condition
(including the movement of the patient from the ambulance cot to the
hospital bed).
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.)
ADULT CARE-(cont.)
If there is any question regarding the position of the endotracheal

tube, the endotracheal tube should be withdrawn and the patient re-
intubated.
E. When in the ambulance, the patient on O2 should be connected to

the on-board oxygen supply and the portable O2 tank securely
stowed. This is to avoid the possibility of the O2 tank becoming a
potentially lethal missile during sudden stops or accidents. All
patients receiving O2 during transport must continue to receive O2
from the vehicle to the ED.
I.3 ECG monitoring should be done in all patients with previous cardiac
history, potential for, or signs of instability. All patients monitored during
transport shall continue to be monitored during transfer from the vehicle
to the receiving ED.
I.4 Venous access:
A. Paramedic discretion should be used in determining which route of

access, if any should be established. General guidelines follow.
B. Establish intravenous access with NS or saline lock, and preferably,

an 18 gauge, or larger catheter in any patient with abnormal vital
signs or in whom the possibility of development of instability exists.
Examples include patients with hypertension, SOB, or chest pain.
C. Medical patients with systolic BP < 90 mm/Hg associated with signs

and symptoms of shock should have an IV of NS established.
D. Cardiac arrests, all significant trauma patients, and diabetics with low
or elevated glucose levels should have a large-bore IV of NS
established unless contraindicated.
I.5 Follow additional protocols as needed, establishing Medical Control

contact as dictated by protocol. If Medical Control is not needed, contact
the destination facility to give patient report, following the 6.14: Radio
Report Protocol.
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE- (cont.)
ADULT CARE- (cont)
I.6 Transport red lights and sirens (Code 3, HOT) if patient’s condition is
critical. Critical is defined by a medical or traumatic condition requiring
immediate medical intervention by physician and nursing personnel
upon arrival at the Emergency Department. Critical may further be
defined as any patient whose deteriorating medical condition cannot be
controlled by the Paramedic. NOTE: The exception to this is the chest
pain patient; the alert chest pain patient’s condition may be worsened by
a red lights and siren transport due to the elevated anxiety factor. The
attending Paramedic should weigh risk vs benefit when deciding how to
transport these patients. All other patients will be transported non-red
lights and sirens (Code 2, COLD).
PEDIATRIC CARE
I.1. Patient assessment and history-taking. Will include charting of at least

two sets of vital signs, including blood pressure.
I.2. Airway Management:
A. Initial management includes patient positioning and manual

maneuvers to assure a patent airway.
B. Patients with signs and symptoms of hypoxia (e.g. tachypnea,

cyanosis, tachycardia, altered mental status,) should initially be
treated with O2 by non-rebreather mask. Respiratory suppression
from oxygen administration should be closely monitored and
managed by assisted ventilation.
C. If the patient has continued difficulty with oxygenation and ventilation

after simple airway maneuvers, airway adjuncts and advanced
airway procedures may be used. Authorized airway access methods
include oral and nasal airways and endotracheal intubation.
Nasotracheal intubation is not recommended in children of less than
8 years of age because anatomical relationships make it especially
difficult.
D. Endotracheal tube placement must be verified by three different

methods immediately following intubation (see 5.7-9: Advanced
Airway Management Protocols). Tube placement must also be
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.)
PEDIATRIC CARE-(cont.)
re-verified after securing tube, after moving the patient, and at any
other time of concern or change in the patient’s condition (including
the movement of the patient from the ambulance cot to the hospital
bed). If there is any question regarding the position of the
endotracheal tube, the endotracheal tube should be withdrawn and
the patient re-intubated.
E. When in the ambulance, the patient on O2 should be connected to

the on-board oxygen supply and the portable O2 tank securely
stowed. This is to avoid the possibility of the O2 tank becoming a
potentially lethal missile during sudden stops or accidents. All
patients receiving O2 during transport must continue to receive O2
from the vehicle to the ED.
I.3 ECG monitoring should be done in all patients with previous cardiac
history, potential for, or signs of instability. All patients monitored during
transport must continue to be monitored during transfer from the vehicle
to the receiving ED.
I.4 Venous access:
A. Paramedic discretion should be used in determining whether venous

access is needed and which route of access is most appropriate.
(NOTE: intraosseous infusion is typically (not EZ-IO) a Level II
intervention and requires Medical Control authorization except in
cases of cardiac arrest.) The need for a “prophylactic” IV is rare in
the pediatric patient. If there is a question as to the necessity of
establishing an IV, contact Medical Control.
B. When needed, establish intravenous access with NS TKO or saline

lock. In children less than 50 kg, use a 250 ml or 500 ml bag with a
Buretrol micro drip and the largest size catheter possible. Average-
sized teenage children (weighing more than 50kg) may be treated
the same as adults in determining type of IV access. If a pediatric
patient requires a significant fluid bolus administration for any
reason, contact with Medical Control is strongly encouraged, though
not necessarily before the volume infusion.
I.5. Follow additional protocols as needed, establishing Medical Control

contact as dictated by protocol. If Medical Control contact is not needed,
contact the destination facility to give patient report, following the 6.14:
Radio Report Protocol.
PROTOCOL 2.1: GENERAL SUPPORTIVE CARE - (cont.)
I.6 Transport red lights and sirens (Code 3, HOT) if patient’s condition is
controlled by the Paramedic. All other patients will be transported non-
red lights and sirens (Code 2, COLD).
Note:
Infants of less than six months of age can be obligate nose-breathers,
therefore nasal congestion can present with apparently severe
respiratory distress. This may be easily remedied by suctioning of
mucous from the nose with a bulb syringe or suction catheter.
Children often naturally assume a position which maintains their airway

adequately. Attempts to force the patient out of this position, away from
comforting family members, or to administer O2 may result in agitation
which may produce further airway compromise. Oxygen may be better
tolerated if administered via blow-by from a mask held by the patient or
parent.
Transport of small children without need of cervical/spinal immobilization

may best be accomplished with the child restrained in a car seat, a
pediatric restraint device made expressly for the ambulance cot, or less
optimally, held by the caretaker and both securely restrained to the
stretcher or seat in the ambulance. No pediatric patient will be
transported without being restrained in some manner. A parent or
caretaker can be allowed to travel with the child unless that person’s
presence may be detrimental to the child’s treatment.
Cardiac dysfunction in children is more likely to respond to effective

oxygenation and ventilation than fluid administration and medications.
Defibrillation alone is rarely successful.
PROTOCOL 2.2: ABDOMINAL PAIN
ADULT CARE
I.1. General Supportive Care.
I.2. Position of comfort.
I.3. Nothing by mouth.
I.4. If systolic BP < 90 (check for orthostatic changes in vital signs) and
signs of shock:
a) O2, 10-15 L/min, non-rebreather mask.
b) IV NS, 500 cc fluid challenge, consider contact with Medical Control

prior to further fluids being infused. Upper abdomen and lower
chest pain may reflect thoracic pathology such as myocardial
infarction, etc. and massive fluid resuscitation may be
contraindicated.
c) Consider second line if fluid resuscitation not contraindicated.
II.1. None.
PEDIATRIC CARE
I.2. Position of Comfort.
I.3. Nothing by mouth.
I.4. If hypotensive (based on age) and signs of shock are present:
a) O2 via non-rebreather mask.
b) IV NS 20 cc/kg initial fluid challenge.
II.1. Contact Medical Control prior to further fluids being infused.
PROTOCOL 2.3: ASYSTOLE
ADULT CARE
I.1 Identify asystole in two leads.
I.2 If asystole is due to blunt trauma and criteria from 6.5: Field
Determination of Death Protocol are met, contact Medical Control for
termination of efforts.
I.3 If asystole is due to penetrating trauma, resuscitation will not terminated

in the field unless signs of irreversible death are present (decapitation,
significant dependent lividity, rigor mortis, etc.). See 6.5: Field
Determination of Death Protocol.
I.4 CPR.
I.5. Intubate and large-bore IV, IO NS, TKO
I.6. Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes for

duration of pulselessness (ET dose 2-2.5 mg if IV/IO access delayed or
unavailable).
I.7. Atropine, 1 mg IV/IO every 3-5 minutes to maximum dose of 3 mg. ET

dose 2-2.5 mg if IV/IO access delayed or unavailable. Maximum dose
also doubled if ET).
I.8. Glucagon, 1-2 mg IV/IO if patient known to be taking or has beta-blocker

medications prescribed. (Tenormin, Monocor, Lopressor, Inderal, etc.)
I.9. Search for and treat possible reversible cause:
a) Hypoxia
Secure airway and ventilate
b) Hyperkalemia (renal failure, dialysis patient, potassium ingestion)

Consider Sodium Bicarbonate / Calcium Gluconate
c) Hypothermia
Limit ALS, handle gently
d) Hyperthermia
Move from heat, resuscitate in cool environment
e) Hypovolemia
History – any suspicions – give fluid boluses
PROTOCOL 2.3: ASYSTOLE- (cont.)
f) Acidosis
Secure airway, ventilate, consider Sodium Bicarbonate
g) Tension pneumothorax
Chest decompression (needle thoracostomy)
h) Drug overdose
Obtain history – treat accordingly
I.10. Consider fine V-Fib
II.1. Consider Sodium Bicarbonate, 1.0 mEq/kg, IV, (hyperkalemia,

metabolic acidosis).
II.2. Consider Calcium Gluconate 2.3 - 3.7 mEq IV injected over 10-20
seconds, repeated at 10 minute intervals if necessary (hyperkalemia).
II.3. Contact Medical Control for possible termination of efforts if steps I.1 to
I.9 are completed and patient remains asystolic. (See 6.5: Field
Determination of Death Protocol).
PEDIATRIC CARE
I.1. Use Broselow Tape!
I.2. Identify asystole in two leads.
I.3. CPR.
I.4. Intubate and IV NS, TKO.
I.5. If peripheral IV access not possible, establish intraosseous line NS, TKO.
I.6. Epinephrine, 0.01 mg/kg, IV/IO 1:10,000 solution every 3-5 minutes for
duration of pulselessness. (If IV/IO access delayed or not available, 0.1
mg/kg ET 1:1000 solution.
I.7. Check glucose level. If blood glucose < 60 in child or < 40 in newborn
a) > 2 years: D50 at 1 ml/kg

b) < 2 years: D25 at 2 ml/kg
c) < 1 month: D10 at 5 ml/kg (D10 = mix 1 ml D50 with 4 ml NS)
d) Glucagon 1 mg IM if no IV / IO and patient > 20 kg. If patient < 20
kg, 0.5 mg IM.
PROTOCOL 2.3: ASYSTOLE- (cont.)
PEDIATRIC CARE- (cont.)
a) Hypoxia
b) Hyperkalemia (renal failure, potassium ingestion)

Consider Sodium Bicarbonate
c) Hypothermia
d) Hyperthermia
e) Hypovolemia
History – any suspicions – give fluid boluses (20 ml/kg NS over
30 minutes)
f) Acidosis
h) Drug overdose
II.1 Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (hyperkalemia,

metabolic acidosis)
PROTOCOL 2.4: BRADYCARDIA
ADULT CARE
I.2 The asymptomatic patient that presents with a bradycardia (< 60 BPM)
should have an IV started, but drug therapy should be withheld if the
patient seems to tolerate the rate well. Contact Medical Control if in
doubt.
I.3. If systolic BP < 90, PVC’s, altered mental status, signs or symptoms of
ischemia: Atropine, 0.5 mg IV or ET, repeated every 3-5 min up to 3 mg
total. (Note: Atropine may not be effective on high degree block / wide
QRS Bradycardia. One 0.5 dose may be attempted, but if completely
ineffective or patient in extremis, pacing should become primary
treatment).
1.4. Obtain 12-lead ECG (when it can be done without delaying needed
treatment).
1.5. Strongly consider pacing (see 5.15: External Cardiac Pacing Protocol)
if:
a) Patient does not respond to Atropine.

b) IV access unsuccessful.
c) Symptoms so severe that waiting for a maximal response to
Atropine would be detrimental.
II.1. Consider Dopamine infusion 2-10 mcg/kg/min. (See Drug Summaries -

Infusion Charts, Page 7-71).
II.2. Consider Epinephrine infusion containing 1 mg in 250 ml D5W given at a

rate of 2-10 mcg, / min. IV (30-150 micro drops/min), titrate to pulse ≥ 60.
(See Drug Summaries - Infusion Charts, Page 7-71).
PEDIATRIC CARE
PROTOCOL 2.4: BRADYCARDIA
PEDIATRIC CARE- (cont.)
I.3. Establish airway and assure ventilation - cardiac arrest or significant

rhythm disturbance in children is almost always due to respiratory
insufficiency first.
I.4. Establish IV access and consider a bolus with 20 ml/kg of NS over 30

minutes.

kg, 0.5 mg IM.
I.6. If hypotension (age dependent) present, PVC’S, altered mental status, or

signs and symptoms of ischemia and poor perfusion:
a) Epinephrine, 0.01 mg/kg IV/IO 1: 10,000 repeated every 3-5

minutes at same dose. If no IV or IV delayed and patient intubated:
ET 0.1 mg/kg (0.1ml/kg) 1:1000.
b) Consider Atropine, 0.02 mg/kg IV/IO; may repeat once. Atropine

may be used first if suspected increased vagal tone or AV
block.
1. 0.1 mg minimum dose

2. Maximum single dose 0.5 mg in child; I mg in adolescent
3. Maximum total dose 1 mg in child; 2mg in adolescent
II.1 Consider pacing see 5.15: External Cardiac Pacing Protocol.
II.2 Consider Epinephrine or Dopamine infusions, (See Drug Summaries -

Pediatric Infusion Charts, Page 7-72)
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA
Note: A narrow QRS is less than .12 milliseconds in duration.
Rate must be > 150; tachycardia is most likely a secondary problem

when the heart rate is less than 150. Treat hypoxia, hypovolemia, pain
and other problems first.
The field treatment of this rhythm will depend on what the rhythm is, and
whether the patient is stable or unstable. “Unstable” is defined as:
A. Systolic BP < 90 mm/Hg OR

B. Decreased level of consciousness OR
C. Signs and symptoms of pulmonary edema OR
D. Severe chest pain and shortness of breath.
ADULT CARE
I.1. General Supportive Care. Record rhythm strip before, during, and after
intervention.
I.2. Obtain 12-lead ECG (when it can be done without delaying needed
treatment).
CONSCIOUS, STABLE:
I.1. Vagal maneuvers.
I.2. If rhythm is Atrial fibrillation (irregular) or Atrial flutter, Adenosine is

ineffective. Contact Medical Control to discuss treatment options.
I.3. Adenosine, 6 mg rapid IV push followed by 20 ml NS IV flush.
I.4. If rhythm persists 1-2 min after initial dose, repeat Adenosine, 12 mg
rapid IV push. Follow all doses immediately with 20 ml NS IV flush.
II.1. Repeat Adenosine, 12 mg dose may be considered in 1-2 min. if rhythm

persists.
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.)
ADULT CARE (cont.)
UNSTABLE: (all rhythms)
II.1. Consider sedation with Etomidate, .1 mg/kg or Valium, 5 mg IV prior to

cardioversion.
Note: Patients with drastically decreased mentation should not receive

sedation.
II.2. Synchronized biphasic cardioversion, 30J**
* If rhythm is not Atrial Fibrillation or Atrial flutter, prior to cardioversion,

pharmacologic conversion with Adenosine may be attempted at the
discretion of Medical Control.
* In the presence of severe hypotension, pulmonary edema or

unconsciousness, administer immediate unsynchronized shocks to
avoid delays.
PEDIATRIC CARE
Note: Pediatric SVT rate is generally greater than 230 bpm.
“Unstable” in the pediatric patient is defined as:
A. Age dependent hypotension (despite oxygenation and ventilation)

OR
B. Decreased level of responsiveness OR
C. Abnormal skin color OR
D. Capillary refill > 2 seconds.
STABLE:
I.1. General Supportive Care if patient is stable.
PROTOCOL 2.5: NARROW-COMPLEX TACHYCARDIA (cont.)
PEDIATRIC CARE (cont.)
UNSTABLE:
I.1. Establish IV NS, TKO.
II.1. If peripheral IV access not possible and patient severely obtunded,

establish intraosseous line NS, TKO.
II.2. Consider vagal maneuvers if child is old enough, but do not delay
pharmacologic therapy or cardioversion if patient is obtunded. Vagal
maneuvers should not be attempted without discussion with Medical
Control.
II.3. If IV access is immediately available, consider Adenosine, 0.1 mg/kg IV

or IO rapid IV push followed by 10 ml NS IV flush. Second dose if
necessary and possible may be doubled (0.2 mg/kg). Maximum first dose:
6 mg; maximum second dose: 12 mg.
II.5. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose)
in preparation for cardioversion, but do not delay cardioversion.
II.3. Synchronized biphasic cardioversion at 0.5 - 1.0 joules/kg.
II.4. Synchronized biphasic cardioversion at 2.0 joules/kg if initial energy

ineffective.
PROTOCOL 2.6: NEONATAL RESUSCITATION
Note: The level of resuscitation the neonate will require will be dependent on
the infants clinical presentation. The APGAR score can be used as a
tool to help determine this, but resuscitation of a newborn child should
not be delayed to obtain an APGAR score if the infant is in obvious
distress. See APGAR Score Chart, Table 2.A, at the end of this protocol
and 2.22: OB / GYN Protocol.
APGAR scoring guidelines:
• 0 to 3 indicates severe distress

• 4 to 6 indicates moderate distress
• 7 to 10 indicates mild or no distress
If the APGAR score at 5 minutes is less than 7, obtain additional scores

(if possible) every 5 minutes until the score reaches 7 or more.
The primary enemy of newborns is hypothermia, which can occur within

minutes due to increased evaporative heat loss due to the infants large
body surface area and the presence of amniotic fluid.
I.1. Dry immediately and warm!
I.2. Tactile stimulation, rub with towel.
I.3. Position airway and suction mouth, oropharynx and then nose.
I.4. If normal respiratory rate, HR > 100 and core color pink, provide
supportive care only.
I.5. If apnea/gasping respirations, HR < 100 or central cyanosis, administer

100% oxygen and assist ventilations with BVM at a rate of 40-60.
I.6. If HR < 60 and no improvement after 30 seconds of BVM assisted

ventilation, intubate.
I.7. If HR < 60 and no improvement after 30 seconds of BVM assisted

ventilation, begin chest compressions at a rate of 120/min.
A. Compression/ventilation ratio 3:1.

B. One third to one half chest depth.
PROTOCOL 2.6: NEONATAL RESUSCITATION (cont.)
C. Perform compressions with both thumbs (with hands encircling the

back) at mid-sternum.
I.8. If meconium present, perform deep tracheal suctioning through ETT with
proper suction adapter.
I.9. Check glucose level, if < 40, administer D10, 5 ml/kg.
II.1. Consider intraosseous IV if infant severely obtunded, but do not delay

transport for IV access; utilize ETT for Epinephrine administration if
needed and vascular access is difficult.
II.2. Consider Epinephrine, 0.01 mg/kg IV/IO/ET (0.1 ml/kg) 1: 10,000

repeated every 3-5 minutes. Use Broselow Tape!
TABLE 2.A.
APGAR Score
APGAR Score
1 5
0 Points 1 Point 2 Points Minute Minutes
Heart Rate Absent <100 >100
Respiratory Effort Absent Slow, irregular Strong cry
Muscle Tone Flaccid Some flexion Active motion
Irritability No response Some Vigorous
Color Blue, pale Blue & pink Fully pink
TOTAL:
* Infants with scores of 7-10 usually require supportive care only.
* A score of 4-6 indicates moderate depression.
* Infants with scores of 3 or less will require aggressive resuscitation.
PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY
Indications:
Treatment of PVC’s should be limited to those patients with probable

cardiac complaints, e.g. chest pain, syncope, SOB, etc. Patients who
have PVC’s and are asymptomatic generally do not require intervention.
Use this protocol if the ventricular complexes meet any of these criteria
and the underlying heart rate is greater than 60:
1. With frequency ≥ 6/min and symptomatic.
2. Multifocal at any frequency.
3. R on T pattern at any frequency.
4. Coupling (bigeminy or trigeminy) at any frequency (This protocol is

for isolated coupling and bursts – (see 2.10: Wide-Complex
Tachycardia With Pulse Protocol for rapid sustained patterns of
ventricular complexes).
Note: Underlying heart rate should be closely monitored, if PVC’s are perfusing
and underlying heart rate is very low, suppressing the PVC’s may leave
the patient unable to perfuse at all. Ventricular escape beats can sustain
a patient temporarily.
Medication dosage should be reduced by 50% if patient age > 70,

presence of CHF, shock or liver disease.
If patient is borderline as to whether and how to treat, contact Medical

Control to discuss treatment options.
Cardiac monitor strip recordings must document premature complexes

prior to pharmacologic intervention.
ADULT CARE
I.2. Lidocaine, 1mg - 1.5mg/kg IV or ET.
I.3. If PVC’s not suppressed with first bolus, Lidocaine, 0.5 - 0.75 mg/kg IV or
ET, repeated as necessary at 10 minute intervals to suppress ventricular
ectopy. Total bolus dose not to exceed 3 mg/kg.
PROTOCOL 2.7: PREMATURE VENTRICULAR ECTOPY (cont.)
ADULT CARE(cont.)
I.4. If PVC’s suppressed, Lidocaine infusion at a rate of 2-4 mg/min. (30-60

microdrops/min. (See Drug Summaries - Infusion Charts, Page 7-71).
II.1. Consider Amiodarone 150 mg over 10 minutes. If Lidocaine ineffective.
PEDIATRIC CARE
I.1. General Supportive Care. Treat ectopy with pharmacologic intervention

only if child is symptomatic.
II.1. Lidocaine, 1 mg/kg IV or ET bolus.
II.2. If PVC’s not suppressed with first bolus, Lidocaine, 0.5 mg/kg IV or ET,
repeated as necessary at 10 minute intervals to suppress ventricular
ectopy. Total bolus dose not to exceed 3 mg/kg.
II.3. If PVC’s suppressed, Lidocaine infusion containing 300 mg Lidocaine in

250 mg D5W given at a rate of 20-50 mcg/kg/min. (1- 2.5
microdrops/kg/min. (See Drug Summaries - Pediatric Infusion Charts,
Page 7-72).
PROTOCOL 2.8: PULSELESS ELECTRICAL ACTIVITY, (PEA)
ADULT CARE
I.1. CPR.
I.2. Intubate and large-bore IV or IO NS, TKO (Consider fluid bolus if

hypovolemia suspected).
I.3. Epinephrine, 1 mg 1:10,000 solution IV every 3-5 minutes for duration of

pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable.
I.4. Atropine, 1 mg IV every 3-5 minutes to maximum dose of 2.5 mg (0.04

mg/kg) IF heart rate < 60/min. (ET dose 2-2.5 mg if IV access delayed or
unavailable. Maximum dose also doubled if ET).

a) Hypoxia
b) Hyperkalemia (renal failure, dialysis patient, potassium ingestion)

Consider Sodium Bicarbonate / Calcium Gluconate
c) Hypothermia
d) Hyperthermia
e) Hypovolemia
History – any suspicions – give fluid boluses
f) Acidosis
h) Drug overdose
PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.)
ADULT CARE (cont.)
II.1. Consider Sodium Bicarbonate 1.0 meq/kg, IV. (Hyperkalemia, metabolic

acidosis)
PEDIATRIC CARE
I.2. CPR.
I.3. Intubate and IV NS, TKO.

kg, 0.5 mg IM.
I.6. Epinephrine, 0.01 mg/kg, IV or IO 1:10,000 solution every 3-5 minutes for
duration of pulselessness. (If IV access delayed or not available, 0.1
mg/kg ET 1:1000 solution.
I.7. Search for and treat possible reversible cause
a) Hypoxia

c) Hypothermia
d) Hyperthermia
PROTOCOL 2.8: PULSESLESS ELECTRICAL ACTIVITY, (PEA) (cont.)
e) Hypovolemia
30 minutes)
f) Acidosis
h) Drug overdose
II.1 Consider Sodium Bicarbonate, 1.0 mEq/kg, IV or IO. (Hyperkalemia,

metabolic acidosis).
PROTOCOL 2.9: VENTRICULAR FIBRILLATION AND PULSELESS

VENTRICULAR TACHYCARDIA:
Note: This protocol assumes refractory V-Fib/pulseless V-Tach, or a

successful conversion to a perfusing rhythm from those rhythms. If at
any time, rhythm converts to another pulseless rhythm (PEA, Asystole),
continue treatment from that protocol.
If interfacing with 1st responder AED, it is always wise to let 1st

responders continue with AED defibrillation sequences if the situation is
progressing correctly, this allows ALS personnel time to set up for airway
and other procedures. If 1st responder defibrillation is not progressing
correctly, disconnect AED, hook up manual cardiac monitor-defibrillator
and continue or begin defibrillation sequence.
Chest compressions are very important and interruptions to chest

compressions should be minimized wherever possible. Compressions
should continue while drugs are being administered and defibrillator is
charging. It is not important whether a drug is administered before or
after a shock. Countershocks should be administered and drug
sequences continued as long as VF/VT persists.
ADULT CARE
I.1. Biphasic countershock, 150 J*.
I.2. CPR (5 cycles or minimum of 2 minutes).
I.3. Intubate and large-bore IV, IO NS, TKO whenever possible.
I.4. Epinephrine, 1 mg 1:10,000 solution IV/IO every 3-5 minutes for duration
of pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable.
I.5. Continue CPR (5 cycles or minimum of 2 minutes), rhythm check.
I.6. Biphasic countershock 150-200 J*.
I.7. Amiodarone, 300 mg IV/IO, consider repeat dose of 150 mg IV/IO in 3-5
minutes.
I.9. Biphasic countershock 150-200 J*.


VENTRICULAR TACHYCARDIA-(cont.):
ADULT CARE (cont.):
I.11. Consider Lidocaine, 1.5 mg/kg IV/IO for max dose of 3 mg/kg.
I.12. If rhythm converts and then patient re-fibrillates, countershock immediately

using the same energy as the last successful shock.
II.1. Consider Sodium Bicarbonate, 1.0 meq/kg, IV,(Hyperkalemia, metabolic

acidosis)
* If countershock restores a perfusing rhythm, treat heart rate, blood

pressure and cardiac rhythm as required by pertinent protocol.
PEDIATRIC CARE
I.2. Biphasic countershock, 2 joules/kg*.
I.3. CPR (5 cycles or minimum of 2 minutes).
I.4. Intubate and IV, NS, TKO whenever possible
I.6. Epinephrine, 0.01 mg/kg, ET, IV or IO 1:10,000 solution every 3-5

minutes for duration of pulselessness. (If IV access delayed or not
available, 0.1 mg/kg ET 1:1000 solution.
I.8. Biphasic countershock 4 joules/kg*.
I.9. Amiodarone, 5 mg/kg IV or IO, (can repeat once in 3-5 minutes).
I.11. Biphasic countershock 4 joules/kg *.

VENTRICULAR TACHYCARDIA-(cont.)
PEDIATRIC CARE (cont.):
I.12. Consider Lidocaine, 1 mg/kg IV or IO (can repeat twice).
I.13. Contact Medical Control at earliest opportunity to discuss treatment

options and transport as soon as possible.
I.14. Search for and treat possible reversible cause
a) Hypoxia

c) Hypothermia
d) Hyperthermia
e) Hypovolemia
30 minutes)
f) Acidosis
h) Drug overdose
I.15. If rhythm converts and then patient re-fibrillates, countershock immediately

using the same energy as the last successful shock.
II.1. Consider Sodium Bicarbonate, 1.0 meq/kg, IV, (Hyperkalemia, metabolic

acidosis)
* If countershock restores a perfusing rhythm, treat heart rate, blood

pressure and cardiac rhythm as required by pertinent protocol.
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE
Note: A wide QRS is more than .11 milliseconds in duration.
The field treatment of this rhythm will depend on whether the patient is
stable or unstable. “Unstable” is defined as:
A. Systolic BP < 90 mm/Hg OR

B. Decreased level of consciousness OR
C. Signs and symptoms of pulmonary edema OR
D. Severe chest pain and shortness of breath.
ADULT CARE
I.1. General Supportive Care. Record rhythm strip before, during, and after
intervention.
I.2. Obtain 12-lead ECG to verify rhythm (when it can be done without
delaying needed treatment).
CONSCIOUS, STABLE
I.1. Amiodarone, 150 mg IV over 10 minutes. May repeat once in 10 minutes

if needed.
I.2. Consider trial of Adenosine (see Protocol 2.5. Narrow Complex

Tachycardia) if rhythm is possibly SVT with aberrancy. If unsure of
rhythm, contact Medical Control and send 12-lead to hospital for
interpretation (do not delay transport).
II.1. Consider Procainamide, 100 mg IV over 5 min. (20mg/min.). Maximum

total dose 17 mg/kg. If chemical conversion successful, maintenance
infusion at 1 to 4 mg/min. (See Drug Summaries - Infusion Charts,
Page 7-72).
II.2. If pharmacologic intervention is unsuccessful, contact Medical Control to

discuss treatment options. The conscious, stable patient in V-Tach
seldom needs cardioversion in the field, but if transport times will be
prolonged, synchronized cardioversion may be attempted at the discretion
of Medical Control (see “UNSTABLE” treatment).
II.3. If at any point the conscious, stable patient begins to deteriorate, prepare
for synchronized cardioversion (see “UNSTABLE” treatment).
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.):
ADULT CARE (cont.):
UNSTABLE:
Note: If patient in extremis and deteriorating rapidly, and contacting

Medical Control will be time consuming, do not delay cardioversion!
proceed and contact Medical Control at earliest opportunity.
II.1. Consider sedation with Etomidate, .1 mg/kg or Valium 5 mg IV prior to

cardioversion.
Note: Patients with drastically decreased mentation should not receive

sedation.
II.2. Synchronized biphasic cardioversion, 75 joules*.
II.6. If wide-complex rhythm re-curs, synchronized cardioversion, at level

previously successful.
* In the presence of severe hypotension, pulmonary edema or

unconsciousness, administer immediate unsynchronized shocks to
avoid delays.
PEDIATRIC CARE
Note: A wide QRS in the pediatric patient is generally considered to be

anything .08 milliseconds or more in duration.
“Unstable” in the pediatric patient is defined as:
A. Age dependent hypotension (despite oxygenation and ventilation)

OR
B. Decreased level of responsiveness OR
C. Abnormal skin color OR
D. Capillary refill > 2 seconds.
PROTOCOL 2.10: WIDE-COMPLEX TACHYCARDIA WITH PULSE (cont.)
STABLE:
I.1. General Supportive Care if patient is stable.
I.3. Establish IV NS, TKO.
I.4. Consider trial of Adenosine (see Protocol 2.5. Narrow Complex

Tachycardia) if rhythm is possibly SVT with aberrancy. If unsure of
rhythm, contact Medical Control for consult.
UNSTABLE:
Note: If patient in extremis and deteriorating rapidly, and contacting

Medical Control will be time consuming, do not delay cardioversion!
proceed and contact Medical Control at earliest opportunity.

II.2. Consider sedation with Valium, 0.2 mg/kg IV, (not to exceed 10 mg/dose)
in preparation for cardioversion, but do not delay cardioversion if
patient in extremis.
II.3. Synchronized Cardioversion at 0.5 - 1.0 joules/kg.*
II.4. Synchronized Cardioversion at 2.0 joules/kg* if initial energy ineffective.
II.5. If a second shock (2.0 joules/kg) is unsuccessful or if the tachycardia

recurs quickly, consider Amiodarone 5 mg/kg over 20 minutes before a
third shock at 2.0 joules/kg.*
* If delays in synchronization occur and patient is severely obtunded,

administer immediate unsynchronized shocks.
PROTOCOL 2.11: AIRWAY OBSTRUCTION
Indications:
1. All patients who cannot phonate and are suspected of foreign body
airway obstruction.
2. Suspect patients in cardiac arrest that occurred in a restaurant or during

a meal.
ADULT CARE
I.2. If air exchange is adequate, do not provide specific treatment.
I.3. If air exchange is inadequate and there is a reasonable suspicion of

foreign body obstruction, perform Heimlich maneuver to try and relieve
obstruction.
I.4. If unable to relieve obstruction with Heimlich maneuver, visualize with

laryngoscope and extract foreign body with McGill forceps.
II.1. If obstruction cannot be relieved by direct laryngoscopy and patient

remains unable to ventilate and continues to deteriorate, contact Medical
Control for possible Surgical Cricothyrotomy intervention (see 5.11:
Advanced Airway Management: Surgical Cricothyrotomy Protocol).
PEDIATRIC CARE
I.2. If air exchange is adequate, do not provide specific treatment.
I.3. If air exchange is inadequate and there is a reasonable suspicion of

foreign body obstruction, perform age-correct Heimlich maneuver to try
and relieve obstruction.
I.4. If unable to relieve obstruction with Heimlich maneuver, visualize with

laryngoscope and extract foreign body with McGill forceps.
PROTOCOL 2.11: AIRWAY OBSTRUCTION (cont.)
II.1. If obstruction cannot be relieved by direct laryngoscopy and patient

remains unable to ventilate and continues to deteriorate, contact Medical
Control for possible Needle Cricothyrotomy intervention (see 5.10:
Advanced Airway Management: Needle Cricothyrotomy Protocol).
PROTOCOL 2.12: ALLERGIC REACTION - ANAPHYLAXIS
Indications:
1. All patients with dyspnea, hoarseness, dysphonia or strider following an

allergic reaction OR
2. Patients with wheezing and other signs of bronchospasm associated with

above OR
3. Hypotension and/or decreased level of consciousness associated with

above OR
4. Hives, swelling and flushing of skin associated with above.
Note: The patient with only hives, rash and or itching that is not getting worse
may need no intervention other than observation and transport. Patient
should be monitored closely, and if symptoms are getting worse, more
aggressive treatment will be warranted.
Ensure airway, early endotracheal intubation may be advisable before

swelling becomes severe. Suction as needed and prepare to assist
ventilations.
ADULT CARE
I.2. Epinephrine, 1: 1000, 0.3 mg IM.
I.3. Benadryl, 25-50 mg, IV or IM.
I.4. If systolic blood pressure < 90 mm/Hg with mild signs of shock, fluid
bolus 250 to 500 ml IV Normal Saline.
I.5. If shortness of breath and wheezing present: Albuterol, unit dose vial of
2.5 mg . Contents of vial is nebulized and administered until dose
complete, may be repeated once if necessary.
II.1. If patient in extremis and systolic blood pressure < 90 mm/Hg with
obvious signs of shock and decreased level of consciousness,
Epinephrine, 1:10,000, 1 ml, slow IV over 3-5 min.
PROTOCOL 2.12: ALLERGIC REACTION - ANAPHYLAXIS (cont.)
PEDIATRIC CARE
I.2. If hypotension present (based on age) with signs of shock, fluid bolus, 20
ml/kg IV.
I.3. If shortness of breath and wheezing present, and patient age less than 2
years old, Albuterol, 1.25 mg (half of unit dose vial). Medication is
nebulized and administered until distress relieved or dose complete. If
more than 2 years old, use adult dosage.
I.4. If patient normotensive, Epinephrine, 1:1,000 0.01 ml/kg (0.01 mg/kg),

not to exceed 0.3 mg, IM.
I.5. Benadryl, 1 mg/kg IM or IV.
II.3. If hypotension present (based on age) with obvious signs of shock,

Epinephrine, 1:10,000, 0.01 mg/kg slow IV over 3-5 min. (not to exceed
1 ml dose).

PROTOCOL 2.13: ASTHMA
Indications:
1. Patients with respiratory distress and :
A. History of asthma AND

B. Wheezing on auscultation and/or prolonged expiration AND
C. No evidence of pulmonary edema or congestive heart failure.
ADULT CARE
I.3. Albuterol, unit dose vial of 2.5 mg. Contents of vial is nebulized and
administered until dose complete. Repeat twice if necessary. If more
than three treatments required, contact medical control.
I.4. Consider CPAP if patient in extremis.
II.1. If Albuterol ineffective and patient in severe distress, consider

Epinephrine, 1:1000, 0.3 mg IM. Use with caution in patients ≥ 50
years old, heart rate > 100, hypertensive, or history of CAD/HTN,
Monitor ECG!
PEDIATRIC CARE
I.3. If patient age more than 2 years old, Albuterol, unit dose vial of 2.5 mg .
Contents of vial is nebulized and administered until dose complete.
Repeat once if necessary. If more than two treatments required, contact
medical control.
I.4. If patient age less than 2 years old, Albuterol, 1.25 mg ( half of unit dose
vial). Medication is nebulized and administered until dose completed. In
children unable to use mouthpiece, administer by nebulizer mask.
II.1. If unable to cooperate with nebulization and patient getting worse,

consider Epinephrine, 1:1000, 0.01 mg/kg IM (not to exceed 0.3 ml).
Do not use Epinephrine if Albuterol has been effective.
PROTOCOL 2.14: BEHAVIORAL / PSYCHIATRIC
ADULT CARE
I.2. Have Law Enforcement remove those individuals who aggravate the
situation.
I.3. Establish a calm, quiet atmosphere, and attempt to establish rapport with
patient. Do not be judgmental or question the patient’s motives.
I.4. Be aware of weapons! Remove any weapons (or potential weapons)

from the patient. Use Law Enforcement assistance if necessary.
I.5. Obtain patient history, this includes a history of the current event as well
as previous psychiatric and medical problems, medications. Inquire
about recent crisis, toxic exposure, drugs, alcohol, emotional trauma or
suicidal thoughts. If suicidal or threatening behavior is suspected do not
leave the patient alone, obtain Law Enforcement assistance if not
already present.
I.6. Obtain vital signs and perform physical exam as indicated. Treat any
medical problem according to appropriate protocol.
I.7. If emergency treatment is unnecessary, do as little as possible except to

reassure while transporting. Try not to violate the patient’s personal
space.
I.8. Psychiatric patients may have another reason for mental disturbances.
Be aware of hypoglycemia, hypoxia, head injury, intoxication or toxic
ingestion.
I.9. If the situation appears threatening, consider a show of force involving

Law Enforcement before attempting to restrain.
I.8. If physical restraint of the patient becomes necessary, refer to 5.22:

Restraint (Physical and Chemical) Protocol.
II.1. If when physically restrained, patient continues to pose a threat to self

and others, consider chemical restraint (see 5.22: Restraint (Physical
and Chemical) Protocol).
PROTOCOL 2.14: BEHAVIORAL / PSYCHIATRIC (cont.)
PEDIATRIC CARE
I.2. Have Law Enforcement remove those individuals who aggravate the
situation.
I.3. Establish a calm, quiet atmosphere, and attempt to establish rapport with
patient. Do not be judgmental or question the patient’s motives.
I.4. Obtain patient history, this includes a history of the current event as well
as previous psychiatric and medical problems, medications. Inquire
about recent crisis, toxic exposure, drugs, alcohol, emotional trauma or
suicidal thoughts. If suicidal or threatening behavior is suspected do not
leave the patient alone, obtain Law Enforcement assistance if not
already present.
I.5. Obtain vital signs and perform physical exam as indicated. Treat any
medical problem according to appropriate protocol.
I.6. If emergency treatment is unnecessary, do as little as possible except to

reassure while transporting. Try not to violate the patient’s personal
space.
I.7. Psychiatric patients may have another reason for mental disturbances.
Be aware of hypoglycemia, hypoxia, head injury, intoxication or toxic
ingestion.
I.8. Truly violent and threatening behavior in the pediatric patient is less
frequent and somewhat easier to manage than it is in the adult patient,
but the threat still exists. The same cautions about weapons and violent
behavior apply as with the adult patient, and Law Enforcement should
always be involved in questionable situations.
I.1. If physical restraint of the patient becomes necessary, refer to 5.22:

Restraint (Physical and Chemical) Protocol.
II.1. If when physically restrained, patient continues to pose a threat to self

and others, consider chemical restraint (see 5.22: Restraint (Physical
and Chemical) Protocol).
PROTOCOL 2.15: CARDIOGENIC SHOCK
Indications:
1. Patients with chest pain or dyspnea, who have not suffered trauma and
have:
A. Systolic BP < 80 mm Hg.

B. Obvious signs and symptoms of shock.
C. No rate problem, if heart rate unacceptably high or low, normalize
rate before using this protocol.
ADULT CARE
I.1. General Supportive Care. IV, NS.
I.2 If lungs clear, consider fluid bolus of 250-500 ml NS to ensure adequate

ventricular filling pressure before considering vasopressor administration.
I.3. If crackles (rales) present, maintain IV at TKO.
I.4. Consider CPAP.
I.5. Obtain 12-lead ECG (when it can be done without delaying needed
treatment).
II.2 Dopamine infusion, 5-20 mcg/kg/min IV. Infusion should be started at 5

mcq/kg/min. and titrated to systolic BP ≥ 90 mm/Hg. (See Drug
Summaries - Infusion Charts, Page 7-1).
PEDIATRIC CARE
I.1 General Supportive Care. IV, NS.
II.1 If lungs clear, consider fluid bolus 20/ml/kg IV.
II.2 Consider Dopamine infusion (See Drug Summaries - Pediatric Infusion

Charts, Page 7-2).
PROTOCOL 2.16: CHEST PAIN
Indications:
1. Patients of either gender age 25 or over complaining of non-pleuritic pain

in the anterior chest, described as CRUSHING, TIGHT, DULL,
CONSTRICTING, BAND-LIKE, HEAVY, ETC.
2. Patients of either gender age 25 or over with non-pleuritic chest, jaw,

back or arm pain associated with nausea, vomiting, pallor, diaphoresis,
or dyspnea.
ADULT CARE
I.2. Position of comfort - Semi-fowler’s is usually best.
I.3. Treatment of any arrhythmia per specific protocol.
I.4. Nitroglycerin, one metered dose, SL spray, if systolic BP > 90 mm/Hg.

May be repeated twice Q 5 min. if systolic BP remains > 90 mm/Hg
(consider patient administered Nitroglycerin within last 15 minutes).
Note: If patient becomes hypotensive after administration of

Nitroglycerin, lie flat temporarily and administer fluid. When patient
becomes normotensive again, return to Semi-fowlers
Note: Ask if patient is taking erectile dysfunction drugs (Viagra, Levitra),

patients taking these drugs should not be given nitroglycerin.
Note: Contact Medical Control prior to the administration of Nitroglycerin

to the patient with a suspected right ventricular infarct. These patients
are pre-load dependent and can decompensate quickly.
I.5. Suspected MIs shall have a 12-lead ECG acquired. If the 12-lead ECG
substantiates the suspicion of an MI, notify the base hospital at the
earliest opportunity and transmit an ECG for base station physician
review.
I.6. Patient must be constantly monitored, including during the move from the
ambulance to the ED. A significant number of patients who develop
ventricular fibrillation may have no warning arrhythmias.
PROTOCOL 2.16: CHEST PAIN (cont.)
ADULT CARE (cont.)
I.7. Aspirin, Have the patient chew and swallow four (4) baby aspirins (324
mg) if the patient meets the following requirements:
a) Pain of probable cardiac origin persisting for at least 15 minutes.

b) No aspirin allergy.
c) Age over 30.
d) Systolic blood pressure less than 180.
e) Diastolic blood pressure less than 110.
f) No surgery or major trauma within the last two weeks.
g) No stroke or serious neurological problems within the last 6 months.
h) No bleeding disorders (ulcers, esophageal varices, etc.)
i) Not pregnant.
I.8. Fentanyl 50-100 mcg (1 mcg/kg) slow (over 1-2 min.) IV. May repeat
as necessary to a total of 150 mcg.
If allergic to Fentanyl, consider Morphine Sulfate, 2 mg incremental

doses, IV, repeated at 5 minute intervals to a total of 4mg, titrated for
pain relief. Do not administer morphine if systolic BP < 90 mm/Hg.
Note: If patient develops depressed respirations following Morphine or

Fentanyl administration, be prepared to actively support airway and
ventilation and possibly administer Narcan.
Note: If patient becomes hypotensive after administration of Morphine or

Fentanyl, lie flat temporarily and administer fluid. When patient becomes
normotensive again, return to Semi-fowlers.
II.1. For doses of Morphine Sulfate or Fentanyl over maximum total dose,
contact Medical Control.
PEDIATRIC CARE
I.2. Treatment of any arrhythmia per specific protocol.
II.1. None.
PROTOCOL 2.17: COMA / ALTERED MENTAL STATUS
Note: Although alcohol is a common cause of altered mental status, it is not

commonly a cause of frank coma (i.e., total unresponsiveness to pain).
No judgment in the field should be made concerning the importance of
the presence of alcohol on any patient’s breath who presents totally
unresponsive to pain.
ADULT CARE
I.1. Strongly consider possible need for cervical spine immobilization.
I.2. Carefully monitor for any neurological deficits. Be aware of Medical Alert
tags, breath odor, signs of drug abuse, sources of gases or potential
toxins.
I.4. Check glucose level, if blood glucose ≤ 70, administer D50, 50ml (25
GM) IV. Consider Glucagon 1 mg IM if unable to obtain IV.
I.5. Administer Thiamine 100 mg IV if alcohol abuse is suspected/apparent.
Note: If both D50 and Thiamine are to be administered and patient is

poorly nourished with alcohol abuse strongly suspected/apparent,
administer Thiamine before D50.
I.6. If blood glucose > 70, administer Narcan 0.4-2 mg, IV, ET, or IM. Use
the larger dose of Narcan if overdose with synthetic narcotic compounds
suspected (Darvocet, Fentanyl, etc.). Opiate overdose should not be
ruled out based just on the patients age or appearance, opiates can be a
commonly prescribed drug for all ages and types of patients.
I.7. Be particularly attentive to airway, protect as needed (positioning, NP,

OP airways, suctioning, elective intubation) the truly unconscious,
unresponsive patient can not control their own airway.
I.8. Use appropriate discretion regarding immediate intubation of patients

who may quickly regain gag reflexes/consciousness, such as the
hypoglycemic diabetic after IV Glucose, opiate overdose patients after
Narcan, and the seizure patient after the seizure is over.
II.1. None.
PROTOCOL 2.17: COMA / ALTERED MENTAL STATUS (cont.)
PEDIATRIC CARE
I.1. Strongly consider need for cervical spine immobilization.
tags, breath odor, signs of drug abuse, sources of gases, potential toxins
or ingestions.

kg, 0.5 mg IM.
I.5. If blood glucose within normal values, consider Narcan 0.1 mg/kg IV, ET,
or IM( not to exceed 2 mg).
I.6. Be particularly attentive to airway, protect as needed (positioning, NP,

OP airways, suctioning, elective intubation) the truly unconscious,
unresponsive patient can not control their own airway.
I.7. Use appropriate discretion regarding immediate intubation of patients

who may quickly regain gag reflexes/consciousness, such as the
hypoglycemic diabetic after IV Glucose, opiate overdose cases after
Narcan, and the seizure patient after the seizure is over.
II.1. None.
PROTOCOL 2.18: COPD
Indications:
1. Patients with respiratory distress and:
A. History of COPD AND

B. Wheezing on auscultation, diminished breath sounds bilaterally,
prolonged expiration AND
C. No evidence of pulmonary edema or congestive heart failure.
ADULT CARE
I.1. General Supportive Care,
I.2. Position of comfort - the short of breath COPD patient will usually find the
position themselves that allows them to breathe the easiest, Fowler’s
position is usually the best, the COPD patient that is lying flat or that
allow you to lie them flat is typically in dire straits.
I.3. O2 starting at 2L/min. If signs and symptoms of hypoxia persist, then

increase O2 as needed.* Observe for changes in mental status or
respiratory depression, assist ventilation as necessary.
I.4. Albuterol unit dose vial of 2.5 mg. nebulized and administered until dose
complete. Repeat twice if necessary. If more than three treatments
required, contact Medical Control. When administering Albuterol
nebulizer treatments to the COPD patient, an IV of NS should be started
and a cardiac monitor attached.
* Note: It is common to find protocols that caution against the use of high
concentrations of supplemental oxygen for patients with COPD
(emphysema, chronic bronchitis). Such protocols may restrict
supplemental oxygen for a spontaneously breathing COPD patient at 2
liters/minute by nasal cannula. The intent is to avoid inhibition of their
spontaneous respiratory efforts. However, it is desirable to minimize the
length of time that any patient, including one with COPD, suffers from
hypoxia. Hypoxia is life threatening. All hypoxic patients should receive
supplemental oxygen as quickly and as in as high a concentration as
their respiratory drive will tolerate. The clinical problem in the field is
determining how much supplementary oxygen a COPD patient can
safely tolerate.
PROTOCOL 2.18: COPD (cont.)
The COPD patient regulates his spontaneous ventilation by internal

measurement of the oxygen content in their blood. This is different from
normal patients who use CO2 content to drive ventilation. When a
COPD patient is hypoxic, ventilation is over-stimulated. If the COPD
patient has a large surplus of oxygen, as may occur with inappropriate
use of high concentrations of supplemental oxygen, spontaneous
ventilation decreases. An understanding of this simple physiologic
control mechanism can be used to safely titrate oxygen administration
with COPD patients.
When COPD patients have acute respiratory distress, oxygen may be

given in high concentrations until the rapid respiratory rate begins to slow
down towards normal. This shows that hypoxia is becoming less severe
and respiratory drive is starting to return to normal. The supplemental
oxygen dosage may then be reduced in a titrated manner as the
respiratory rate returns to normal. This simple approach allows
oxygenation to be restored as quickly as possible and reduces the
potential harm of extended hypoxia.
II.1 None
PROTOCOL 2.19: DIABETIC EMERGENCIES
Note: Hypoglycemia may present as focal neurologic deficit or coma (could be

mistaken for stroke). All patients with altered mentation should have
glucose checked.
Unconsciousness in the diabetic may be due to hypoglycemia or

hyperglycemia, check glucose before administering D50.
The hypoglycemic diabetic contacted by EMS in the field will many times
try to refuse transport if D50 is administered prior to the patient being
loaded into the ambulance and transport begun. The Paramedic should
exercise careful discretion with these refusal situations, and transport to
a medical facility should always be strongly encouraged and offered. If
the conscious and fully alert patient ultimately refuses, make it very clear
to them that a good meal must be consumed in a short time frame as the
D50 will not last, refer to 6.11: No Transport (Refusal, Cancel)
Protocol. Statistically, the insulin-dependent diabetic tends to do
reasonably well if left at home after being treated with D50 in the field
following a profound hypoglycemic episode. The same cannot be said of
the diabetic that controls their disease only with an oral medication or
diet. These patients tend to have poorer outcomes and every possible
means must be utilized to encourage this sub-set of patients to accept
transport. The best way to treat these patients is to administer any
required D50 after the patient is in the ambulance and enroute to the
hospital.
ADULT CARE
I.2. Do finger stick and check glucose regardless of potential need for IV.
I.3. If glucose ≤ to 70 and patient is alert (able to hold glass in hand and
drink from it), give oral self-administered sugar solution (Glutose, soda
or orange juice with sugar).
I.4. If patient is stuporous or unconscious and glucose ≤ to 70, administer

D50 (25 gm) 50ml, IV (start large-bore NS IV in good vein and run NS in
liberally as D50 is injected).
I.5. Do not delay transport to determine response to D50.
I.6. If unable to start IV, administer Glucagon, 1 mg., IM.
PROTOCOL 2.19: DIABETIC EMERGENCIES (cont.)
ADULT CARE (cont.)
I.7. If patient does not return to normal LOC or if patient condition

deteriorates, repeat glucose check.
I.8. If glucose remains < 70, repeat D50 IV.
II.1. None.
PEDIATRIC CARE
I.1. General Supportive Care,
I.2. Do finger stick and check glucose regardless of potential need for IV.
I.3. If glucose less than threshold values noted below* and patient is alert,
(able to hold glass in hand and drink from it), give oral self-administered
sugar solution (Glutose, soda or orange juice with sugar).
I.4. *If blood glucose < 60 in child or < 40 in newborn

kg, 0.5 mg IM.
I.5. Do not delay transport to determine response to D25/D50.
I.6. If patient does not return to normal LOC or if patient condition

deteriorates, repeat glucose check.
I.7. If remains below threshold values, repeat D50 or D25 IV.
II.1. None.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING
Note: The intentional overdose or suicide gesture patient is to be considered

potentially dangerous. Additionally, certain types of ingestions such
methamphetamines (Crank, Crystal, Speed. Meth) and drugs such as
PCP (Phencyclidine, Angel Dust) can cause a patient to be particularly
violent and uncooperative, utilize Law Enforcement assistance to
manage these patients as necessary. During response to these
incidents EMS will be required to stage in the area until Law
Enforcement arrives and determines the scene is secure.
The suicide gesture and illicit drug overdose patient that is alert will
frequently resist the suggestion that they be transported to a medical
facility, If it is determined that a true intentional overdose did occur, the
patient must be transported. Law Enforcement assistance should be
sought to accomplish this if necessary.
The use of certain types of “Designer” or “Club” drugs such as Ecstasy

(MDMA) in the “Rave Party” setting can result in the patient becoming
hyperthermic and profoundly dehydrated, be aware and treat as
necessary.
The over-all goal of treatment of the overdose/ingestion/poisoning patient

should be general supportive care and support of the ABC’s. Treatment
of specific problems should be guided by the pertinent protocol.
ADULT CARE
I.1. General Supportive Care. (Special attention provided to airway

protection up to and including elective intubation. IV NS.
I.2. Check blood glucose level, if ≤ 70 administer D50, 25 gm IV, see 2.19:
Diabetic Emergencies Protocol.
I.3. If suspected narcotic involvement or with a change in level of

consciousness due to an unknown agent, Narcan, 0.4-2 mg IV, ET, or
IM. Use the larger dose if overdose with synthetic narcotic compounds
suspected (Darvocet, Fentanyl, etc.). Opiate overdose should not be
ruled out based just on the patients age or appearance, opiates can be a
commonly prescribed drug for all ages and types of patients.
PROTOCOL 2.20: DRUG OVERDOSE / INGESTION / POISONING (cont.)
ADULT CARE (cont.)
Consider titrating Narcan to achieve adequate respiratory effort and

avoid a withdrawl reaction or combativeness.
I.4. Consider repeating Narcan, 0.4-2 mg via IV, ET, or IM for patient with
pinpoint pupils, depressed respiratory effort or LOC but no response to
initial dose.
I.5. In suspected narcotic overdoses, withhold decision to intubate until after

the patient has received Narcan.
I.6. If suspected Tricyclic Antidepressant (TCA) (Doxepin, Amitriptyline, etc.)

overdose and tachycardia, QRS widening present, Sodium Bicarbonate
1.0 meq,kg IV. Contact Medical Control for potential additional doses.
Note: Statistically, intentional overdose with TCA’s is quite common. In

the absence of direct evidence of TCA overdose (inappropriately empty
pill bottles, etc.), the ECG is an essential part of the diagnosis and
treatment (tachycardia, QRS widening). Patient should also be observed
for anticholinergic effects, (dry mouth/mucosa, vasodilation, hypotension,
decreased sweating, lethargy/altered mentation). Patient may also
experience seizures.
Control airway aggressively, patient may become severely obtunded

very quickly. Treat cardiotoxic effects with Sodium Bicarbonate,
hypotension with fluids, and seizures with benzodiazepines (see 2.24:
Seizures and Status Epilepticus Protocol).
I.7. Contact Medical Control or Poison Control* for information on the

suspected poison(s) or drugs if needed.
I.8. Observe any emesis for possible pill fragments.
I.9. Gather all medications, over-the-counter drugs, or other possible safe to

transport toxins accessible to the patient and transport with the patient to
the ED.
I.10. Utilize Law Enforcement assistance as needed in managing the violent,

uncooperative or suicide gesture patient. If necessary to restrain patient,
refer to 5.22: Restraint (Physical and Chemical) Protocol.
ADULT CARE (cont.)
I.11. Situations involving inhaled and cutaneous exposure to toxins can pose
significant risks to rescuers. Be aware of Hazardous Materials
implications and do not enter an environment where such an exposure
has taken place until it has been determined to be safe to do so (Don’t
needlessly make more patients, seek Haz-Mat team assistance when in
doubt). For specific treatment of medical problems caused by
Hazardous Materials, see 6.6: Hazardous Materials/WMD Incidents
Protocol.
I.12. Where no Haz-Mat problem exists, inhaled toxins should be treated with
100% O2 via NRB mask (unless specifically contraindicated).
I.13. Where no Haz-Mat problem exists, cutaneous exposure patients should

be removed from environment and decontaminated with copious
amounts of water. All clothes should be removed and care should be
taken not to contaminate rescuers.
I.14. If overdose is suspected with antipsychotic drugs (Thorazine,

Compazine, Haldol, Lithium, Risperdal, etc.) and patient is awake and
experiencing extrapyramidal reaction symptoms, Benadryl 50 mg IV or
IM repeat as needed. Do not administer Benadryl if patient is not alert or
unconscious.
PEDIATRIC CARE
I.1. General Supportive Care. (Special attention provided to airway

protection up to and including elective intubation. IV NS if patient
obtunded or significant altered mentation.
I.2. Check blood glucose level, if < 60 in child or < 40 in newborn, administer
IV glucose or Glucagon, see 2.19: Diabetic Emergencies Protocol.
I.3. If suspected narcotic involvement or with a change in level of

consciousness due to an unknown agent, Narcan, 0.1m/kg IV, ET, IO or
IM (not to exceed 2 mg). Suspicion of opiate overdose in the pediatric
patient should be based on a history gathered relative to the patients
possible access to the drug.
I.4. In suspected narcotic overdoses, withhold decision to intubate until after

the patient has received Narcan.
I.5. Contact Medical Control or Poison Control* for information on the

suspected poison(s) or drugs if needed.
I.6. Observe any emesis for possible pill fragments.
I.7. Gather all medications, over-the-counter drugs, or other possible safe to

transport toxins accessible to the patient and transport with the patient to
the ED.
I.8. Utilize Law Enforcement assistance as needed in managing the violent,

uncooperative or suicide gesture patient. If necessary to restrain patient,
refer to 5.22: Restraint (Physical and Chemical) Protocol.
I.9. Situations involving inhaled and cutaneous exposure to toxins can pose
significant risks to rescuers and when children are involved, rescuers
may be prone to take risks they would not otherwise take. Be aware of
Hazardous Materials implications and do not enter an environment
where such an exposure has taken place until it has been determined to
be safe to do so (Don’t needlessly make more patients, seek Haz-Mat
team assistance when in doubt). For specific treatment of medical
problems caused by Hazardous Materials, see 6.6: Hazardous
Materials/WMD Incidents Protocol.
I.10. Where no Haz-Mat problem exists, inhaled toxins should be treated with
100% O2 via NRB mask (unless specifically contraindicated).
I.11. Where no Haz-Mat problem exists, cutaneous exposure patients should

be removed from environment and decontaminated with copious
amounts of water. All clothes should be removed and care should be
taken not to contaminate rescuers.
II.1 If suspected Tricyclic Antidepressant (TCA) (Doxepin, Amitriptyline, etc.)

overdose and tachycardia, QRS widening present, Sodium Bicarbonate
1.0 meq,kg IV. Additional information above (Note) for adult TCA
overdose also applies to pediatric patient.
II.2. Consider repeating Narcan, 0.1 mg/kg/via IV, ET, IO, or IM (not to
exceed 2 mg) for patient with pinpoint pupils, depressed respiratory
effort or LOC but no response to initial dose.
II.3. If overdose is suspected with antipsychotic drugs (Thorazine,

Compazine, Haldol, Lithium, Resperidal, etc.) and patient is experiencing
extrapyramidal reaction symptoms, Benadryl 1 mg/kg IV or IM repeat as
needed.
* Poison Control 1-800-764-7661
PROTOCOL 2.21: HYPERTENSIVE EMERGENCIES
Note: Hypertension in itself is not the primary concern or focus, the problems
resulting from the hypertension are the most concerning aspect. In the
presence of neurologic findings, pre-hospital treatment of hypertension
may be contraindicated because a rapid or precipitous drop in BP may
compromise cerebral blood flow and cause further neurological
complications.
Secondary hypertension (high BP in response to stress or pain) is

commonly seen in the field. It does not require field treatment, and may
not even mean the patient has chronic hypertension requiring ongoing
treatment.
Hypertension is seen in severe head injury and intracranial bleeding and

may be a protective response which increases perfusion to the brain.
Treatment should be directed at lowering the intracranial pressure, not
the blood pressure.
ADULT CARE
I.1 General Supportive Care, IV NS.
I.2 Cardiac monitor, Obtain 12-lead ECG (when it can be done without
delaying needed treatment).
I.3. Recheck BP with special attention to correct cuff size and placement.
Falsely elevated BP readings can result from a cuff which is too small for
the patient. The cuff should cover ⅓ to ½ of the upper arm, and the
bladder should completely encircle the arm.
I.4. If unconscious, support airway and hyperventilate. Consider intubation

using Lidocaine 1mg/kg IV to reduce increased intracranial pressure.
I.5. If the patient is seizing, in congestive heart failure or having chest pain,
treat per appropriate protocol.
I.6. Consider elevation of head 45 degrees if not contraindicated.
PROTOCOL 2.21: HYPERTENSIVE EMERGENCIES
PEDIATRIC CARE
I.2. Recheck BP with special attention to correct cuff size and placement.
Falsely elevated BP readings can result from a cuff which is too small for
the patient. The cuff should cover ⅓ to ½ of the upper arm, and the
bladder should completely encircle the arm.
I.3. If unconscious, support airway and hyperventilate.
II.1. None.
PROTOCOL 2.22: OB / GYN
Definitions:
Imminent Delivery:
1. Amniotic sac has broken AND

2. Contractions are 2-3 minutes apart or less (constant).
3. There is crowning of the fetal head or bulging in the perineum that
suggests the fetus is about to exit the birth canal.
4. Mother has urge to bear down or have bowel movement.
Delayed Delivery:
1. Contractions are 5 or more minutes apart.

2. Amniotic sac is not broken.
3. First pregnancy for the mother and both of the above are present.
Determine:
1. The number of previous pregnancies the mother has had.

2. The frequency and duration of contractions.
3. The condition of the amniotic sac (broken, unbroken).
4. The presence or absence of vaginal bleeding.
5. Approximate gestational age of the fetus.
ADULT CARE
I.1. General Supportive Care, O2, IV NS.
I.2. If vaginal bleeding, check for orthostatic changes in vital signs. If

hypotensive, give fluid bolus and consider second line.
I.3. If vaginal bleeding, attempt estimate of blood loss (number of pads

saturated in past 6 hours). Ask about clots or tissue fragments (bring
tissue to hospital if possible).
I.4. Position patient with advanced pregnancy on left side. If on long

backboard for trauma, tilt board to left and block up..
I.5. If patient pregnant and indications of delayed delivery, begin transport

and establish Medical Control contact as soon as possible so Labor and
Delivery can prepare for patient arrival..
PROTOCOL 2.22: OB/GYN (cont.)
ADULT CARE (cont.)
I.6. If there is indication of Imminent Delivery, make decision to deliver on

scene or transport immediately. Be prepared to stop ambulance if
delivery occurs enroute.
Delivery
I.1. Use clean or sterile technique.
I.2. Guide and control, but do not retard or hurry delivery.
I.3. Once the fetus’s head has emerged, check for nuchal cord, suction the
mouth, then nose with bulb syringe.
I.4. Suction again after delivery. Stimulate by drying (this should be enough
to start infant crying).
I.5. Protect infant from fall and temperature loss; dry and wrap for warmth
(especially head, use beanie).
I.6. Note time of delivery.
I.7. Assess infant’s status using APGAR score. If less than 7, see 2.6:
Neonatal Resuscitation Protocol.
TABLE 2.A.
APGAR Score
APGAR Score
1 5
0 Points 1 Point 2 Points Minute Minutes
Heart Rate Absent <100 >100
Respiratory Effort Absent Slow, irregular Strong cry
Muscle Tone Flaccid Some flexion Active motion
Irritability No response Some Vigorous
Color Blue, pale Blue & pink Fully pink
TOTAL:
* Infants with scores of 7-10 usually require supportive care only.
* A score of 4-6 indicates moderate depression.
* Infants with scores of 3 or less will require aggressive resuscitation.
ADULT CARE (cont.)
I.8. Clamp the cord in two places approximately 6-8 inches from the infant.
(keep the infant at or below the level of the mother until the cord is
clamped.
I.9. Cut the cord between the clamps.
I.10. If excessive bleeding occurs postpartum, massage the top of the uterus
gently.
I.11. Assess infant’s status again at 5 minutes using APGAR score.
I.12 Do not delay transport for or attempt to deliver placenta. If placenta

delivers spontaneously, take to the hospital in plastic bag.
Prolapsed Cord
I.1. Place the mother in left lateral Trendelenburg position, elevate hips if
possible or knee-chest position.
I.2. Insert gloved hand for counter-pressure against infants head to allow
blood flow through cord. Elevation of the buttocks may also help to
alleviate pressure on the cord.
I.3. Transport Code 3 (HOT) to the nearest appropriate facility.
Breech Position
I.1. If the presenting part of the fetus is not the head, coach the mother and
attempt to assist a controlled delivery.
I.2. If unable to deliver, place the mother in left lateral Trendelenburg

position.
I.3. Transport Code 3 (HOT) to the nearest appropriate facility.
Nuchal Cord
I.1 If the fetus presents at the perineum with the umbilical cord wrapped
around its neck, try to slip the cord gently over the baby’s head. If cord
too tight to do so, place two clamps about 2 inches apart on the cord and
cut cord in between. Unwind, then deliver infant quickly.
II.1 None
PEDIATRIC CARE
(Childbearing minor treated medically same as adult)
PROTOCOL 2.23: PULMONARY EDEMA
Indications:
1. Patients presenting with dyspnea, having a history of CHF, MI, HTN or

coronary artery disease with three or more of the following:
A. cyanosis
B. rales (crackles)
C. peripheral edema
D. frothy pink sputum
E. respiratory rate > 25 or <10
F. neck vein distension
2. Systolic blood pressure must be ≥ 90 mm Hg and pulse < 150 (otherwise

see 2.15: Cardiogenic Shock Protocol or pertinent arrhythmia
protocol).
ADULT CARE
I.1. General Supportive Care, IV saline lock or NS TKO.
I.2. High Fowler’s position, assist with ventilation and intubate as needed.
I.3. Consider CPAP.
I.4. If normotensive or hypertensive, Nitroglycerin, up to (3) SL sprays or

0.4 mg SL tabs Q 5 min. (watch BP). Nitro therapy should be directed
toward relieving the worst of the patients respiratory distress so relatively
comfortable transport is possible.
II.1. If normotensive or hypertensive, Lasix, 40 mg, IV.
II.2. If normotensive or hypertensive, Morphine, 2 - 5 mg, slow IV. Use 2 mg

increments and avoid if patient is obtunded.
PEDIATRIC CARE
I.1. General Supportive Care, IV saline lock or NS TKO.
I.2 High Fowler’s position, assist with ventilation and intubate as needed.
II.1. If normotensive or hypertensive for patient age, Lasix, 1 mg/kg, IV.
PROTOCOL 2.24: SEIZURES AND STATUS EPILEPTICUS
Note: The pharmacologic interventions in this protocol should be used when

patient is having continuous seizures or repeating episodes of
seizure activity without regaining consciousness. Pharmacologic
intervention is not absolutely required in every case, but should be used
whenever the attending Paramedic deems it necessary. Consider
underlying etiology, such as hypoglycemia, cardiac arrhythmias,
overdose, head injury or fever.
The patient with a seizure disorder that seizes, but clears completely and
has no outstanding problem may need little or no intervention and may
even wish to refuse transport. This should only be allowed if the patient
proves they are able to care for themselves and transport to a medical
facility should be strongly encouraged.
ADULT CARE
I.1 Move hazardous objects away from seizing patient and protect their
head.
I.2. When (if) patient stops seizing, place in left lateral recumbent position( if
no c-spine injury is suspected) and clear airway, suction if needed.
I.3. The seizure patient that regains consciousness may be extremely

disoriented upon awakening. Do not allow patient to wander around or
even get up until they are fully alert.
I.4. General Supportive Care. IV NS if status seizures or prolonged

significantly altered mentation.
I.5 Check blood glucose level, if ≤ 70 administer D50, 25 gm IV,, see 2.19:
Diabetic Emergencies Protocol.
I.6. If not hypoglycemic, administer Ativan, 1 mg IV repeated once to a total

of 2 mg, dose to effect.
I.7. Consider Valium, 5 mg, slow IV repeated once to a total of 10 mg, dose
to effect.
I.8. If unable to obtain venous access, then Valium 5-10 mg IM route,

(acceptable but slower acting and less predictable).
II.1. If above total doses of Ativan and Valium are ineffective in controlling
status seizures, contact Medical Control to discuss treatment options.
PROTOCOL 2.24: SEIZURES AND STATUS EPILEPTICUS
PEDIATRIC CARE
I.1 Move hazardous objects away from seizing patient and protect their
head.
I.2. When (if) patient stops seizing, place in left lateral recumbent position ( if
no c-spine injury is suspected) and clear airway, suction if needed.
I.3. The seizure patient that regains consciousness may be extremely

disoriented upon awakening. Do not allow patient to wander around or
even get up until they are fully alert.
I.4. The febrile seizure patient may need little in the way of intervention if the
seizure is over, but absolutely should be transported. Parents that try to
refuse service for such a patient should be strongly encouraged to
accept transport. Attempts at cooling the febrile seizure patient are
usually of little value and may actually make things worse. It should just
be assured that the patient is not overheated by excessive layers of
blankets, etc. The issue that needs to be addressed and treated is the
cause of the fever.
I.5. General Supportive Care. IV NS if status seizures or prolonged

significantly altered mentation.
I.6 Check blood glucose level, if < 60 in child or < 40 in newborn, administer
IV glucose or Glucagon, see 2.19: Diabetic Emergencies Protocol.
II.1. If not hypoglycemic, administer Ativan 0.05 - 0.2 mg/kg slow IV, IO or IM
until seizures begin to diminish. (for IV or IO use, dilute 1:1 in NS)
II.2. Consider Valium 0.25 mg/kg slow IV or IO until seizures begin to

diminish.
II.3. If unable to obtain venous access, Valium may also be administered

rectally at 0.5 mg/kg using a tuberculin syringe (without needle) inserted
rectally 4-5 cm.
PROTOCOL 2.25: SUDDEN INFANT DEATH SYNDROME (SIDS)
Note: This protocol should be used if it is determined after a careful

examination that an infant that has suffered a cardiac arrest is non-
resuscitatable by Advanced Life Support standards, refer to 6.5: Field
Determination of Death Protocol for criteria. If patient does not meet
criteria for field determination of death, immediately begin resuscitation
using pertinent protocol based on patients presenting cardiac rhythm.
SIDS cause is unknown, cases typically occur between one month and
one year of age.
I.1. Deliver death message in a gentle manner to parents or caregivers. A

resuscitation should not be begun on a infant that has advanced rigor
mortis and post mortem lividity “for the family”. Doing so only creates a
false illusion of a potential positive outcome.
I.2. Contact Law Enforcement for coroner involvement.
I.3. Support family, assist with activating any available support structure
(clergy, family members, etc.).
I.4. Gather and document as complete a history as is possible:
a) Position in which child was found

b) Condition of bed
c) Last time child seen well
d) Seizure activity, trauma, possible ingestion
e) Associated S/S, fever, respiratory problems, infection, vomiting,
etc.
f) Past medical history, prematurity, development, nutrition
I.5. Note and completely document physical findings relative to both patient
and environment:
a) Presence of rigor mortis and or post mortem dependent lividity

b) Presence of froth or blood tinged sputum at mouth or nose
c) Signs of trauma
d) Living conditions in residence
I.6. Avoid premature assessments, statistically, most SIDS cases are not
child abuse or homicides. However they do occur, so thorough
assessment and documentation is essential.
PROTOCOL 2.26: SYNCOPAL EPISODE
Note: Syncope is by definition a transient state of unconsciousness from which

the patient has recovered. If the patient is still unconscious, see 2.17:
Coma/Altered Mental Status Protocol. Emphasis should be placed on
underlying cause of syncope and its treatment.
Statistically, the most common cause of unconsciousness in the elderly

patient in the pre-hospital setting is CVA/stroke problems. In the
younger patient it is seizures.
ADULT CARE
I.2. ECG. IV NS if patient remains not alert.
I.3. Consider possible need for cervical spine immobilization if patient

sustained fall during syncope.
or ingestions.
I.5. Consider past medical history and possibility of transient dysrhythmia,

hypovolemia (check for orthostatic changes in vital signs),
medication side effects, glucose level abnormalities, inner ear disorders,
CVA/TIA.
I.6. The patient that has passed out and then regained consciousness will
frequently want to refuse service. Make sure patient has received full
assessment (vitals, ECG, glucose check) and remind them that passing
out is not normal before processing such a refusal, refer to 6.11: No
Transport (Refusal, Cancel) Protocol.
II.1. None.
PEDIATRIC CARE
I.2. ECG. IV NS if patient remains not alert.
PROTOCOL 2.26: SYNCOPAL EPISODE (cont.)
I.3. Consider possible need for cervical spine immobilization if patient

sustained hard fall during syncope.
or ingestions.
I.5. Consider past medical history and possibility of transient dysrhythmia,

hypovolemia (check for orthostatic changes in vital signs),
medication side effects, glucose level abnormalities, inner ear disorders,
CVA/TIA.
I.6. The parents of a pediatric patient that has passed out and then regained
consciousness may want to refuse service. Make sure patient has
received full assessment (vitals, ECG, glucose check) and remind them
that passing out is not normal before processing such a refusal, refer to
6.11: No Transport (Refusal, Cancel) Protocol.
II.1. None.
Pre-hospital Advanced Life Support Protocols Treatment Protocols - Trauma
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE
NOTE:
This protocol presents the basic components of patient “packaging” for

trauma patients. Due to the significant differences in priorities and packaging
in the pre-hospital care of medical cases, a separate General Supportive
Care Protocol has been developed. This Trauma and Hypovolemic
Supportive Care Protocol may be the only protocol used in trauma or
hypovolemia situations where a specific diagnostic impression and choice of
protocol(s) cannot be made. If there is a question as to whether a patient
requires a particular intervention, contact with Medical Control is advised.
This protocol is frequently referred to by other protocols which may override it
in recommending more specific therapy.
Although the following protocol is oriented toward the treatment of the trauma
patient, the principles of rapid evaluation, treatment, and transport of patients
with hypovolemia secondary to other problems parallel those listed below.
Fluid resuscitation may be required in large volumes or in smaller
incremental boluses. Careful monitoring for signs of volume overload is
essential. Medical Control contact may be useful for patients requiring fluid
resuscitation.
ADULT CARE
I.1. Assessment of scene.
I.2. Primary survey.
I.3. Airway access with cervical spine control, initial management includes
patient positioning and manual maneuvers to assure a patent airway.
Patients with signs and symptoms of hypoxia should initially be treated
with O2 12-15 L/min via non-rebreather mask. Assist ventilation (24
breaths/min) in patients with respiratory rate<12/min, shallow respirations
with inadequate tidal volume, or a decreased level of consciousness.
(GCS 8 or less).
I.4. If the patient has continued difficulty with oxygenation and ventilation
after simple airway maneuvers, airway adjuncts and advanced airway
procedures may be used.
I.5. Endotracheal tube placement must be verified by three (3) different

methods immediately following intubation (see 5.7-9: Advanced Airway
Management Protocols). Tube placement must also be re-verified
after securing tube, after moving the patient, and at any other time of
PROTOCOL 3.1: TRAUMA AND HYPOVOLEMIC SUPPORTIVE CARE (cont.)
ADULT CARE (cont.)
concern or change in the patient’s condition (including the movement of

the patient from the ambulance cot to the hospital bed).
If there is any question regarding the placement of the endotracheal

intubated. In line cervical spine stabilization must be maintained during
attempts at oral intubation. If cervical spine injury is strongly suspected
and/or obvious, and field intubation is necessary, strongly consider nasal
intubation if there is spontaneous respiratory effort present (see 5.8:
Advanced Airway Management: Nasotracheal Intubation Protocol).
I.6 Hemorrhage control as necessary.
I.7. Immobilization on long backboard with cervical collar, CID, and straps
(minimum of 4). In the event of significant localized facial injury and
patient insists on sitting forward to maintain own airway, do not force
patient onto backboard, manage c-spine as best as is possible with c-
collar and KED only.
I.8. If patient meets Trauma Alert criteria (see 5.28: Trauma Alert
Protocol) Facilitate immediate transport and early as possible
notification of receiving hospital (before leaving scene if possible). Goal
with Trauma Alert and other significant trauma cases is maximum of ten
minutes on scene.
I.9. If injuries are minor in nature, the Paramedic may elect to complete the
secondary survey at the scene.
I.10. Immediately stabilize any life threatening respiratory problems:
a) Sucking chest wound

b) Tension pneumothorax (see 5.27: Tension Pneumothorax
Decompression Protocol)
c) Flail chest
NOTE: The following steps should not delay transport.
I.11. IV NS using two large bore lines using at least one blood tubing set.
ADULT CARE (cont.)
Note: Fluid administration in the field should be geared toward raising

the patients systolic BP to no more than 90 – 100 mm/Hg. Any more
could potentially worsen internal bleeding.
I.12. ECG monitoring.
I.13. Complete bandaging, splinting and packaging.

Report Protocol.
I.15. Transport red lights and sirens (Code 3, HOT) if patient’s condition is
PEDIATRIC CARE
I.1 Assessment of scene.
I.2. Primary survey.
I.3. Airway access with cervical spine control, initial management includes
patient positioning and manual maneuvers to assure a patent airway.
Patients with signs and symptoms of hypoxia should initially be treated
with O2 via non-rebreather mask at 10-12 LPM. Assist ventilation (24
breaths/min) in patient with respiratory rate<12/min, shallow respirations
with inadequate tidal volume, or decreased level of consciousness. (GCS
8 or less).
I.4. If the patient has continued difficulty with oxygenation and ventilation
after simple airway maneuvers, airway adjuncts and advanced airway
procedures may be used.
I.5. Endotracheal tube placement must be verified by three (3) different

methods immediately following intubation (see 5.7-9: Advanced Airway
Management Protocols). Tube placement must also be re-verified
after securing tube, after moving the patient, and at any other time of
concern or change in the patient’s condition (including the movement of
the patient from the ambulance cot to the hospital bed).
If there is any question regarding the placement of the endotracheal

intubated. In line cervical spine stabilization must be maintained during
attempts at oral intubation. If cervical spine injury is strongly suspected
and/or obvious, and field intubation is necessary, strongly consider nasal
intubation (if more than 8 y/o) if there is spontaneous respiratory effort
present (see 5.8: Advanced Airway Management: Nasotracheal
Intubation Protocol).
I.6. Hemorrhage control as necessary.
I.7. Immobilization on long backboard with cervical collar, CID, and straps
(minimum of 4). Use pediatric immobilization device if patient size
appropriate. In the event of significant localized facial injury and patient
insists on sitting forward to maintain own airway, do not force patient
onto backboard, manage c-spine as best as is possible with c-collar and
KED only.
I.8. If patient meets Trauma Alert criteria (see 5.28: Trauma Alert
Protocol) Facilitate immediate transport and early as possible
notification of receiving hospital (before leaving scene if possible). Goal
with Trauma Alert and other significant trauma cases is maximum of ten
minutes on scene.
I.9. If injuries are minor in nature, the Paramedic may elect to complete the
secondary survey at the scene.
I.10. Immediately stabilize any life threatening respiratory problems:
a) Sucking chest wound

b) Tension pneumothorax (see 5.27: Tension Pneumothorax
Decompression Protocol)
c) Flail chest
NOTE: The following steps should not delay transport.
I.11. IV NS - initial fluid bolus should be 2O ml/kg. (Keep in mind that “normal”
BP and heart rate varies with child’s age).
I.12. ECG monitoring.
I.13. Complete bandaging, splinting and packaging.

Report Protocol.
I.15. Transport red lights and sirens (Code 3, HOT) if patient’s condition is
I.16. Intraosseous venous access may be attempted during transport if:
a) Full Arrest
II.1. Intraosseous venous access may be attempted during transport with

authorization from Medical Control if:
a) Child ≤ 3 years old AND

b) unconscious, AND
c) signs and symptoms of shock
PROTOCOL 3.2: ABDOMINAL / PELVIC TRAUMA
NOTE: The extent of abdominal injury is difficult to assess in the field. Be

very suspicious; with significant blunt trauma, injuries to multiple
organs are the rule.
Patients with spinal cord injury or altered mentation due to drugs,

alcohol or head injury may not complain of pain and may lack
guarding in the face of significant intra-abdominal injury.
Significant intra-abdominal injury may occur without any external

signs of injury, particularly in children. Strongly consider the
mechanism of injury, the forces involved and be highly suspicious of
occult trauma.
ADULT CARE
I.1. Trauma and Hypovolemic Supportive Care.
I.2. High flow O2 via NRB mask.
I.3. Large-bore IV NS, consider second line. Always place second line if
signs of shock.
I.4. Cover eviscerated tissue with moist saline dressing, then dry sterile
dressing. Do not attempt to replace eviscerated contents back into
abdominal cavity.
I.5. Immobilize impaled objects in place to prevent further movement.
II.1. None.
PEDIATRIC CARE
I.3. Large-bore IV NS, consider second line.
PROTOCOL 3.2: ABDOMINAL/PELVIC TRAUMA (cont.)
I.4. Cover eviscerated tissue with moist saline dressing, then dry sterile
dressing. Do not attempt to replace eviscerated contents back into
abdominal cavity.
I.5. Immobilize impaled objects in place to prevent further movement.
II.1. None.
PROTOCOL 3.3: AMPUTATION
ADULT CARE
I.3. Large-bore IV NS at appropriate rate maintain systolic BP 90-100 mm/Hg

only.
I.4. Gently rinse stump with saline, cover with moistened sterile gauze, and
cover with dry dressing. Elevate. Dress and use direct pressure to
control hemorrhage as needed.
I.5. If partial amputation, dress and splint in anatomical position to facilitate

optimum vascular status. Wrap with bulky dressings. Avoid torsion in
handling and splinting.
I.6. Consider pain control with Morphine, see 5.20: Pain Management
Protocol.
II.1. If pain control requires medication dosages above those set by the Pain
Management protocol, contact Medical Control.
Amputated part care
I.1. Irrigate amputated part thoroughly and gently in NS to remove loose

debris do not scrub.
I.2. Wrap amputated part in moistened sterile gauze (several layers).
I.3. (If possible) Place amputated part in sealed plastic bag and if ice and
sufficient size cooler is available, float bag in cooler filled with ice water.
If plastic bag, ice and cooler not immediately available, transport in
moistened gauze only affording part all protection possible. Handle
gently.
I.4. Transport part with patient as quickly as possible, do not delay transport
of amputated part for care.
I.5. Do not freeze part by placing it directly on ice or by adding any other
coolant (never use dry ice).
PROTOCOL 3.3: AMPUTATION (cont.)
Amputated part care (cont.)
I.6. Do not float part in container of any solution.
I.7. Do not use any antiseptic or other solution.
PEDIATRIC CARE
I.3. Large-bore IV NS.
I.4. Gently rinse stump with saline, cover with moistened sterile gauze, and
cover with dry dressing. Elevate. Dress and use direct pressure to
control hemorrhage as needed.
I.5. If partial amputation, dress and splint in anatomical position to facilitate

optimum vascular status. Wrap with bulky dressings. Avoid torsion in
handling and splinting.
I.6. Amputated part care as above for adult.
II.1 Contact Medical Control for pain control in the pediatric patient.
PROTOCOL 3.4: BURNS
A. Thermal Burns
1. Hot toxic gases, including carbon monoxide are given off. It is

important to note if the burn occurred inside an enclosed space. The
patient that has been trapped in an enclosed space with hot gases,
steam or smoke is the one most likely to suffer burn inhalation injury
or toxic inhalation. It is prudent to assume carbon monoxide
poisoning and airway involvement in all closed space burns evaluate
airway constantly.
2. Assess and treat for associated trauma (blast or fall).
3. Two percent or greater burns should be seen by a physician.
B. Chemical Burns
1. Situations involving inhaled and cutaneous exposure to chemicals

can pose significant risks to rescuers. Be aware of Hazardous
Materials implications and do not enter an environment where such
an exposure has taken place until it has been determined to be safe
to do so (Don’t needlessly make more patients, seek Haz-Mat team
assistance when in doubt). When unknown or potential Hazardous
Materials are involved, see 6.6: Hazardous Materials/WMD
Incidents Protocol.
2. Usually more localized than thermal burns.
3. Noxious gases will often affect the lungs to produce pulmonary

insult. Laryngeal and bronchial edema may cause subsequent
significant airway obstruction.
4. If safe to do so, remove or brush off any dry particles or powder, then
irrigate with copious amounts of saline or water (including eyes).
a) Do not perform decontamination yourself if Hazardous or

unknown chemicals are involved. Seek Haz-Mat team
assistance. Do not transport contaminated patients, de-con
first, notify medical facility early.
b) Watch for hypothermia! The wet, burned patient will become

hypothermic easily. Protect from weather.
5. Evaluate for systemic effects of chemical contamination.
PROTOCOL 3.4: BURNS (cont.)
6. Assess and treat for associated trauma (blast or fall).
C. Electrical Burns (including lightning)
1. Be sure the patient is no longer in contact with the electrical source,

obtain engine company and power company assistance if necessary.
Don’t become a victim yourself!
2. Closely evaluate airway and cardiac status. Prolonged respiratory

support may be needed, lightning injuries can cause prolonged
respiratory arrest. Prompt, continuous respiratory support
(sometimes for hours) can result in full recovery.
3. Patients often suffer from traumatic injuries as well. These can be

from fall, blast, or extreme muscle contractions. Immobilize cervical
spine.
4. Even though the surface area of the burn may be small, involvement
of internal organ systems can be extensive.
5. All electrical burns should be evaluated by a physician.
D. Assess burns by the following criteria:
1. Percent of body burned:

a) “Rule of Nines” (see Table 3.B., Rule of Nines Chart below).
2. Extent of burn based on depth:

b) Superficial, partial-thickness, full-thickness (see Table 3.C.,
Burn Classification Chart below)
3. Age of the patient.
4. Site of burns:
c) Face, extremities, etc.
E. American Burn Association Burn Severity Grading System:
Note: Burn = partial-thickness or full-thickness burn unless specified.

TBSA = total percentage of body surface area affected by injury.
Young = patient younger than 10 years of age.
Adult = patient 10 to 50 years of age.
Old = patient older than 50 years of age.
1. Minor Burn (Potential outpatient management)
a) < 10 % TBSA burn in adult

b) < 5 % TBSA burn in young or old
c) < 2 % full-thickness burn
2. Moderate Burn (Hospital admission)
a) 10 to 20 % TBSA burn in an adult

b) 5 to 10 % TBSA burn in young or old
c) 2 to 5 % full-thickness burn
d) High-voltage injury (visible external burns may be minor or not
evident)
e) Suspected inhalation injury
f) Circumferential burn
g) Concomitant medical problem predisposing patient to infection
(diabetes, sickle cell disease, etc.)
3. Major Burn (Referral to Burn Center)
a) > 20 % TBSA burn in an adult

b) > 10 % TBSA burn in young or old
c) > 5 % full-thickness burn
d) High-voltage burn
e) Known inhalation injury
f) Any significant burn to face, eyes, ears, genitalia or joints
g) Significant associated trauma (fractures, other major trauma)
ADULT CARE
I.2. Remove clothing that is hot, smoldering, wet, contaminated with

chemicals or which is not adhered to the patient. (Prevent hypothermia).
.
I.3. Obtain information regarding possibility of smoke/toxic fume inhalation.
Treat with 100% O2 via NRB mask. If patient known to have been in
enclosed space, be prepared to manage airway aggressively and
possibly intubate early.
I.4. Assess and treat for associated trauma (blast, fall).
ADULT CARE (cont.)
I.5. Remove rings, bracelets and other constricting items.
I.6. If burns are < 10% TBSA (Minor Burn), cover with sterile, moist burn
dressings (do not use ice)
I.7. If burns are > 10% TBSA (Moderate to Major Burn), cover with dry,
sterile burn dressings or sheets to avoid hypothermia.
I.8. Large-bore IV access (2 lines if possible). If necessary IV’s may be

started through area of burn, but try to avoid.
I.9. If Moderate to Major burn, consider fluid infusion 250-500 ml NS titrated

to maintain adequate BP (SBP 100) and perfusion. For additional fluids
contact Medical Control.
Note: Be aware that the severely burned patient may need significant
fluid infusions (see Table 3.A., Parkland Burn Formula below), but they
may not need it right away. Lines should be in place irregardless of
immediate need for fluid.
I.10. Morphine, 2-4 mg repeated q 5 min. to a total of 10 mg for pain control

(see 5.20: Pain Management Protocol) as long as patient remains
hemodynamically stable.
I.11. Contact receiving hospital at earliest opportunity. Trauma Alert if patient

meets criteria, see 5.28: Trauma Alert Protocol. When giving report to
receiving hospital reference the burn patient, avoid giving complicated
percentages and descriptions. Just clearly describe extent (partial, full-
thickness) and where on the body the burns are.
II.1. For analgesic dosages above those referenced by the Pain Management
Protocol or fluid resuscitation above that listed above, contact medical
Control.
PEDIATRIC CARE
I.2. Remove clothing that is hot, smoldering, wet, contaminated with

chemicals or which is not adhered to the patient. (Prevent hypothermia).
.
I.3. Obtain information regarding possibility of smoke/toxic fume inhalation.

Treat with 100% O2 via NRB mask. If patient known to have been in
enclosed space, be prepared to manage airway aggressively and
possibly intubate early.
I.4. Assess and treat for associated trauma (blast, fall).
I.5. Remove rings, bracelets and other constricting items.
I.6. With the pediatric patient only use sterile, moist burn dressings on very
minor or small burns (burn that you can cover with your hand), the
pediatric patient is more susceptible to hypothermia than the adult
patient. On all other burns, cover only with dry, sterile burn dressings or
sheets. (do not use ice)
I.7. Large-bore (for patient size) IV access. If necessary IV’s may be started
through area of burn, but try to avoid.
I.9. If Moderate to Major burn, consider fluid infusion 20 ml/kg NS. If in doubt
or for additional fluids contact Medical Control.
I.10. Contact receiving hospital at earliest opportunity. Trauma Alert if patient

meets criteria, see 5.28: Trauma Alert Protocol. When giving report to
receiving hospital reference the burn patient, avoid giving complicated
percentages and descriptions. Just clearly describe extent (partial, full-
thickness) and where on the body the burns are.
II.1. Consider Morphine, 0.1 mg/kg slow IV
TABLE 3.A.
Parkland Burn Formula
Parkland Burn Formula (24 Hr.)
4ml. x patient kg. x % of TBSA burn (partial and full-thickness

together) = total fluids in 24 hrs.
1st 50% admin. in 1st 8 hrs. 2nd 50% over following 16 hrs.
ILLUSTRATION 3.A.
Rule of Nines Chart
TABLE 3.B.
Burn Classifications
CHARACTERISTICS
Classification Cause Appearance
Ultraviolet light, very

Superficial burn Dry and red; blanches
short flash (flame
with pressure
exposure)
Superficial partial- Scald (spill or splash), Blisters; moist, red and

thickness burn short flash weeping; blanches with
pressure
Deep partial-thickness Scald (spill), direct Blisters (easily unroofed);

burn flame, oil, grease wet or waxy dry; variable
color (patchy to cheesy
white to red); does not
blanch with pressure
Full-thickness burn Scald (immersion), Waxy white to leathery

direct flame, steam, oil, gray to charred and
grease, chemical, high- black; dry and inelastic;
voltage electricity does not blanch with
pressure
PROTOCOL 3.5: CHEST TRAUMA
NOTE: Chest trauma is not able to be definitively treated in the field and
prolonged treatment prior to transport is not indicated if significant
injury is suspected. If patient is critical, transport rapidly and avoid
treatment of non-emergent problems at the scene.
The depth and severity of penetrating chest trauma is impossible to

determine in the field, and all penetrating chest trauma patients
should receive rapid transport with Trauma Alert notification
regardless of how stable they may seem.
Chest injuries sufficient to cause respiratory distress are frequently

associated with significant internal blood loss. Look for hypovolemia.
Significant intrathoracic injuries can exist without any external signs

of injury. Note mechanism of injury carefully and maintain a high
index of suspicion.
ADULT CARE
I.2. Assess chest and back (including axillary region and base of neck) for
wounds, bruising, paradoxical chest wall movement, rib cage/ sternal
instability or crepitus, and areas of tenderness. Note if neck veins flat or
distended.
I.3. Auscultate lung sounds as soon as possible and re-assess frequently.
I.4. Consider Trauma Alert if patient meets criteria, see 5.28: Trauma Alert
Protocol. Make notification early and transport rapidly if patient meets
criteria.
I.6. If patient deteriorating rapidly, intubate early!
I.7. If significant trauma, IV NS using two large bore lines and at least one
blood tubing set. Remember, Trauma fluid administration in the field
should be geared toward raising the patients systolic BP to no more than
90 – 100 mm/Hg. Any more could potentially worsen internal bleeding.
PROTOCOL 3.5: CHEST TRAUMA (cont.)
ADULT CARE (cont.)
I.8. Stabilize any flail chest segments.
I.9. Cover any open chest wound (“sucking chest wound”) with Vaseline
gauze taped on three sides to vent air out. If sealed completely, may
convert injury to tension pneumothorax.
I.10. Do not attempt to remove any impaled objects; stabilize these in place
with bulky dressings and tape or by any means necessary.
II.1. Needle decompression if suspected tension pneumothorax, see 5.27

Tension Pneumothorax Decompression Protocol. Remember,
needle decompression in the field is only for the patient with a suspected
tension pneumothorax, not a simple pneumothorax. The distinction
must be made between the two. If covered sucking chest wound is
present, remove the seal and allow chest pressures to equilibrate, no
further treatment may be necessary.
PEDIATRIC CARE
I.2. Assess chest and back (including axillary region and base of neck) for
wounds, bruising, paradoxical chest wall movement, rib cage/ sternal
instability or crepitus, and areas of tenderness. Note if neck veins flat or
distended.
I.3. Auscultate lung sounds as soon as possible and re-assess frequently.
criteria.
I.6. If patient deteriorating rapidly, intubate early!
I.7. If significant trauma, IV NS, consider 20 ml/kg fluid bolus if patient

hypotensive. Contact Medical Control for further fluids.
PROTOCOL 3.5: CHEST TRAUMA (cont.)
I.8. Stabilize any flail chest segments.
I.9. Cover any open chest wound (“sucking chest wound”) with Vaseline
gauze taped on three sides to vent air out. If sealed completely, may
convert injury to tension pneumothorax.
I.10. Do not attempt to remove any impaled objects; stabilize these in place
with bulky dressings and tape or by any means necessary.
II.1. Needle decompression if suspected tension pneumothorax, see 5.27

Tension Pneumothorax Decompression Protocol. Remember,
needle decompression in the field is only for the patient with a suspected
tension pneumothorax, not a simple pneumothorax. The distinction
must be made between the two. If covered sucking chest wound is
present, remove the seal and allow chest pressures to equilibrate, no
further treatment may be necessary.
II.2. Contact Medical Control if the need is seen for fluids above the initial 20
ml/kg. fluid bolus for the hypotensive pediatric patient.
PROTOCOL 3.6: EXTREMITY INJURIES
ADULT CARE
I.1. Trauma and hypovolemic supportive care. Avoid IV on injured extremity.
I.2. Assess distal pulses and sensation prior to immobilization of injured

extremity.
I.3. Apply sterile dressing to open fractures. Note carefully wounds that
appear to communicate with bone, and initial position of bone in wound.
I.4. Splint areas of tenderness or deformity; immobilize the joint above and
below the injury in the splint.
I.5. Grossly angulated fractures may be re-aligned by applying gentle axial

traction and returning to anatomical position if indicated:
a) To restore distal circulation
b) To immobilize adequately (i.e., realign femur fracture)
Make one attempt, if resistance is met or extreme increased pain is

caused, stabilize the limb in the position of most comfort with the best
circulation.
I.6. Assess distal pulses and sensation after splinting.
I.7. Elevate simple extremity injuries. Apply padded cold pack (do not place
directly on skin) if time and extent of injuries allow.
I.8. Monitor circulation (pulse and skin temperature), sensation, and motor
function distal to site of injury during transport.
I.9. Consider pain management, see 5.20: Pain Management Protocol.
II.1. None.
PEDIATRIC CARE
I.1. Trauma and hypovolemic supportive care. Avoid IV on injured extremity.
I.2. Assess distal pulses and sensation prior to immobilization of injured

extremity.
PROTOCOL 3.6: EXTREMITY INJURIES (cont.)
I.3. Apply sterile dressing to open fractures. Note carefully wounds that
appear to communicate with bone, and initial position of bone in wound.
I.4. Splint areas of tenderness or deformity; immobilize the joint above and
below the injury in the splint.
I.5. Grossly angulated fractures may be re-aligned by applying gentle axial

traction and returning to anatomical position if indicated:
a) To restore distal circulation
b) To immobilize adequately (i.e., realign femur fracture)
Make one attempt, if resistance is met or extreme increased pain is

caused, stabilize the limb in the position of most comfort with the best
circulation.
I.6. Assess distal pulses and sensation after splinting.
I.7. Elevate simple extremity injuries. Apply padded cold pack (do not place
directly on skin) if time and extent of injuries allow.
I.8. Monitor circulation (pulse and skin temperature), sensation, and motor
function distal to site of injury during transport.
II.1. Contact Medical Control for pain management.
PROTOCOL 3.7: EYE INJURIES
ADULT CARE
I.1. Trauma and Hypovolemic Supportive Care. Be alert for associated head
and cervical spine injury.
I.2. If chemicals in eyes, irrigate eyes with copious normal saline or clean
water (if only one eye is affected, flush with affected eye down so
chemical is not flushed into unaffected eye). Do not irrigate if globe
disruption is suspected. Do not attempt to remove foreign bodies by
other means.
I.3. If suspected or obvious laceration or disruption of the globe is present,

do not place any pressure on the globe or orbit. Place dressings over
both eyes, but only if they do not contact any impaled foreign bodies or
put pressure on eyes.
I.4. If hyphema is present, do not put pressure on the orbit or globe.

Transport patient in sitting position or with head elevated unless c-spine
immobilization is required (block up head end of backboard). Place
dressings over both eyes, but only if they do not contact any impaled
foreign bodies or put pressure on eyes.
I.5. Don’t be concerned with contact lens removal in the field.
II.1. None.
PEDIATRIC CARE
I.1. Trauma and Hypovolemic Supportive Care. Be alert for associated head
and cervical spine injury.
I.2. If chemicals in eyes, irrigate eyes with copious normal saline or clean
water (if only one eye is affected, flush with affected eye down so
chemical is not flushed into unaffected eye). Do not irrigate if globe
disruption is suspected. Do not attempt to remove foreign bodies by
other means.
I.3. If suspected or obvious laceration or disruption of the globe is present,

do not place any pressure on the globe or orbit. Place dressings over
both eyes, but only if they do not contact any impaled foreign bodies or
put pressure on eyes.
PROTOCOL 3.7: EYE INJURIES
I.4. If hyphema is present, do not put pressure on the orbit or globe.

Transport patient in sitting position or with head elevated unless c-spine
immobilization is required (block up head end of backboard). Place
dressings over both eyes, but only if they do not contact any impaled
foreign bodies or put pressure on eyes.
I.5. Don’t be concerned with contact lens removal in the field.
II.1. None.
PROTOCOL 3.8: HEAD TRAUMA
NOTE: When head injury patients deteriorate, check first for airway,
oxygenation and blood pressure problems in that order! If the
patient is tachycardic or hypotensive, evaluate for hypovolemia from
other injuries.
The most important information you can provide for the base
physician is the level of consciousness and its changes. Is the
patient stable, deteriorating or improving?
Restlessness can be a sign of hypoxia. Cerebral anoxia is the most

frequent cause of death in head injury. Control airway and ventilate,
hypoventilation aggravates cerebral edema.
ADULT CARE
I.2. Cervical spine immobilization. The patient with significant head trauma
will always need to be immobilized. Secure patient to LBB in a manner
that will allow it to be safely turned to the side if patient vomits.
I.3. High flow O2 via NRB mask. If unconscious, control airway and ventilate
at 24 breaths/min. Use BLS methods initially to control airway: NP/OP
airways, suction, BVM, etc. Many times a patients airway can initially be
adequately managed this way before having to intubate.
I.4. If patient deteriorating rapidly, intubate early! If time allows, administer

Lidocaine 1-1.5 mg/kg IV I minute prior to intubation.
I.5. Consider nasotracheal intubation if patients mid-face is intact, (see 5.8:

Advanced Airway Management: Nasotracheal Intubation Protocol).
criteria.
I.7. Large-bore IV’s NS X 2, run fluids at TKO rate unless hypotensive.
I.8. Control scalp hemorrhage with direct pressure, this can be difficult
hemorrhage to control, continued pressure may be needed. If underlying
skull is instable, pressure should be applied to the periphery of the
laceration over intact bone.
PROTOCOL 3.8: HEAD TRAUMA (cont.)
ADULT CARE (cont.)
I.9. Constantly reassess level of consciousness and any changes, use

Glasgow Coma Scale, see Assessment-Neurologic, Table 1.B.
II.1. Consider Rapid Sequence Induction for intubation, see 5.9: Advanced
Airway Management: Rapid Sequence Induction Protocol.
II.2. Contact Medical Control for sedation of the combative patient that is
already intubated.
PEDIATRIC CARE
I.2. Cervical spine immobilization. The patient with significant head trauma
will always need to be immobilized. Secure patient to LBB in a manner
that will allow it to be safely turned to the side if patient vomits.
I.3. High flow O2 via NRB mask. If unconscious, control airway and ventilate
at 24 breaths/min. Use BLS methods initially to control airway: NP/OP
airways, suction, BVM, etc. Many times a patients airway can initially be
adequately managed this way before having to intubate.
I.4. If patient deteriorating rapidly, intubate early! If time allows, administer

Lidocaine 1-1.5 mg/kg IV I minute prior to intubation.
I.5. If patient ≥ 8 years of age, consider nasotracheal intubation if patients

mid-face is intact, (see 5.8: Advanced Airway Management:
Nasotracheal Intubation Protocol).
criteria.
I.7. IV NS, consider 20 ml/kg fluid bolus if patient hypotensive. Contact

Medical Control for further fluids.
I.8. Control scalp hemorrhage with direct pressure, this can be difficult
hemorrhage to control, continued pressure may be needed. If underlying
skull is instable, pressure should be applied to the periphery of the
laceration over intact bone.
PROTOCOL 3.8: HEAD TRAUMA (cont.)
I.9. Constantly reassess level of consciousness and any changes, use

Glasgow Coma Scale, see Assessment-Neurologic, Table 1.B-C.
II.1. Consider Rapid Sequence Induction for intubation, see 5.9: Advanced
Airway Management: Rapid Sequence Induction Protocol.
II.2. Contact Medical Control for sedation of the combative patient that is
already intubated.
II.3. Contact Medical Control if the need is seen for fluids above the initial 20
ml/kg. fluid bolus for the hypotensive pediatric patient.
PROTOCOL 3.9: SPINAL TRAUMA
NOTE: In the spine injured patient that has hypotension that is unresponsive
to simple measures, it is likely due to other injuries. Neurologic
deficits make these other injuries hard to evaluate. Cord injury
above the level of T-8 removes tenderness, rigidity and guarding as
clues to abdominal injury.
Full spinal immobilization should be accomplished in all patients that

have penetrating trauma to the neck or torso irregardless of the lack
of complaints of pain or presence of neurologic deficits.
ADULT CARE
I.2. Cervical spine immobilization.
a) Secure patient to LBB in a manner that will allow it to be safely

turned to the side if patient vomits.
b) Check patients back before logrolling onto LBB.
c) Assess neurologic function before and after moving to LBB.
I.4. Large-bore IV NS, fluid bolus only if hypotensive.
I.5. Reassess neurologic function frequently during transport with special

attention to evidence of neurologic function below level of injury and any
limbs which may not have sensation.
II.1 None.
PEDIATRIC CARE
I.2. Cervical spine immobilization.
a) Secure patient to LBB in a manner that will allow it to be safely

turned to the side if patient vomits.
b) Check patients back before logrolling onto LBB.
PROTOCOL 3.9: SPINAL TRAUMA (cont.)
c) Assess neurologic function before and after moving to LBB
d) Use appropriate pediatric immobilization device.
I.4. IV NS, consider 20 ml/kg fluid bolus if patient hypotensive. Contact

Medical Control for further fluids.
I.5. Reassess neurologic function frequently during transport with special

attention to evidence of neurologic function below level of injury and any
limbs which may not have sensation.
II.1 None.
PROTOCOL 3.10: TRAUMA CARDIAC ARREST
NOTE: Victims of blunt trauma cardiac arrest without vital signs (pulse,
respirations) at the scene have a mortality rate of essentially 100%.
Trauma cardiac arrests secondary to penetrating injuries can be

successfully resuscitated. There is a higher rate of survival in
patients with low velocity penetrating injuries (knife, etc.) versus
patients with high velocity injuries (gunshot. etc.).
Carefully assess and compare the patients pulseless, apneic state

with the mechanism of injury present. Consider if there may have
been a medical cause for the cardiac arrest or the patient may just
have had an occluded airway secondary to being knocked
unconscious during an MVA, etc. If there is any doubt as to whether
the cardiac arrest was caused by the trauma, a resuscitation should
be begun in the absence of signs of irreversible death (decapitation,
significant dependent lividity, rigor mortis, etc.).
A. Blunt Trauma Arrest
1. Assess patient for spontaneous respirations and or pulse.
2. Assess mechanism carefully.
3. Assess for signs of massive external blood loss and or, massive blunt
head, torso or abdominal trauma.
4. If patient has no spontaneous respirations and no pulse and

mechanism of injury or other signs at the scene indicate that arrest
was caused by the blunt trauma, consider field determination of
death. See 6.5: Field Determination of Death Protocol.
5. If a resuscitation is started on a blunt trauma patient that still has vital

signs and a cardiac arrest occurs, continue resuscitation and contact
Medical Control to determine the viability of continuing the
resuscitation to the hospital.
B. Penetrating Trauma Arrest
1. Initiate BLS and immobilize C-spine.
PROTOCOL 3.10: TRAUMA CARDIAC ARREST (cont.)
Penetrating Trauma Arrest (cont.)
2. Intubate and rapid transport (Code 3, HOT)
3. Large bore IV NS X2 using at least one blood tubing set, fluid bolus
20 ml/kg.
4. If cardiac activity returns with above treatment, treat any arrhythmias

per pertinent protocol.
5. Consider field determination of death if signs of irreversible death are

present (decapitation, significant dependent lividity, rigor mortis, etc.).
See 6.5: Field Determination of Death Protocol.
Pre-hospital Advanced Life Support Protocols Treatment Protocols – Environmental Injury
PROTOCOL 4.1: BITES AND STINGS
NOTE: For all types of bites and stings, the goal of pre-hospital care is to
prevent further inoculation and to treat any possible allergic reaction.
Time since envenomation is important, as anaphylaxis rarely occurs

more than 60 minutes after inoculation. Roughly 60% of patients
who have experienced a generalized reaction to a bite or sting in the
past will have a similar or more severe reaction upon reinoculation.
It is possible to have a severe reaction with a “first” inoculation.
If possible and the offending insect, snake, etc. is dead and or

contained, try to have it transported to the hospital for positive
identification. Be careful: a dead snake may reflexively bite and
envenomate.
All human bites, dog or cat bites, and snake bites, should be further
evaluated at a medical facility for proper cleansing and potential
antibiotic therapy.
ADULT CARE
I.2. Any suspected poisonous bite should receive a large-bore IV of NS.
I.3. If allergic reaction suspected, see 2.12: Allergic Reaction/Anaphylaxis

Protocol.
I.4. Immobilize affected area, keep patient quiet to reduce venom absorption
Do not use ice.
I.5. Remove rings, bracelets, constrictive clothing, etc. immediately from

bitten extremities, swelling may make them difficult to remove later.
I.6. If bee or wasp sting, and stinger mechanism is visible, try to remove
without breaking venom sac by scraping out with a straight edge.
II.1. None.
PROTOCOL 4.1: BITES AND STINGS (cont.)
PEDIATRIC CARE
I.2. Any suspected poisonous bite should receive a large-bore IV of NS.
I.3. If allergic reaction suspected, see 2.12: Allergic Reaction/Anaphylaxis

Protocol.
I.4. Immobilize affected area, keep patient quiet to reduce venom absorption
Do not use ice.
I.5. Remove rings, bracelets, constrictive clothing, etc. immediately from

bitten extremities, swelling may make them difficult to remove later.
I.6. If bee or wasp sting, and stinger mechanism is visible, try to remove
without breaking venom sac by scraping out with a straight edge
II.1. None.
PROTOCOL 4.2: DROWNING / NEAR DROWNING
NOTE: All near drowning patients or submersions should be transported.

Even if patient initially appears fine, they can deteriorate rapidly.
Monitor closely, pulmonary edema frequently occurs due to
aspiration, hypoxia and other factors. It may not be evident until
several hours after a near drowning episode.
Beware of cervical spine injuries – they often go unrecognized in the

drowning/near drowning patient. C-spine immobilization can be
accomplished while the patient is still in the water.
If the patient is hypothermic, defibrillation and pharmacologic therapy

may be unsuccessful until the patient is re-warmed. Prolonged CPR
may be needed, see 4.4: Hypothermia and Frostbite Protocol.
.
ADULT CARE
I.1. General Supportive Care - strongly consider need for cervical

immobilization.
I.2. Assess the need for trauma supportive care that may be interrelated.
Large-bore IV NS, TKO.
I.3. Administer O2 on all patients. Suction if needed and support airway as

indicated. In the patient that needs to be intubated, try to refrain from
bagging the patient before intubating, it may precipitate significant
vomiting. Go immediately to intubation when needed.
I.5. Monitor cardiac rhythm during transport; treat any arrhythmia per
pertinent protocol.
I.6. With the submerged patient, assess rescue vs. body recovery. Contact
Medical Control for guidance in determining rescue vs. recovery. The
following parameters will need to be considered:
a) How long was patient submerged? Generally speaking, a rescue will

turn into a body recovery after the patient has been submerged for
1½ - 2 hours (remember, submersion times can be approximate, try
to obtain as accurate information as possible.
PROTOCOL 4.2: DROWNING / NEAR DROWNING (cont.)
ADULT CARE (cont.)
b) Temperature of water. Medical literature supports the possibility of

survival with little or no neurological sequelae after being submerged
as long as an hour or more in cold water (≤ 68º F). In the Black Hills,
even in the summer, many natural bodies of water will still qualify as
“cold water”. If patient submerged in cold water, see 4.4:
Hypothermia and Frostbite Protocol.
c) Degree of contamination of water.
II.1. None.
PEDIATRIC CARE
I.1. General Supportive Care - strongly consider need for cervical

immobilization.
I.2. Assess the need for trauma supportive care that may be interrelated. IV
NS, TKO.
I.3. Administer O2 on all patients. Suction if needed and support airway as

indicated. In the patient that needs to be intubated, try to refrain from
bagging the patient before intubating, it may precipitate significant
vomiting. Go immediately to intubation when needed.
I.4. Monitor cardiac rhythm during transport; treat any arrhythmia per
pertinent protocol.
I.5. With the submerged patient, assess rescue vs. body recovery. Contact
Medical Control for guidance in determining rescue vs. recovery. The
following parameters will need to be considered:
a) How long was patient submerged? Generally speaking, a rescue will

turn into a body recovery after the patient has been submerged for
1½ - 2 hours (remember, submersion times can be approximate, try
to obtain as accurate information as possible.
PROTOCOL 4.2: DROWNING / NEAR DROWNING (cont.)
b) Temperature of water. Medical literature supports the possibility of

survival with little or no neurological sequelae after being submerged
as long as an hour or more in cold water (≤ 68º F). In the Black Hills,
even in the summer, most natural bodies of water will still qualify as
“cold water”. If patient submerged in cold water, see 4.4:
Hypothermia and Frostbite Protocol.
c) Degree of contamination of water.
II.1. None.
PROTOCOL 4.3: HYPERTHERMIA
NOTE: Heat stroke is a life-threatening medical emergency, It is

distinguished by an altered level of consciousness. Sweating may
still be present, especially in exercise-induced heat stroke. The
other persons at risk for heat stroke are the elderly and persons on
medications which impair the body’s ability to regulate heat.
Differentiate heat stroke from heat exhaustion (hypovolemia of more

gradual onset) and heat cramps (abdominal or leg cramps). Be
aware that heat exhaustion can lead to heat stroke.
Do not let cooling in the field delay transport. Cool patient as is

possible enroute. Do not use ice water or very cold water to cool
patients, these may induce vasoconstriction. Use only slightly cool
or even tepid water.
ADULT CARE
I.2. Remove from hot environment immediately, remove excess clothing.
I.3. If patient alert and heat cramps or mild heat exhaustion, give small
amounts cool liquids PO as tolerated (be alert for potential vomiting).
I.4. Cool with water or saline, including head. Direct the patient
compartment fan over the patient to promote evaporation. Note: do not
put water on a patient without air from some source blowing over them,
you may make the problem worse. If patient with heat stroke or severe
heat exhaustion, continue cooling measures enroute to medical facility.
I.5. For heat stroke/exhaustion, large-bore IV NS, TKO if vital signs within
normal parameters. If hypotensive, fluid bolus 250-500 ml. Assess
need for further fluids.
I.6. Monitor cardiac rhythm.
I.7. Assess temperature if possible (may be 104º F or greater).
I.8. Treat any seizure activity per 2.24: Seizures and Status Epilepticus
Protocol.
II.1. None.
PROTOCOL 4.3: HYPERTHERMIA (cont.)
PEDIATRIC CARE
I.2. Remove from hot environment immediately, remove excess clothing.
I.3. If patient alert and heat cramps or mild heat exhaustion, give small
amounts cool liquids PO as tolerated (be alert for potential vomiting).
I.4. Cool with water or saline, including head. Direct the patient
compartment fan over the patient to promote evaporation. Note: do not
put water on a patient without air from some source blowing over them,
you may make the problem worse. If patient with heat stroke or severe
heat exhaustion, continue cooling measures enroute to medical facility.
I.5. For heat stroke/exhaustion, IV NS, TKO if vital signs within normal
parameters. If hypotensive for age, fluid bolus 20 ml/kg. Assess need
for further fluids.
I.6. Monitor cardiac rhythm.
I.7. Assess temperature if possible (may be 104º F or greater).
I.8. Treat any seizure activity per 2.24: Seizures and Status Epilepticus
Protocol.
II.1. None.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE
NOTE: Generalized Hypothermia:
The profoundly hypothermic patient may need prolonged

palpation/observation to detect any pulse, respiratory effort or
organized cardiac rhythm. Hypothermic patients (cold air or
water) should not be determined “dead” until re-warmed or
determined dead by other criteria.
Bradycardia is normal and should not be treated. Even very slow

rates may be sufficient for metabolic demands. CPR is only
indicated for asystole and ventricular fibrillation, if patient has any
organized cardiac rhythm, CPR is currently felt to be unnecessary.
When CPR is done, it should be done gently.
Excessive movement of the patient and intubation attempts have

been known to precipitate ventricular fibrillation, therefore, patients
with any organized cardiac rhythm should not be intubated if airway
can be supported by alternative measures. The profoundly
hypothermic patients metabolic demand for O2 will be diminished
anyway.
The heart is most likely to fibrillate below 85-88º F. Defibrillation

should be attempted one time, but prolonged CPR may be
necessary until core temperature is above this level. ALS drugs
should be used sparingly, one round can be attempted, but
peripheral vasoconstriction may prevent entry into central circulation
until temperature is restored. At that time, a large bolus of unwanted
drugs may be circulated into the heart.
Shivering typically does not occur below 90º F. Below this, patient
may not even feel cold, and occasionally will even undress and
appear vasodilated.
Re-warming should be accomplished with careful monitoring in a

hospital setting, field re-warming is not indicated. The goal should
be to prevent further heat loss and maintain warm environment.
Local (frostbite):
Thawing is extremely painful and should be done under controlled

conditions in the hospital. Careful monitoring, pain medications,
prolonged re-warming and sterile handling are required.
PROTOCOL 4.4: HYPOTHERMIA AND FROSTBITE (cont.)
Local (frostbite) (cont.):
Do not re-warm prematurely, this includes warm water soaking and

applying heat packs in the field. It is clear that partial re-warming or
re-warming followed by re-freezing is far more injurious to tissue than
any delay in re-warming. Indications for field re-warming are almost
non-existent.
ADULT CARE
Generalized Hypothermia:
I.1. General Supportive Care, handle patient gently.
I.2. Prolonged gentle CPR may be required. No CPR if any organized

electrical cardiac activity is present. Attempt defibrillation once if
ventricular fibrillation present. One round of ALS drugs may be
attempted if indicated.
I.3. Avoid unnecessary suctioning or airway manipulation. Indications for

intubation are the patient in asystole and ventricular fibrillation. If the
patient has an organized cardiac rhythm, manage airway and oxygenate
by alternative means if possible.
I.4. Remove all clothing (especially if wet or constrictive) from patient. Wrap
in blankets and protect from wind exposure. Increase ambient air
temperature in ambulance. The goal is not field re-warming, it is to
prevent further heat loss and maintain warm environment.
I.5. Large-bore IV with warmed NS, TKO. Do not start IV until patient is
moved to transport vehicle.
I.6. Consider reason patient in cold environment and also alternative reasons
for altered mental status (ETOH, medical cause – stroke, hypoglycemia,
drug overdose, etc.). Treat as indicated.
I.7. Assess core temperature if possible.
II.1. None.
Local (frostbite):
I.1. Remove wet or constricting clothing. Keep skin dry and protected from
wind.
I.2. Do not attempt to re-warm the affected areas, prevent further heat loss
and maintain warm environment. Avoid thaw and re-freeze at all costs.
I.3. Dress affected areas lightly in clean dressings to protect from pressure,
trauma or friction. Do not rub, do not break blisters.
I.4. Maintain core temperature by keeping patient warm with blankets, warm
IV fluids, etc.
I.5. Transport with frostbitten areas supported and elevated, if feasible.
II.1. None.
PEDIATRIC CARE
Generalized Hypothermia:
I.1. General Supportive Care, handle patient gently.
I.2. Prolonged gentle CPR may be required. No CPR if any organized

electrical cardiac activity present. Attempt defibrillation once if
ventricular fibrillation present. One round of ALS drugs may be
attempted if indicated.
I.3. Avoid unnecessary suctioning or airway manipulation. Indications for

intubation are the patient in asystole and ventricular fibrillation. If the
patient has an organized cardiac rhythm, manage airway and oxygenate
by alternative means if possible.
I.4. Remove all clothing (especially if wet or constrictive) from patient. Wrap
in blankets and protect from wind exposure. Increase ambient air
temperature in ambulance. The goal is not field re-warming, it is to
prevent further heat loss and maintain warm environment.
I.5. IV with warmed NS, TKO. Do not start IV until patient is moved to
transport vehicle.
Generalized Hypothermia (cont.):
I.6. Consider reason patient in cold environment and also alternative reasons
for altered mental status (ETOH, medical cause - hypoglycemia, drug
overdose, etc.). Treat as indicated.
I.7. Assess core temperature if possible.
II.1. None.
Local (frostbite):
I.1. Remove wet or constricting clothing. Keep skin dry and protected from
wind.
I.2. Do not attempt to re-warm the affected areas, prevent further heat loss
and maintain warm environment. Avoid thaw and re-freeze at all costs.
I.3. Dress affected areas lightly in clean dressings to protect from pressure,
trauma or friction. Do not rub, do not break blisters.
I.4. Maintain core temperature by keeping patient warm with blankets, warm
IV fluids, etc.
I.5. Transport with frostbitten areas supported and elevated, if feasible.
II.1. None.
Pre-hospital Advanced Life Support Protocols Procedure Protocols
PROTOCOL 5.1: Airway Management - General Principles
The following principles should be remembered in the “heat of battle” to allow

optimum care of the airway without unnecessary intervention.
1. Use the simplest method of airway management appropriate to the

patient. BLS procedures should generally be used first, progressing to
more invasive ALS procedures. BLS procedures by themselves may be
all that are needed to efficiently manage the patients airway.
2. Use a method with which you, as a responder, are comfortable.
3. Use meticulous suctioning to keep the airway clear of debris always

being aware of oxygenation.
4. Monitor continuously to be sure that your treatment is still effective.
5. The following must always be considered:
A. Patency: how open and clear is the airway, free of foreign

substances, blood, vomitus, and tongue.
B. Ventilation: the amount of air the patient is able to inhale and

exhale in a given time.
C. Oxygenation: the amount of oxygen the patient is carrying to their

tissues.
6. Gloves, mask and eye protection should be used for all airway
procedures.
The following protocols are recommended as a guide for approaching both

simple and difficult medical and trauma airway problems. They assume that the
responder is proficient in the various procedures, and will need to be modified
according to training level. Advanced procedures should only be attempted if
simpler ones fail and if the technician is qualified. Individual cases may require
modification of these protocols.
Medical Respiratory Arrest:
1. Open airway using head tilt-chin lift or head tilt-neck lift.
2. Use BVM with supplemental oxygen to ventilate.
PROTOCOL 5.1: Airway Management-General Principles (cont.)
Medical Respiratory Arrest: (cont.)
3. Insert nasopharyngeal airway or oropharyngeal airway if patency difficult to

maintain.
4. Suction as needed.
5. Perform orotracheal intubation after initial airway management if respiratory

arrest continues.
Medical Respiratory Insufficiency:
1. Open the airway using most efficient method.
2. Insert nasopharyngeal airway if patient will tolerate.
3. Suction as needed, being aware of oxygenation.
4. Apply supplemental oxygen by mask as needed.
5. Assist ventilations with BVM if needed.
6. Perform nasotracheal or orotracheal intubation if prolonged support is

needed, or if airway requires continued protection from aspiration.
Traumatic Respiratory Arrest
1. Open airway using jaw thrust maneuver, protecting neck.
2. Clear the airway, suction as needed.
3. Have assistant perform manual in-line stabilization to head and neck.
4. Use hand to draw tongue and mandible forward if needed in patients with
facial injuries.
5. Use BVM for initial control of ventilation.
6. Perform orotracheal intubation with in-line stabilization. Cricoid pressure

may make intubation easier. (Sellick maneuver)
PROTOCOL 5.1: Airway Management-General Principles (cont.)
Traumatic Respiratory Arrest (cont.)
7. If intubation cannot be performed due to severe facial injury, and patient

cannot be ventilated with BVM and adjuncts, consider surgical or needle
cricothyrotomy only after contact with Medical Control.
Traumatic Respiratory Insufficiency:
1. Open airway using jaw thrust maneuver, protecting neck.
2. Clear the airway, suction as needed.
3. Have assistant apply continued manual in-line stabilization to head and neck.
4. Use hand to draw tongue and mandible forward (if needed) with facial
injuries.
5. Insert nasopharyngeal airway.
6. Administer high flow 02 and assist ventilations with BVM if necessary.
7. If midface intact, attempt nasotracheal intubation to secure airway if needed.
8. If patient deteriorates, and cannot be supported by less invasive means:
a. Attempt orotracheal intubation with in-line stabilization, or
b. Consider surgical cricothyrotomy only after contact with Medical Control.
PROTOCOL 5.2: Airway Management: Assisting Ventilation
Indications:
A. Inadequate patient ventilation due to fatigue, coma, or other causes of

respiratory depression.
B. To apply positive pressure ventilation in patients with pulmonary edema and

severe fatigue.
C. To ventilate patients in respiratory arrest.
D. For use in conjunction with ETT or Combitube to ventilate.
E. To break laryngospasm.
Technique:
A. Open the airway.
B. Check for ventilation.
C. If patient is not breathing, perform 2 quick breaths, and check pulse. Begin
CPR as needed.
D. If pulse is present but patient is not breathing, ventilate with adjuncts (OPA,
NPA) and BVM.
E. Assure high-flow oxygen is connected to BVM.
F. Position yourself above patient’s head, continue to hold airway position, seat
mask firmly on face, and begin assisted ventilation.
G. Watch chest for rise, and feel for air leak or resistance to air passage. Adjust
mask fit as needed.
H. If patient resumes spontaneous respirations, switch to high-flow oxygen via

NRB mask. Intermittent assistance with BVM may still be needed.
Complications:
A. Inadequate ventilations due to poor seal between patient’s mouth and

ventilatory device.
PROTOCOL 5.2: Airway Management: Assisting Ventilation (cont.)
B. Gastric distention, possibly causing vomiting, may require placement of a

nasogastric or orogastric tube.
C. Pneumothorax in children.
Special Notes:
A. Assisted ventilation will not hurt a patient, and should be used whenever the
breathing pattern seems shallow, slow, or otherwise abnormal. Do not be
afraid to be aggressive about assisting ventilations, even in patients who do
not require or will not tolerate intubation.
PROTOCOL 5.3: Airway Management: Clearing and Suctioning the Airway
Indications:
A. Trauma to the upper airway, with blood, teeth, or other material causing
partial obstruction.
B. Vomitus, food or other foreign material in airway.
C. Excess secretions or pulmonary edema fluid in upper airway or lungs (with

endotracheal tube in place).
D. Meconium or amniotic fluid in mouth, nose and oropharynx of newborn.
Precautions:
A. Suctioning, particularly through endotracheal tubes, always risks suctioning

away the available oxygen as well as the fluid from the airway. Limit the
suction time to a few seconds while the catheter is being withdrawn.
B. The above precaution should NOT be followed when significant vomitus or

other material continues to well up and completely obstruct the airway. In
that instance, suctioning must be continued until an airway is re-established.
C. Use equipment large enough for the job at hand. Large amounts of
particulate matter require large-bore suction tips using connecting tubing.
D. The catheter and tubing will require frequent rinsing with water or saline
solution to permit continued suction. Have a bottle of water or saline at hand
before you begin. Use gauze to remove large material from the end of the
catheter.
E. Do not insert a suction catheter with the suction functioning. Suction only
on withdrawal of the catheter.
Technique:
A. Open airway and inspect for visible foreign material.
B. Turn patient on side, if spinal trauma is not a concern, to facilitate clearance.
C. Remove large or obvious foreign matter with gloved hands. Sweep finger
ACROSS posterior pharynx and clear material out of mouth.

(cont.)
Technique (cont.):
E. Suction of oropharynx:
1. Attach tonsil tip (or use open end of tubing for large amounts of debris).
2. Ventilate and oxygenate the patient prior to the procedure as needed.
3. Insert tip into oropharynx under direct vision, with sweeping motion.
4. Continue intermittent suction interspersed with active oxygenation by

mask or positive pressure ventilation with BVM if needed.
5. If suction becomes clogged, dilute by suctioning sterile water or saline

solution to clean tubing. If suction clogs repeatedly, use connecting
tubing alone, or manually remove large debris.
F. Catheter suction of endotracheal tube:
1. Attach appropriate size suction catheter to tubing of suction device

(leaving suction end in sterile container).
2. Hyperventilate patient 4-5 times rapidly.
3. Detach bag from endotracheal tube and insert sterile tip of suction
catheter without suction.
4. When catheter tip has been gently advanced as far as possible, apply
suction in a circular motion and withdraw catheter slowly.
5. Rinse catheter tip in sterile water or saline solution.
6. Hyperventilate patient before each suction attempt.
Complications:
A. Hypoxia due to excessive suctioning time without adequate ventilation

between attempts.
B. Persistent obstruction due to inadequate tubing size for removal of debris.

(cont.)
Complications (cont.):
C. Lung injury from aspiration of stomach contents due to inadequate

suctioning.
D. Asphyxia due to recurrent obstruction if airway is not monitored after initial

suctioning.
E. Trauma to the posterior pharynx from forced use of equipment.
F. Vomiting and aspiration from stimulation of gag reflex.
G. Induction of cardiac arrest from vagal simulation.
Special Notes:
A. Bulb suction should be used on the newborn. Consider intubation and/or use
of a meconium suction device if meconium is present and a depressed
newborn is delivered.
B. Patients with pulmonary edema may have endless frothy secretions. Be sure
to also oxygenate and assist ventilations even though you might be tempted
to suction continuously.
C. You will note that complications may be caused both by inadequate and
overly vigorous suctioning. Technique and choice of equipment are very
important. Choose equipment with enough power to suction large amounts
rapidly to allow time for ventilation.
D. Proper airway clearance can make the difference between a patient who
survives and one who dies. Airway obstruction is one of the most common
treatable cause of pre-hospital death.
PROTOCOL 5.4: Airway Management: Obstructed Airway
Indications:
A. Complete or partial obstruction of the airway due to a foreign body.
B. Complete or partial obstruction due to airway swelling from anaphylaxis,

croup or epiglottis.
C. Patient with unknown injury or illness who cannot be ventilated after airway
opening procedures.
Precautions:
A. Perform chest thrusts only in visibly pregnant patients, obese patients and in
infants.
B. Patients with a partial airway obstruction can be extremely uncomfortable

and hard to manage. Abdominal or chest thrusts will not be effective and
may injure the patient who is still ventilating on their own. Resist the
temptation to attempt relief of obstruction if it is not complete, but be ready to
intervene promptly if full obstruction occurs.
C. Hypoxia from airway obstruction can cause seizures. Chest or abdominal

thrusts may not be effective until the patient relaxes when the seizure
terminates.
Technique:
Complete Airway Obstruction:
A. Open airway using head tilt-chin lift or jaw thrust.
B. Attempt to ventilate using BVM.
C. If unable to ventilate, reposition the airway and reattempt ventilations.
D. If airway remains obstructed, visualize with laryngoscope and remove any

obvious foreign body with Magill forceps.
E. Reposition the airway and attempt to ventilate.
F. If unable to ventilate, administer 5 subdiaphragmatic thrusts.
G. Reposition the airway and reattempt to ventilate.
PROTOCOL 5.4: Airway Management: Obstructed Airway (cont.)
Technique:
Complete Airway Obstruction (cont.):
H. Consider surgical or needle cricothyrotomy if obstruction above the cords is

unrelieved or unable to ventilate adequately with BVM. (Remember; surgical
cricothyrotomy is a difficult and hazardous technique that is to be used only
in extraordinary circumstances and after contact with Medical Control).
I. When obstruction relieved:
1. Transport patient on side if necessary, keeping airway clear of debris

and oral secretions.
2. Apply high-flow oxygen via NRB mask.
3. Constantly reassess adequacy of ventilations and support as needed.
4. Suction aggressively as needed, being aware of oxygenation.
5. Restrain if combative.
Partial Airway Obstruction:
A. Have patient assume most comfortable position.
B. Apply high-flow oxygen via NRB mask.
C. Suction upper airway if needed.
D. If patient unable to move air, confused or otherwise deteriorating, visualize

airway and remove foreign body or perform abdominal thrusts as noted
above.
Complications:
A. Hypoxic brain damage and death from unrecognized or unrelieved

obstruction.
B. Trauma to ribs, lungs, liver and spleen from chest or abdominal thrusts
(particularly when forces are not evenly distributed).
C. Vomiting and aspiration after relief of obstruction.
PROTOCOL 5.4: Airway Management: Obstructed Airway (cont.)
D. Creation of complete obstruction after incorrect blind finger probing in airway.
E. Tonsillar or pharyngeal laceration from over-vigorous finger sweep or

laryngoscope insertion.
PROTOCOL 5.5: Airway Management: Opening the Airway
Indications:
A. Inadequate air exchange in the lungs due to jaw or facial fracture causing
narrowing of air passage.
B. Lax jaw or tongue muscles causing airway narrowing in the unconscious

patient.
C. Noisy breathing or excessive respiratory effort, which could be due to partial

obstruction.
D. In preparation for suctioning, assisted ventilation or other airway

management maneuvers.
Precautions:
A. For trauma patients, keep neck in midline and avoid flexion or

hyperextension.
B. For medical patients, neck extension may be difficult in an elderly person

with extensive arthritis and little neck motion. Do not use excessive force or
movement, a jaw thrust or chin lift without head tilt will be more successful.
C. All airway maneuvers should be followed by an evaluation of their success; if

breathing is still labored, a different method or more time for recovery may be
needed.
D. Children’s airways have less supporting cartilage; overextension can kink the
airway and increase the obstruction. Watch chest movement to determine
the best head angle.
E. Dentures should usually be left in place since they provide a framework for
the lips and cheeks and allow more effective BVM ventilation.
Technique:
A. To open the airway initially, choose method most suitable for patient, head
tilt-chin lift or jaw thrust (see below).
B. Assess ventilations.
C. Relieve partial or complete obstruction, if present
PROTOCOL 5.5: Airway Management: Opening the Airway (cont.)
Technique (cont.):
D. Assess oxygenation; use supplemental oxygen as needed.
E. Choose method to maintain airway patency during transport.
1. Position patient on side if needed (if medical problem).
2. Oropharyngeal (OP) airway;
a. Choose size by measuring from corner of mouth to ear margin.

b. Depress tongue with tongue blade, or insert gently following the
curvature of the pharynx.
c. Insert gently with curve pointing upward.
d. Advance to back of tongue, then turn to follow curve of airway.
Move gently to be the tip is free in back of pharynx.
3. Nasopharyngeal (NP) airway.
a. Lubricate tube with water soluble lubricant

b. Insert in right nostril first with tube at 90 degrees to face, along floor
of nose until flange is seated at nostril. Keep curve in line with
normal airway curve. If you meet resistance or passage appears
too narrow, try left side.
G. Assess breathing to be sure maneuver has resolved problem.
H. Consider intubation.
I. Resume ventilatory assistance and oxygenation as appropriate.
Complications:
A. Cervical spinal cord injury from neck hyperextension in trauma victim with
cervical fracture.
B. Neck fracture in older patients with rigid neck due to forced extension during
airway maneuvers.
C. Death due to inadequate ventilation or hypoxia.
D. Nasal or posterior pharyngeal bleeding due to trauma from tubes.
PROTOCOL 5.5: Airway Management: Opening the Airway (cont.)
E. Increased airway obstruction from tongue following improper oropharyngeal

airway placement.
F. Aspiration of blood or vomitus from inadequate suctioning and continued

contamination of lungs from upper airway.
Special Notes:
A. During transport, medical patients can be placed in a stable position on their

sides for effective airway control, use a flexed leg, arms, or pillows for
support.
B. Nasopharyngeal airways are very useful for airway maintenance, and are
underused. The nasal insertion provides more stability, the airway is better
tolerated in partially awake patients, and it does not carry the risk of blocking
the airway further like the stiff oropharyngeal airway.
METHODS OF OPENING THE AIRWAY:
HEAD TILT-CHIN LIFT:
Technique:
From beside head, place one hand on forehead. Grasp lower edge of chin
with fingers of other hand and lift chin forward. Teeth may come together.
Indications:
Trauma or medical patient.
JAW THRUST:
Technique
Position yourself above patient. Place fingers of each hand under angle of
jaw, just below ears, using forearms to maintain head alignment. Gently
thrust angle of jaw forward.
Indications:
Trauma or medical patient where neck extension is not possible.
PROTOCOL 5.6: Advanced Airway Management: Combitube
Indication:
Patient requiring advanced airway and attempts at oro/nasotracheal intubation

have been unsuccessful.
Contraindications:
A. Patients under 5 feet tall.
B. Responsive patients with an intact gag reflex.
C. Patients with known esophageal disease.
D. Patients who have ingested caustic substances.
Technique:
A. Begin ventilation or CPR, taking usual precautions to verify an open airway.
B. Prepare Combitube for insertion by testing cuff integrity and lubricating with
water soluble lubricant.
C In the supine patient, lift the tongue and lower jaw upward with one hand.
CAUTION: When facial trauma has resulted in sharp, broken teeth or dentures,
remove dentures and exercise extreme caution when passing the Combitube
into the mouth to prevent the cuff from tearing.
D With the other hand, hold the Combitube so that it curves in the same
direction as the natural curvature of the pharynx. Insert the tip into the mouth
and advance gently until the black printed ring is aligned with the teeth or
alveolar ridges (see illustration 5.A. Combitube placement below).
CAUTION: DO NOT FORCE THE COMBITUBE If the tube does not advance
easily, redirect it or withdraw and reinsert.
E Inflate the blue pilot balloon leading to the pharyngeal cuff, with 100 ml of air
using the 140 ml (cc) syringe. Note that this may cause the Combitube to
move slightly from the patient’s mouth. (see illustration 5.B. Combitube
Anatomy below).
F Inflate the white pilot balloon leading to the distal cuff, with approximately 15
ml of air using the 20 ml (cc) syringe. (see illustration 5.B.)
PROTOCOL 5.6: Advanced Airway Management: Combitube (cont.)
Technique (cont.):
G. Begin ventilation through the longer blue Pharyngeal Lumen (#1). (see
illustration 5.C. Combitube Anatomy below). If auscultation of breath sounds
is positive and auscultation of gastric insufflation is negative, continue
ventilation. Confirm with end-tidal CO2 detector.
H. IF NECESSARY, if auscultation of breath sounds is negative, and gastric

insufflation is positive, immediately begin ventilation through the shorter clear
Tracheal Lumen (#2) (see illustration 5.C.). Assess tracheal ventilation by
auscultation of breath sounds and absence of gastric insufflation. Confirm
with end-tidal CO2 detector.
I. If a Combitube is placed and is functioning correctly, it should be left in place

until the patient is brought to the Emergency Department.
ILLUSTRATION 5.A.
COMBITUBE PLACEMENT
Technique (cont.):
ILLUSTRATION 5.B.
COMBITUBE ANATOMY
Distal Tracheal Cuff
Pilot Balloon for Small

Distal Tracheal Cuff (#2)
Pilot Ballon for Large

Pharyngeal Cuff (#1)
Large Proximal Pharyngeal Cuff
Technique (cont.):
ILLUSTRATION 5.C.
COMBITUBE ANATOMY
Pharyngeal
Lumen (#1)
Tracheal Lumen (#2)
Black Teeth Rings
PROTOCOL 5.7: Advanced Airway Management: Orotracheal Intubation
Indications:
A. Patient with persistent hypoxia and hypoventilation despite initial simple

airway interventions and adjuncts.
B. Patient requiring airway protection to:
1. Prevent aspiration of gastric contents, upper airway secretions, or

bleeding.
2. Suction secretions and maintain airway patency.
C. To administer drugs during resuscitation for absorption through the lungs

when an IV or IO cannot be obtained immediately.
Precautions:
A. Do not use intubation as the initial method of managing the airway in a

cardiac/respiratory arrest, oxygenate prior to intubation. (accomplish with
BVM and adjuncts as needed).
B. Nasotracheal intubation may be the preferred technique in the breathing

patient. Oral intubation with in-line stabilization of the cervical spine is the
best alternative in the non-breathing or inadequately breathing trauma
patient. Careful visualization with the laryngoscope is needed, and Magill
forceps may be useful in guiding the ET tube. Surgical or needle
cricothyrotomy may be indicated in a traumatic respiratory arrest if intubation
is not successful.
C. Never lever the laryngoscope against the teeth. The jaw should be lifted with
direct upward and outward traction by the laryngoscope.
D. Prepare suction beforehand. Vomiting is particularly common when the

esophagus is intubated.
E. Intubation should take no more than 15-20 sec to complete: do not lose
track of time. If visualization is difficult, stop and re-ventilate before trying
again.

(cont.)
Technique:
A. Assemble equipment while continuing ventilation:
1. Choose tube size (see Table 5.A. ETT Size by Age). Use as large a
tube as possible.
2. Introduce the stylette into the tube and be sure it stops 1/2” short of the
tube’s end.
3. Assemble laryngoscope and check light.
4. Connect and check suction.
5. Test cuff integrity (in cuffed tube) by inflating with 10 ml syringe then
deflate. Syringe may be left connected.
B. Position patient: neck flexed forward, head extended back. Back of head
should be level with or higher than back of shoulders.
C. Give a minimum of 4 good ventilations before starting procedure.
D. Insert laryngoscope to right of midline. Move it to midline, pushing tongue to

left and out of view.
E. Lift straight up on blade and out (no levering) to expose posterior pharynx.
F. Identity epiglottis: tip of curved blade should sit in vallecula (in front of
epiglottis), straight blade should slip over epiglottis. Sellick maneuver
(cricoid pressure) by assistant may improve cord visualization and reduce
risk of aspiration.
G. With additional gentle pressure to straighten the airway, identify trachea from
arytenoid cartilage’s and vocal cords.
H. Insert tube from right side of mouth, along blade into trachea under DIRECT
VISION.
I. Advance tube so cuff is 1-1.5’ beyond cords. Ventilate and watch for chest
rise. Listen for sounds over stomach (should not be heard) and lungs and
axillae.

(cont.)
Technique (cont.):
J. Inflate cuff with 7-8 ml air.
K. To avoid accidental extubation ALWAYS maintain control of tube with one

hand until secured.
L. If the medical patient needs to be moved excessively, it is also a wise

practice to put a c-collar on the patient and immobilize their head and neck
with a cervical immobilization device (CID) to further avoid the possibility of
accidental extubation. The trauma patient will be routinely immobilized.
M. In the patient who is still somewhat awake, or who may reawaken during
transport. If not using a commercial tube holder, before securing tube
consider a bite block made from a cut off OP airway to prevent patient’s teeth
from damaging tube.
N. Re-auscultate over stomach, both sides of chest and axillae.
O. Note proper tube position (21 cm at teeth for females, 23 cm at teeth for
males) and secure tube with tape, ties or commercial tube holder.
P. In all cases where an ET tube has been placed, Three different methods
will be used to confirm tube placement.
1. Direct auscultation over the stomach and bilateral chest wall.
2. The use of an esophageal intubation detector (EID).
3. The use of an end-tidal CO2 detector of either the color metric type or
the constant-monitoring type (constant-monitoring type preferred).
Familiarization with the end-tidal CO2 detector will be maintained
reference pediatric vs adult sizes, fluids down tube, length of usage, etc.
Fogging of the ET tube, while it is helpful in assessing placement, is not

100% reliable and should not be used as one of the primary methods of
confirming tube placement.
Q. Tube placement must also be re-verified after securing tube, after moving
the patient, and at any other time of concern or change in the patient’s
condition (including the movement of the patient from the ambulance cot to
the hospital bed).

(cont.)
Technique (cont.):
R. If there is any doubt about the placement of the tube, it should be withdrawn
and the patient re-intubated.
Complications:
A. Esophageal intubation: particularly common when tube not visualized as it

passes through cords. The greatest danger is in not recognizing the
error. Auscultation over stomach during trial ventilations should reveal air
gurgling through gastric contents with esophageal placement. Also, make
sure your patient’s color improves, as it should when ventilating.
B. Intubation of right mainstem bronchus: be sure to listen to chest bilaterally.
C. Upper airway trauma due to excess force with laryngoscope or to traumatic

tube placement.
D. Vomiting and aspiration during traumatic intubation or intubation of patient

with intact gag reflex.
E. Cervical spine fracture in patients with arthritis and poor cervical mobility.
F. Hypoxia due to prolonged intubation attempt.
G. Cervical cord damage in trauma victims with unrecognized spine injury.
H. Ventricular arrhythmias or fibrillation in hypothermia patients from stimulation

of airway.
I. Induction of pneumothorax, either from traumatic insertion, forceful bagging,

or aggravation of underlying pneumothorax.
Special Notes:
A. REMEMBER: Endotracheal intubation is NOT the procedure of choice in the

first seconds of a resuscitation. It is secondary procedure only. Most
patients can be adequately ventilated with a BVM with oropharyngeal or
nasopharyngeal airway.

(cont.)
B. Difficult intubations can frequently be made easier by continuous pressure

placed over the thyroid and cricoid cartilages moving the vocal cords
posteriorly into view (Sellick Maneuver).
C. Do not be overly aggressive and quick to intubate in trauma patients with

upper airway trauma. If you are able to manage secretions and ventilate,
intubation is often not required and the complications may outweigh the
advantages if your hand is not forced.
TABLE 5.A.
ETT SIZE BY AGE
AGE OROTRACHEAL TUBE SIZE
Premature 2.5 - 3.0
Newborn 3.0 - 3.5
6 Months 3.5
18 Months 4.0
3 Years 4.5
5 Years 5.0 Cuffed
8 Years 6.0 Cuffed
10-15 Years 6.5 - 7.0 Cuffed
Adult 7.0 - 9.0 Cuffed
PROTOCOL 5.8: Advanced Airway Management: Nasotracheal Intubation
Indications:
A. Same function as orotracheal intubation.
B. Most useful in breathing, comatose patients requiring intubation. May be

better tolerated in partly conscious patients than oral intubation.
C. Asthma, pulmonary edema, certain cases of facial trauma and epiglottitis

with respiratory failure, where intubation may need to be achieved in a sitting
position.
Precautions:
A. Head must be exactly in midline for successful intubation.
B. Have suction ready. Vomiting can occur, as with any stimulation of the
airway.
C. Nasotracheal intubation can be more time-consuming than orotracheal

intubation.
D. Often nares are asymmetrical and one side is much easier to intubate. Avoid
inducing bilateral nasal hemorrhage by forcing a nasotracheal tube on
multiple attempts.
E. Do not use in patients with an obviously fractured and mis-aligned nose.

Craniofacial trauma is not a contraindication to nasotracheal intubation if mid-
face is intact. If mid-face is not intact, nasotracheal intubation is
contraindicated.
F. Be sure adapter on distal end of tube is firmly in place.
G. Nasotracheal intubation is not recommended in children less than 8 years of

age.
Technique:
A. Choose correct ET tube size (usually 7.0-7.5 mm tube in adult or 1/2 size
smaller than orotracheal size, limitation is nasal canal diameter. The size of
the patients little finger can be used as an approximate guide to tube size,
the two will be very similar in size.
B. Position patient with head in midline, neutral position (cervical collar may be
in place, or assistant may hold in-line stabilization in trauma patients).

(cont.)
Technique (cont.):
C. Assist ventilations prior to procedure if spontaneous respirations are

inadequate. Pre-dilatation of the chosen nostril with a lubricated (2% viscous
Lidocaine) nasal airway slightly larger than selected ET tube will facilitate
passage and decrease epistaxis.
D. Connect BAAM to tube adapter and orient adapter to curvature of tube (this
will help you know the direction the eye of the tube is going once it
disappears into the patients nose).
E. Test cuff integrity by inflating with 10 ml syringe then deflate. Syringe may
be left connected.
F. Lubricate ET tube with 2% viscous Lidocaine. Give 2 sprays of Neo-

Synephrine in each nostril.
G. With gentle steady pressure, and the tube at right angles to the patients face,
introduce the tube through the nose towards the posterior pharynx. Use the
right nostril if possible. The whistling noise made through the BAAM by the
patients respirations will help you guide the tube toward the tracheal opening.
If the whistling stops (and the patient is still breathing) the tube needs to be
re-directed so the whistling is heard again.
H. There will be a slight resistance just before entering trachea. Wait for an
inspiratory effort before final advance into trachea. Patient may also cough
or buck just as tube passes through vocal cords..
I. Laryngospasm may be encountered during nasotracheal intubation.
J. Continue advancing until air is exchanging through the tube, this will be
noted by constant whistling through the BAAM.
K. Advance about 1-1.5 inch further, then inflate cuff.
L. Coughing after intubation can be reduced by instilling 5ml of 2% Lidocaine

down the tube.
M. Ventilate and check for breath sounds bilaterally and abdominal (stomach)
sounds.

(cont.)
Technique (cont.):
N. If there is any doubt about the placement of the tube, it should be withdrawn
and the patient re-intubated.
O. Note proper tube position and secure.
P. In all cases where an ET tube has been placed, Three different methods
will be used to confirm tube placement.
1. Direct auscultation over the stomach and bilateral chest wall.
2. The use of an esophageal intubation detector (EID).
3. The use of an end-tidal CO2 detector of either the color metric type or
the constant-monitoring type (constant-monitoring type preferred).
Familiarization with the end-tidal CO2 detector will be maintained
reference pediatric vs adult sizes, fluids down tube, length of usage, etc.
Fogging of the ET tube, while it is helpful in assessing placement, is not

100% reliable and should not be used as one of the primary methods of
confirming tube placement.
Q. Tube placement must also be re-verified after securing tube, after moving
the patient, and at any other time of concern or change in the patient’s
condition (including the movement of the patient from the ambulance cot to
the hospital bed).
Complications:
A. Same as orotracheal intubation. In addition:
B. Further craniofacial injury particularly in patients presenting with facial trauma

and mid-face instability.
C. Upper airway bleeding caused by tube trauma.
C. Vomiting and aspiration in the patient with intact gag reflex.
Special Notes:
A. In the field, the secret of blind nasotracheal intubation is perfect positioning

and gentle patience.

(cont.)
B. After accomplishing nasotracheal intubation, avoid flexion or extension of the

patient’s head as this may result in extubation or advancement of the tube
down the right main stem bronchus (C-collar and CID are very useful for
this).
C. In head trauma, 1 mg/kg of Lidocaine should be given IV prior to intubation to

decrease any rise in intracranial pressure associated with the intubation.
D. Difficult nasotracheal intubations can frequently be made easier by

continuous pressure placed over the thyroid and cricoid cartilages moving
the vocal cords posteriorly (Sellick Maneuver). The tube can frequently be
felt going through (or not going through) the cords while this is being done.
PROTOCOL 5.9: Advanced Airway Management: Rapid-Sequence Induction

For Endotracheal Intubation
Rapid-sequence induction for intubation may be performed by Paramedics who

have completed both a Surgical Airway course approved by the Medical Director
and a Rapid-Sequence Induction course, and who have demonstrated evidence
of skill competency to the Medical Director at least 3 times per year.
Indications:
A. Patients with potential or actual airway compromise due to depressed

sensorium (GCS of 8 or less) or whose combativeness threatens the airway
or spinal cord stability.
B. Patients who demonstrate a high probability of airway compromise during

transport (i.e. smoke inhalation, severe head injury).
C. Patients who need ventilatory assistance or airway protection.
Precautions:
A. May produce initial muscle fasciculations.
B. May cause vomiting during muscle fasciculations.
C. Cardiac dysrhythmias; bradycardia, PVC’s and V-fib may be induced.
D. Malignant hyperthermia is a rare metabolic process of the skeletal muscles

that may be triggered by Succinylcholine.
E. Succinylcholine is associated with increased intraocular pressure.
Equipment:
1. Endotracheal tube of appropriate size w/stylet

2. 10 cc syringe
3. Laryngoscope handle and appropriate blade
4. Commercial tube holder or tape
5. BVM and O2
6. RSI medications (Lidocaine, Atropine (if Peds), Etomidate,
Succinylcholine)
7. Suction equipment
8. Combitube
9. Surgical cricothyrotomy equipment (#10 scalpel, endotracheal tube of
appropriate size).

For Endotracheal Intubation (cont.)
Technique:
A. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL

MUST BE CONTACTED! Be prepared to give Medical Control an airway
assessment consisting of:
1. Mallampati Classification (if possible). (see illustration 5.D. below)
2. Thyromental distance. (see illustration 5.E. below)
3. Assessment of mouth opening (should be at least two finger widths).
4. Assessment of cervical mobility and any other problems.
B. Ensure all equipment is set up for intubation, Combitube placement and

surgical cricothyrotomy.
C. Connect the patient to the cardiac monitor and pulse oximeter.
D. Pre-oxygenate with high-flow oxygen by mask. Do not manually ventilate the

patient unless respiratory effort is ineffective, as this may result in gastric
distention with vomiting and aspiration,.
E. Premedicate the patient with Lidocaine 1 mg/kg IV. (head injury)
F. Premedicate child less than 5 years of age with Atropine .01 mg/kg IV.
G. Sedate (induce) the patient with Etomidate .3 mg/kg IV.

Note: The administration of the sedation drug alone may be enough to
facilitate intubation, always check.
H. Consider opening the cervical collar while providing in-line manual

immobilization of the head and neck. Apply cricoid pressure to occlude the
esophagus until intubation is successfully completed and the ETT cuff is
inflated. If the patient actively vomits, cricoid pressure must be released.
I. Administer Succinylcholine 2.0 mg/kg IV over 30 seconds, wait until muscle

fasciculations stop and perform intubation. If unable to intubate during the
first 20 seconds, stop and ventilate the patient with BVM for 30-60 seconds
and reattempt to intubate. If endotracheal intubation fails and you are unable
to adequately ventilate the patient with the BVM, consider Combitube
placement or cricothyrotomy.

Technique I. (cont.):
Note: per physician request only Zemuron (Rocuronium) .6 mg/kg IV/IO

may be used as an initial paralyzing agent as an alternative to
Succinylcholine. Keep in mind that Zemuron is contraindicated in the patient
that presents as difficult to orally intubate, due to it’s relatively long duration
and the possibility of the need for prolonged airway support.
J. Once intubation is completed, confirm tube placement by three different

methods and secure the tube.
K. Treat bradycardia during intubation by temporarily halting intubation attempt

and hyperventilating the patient with BVM and 100% oxygen. If the patient
remains bradycardic, consider Atropine 0.5 mg IV (adult), 0.01 mg/kg (ped).
L. Re-secure the cervical collar and complete any unfinished spinal precautions
for transport.
M. Consider the use of Zemuron (Rocuronium) 0.6 mg/kg IV/IO for prolonged
paralysis during longer transports.
Note: Do not administer Zemuron to the patient who is already starting to
awaken from the administration of Succinylcholine. Sedate first with
Morphine, Valium or Etomidate, then administer Zemuron. If patient has not
started to reawaken, then Zemuron only is acceptable.
Contraindications:
A. Penetrating eye injury.
B. Neurological disease (i.e. multiple sclerosis).
C. Severe burn or trauma greater than 48 hours old.
D. Malignant hyperthermia or known history of malignant hyperthermia.
E. Anatomical considerations that would make orotracheal intubation very

difficult.
Documentation:
The following items must be documented in the Patient Care Report:

Documentation (cont.):
1. Indication for intubation.

2. Tube size.
3. Pre-oxygenation prior to intubation and oxygen saturation.
4. Classification and condition of airway; (clear, emesis, blood, etc.).
5. Confirmations of tube placement, including auscultating breath sounds over
both lung fields, as well as absence of sounds over epigastric region. Use of
EID and end-tidal CO2 device (pleth and readout) as additional adjunct for
confirmation.
6. Difficulty with the procedure, including number of attempts.
7. Depth of insertion and how the tube is secured.
8. Who performed the procedure.
9. Cricoid pressure.
10. Manual in-line immobilization of c-spine for trauma patients.
11. Means by which patient was ventilated after intubation and oxygen delivered.
12. Cardiac rhythm.
13. Status of ETT after each movement of patient.
14. Status of tube at receiving facility; breath sounds, oxygen saturation, end-
tidal CO2 reading, clinical improvement/stability.
15. Document MD who confirms tube placement.
ILLUSTRATION 5.D.
MALLAMPATI CLASSIFICATION
Class I Class II Class III Class IV

ILLUSTRATION 5.E.
THYROMENTAL DISTANCE
The Thyromental Distance is the distance of the lower mandible in the midline
from the chin to the thyroid notch. This measurement is performed with the adult
patient’s neck fully extended. It helps one determine how “anterior” the patient
may be and how much room there is for the tongue to be displaced during
laryngoscopy.
PROTOCOL 5.10: Advanced Airway Management: Needle Cricothyrotomy

(PTLV)
An emergent needle cricothyrotomy (Percutaneous Translaryngeal Ventilation or

PTLV) may be performed by the Paramedic who has completed a surgical airway
course approved by the Medical Director, and who has proven evidence of skill
competency to the Medical Director at least two (2) times per year. Evidence will
be documented and signed by the Medical Director annually.
Criteria: A patient of less than 8 years of age with a life-threatening airway

obstruction.
Indications:
A. A patient in whom a patent airway cannot be secured with intubation.
B. Situations in which standard endotracheal intubation cannot be performed

due to:
1. Severe laryngeal edema.
2. Massive traumatic facial/oropharyngeal injury.
3. Massive congenital deformities.
4. Complete airway obstruction by a foreign body that cannot be extricated

with direct laryngoscopy techniques.
C. A minimum of three (3) attempts at intubation have been made, and all
Paramedics present have attempted to visualize the cords.
Precautions:
A. This procedure is not without considerable hazards. The cricothyroid

membrane must be correctly identified to prevent uncontrollable bleeding and
possible damage to surrounding structures when the puncture is made.
B. Maintain manual cervical spine alignment during procedure.
C. The needle cricothyrotomy provides minimal oxygenation and

ventilation, short scene times and expedited transport are essential.

(PTLV) (cont.)
Equipment: (In PTLV Kit)
1. 14 gauge X 1.25 inch IV catheter (unprotected)

2. 10 cc syringe
(remove stopper from IV catheter and attach 10 cc syringe)
3. Povidone-iodine or alcohol swabs
4. O2 delivery (ventilation) device (see illustration 5.F. below)
5. Tape and 4x4 gauze pads
Technique:
A. Assess need to perform needle cricothyrotomy. NOTE: THIS IS A LEVEL II

INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED!
B. Gather all needed equipment and hook patient to cardiac monitor,

capnography and pulse oximeter.
C. Place the patient in a supine position. If no cervical spinal injury exists,

slightly hyperextend the neck to identify the cricoid and thyroid cartilage. If
possibility of cervical spine injury, maintain neck in neutral position.
D. Palpate and locate the cricothyroid membrane between the thyroid and
cricoid cartilages (see illustration 5.G. below).
E. Stabilize the thyroid cartilage with non-dominant hand between thumb and
index finger. Prep the area by swabbing with Povidone-iodine or alcohol
swabs.
F. With the dominant hand, puncture the skin midline directly over the
cricothyroid membrane with the catheter/syringe assembly. Advance the
needle through the membrane caudally (towards the feet) at a 45 degree
angle aspirating with the syringe as the needle is advanced. Be careful to
avoid the posterior tracheal wall.
G. Aspiration of air signifies entry into the trachea.
H. Once in the trachea, advance the catheter over the needle and withdraw the
needle and syringe.
I. Remove blue cap from PTLV O2 delivery device and attach to hub of IV
catheter, turn petcock to ON, attach O2 tubing end to O2 tank regulator and
open to 25 LPM.

(PTLV) (cont.)
Technique (cont.):
J. Ventilate/oxygenate for 1 second by placing thumb over suction catheter

opening in PTLV O2 delivery device, then remove thumb for 4 seconds to
allow for passive exhalation. Continue to “ventilate” at a ratio of 1 to 4.
K. Observe for any lung inflations and auscultate for ventilation. Monitor ECG,
O2 saturation and end-tidal CO2.
L. Secure catheter and device to neck with tape and 4X4’s.
M. Document procedure and responses completely.
Complications:
A. Air escaping out of the trachea through the hole created by the catheter
could cause subcutaneous or mediastinal emphysema to develop.
B. Exsanguinating hematoma.
C. False passage into tissue.
D. Perforation of the posterior trachea/esophagus.
E. Non-sealed trachea won’t permit adequate ventilation.
F. Aspiration.
G. Patient will retain high CO2 and low O2 sats even if procedure is done
properly.
H. Inadequate ventilations resulting in hypoxia and death.
Special Notes:
A. Remember this is a temporizing measure for a desperate situation,

ventilation and oxygenation will be minimal.
B. Allow for passive exhalation, the air is coming out of a very small hole.
C. Any attempt at hyperventilation is contraindicated.

(PTLV) (cont.)
ILLUSTRATION 5.F.
PTLV O2 DELIVERY DEVICE
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY
An emergent surgical cricothyrotomy may be performed by the Paramedic who

has completed a surgical airway course approved by the Medical Director, and
who has proven evidence of skill competency to the Medical Director at least two
(2) times per year. Evidence will be documented and signed by the Medical
Director annually.
Criteria: Adults or children greater than 40 kg or more than 8 years of age with a
life-threatening airway obstruction.
Indications:
A. A patient in whom a patent airway cannot be secured with intubation.
B. Situations in which standard naso/orotracheal intubation cannot be

performed due to:
1. Severe laryngeal edema.
2. Massive traumatic facial/oropharyngeal injury.
3. Massive congenital deformities.
4. Complete airway obstruction by a foreign body that cannot be extricated

with direct laryngoscopy techniques.
C. A minimum of three (3) attempts at intubation have been made, and all
Paramedics present have attempted to visualize the cords.
Precautions:
A. This procedure is not without considerable hazards. The cricothyroid

membrane must be correctly identified to prevent uncontrollable bleeding and
possible damage to surrounding structures when the incision is made.
B. This is an emergent, invasive procedure that should only be undertaken after

all other means to establish a secure airway have been considered, i.e.
Combitube, etc.
C. Maintain manual cervical spine alignment during procedure.
PROTOCOL 5.11: SURGICAL CRICOTHYROTOMY (cont.)
Equipment:
1. 5.0-6.5 cuffed ET tube or Shiley (use size appropriate tube for age of patient)
2. Scalpel, #10 or 11 blade
3. Trach hook
4. 10 cc syringe
5. Povidone-iodine or alcohol swabs
6. Tape or tube tie
7. 4x4 gauze pads
8. BVM with oxygen
9. Suction
Technique:
A. Assess need to perform surgical cricothyrotomy. NOTE: THIS IS A LEVEL II

INTERVENTION AND MEDICAL CONTROL MUST BE CONTACTED!
B. Gather all needed equipment and hook patient to cardiac monitor and pulse
oximeter.
C. Place the patient in a supine position. If no cervical spinal injury exists,

slightly hyperextend the neck to identify the cricoid and thyroid cartilage. If
possibility of cervical spine injury, maintain neck in neutral position.
D. Palpate and locate the cricothyroid membrane between the thyroid and
cricoid cartilages (see illustration 5.G. below).
E. Stabilize the thyroid cartilage with non-dominant hand between thumb and
index finger. Prep the area by swabbing with Povidone-iodine or alcohol
swabs.
F. With the dominant hand, make an 1 inch incision vertically through the skin
only directly over the cricothyroid membrane and bluntly dissect to expose
the cricothyroid membrane.
G. Then, make a horizontal stab incision through the cricothyroid membrane.

Air should move freely through the incision if there is spontaneous respiratory
effort. Be careful to hold the scalpel so as to limit the depth it can penetrate
to prevent posterior trachea/esophageal perforation.
Technique (cont.):
H. Invert the scalpel and insert the scalpel handle through the cricothyroid
membrane incision and rotate 90° to the incision to widen it and maintain a
pathway. Use Trach hook to lift the trachea and expose the incision and
pathway into the trachea. The scalpel handle may be removed if the
pathway is clear and stable. If the pathway is not clear and stable, leave the
scalpel handle in place. If there is adequate stabilization, proceed.
I. If the scalpel handle is left in place, insert the endotracheal tube or Shiley
past it into the cricothyrotomy, directing the tube distally into the trachea. If
an ET tube is used, the tube should only be inserted 1 to 2 centimeters
above the superior border of the cuff to avoid a right mainstem intubation.
After the tube is in place, remove the scalpel handle if it was left in place.
J. Inflate the cuff and ventilate the patient.
K. Evaluate the effectiveness of the airway per Advanced Airway Management

protocol. Check for subcutaneous emphysema, air leaking from the incision,
or bleeding.
L. Bleeding from superficial neck vessels is very common. Use direct pressure
and dress wound after tube in place and ventilating.
M. Secure the tube and watch carefully. Continue to ventilate with 100%
oxygen via BVM, and monitor.
N. Suction trachea as needed using sterile technique. Even with inflated

balloon, some blood will get into trachea, causing irritation and hypoxia.
O. Document procedure and responses completely.
Complications:
A. Hemorrhage by laceration of a major vessel (e.g. jugular or carotid).
B. Laceration of the thyroid gland.
C. Damage to the larynx and/or laryngeal nerve.
D. Posterior perforation of the posterior trachea/esophagus.
F. False passage into tissue.
G. Subcutaneous emphysema.
H. Aspiration.
I. Inadequate ventilations resulting in hypoxia and death.
Special Notes:
A. Evaluate the neck for any expanding hematomas, anterior expanding

hematomas in the neck may be a relative contraindication to the procedure.
B. Existing massive subcutaneous emphysema in the neck may distort

landmarks and may be a relative contraindication to the procedure.
C. Direct the scalpel posteriorly at a 90 degree angle to the cricothyroid

membrane to avoid injury to the vocal cords.
D. Placement of an oversized tube can lead to a fractured larynx.
ILLUSTRATION 5.G.
LARYNGEAL ANATOMY
The laryngeal framework is made up of the thyroid

cartilage and cricoid cartilage. The shield-like thyroid
cartilage is the prominent “Adam’s apple” that is often
seen in men. At the superior aspect of the shield is a
prominent notch that is easily palpable through the
skin. This notch is the only reliable landmark in the
neck when attempting to find the thyroid cartilage in
women or in people with short, fat necks.
It is difficult if this notch is not sought, because the

hyoid bone or the cricoid cartilage may be easily
misidentified as the thyroid cartilage with disastrous
surgical results. Once the thyroid cartilage is
identified, the airway is followed caudally by palpation
until the first complete ring is found. This is the cricoid
ring, the only circumferential ring in the airway. This
cartilage is shaped like a high school class ring with
the shield located posteriorly. The membrane
connecting the cartilages is the cricothyroid
membrane.
PROTOCOL 5.12: CPAP
General Principles:
CPAP (Continuous Positive Airway Pressure) has been shown to rapidly improve
vitals signs and gas exchange in a subset of extremely dyspneic patients. It can
also reduce the work of breathing, decrease the sense of dyspnea and decrease
the need for endotracheal intubation in many of these patients. In patients with
CHF, CPAP improves hemodynamics by reducing left ventricular preload and
afterload.
Criteria:
A. Patient must be awake and able to follow commands.
B. Patient must be ≥ 12 y/o and able to fit the CPAP mask.
C. Patient must have the ability to maintain their own open airway.
D. AND exhibit two or more of the following:
1. Respiratory rate greater than 25 breaths per minute
2 O2 saturation of less than 94% on high-flow oxygen
3. Use of accessory muscles during respirations
Indications:
A. Acute respiratory distress secondary to:
1. Congestive heart failure (CHF)
2. Acute cardiogenic pulmonary edema
3. Near drowning
4. Pneumonia
5. COPD (Emphysema, chronic bronchitis, asthma)
Contraindications:
A. Circumstances in which ET intubation is preferred or necessary to maintain

patent airway.
PROTOCOL 5.12: CPAP (cont.):
Contraindications (cont.):
B. Patient does not improve at all or continues to deteriorate despite CPAP

administration.
C. Patient in respiratory arrest/apneic.
D. Patient suspect of having a pneumothorax or has suffered chest trauma.
E. Patient with tracheostomy.
F. Patient is actively vomiting or has upper GI bleed.
Technique:
A. Assure patent airway and deliver 100% O2 via appropriate delivery system.
B. EXPLAIN THE PROCEDURE TO THE PATIENT. When you are extremely

short of breath, having a tight-fitting mask placed over your mouth and face
can be terrifying. Explaining the procedure and coaching the patient through
it can many times dictate the success or failure of the procedure.
C. Ensure adequate oxygen supply to the device.
D. Place patient on cardiac monitor and continuous pulse oximetry. (monitor

end-tidal CO2 if possible).
E. Large-bore IV NS (TKO unless otherwise indicated).
F. Place the delivery device over the mouth and nose and secure with provided
straps.
G. Start with 5 cm H2O of PEEP, use 10 cm H2O of PEEP maximum.
H. Check for air leaks.
I. Continue to coach patient to keep mask in place and readjust as needed.
K. Monitor and document the patients respiratory response to the treatment.
L. Check and document vitals signs every 5 minutes due to changes in preload
and afterload of the heart during CPAP therapy.
PROTOCOL 5.12: CPAP (cont.):
M. Consider and use medications as indicated (Albuterol, nitroglycerine, etc.). If

used, Nitroglycerine should be administered in tablet form during CPAP
therapy. CPAP mask may have a side port for administering nebulized
medications during CPAP therapy.
Special Notes:
A. Watch patient closely for gastric distention, which can result in vomiting.
B. Close observation of patients on CPAP is critical. At a minimum, continuous

pulse oximetry coupled with close observation of respiration should be done
and will signify a better or worsening condition. Don’t ignore the pulse
component of pulse oximetry, bradycardia often announces missed
respiratory insufficiency, and can rapidly progress to full cardiac arrest. In
any situation in which status of breathing becomes questionable or patient
significantly deteriorates, CPAP should be removed and ventilations assisted
with a BVM and/or advanced airway procedures instituted.
C. Assure that receiving hospital knows CPAP therapy is being performed.
PROTOCOL 5.13: Defibrillation
Application:
A. Place patient in a safe environment, away from pooled water and metal
surfaces under either the patient or the operator.
B. Remove clothing from patients upper torso.
C. Always remove excessive hair with 3M clippers. Excessive hair will create
an unacceptable space between the electrodes and the patients skin.
D. Wipe chest dry, electrodes will adhere best when applied to a dry chest.
NOTE: do not use alcohol preps.
E. Attach patient therapy cable to patient therapy electrodes and confirm cable
connection to the MRX.
F. Remove protective liner and place the sternum electrode (RA) to the right of
the upper sternum just below the right clavicle.
G. Remove protective liner and place the apex electrode (LL) to the left of the
left nipple in the mid-axillary line over the lower ribs.
H. The anterior-posterior position is also acceptable.
I. Do not place electrodes over pacemakers, ICD generators or nitroglycerin

paste. Remove medication patches before defibrillation.
J. Apply firm pressure to both electrodes smoothing from the center out to the
edges to assure maximal contact.
Techniques:
A. Defibrillation
1. Turn MRX power ON.
2. Rotate Therapy Knob to desired energy level.
3. Press the CHARGE button, when the defibrillator is fully charged to the
proper energy level, the tone will change and the correct energy level
appears on the screen.
4. Call for and check to make sure everyone, including the operator, is
clear of the patient and any equipment attached to the patient.
PROTOCOL 5.13: Defibrillation (cont.)
Techniques (cont.):
5. Confirm rhythm, confirm available energy.
6. Press flashing SHOCK button to discharge energy to the patient.
Note: If the SHOCK button is not pressed within 30 seconds, the stored
energy is internally removed.
Note: Selected energy may be increased or decreased anytime after

charging has started or is complete. Simply rotate Therapy Knob to
desired energy.
B. Synchronized Cardioversion.
1. Turn MRX power ON.
2. Attach patient therapy cables and electrodes as previously described.
3. Select Lead II or the lead with a clear signal and the greatest QRS
amplitude (positive or negative).
4. With the Therapy Knob in the Monitor position, press the SYNC button,
confirm the Sync message appears in the upper right corner of Wave
Sector 1.
5. Observe the ECG rhythm and confirm that a Sync marker appears near
the middle of each “R” wave. If the sense markers do not appear or are
outside the “R” waves, adjust ECG SIZE (or select another lead) until
they do.
6. Turn the Therapy Knob to the desired energy level.
7. Press the CHARGE button, when the defibrillator is fully charged to the
proper energy level, the tone will change and the correct energy level
appears on the screen.
8. Call for and check to make sure everyone, including the operator, is
clear of the patient and any equipment attached to the patient.
9. Confirm rhythm, confirm available energy.
PROTOCOL 5.13: Defibrillation (cont.)
Techniques (cont.):
10. Press and hold the SHOCK button until discharge of energy occurs to
patient with next detected QRS complex. Release SHOCK button.
Note: If the SHOCK button is not pressed within 30 seconds, the stored
energy is internally removed.
Note: Selected energy may be increased or decreased anytime after

charging has started or is complete. Simply rotate Therapy Knob to
desired energy.
Special Notes:
A. Defibrillation electrodes may be used to monitor patients who you believe to

have a high probability of life threatening arrhythmias. To monitor through
the therapy electrodes, attach patient therapy cables and electrodes as
previously described and select PADDLES lead.
B. Anterior-Posterior placement: The apex electrode (LL) is placed anterior just

to the left of the lower sternal border, the sternal electrode (RA) is positioned
posterior behind the heart.
C. A patient can be defibrillated in wet conditions, such as near water or in rain

or snowy weather. The patients chest should be kept dry between the
defibrillation electrodes and care should be taken to keep the patient, the
operator and the equipment out of pooled water. In a rainstorm, it is best to
bring the patient inside.
D. If interfacing with 1st responder AED, begin 1st shock at appropriate shock
level. It is always wise to let 1st responders continue with AED defibrillation
sequences if the situation is progressing correctly, this allows ALS personnel
time to set up for other procedures. If 1st responder defibrillation is not
progressing correctly, hook up MRX, disconnect AED, and continue or begin
defibrillation sequence.
PROTOCOL 5.14: Endotracheal Drug Administration
Indications:
In critical situations requiring pharmacologic intervention, intravenous access

may be difficult to achieve. Endotracheal administration of certain drugs provides
adequate systemic absorption to achieve the desired effects. This is made
possible by the large absorptive surface of the distal bronchial tree and the
proximity of capillary beds to that area. Absorption is not as effective in the
proximal bronchial tree; therefore, consideration must be given to methods,
which deliver the drug most distally. Because endotracheal intubation is one of
the first interventions in many critically ill patients, the endotracheal route of drug
delivery may be available before venous access is obtained.
Drugs available for Endotracheal use:
1. Narcan
2. Atropine
3. Valium
4. Epinephrine
5. Lidocaine
Drug Dosages:
Refer to drug summaries and protocols for individual drug doses. Endotracheal
dose is typically 2 - 2.5 times the IV dose.
Method of Administration:
A. Volume of Solution:
Dilute desired drug dose in the following quantity of normal saline.
ADULT: 10 ml
CHILD: 5 ml
INFANT: 1 to 2 ml
B. Inject above solution into ET tube as deeply as possible. If CPR is in

progress, stop chest compressions during injection.
C. Follow injection with 3 to 5 bagged breaths to further disperse drug distally.
PROTOCOL 5.14: Endotracheal Drug Administration (cont.)
Contraindications:
None:
Precautions:
A. Only the drugs listed above should be given via the endotracheal route.
Other medications may either not be absorbed adequately, may not be
effective or may actually damage the pulmonary mucosa.
B. Blood, emesis, or secretions in the airway may impair delivery and

absorption of the drug. The patient should be suctioned prior to drug
administration if needed.
C. Care should be taken, especially in pediatric patients, not to bag the patients
overly vigorously to disperse the medication. Such bagging may create
barotrauma.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing
Indications:
A. Symptomatic bradycardia with pulse unresponsive to pharmacologic therapy.
Note: In patients with symptoms (significant hypotension, altered mentation,

chest pain) due to any form of bradycardia, treatment should include
supplemental oxygen, ventilatory support as needed, establishment of IV
access, and administration of Atropine (0.5 mg to 1.0 mg every 5 minutes
until desired response or total of 3.0 mg given). Pacing should be
considered if the patient does not respond to Atropine, if IV access cannot be
obtained, or if symptoms are so severe that waiting for a maximal response
to Atropine would be dangerous. In patients with severe bradycardia but no
symptoms, the external pacer can be put in place, but not turned on unless
the patient’s status deteriorates.
Contraindications:
A. Bradycardia in the setting of profound hypothermia.
Technique:
The following steps are needed to initiate pacing with the Philps MRX: The MRX
can pace in either demand or fixed mode. Default is demand mode.
In demand mode the pacer only delivers paced pulses when the patients heart
rate is below the selected pacing rate. Default pacing rate is 70 bpm.
In fixed mode the pacer delivers paced pulses at the selected rate. Default rate
is again 70 bpm.
Note: Use demand mode whenever possible. Use fixed mode when motion
artifact or other ECG noise makes R-Wave detection unreliable.
Demand Mode:
A. If patient is awake, consider sedation.
B. Attach patient monitoring and therapy electrodes and cable as described in

Defibrillation Protocol 5.12. Anterior-lateral or anterior-posterior positioning is
acceptable.
PROTOCOL 5.15: External (Transcutaneous) Cardiac Pacing (cont.)
Technique (cont.):
C. Turn the Therapy Knob to the Pacer position. Message “Pacing Paused” will
appear indicating pacing function is enabled, but pace pulses are not yet
being delivered.
D. Select the lead with the most easily detectable R-wave and observe the ECG
rhythm. Verify that a white R-wave marker appears on or above the ECG
wave form. A single marker should be associated with each R-wave. If the
markers do not appear or are displayed in the wrong location (for example on
the T wave), adjust ECG SIZE or select another lead until they do (it is
normal for the sense marker location to vary slightly on each QRS complex).
E. Default pre-set Pacer Rate is 70 beats per minute. If a change in this rate is
desired, use the NAVIGATION and MENU SELECT buttons to change.
F. Press START PACING button, the message “Pacing” will appear. Verify that
white pacing markers appear on the ECG waveform.
G. Press the PACER OUTPUT button and use the NAVIGATION and MENU
SELECT buttons to increase current slowly until electrical capture is
achieved. Default pre-set starting current is 30 mA. Current can be
increased in 5 mA increments
H. Electrical capture will typically be evidenced by a wide QRS and broad T

waves after each pacing marker. In some patients capture is less obvious,
may be indicated only as a change in the shape of the QRS.
I. Energy requirements for capture may vary widely, but most adults will
capture between 50 and 100 mA.
J. Evaluate for mechanical capture, verify presence of pulses.
1. Assess pulses on the patients right side. Check for a right carotid, right
femoral or brachial pulse. The pacer will make chest and back muscles
twitch at the same rate as the heart, so palpation of pulses at the left
carotid or left femoral artery can be misleading.
2. Assess for improved LOC and blood pressure.
Technique (cont.):
3. Spontaneous beats may be present that are not associated with the
delivery of paced pulses.
Note: If the patients heart rate is above the pacer rate, paced pulses are
not delivered and pacing markers will not appear.
K. Continuously monitor patients BP, level of consciousness and record ECG

rhythm.
L. Documentation will include time pacing was initiated, current required to

obtain capture, pacing rate, patient responses, any medications administered
during the procedure and baseline and paced rhythm strips.
Note: To stop delivery of paced pulses, press PAUSE PACING button,

press RESUME PACING to continue delivery of paced pulses. Delivery of
paced pulses may also be stopped by turning Therapy Knob off the Pacer
position.
Fixed Mode:
A. To pace in the Demand mode, after the Therapy Knob is turned to the Pacer
position, go into the Main Menu and use the Navigation and Menu Select
buttons to change the Pacer Mode from Demand to Fixed (default is
demand). The rest of the procedure for Fixed Mode pacing is the same as
Demand Mode.
Complications:
A. Coughing.
B. Skin burns.
C. Interference with sensing because of patient agitation or muscle contractions.
D. Pain from skin and muscle stimulation.
E. Failure to recognize pacer is not capturing.
F. Failure to recognize the presence of underlying treatable VF.
Special Notes:
A. If electrical capture is achieved without mechanical capture, treat per PEA

(pulseless electrical activity) Protocol 2.8.
B. If defibrillation becomes necessary while pacing, move Therapy Knob from

Pacer position to the desired Manual Defib energy position. Once the
Therapy Knob is moved from the Pacer position, pacing automatically stops.
Proceed with defibrillation.
C. To resume pacing after defibrillation, repeat the pacing procedure as

described above. When pacing is resumed, pacing settings selected prior to
defibrillation (mode, rate and output) are retained.
PROTOCOL 5.16: Glucose Level Determination
Indications:
Any patient with altered mental status should have their glucose level checked as
part of their assessment regardless of the suspicion of hypoglycemia or
hyperglycemia. Glucose level determination will always precede any
administration of Dextrose.
Technique:
Note: This protocol is for the One Touch Ultra blood glucose monitor and test
strips.
A. Assemble items needed for testing: Blood glucose monitor, test strips,
disposable lancets, alcohol preps, 4X4’s, band-aids.
B. This procedure is not without infection control concerns, always wear gloves
and possibly eye protection.
C. Clean the puncture site with an alcohol prep, allow to dry.
D. Insert a test strip into the monitor with the contact bars end first and facing up
into the port, push it in until it stops. The monitor will turn on automatically
and the display check will appear briefly.
Note: The code number will appear on the monitor, followed by the blood
drop symbol. Be sure the code number that is displayed on the meter
matches the test strip code, if they do not, the meter code must be reset
before you continue (see below).
E. When the blood drop symbol appears, the monitor is ready for test blood.
Prick the side of a fingertip using a clean sterile lancet. Touch and hold the
drop of blood to the narrow test channel in the top edge of the test strip, try
not to smear the blood or push the finger against the test strip. If further
stimulation is needed to obtain blood, massage the forearm down the wrist
and palm and/or allow the hand to hang at patient’s side. Avoid squeezing
excessively.
F. Hold the blood drop to the top edge of the test strip until the confirmation
window is full before the monitor begins to count down. If the
confirmation window does not fill completely before the monitor begins to
count down, do not add more blood, discard the test strip and re-test.
PROTOCOL 5.16: Glucose Level Determination (cont.)
Technique (cont.):
Note: If you do not apply a blood sample within two minutes after the blood
symbol appears, the monitor will turn itself off. You must remove the test
strip and insert it back into the monitor to re-start the test procedure.
G. The display will show the numerical blood glucose value when the monitor
counts down from 5 to 1 (5 seconds). The following messages may also be
displayed:
1. LO - This may indicate a blood glucose level below 20 mg/dl
2. HI – This may indicate a blood glucose level above 600 mg/dl
3. Er5 – This typically indicates not enough blood on the test strip or an
inaccurate test result.
G. The monitor will turn off by removing the test strip.
Special Notes:
A. At the start of each shift, the kit containing the blood glucose monitor and the
vial of test strips will be checked. It is checked to make sure the code
number on the monitor display matches the code number on the test
strip vial. Failure to code the monitor correctly will cause inaccurate
test results.
B. The blood glucose monitor coding must be checked with each new vial of
test strips as follows:
1. Insert a test strip to turn on the meter. Compare the code number on the
monitor display with the code number on the test strip vial. If the two
code numbers match, monitor is coded correctly.
2. If the two numbers do not match, code the monitor by pressing the “C”
button to select the correct code number. Every time the “C” button is
pressed, the number will increase by one. To move more quickly, press
and hold the “C” button.
3. After selecting the correct code number, it will flash for 3 seconds, then
appear solid for 3 seconds. The blood drop symbol will then appear,
indicating the monitor is ready for testing.
PROTOCOL 5.16: Glucose Level Determination (cont.)
C. A “control solution” test should be done on the monitor under the following
circumstances:
1. Every time a new vial of strips is opened.
2. Whenever the monitor is dropped or seems to be damaged.
3. Whenever test results seem to be inconsistent with the patients clinical

presentation.
D. Control solution test should be done per the instructions found in the One
Touch Ultra owners booklet available in each station.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO)
JAMSHIDI:
Rationale:
In children, the bone marrow is a very vascular space, with rapid drainage into
the central circulation. In children less than 3 years of age, it is quickly
accessible with the appropriate equipment and does not collapse during shock as
does the venous system. Crystalloids, blood, antibiotics, and the classic
resuscitative drugs can all be delivered successfully via this route. To date, no
drug has been specifically contraindicated for use by intraosseous infusion.
Because it is a painful technique, it should be used only in unconscious patients.
Intraosseous infusion should only be used where other methods of venous
access are exhausted or not immediately available. Cardiopulmonary arrest and
severe shock are the most frequently encountered indications for use of I/O.
Indications:
A. Child less than 3 years of age AND
B. Child unconscious AND
C. There is an urgent need to administer IV fluids or drugs that cannot be given

effectively by another route AND
D. Peripheral venous access is not obtainable
Contraindications:
A. Intraosseous lines should not be started through obviously infected or burned

skin or underlying tissues.
B. Intraosseous lines should not be started in extremities with bone or crush

injuries because of fluid and /or drug infiltration through disrupted bone or
venous circulation.
C. Jamshidi intraosseous lines are never to be attempted in a responsive child.
D. Insertion of an intraosseous line should not delay transport in an emergent

situation.
Sites for Insertion:
A. Proximal Tibia:
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi &EZ-IO) (cont.)
Sites for Insertion (cont.):
1. First choice site
2. Anterior medial surface of the tibia 2 cm below the tibial tuberosity.
B. Distal Tibia:
1. Second choice site
2. Approximately 0.5 to 1 cm proximal to the medial malleolus.
C. NOTE: if the bony cortex has been penetrated during a failed insertion
attempt, no further attempts should be made on that bone.
Technique:
A. NOTE: THIS IS A LEVEL II INTERVENTION AND MEDICAL CONTROL

MUST BE CONTACTED EXCEPT IN SITUATIONS OF CARDIAC ARREST.
B. Assemble the following materials:
1. Intraosseous Needle
a. Size 18 G. for infants up to 6 months of age.

b. Size 15 G. for children from 6 months to 3 years of age.
2. Alcohol and/or Betadine prep.
3. Sterile gauze and tape for dressing.
4. Splint for stabilization of extremity.
5. 5 or 10 ml syringe containing 5 ml of NS flush solution.
6. 60 drop (mini) IV set and IV solution (NS).
C. Record neurovascular status of the limb before and after the procedure.
D. Clean the insertion site with alcohol and/or Betadine.
E. Immobilize the extremity.
PROTOCOL 5.17: Intraosseous Infusion (Jamshidi & EZ-IO) (cont.)
Technique (cont.):
F. Set the flange on the needle to the estimated depth of penetration to marrow
(generally between 1/4 and 1/2 inch or 1 cm). The distance from the skin
through the cortex is rarely more than I cm in an infant or a small child and
penetration to this depth is usually adequate.
G. Insert the needle and obturator into the bone at the selected site, using a
rotary motion with downward pressure. If using the proximal tibia site, angle
the needle slightly inferiorly, away from the knee. If using the distal tibial site,
angle the needle slightly superiorly, away from the ankle. When the needle
reaches the marrow space, a “pop” with a decrease in resistance is usually
felt. DO NOT ROCK THE NEEDLE.
H. When the “pop”, or at least a decrease in resistance is felt, remove the

obturator. Attempt to aspirate marrow through the needle with the syringe
containing the flush solution. If unable to aspirate marrow, the needle may
be plugged or malpositioned. Try rotating the needle to reorient the bevel
and aspirate again. If unsuccessful, flush needle with at least 5 cc of NS. If
line flushes easily without signs of significant subcutaneous infiltration, attach
IV line. If line flushes with difficulty, try repeating aspiration to clear out
possible clots, rotating the needle bevel, or repositioning the needle. The
properly placed needle will stand upright without support.
I. Secure the needle with gauze and tape but maintain surveillance of the site
for signs of infiltration. Should significant infiltration occur, remove the
needle and place pressure on the puncture site.
J. Drug boluses should be flushed into circulation with 1 to 2 cc of NS flush for

ages less than 1 year, 5 cc for ages greater than 1 year. Hypertonic
solutions such as dextrose and sodium bicarb should be diluted and pushed
slowly, as with peripheral IV administration.
Complications:
A. Localized bleeding and infiltration of fluid and drugs into surrounding tissues.
B. Osteomyelitis or sepsis.
C. Injury to the growth plate of the bone if placed incorrectly.
D. Tibial fracture in small newborns.
E. Fat embolus. (Much less fat is present in a child’s marrow than in an adult’s).
F. Extravasation of fluid and drugs into popliteal space if needle tip perforates
through posterior cortex of tibia, causing compression of popliteal vessels or
tibial nerve.
G. Fluid overload if volume administered and patient is not carefully monitored.
ILLUSTRATION 5.H.
INTRAOSSEOUS NEEDLE PLACEMENT
EZ-IO:
Rationale:
The rationale for the use of the EZ-IO is the same as the rationale for the use of
the Jamshidi style bone marrow needle. The primary difference is the EZ-IO may
be used on both the adult and the pediatric patient.
The EZ-IO placement is much less painful then the Jamshidi, so it may be placed
in the patient that is still awake, as opposed to the Jamshidi requiring a patient
that is either in cardiac arrest or fully unconscious.
EZ-IO (cont.):
Indications:
A. EZ-IO AD (Adult) patient weight 40 kg and over.
B. EZ-IO PD (Pediatric) patient weight 3 – 39 kg.
C. IV fluids or medications are needed and a peripheral IV cannot be

established after 3 attempts AND the patient exhibits one or more of the
following:
1. Significantly altered mental status (GCS of 8 or less)
2. Respiratory compromise (O2 saturation 80% or less after appropriate

oxygen therapy, respiratory rate < 10 or > than 40)
3. Hemodynamic instability (Systolic BP of < 90)
Contraindications:
A. Fractures or crush injuries of the bone selected for IO infusion (consider

alternative site).
B. Excessive tissue at the insertion site with the absence of anatomical

landmarks (consider alternative site).
C. Obvious, previous significant orthopedic procedures on the bone

selected for IO infusion (consider alternative site).
D. Obvious infection at the insertion site (consider alternative site).
E. Insertion of an intraosseous line should not delay transport in an

emergent situation.
Site for Insertion:
A. Proximal Tibia:
1. Anterior medial surface of the tibia 1 cm (I finger width) medial to the

tibial tuberosity on the flat, broad portion of the tibia.
EZ-IO (cont.):
Technique:
A. Assemble the following materials:
1. EZ-IO driver
2. EZ-IO needle set, AD for adults, PD for pediatric
3. Alcohol or Betadine swabs
4. EZ-Connect extension set
5. 10 ml syringe containing 10 ml of NS flush solution
6. 60 drop IV set and NS IV solution
7. Pressure bag or infusion pump
8. 2% Lidocaine (preservative free)
9. EZ-IO yellow wristband
B. Record neurovascular status of the limb before and after the procedure.
C. Locate landmarks and identify insertion site.
D. Prepare driver and needle set, using AD needle set for adult, PD needle set
for pediatric patients. Assure that needle set is securely seated on the driver.
Prime extension set with NS.
E. Clean the insertion site with alcohol or Betadine and stabilize leg.
F. Position the driver at the insertion site with the needle set at a 90-degree
angle to the bone. Gently power the needle set until the needle set tip
touches the bone.
G. Check to ensure that at least 5mm of the needle set is visible as indicated by
the black 5 mm line on the shaft, if the black 5 mm line is not visible, the
patient has too much soft tissue at the insertion site and that site will not be
able to be used. Consider an alternative location or abort the procedure
completely.
EZ-IO (cont.):
Technique (cont.):
H. Penetrate the bone cortex by squeezing the trigger and applying gentle,
steady, downward pressure, DO NOT FORCE, allow the driver to do the
work. When performing the procedure on a pediatric patient, the weight of
the driver alone should generally provide enough force for successful
insertion.
I. Release the trigger and stop when the needle flange touches the patients
skin or a sudden give or “pop” is felt upon entry into the medullary space. A
properly placed catheter will stand up straight at a 90-degree angle and will
be firmly seated in the tibial bone.
J. While supporting the needle set with one hand, remove the driver by pulling
straight up and away.
K. Remove the stylet from the catheter by grasping the hub firmly with one hand
and unscrewing the stylet from the catheter by turning it counter clockwise.
Place the stylet in a sharps container, do not attempt to re-cap it.
L. Connect the primed connection set to the catheter hub‘s Luer lock and
rapidly flush with 10 ml NS in an adult patient and 5 ml NS in a pediatric
patient. No Flush = No Flow. Failure to appropriately flush the catheter
may result in a limited or no flow situation. Do not use a syringe directly on
the catheter hub, use the extension set at all times.
Note: In the conscious patient, slowly administer (20-50 mg – adult, .5

mg/kg – pediatric) 2% Lidocaine into the port (through the extension set)
prior to the initial flush. This may cause transient pain but will make
subsequent infusions much less painful. While the insertion procedure itself
is known to be only minimally to moderately painful, infusion of fluid (which
causes intramedullary pressure) can be quite painful in the conscious patient
without the Lidocaine.
M. Initiate infusions or medications as needed. A pressure infuser bag or pump

will typically have to be used to maintain adequate flow rates.
N. Apply a yellow EZ-IO wristband to the patient (the wristband is necessary as

a reminder of EZ-IO placement and the need for timely removal) and dress
and secure the catheter and tubing as needed to protect it. Assure that any
dressings do not interfere with your ability to observe the site for problems.
EZ-IO (cont.):
Complications:
A. The complications with the EZ-IO intraosseous placement and infusion are
the same as the Jamshidi placement noted above.
Considerations:
A. If the insertion site fails the tests, appears obstructed and cannot be flushed,
extravasates or the needle set bends or breaks, the needle set must be
removed and disposed of in a sharps container. If the procedure must be
repeated, do it the other leg with a new needle set, DO NOT attempt a
second placement on the same leg.
B. To remove the EZ-IO catheter, support the patients leg with one hand, grasp
the hub itself firmly (or attach a sterile syringe to the hub for a larger
“handle”) and rotate the catheter clockwise while applying gentle upward
traction. The site may be dressed with a band-aid.
C. The EZ-IO catheter must be removed within 24 hours of placement.
PROTOCOL 5.18: Medication Administration
Indications:
Illness or injury which requires medication to improve or maintain the patient’s

condition.
Precautions:
A. Certain medications can be administered via only one route, others via
several. If you are uncertain about the drug you are giving, check with
Medical Control.
B. Make certain that the medication you want to give is the one in your hand.
Always double check medication, dose, and expiration date before
administration.
Technique:
A. Use syringe just large enough to hold appropriate quantity of medication (or
use pre-filled syringe).
B. Use larger gauge needle (18-21 gauge) on syringe to draw up medication.
C. Break top from ampule by grasping it with 4X4’s to avoid being cut by glass.
D. Cleanse top of multi-dose vial with alcohol prep before drawing from it.
E. Using sterile technique, draw medication into syringe.
F. Change needles to smaller gauge (21 gauge or smaller) for IM or SQ

administration.
G. Needleless supplies will use essentially the same techniques as the needle
supplies except the needles will be replaced by blunt cannulas, filter straws
and Luer lock connections.
Intravenous (IV) Injection Technique:
A. Use size needle appropriate for viscosity of fluid injected. Glucose requires
larger gauge needle (18 gauge), for most other medications 20 gauge or
smaller is appropriate.
B. Cleanse IV tubing injection site with alcohol prep.
PROTOCOL 5.18: Medication Administration (cont.)
Intravenous (IV) Injection Technique (cont.):
C. Check medication in hand - confirm medication, dose, and amount.
D. Eject air from syringe.
E. Insert needle into injection site.
F. Pinch IV tubing closed between bottle and needle.
G. Inject at rate slow enough to stop if any untoward effects develop (except
with medications that require a rapid push) .
H. Withdraw needle and release tubing to restore flow.
I. Record medication given, dose, amount, and time.
Endotracheal (ET) Injection Technique:
A. Prepare medication to be given. Dilute with NS so that the drug administered

is in a total volume consistent with Endotracheal Drug Administration
Protocol 5.14.
B. Ventilate fully 4-5 times prior to disconnecting the bag from the endotracheal
tube.
C. Check medication in hand. Confirm medication, dose, and amount.
D. Administer the appropriate dose into the endotracheal tube.
E. Connect the bag and ventilate fully an additional 4-5 times.
F. Record medication given, dose, amount, and time.
Intramuscular (IM) Injection Technique:
A. Use long 21-22 gauge needle (1 - 1.5”).
B. Check medication in hand - confirm medication, dose and amount.
C. Select injection site (usually deltoid, but may be upper outer quadrant of
gluteus if more convenient).
Intramuscular (IM) Injection Technique (cont.)
D. Cleanse site with alcohol prep.
E. Eject air from syringe.
F. Stretch skin over injection site.
G. Insert needle through skin into muscle, aspirate and if no blood returns, inject
medication.
H. Remove needle and put pressure over injection site with sterile gauze.
I. Record medication given, dose, amount, time.
Subcutaneous (SQ) Injection Technique:
A. Use 25 gauge needle 5/8” length for most subcutaneous injections.
B. Check medication in hand - confirm medication, dose, and amount.
C. Select injection site (usually just distal and posterior to deltoid).
D. Cleanse site with alcohol prep.
E. Eject air from syringe.
F. Insert needle tangentially, just underneath the skin.
G. Aspirate and, if no blood returns, inject medication.
H. Remove needle and put pressure over injection site with sterile gauze.
I. Record medication given, dose, amount, and time.
Complications:
A. Local extravasation during IV medication injection, particularly with calcium

or dextrose, can cause tissue necrosis. Watch carefully and be ready to stop
injection immediately.
B. Allergic and anaphylactic reactions occur more rapidly with IV injections, but
may occur with medication administered by any route.
C. Too rapid IV injection of some drugs can cause untoward side effects; for
example, Valium can cause apnea, and Epinephrine can cause severe
hypertension and malignant arrhythmias.
D. IM or SQ injection can cause uncertain medication levels over time. Later

treatment may be jeopardized because of slow release and late effects of
medication given hours before.
Special Notes:
A. Several medications are carried in different concentrations in a Paramedics

drug box. Be sure you are using the correct concentration!
B. Carry pediatric drugs in separate areas of the drug box or in a completely

separate box.
C. Endotracheal medication administration may provide onset of drug effect

almost as rapid as with IV administration.
PROTOCOL 5.19: Nebulized Bronchodilators
Indications:
A. Nebulized bronchodilators are indicated for relief of bronchospasm in

patients with reversible obstructive airway disease, including asthma.
B. Indicated in the treatment of bronchospasm related to anaphylactic reaction.
Note: Albuterol is the only bronchodilator currently in use in the Rapid City
Pennington County EMS system. Contraindications and Precautions for the
use of nebulized bronchodilators are those found in the Drug Summary for
Albuterol.
Technique:
A. Twist open the top of one unit dose of Albuterol Sulfate and pour contents
into the nebulizer reservoir.
B. Assemble the unit including the mouth piece, and oxygen supply tubing.
C. Insure that the unit is held upright to facilitate proper updraft and nebulization
of the medication.
D. Connect to oxygen source and set flow at 7-8 liters per minute until “vapor” is
coming out of the unit.
E. Have the patient sit upright and close their lips around the mouth piece.
Have them breathe the medication in and out as slowly and as deeply as
possible. Encourage the patient to keep their lips closed around the mouth
piece.
F. To assist in effectively administering the drug, the patient should be coached

deep, smooth, slow breaths.
G. In children unable to use mouthpiece, administer by mask (mask can be

made by removing reservoir from non-rebreather mask and attaching tee
without mouthpiece to mask) or by removing mouthpiece from tubing.
H. Nebulized bronchodilators may be given via an endotracheal tube with the

proper ET Neb set-up.
PROTOCOL 5.19: Nebulized Bronchodilators (cont.)
Technique (cont.):
I. Nebulized Bronchodilator treatments may be administered to a total of three

if the Paramedic believes the patient’s clinical condition warrants it. If the
Paramedic believes successive treatments are warranted, Medical Control
must be contacted.
Special Notes:
A. Proper technique in the administration of Nebulized Bronchodilators is crucial

to its successful delivery into the lower airways.
B. Patient’s ECG should be monitored if the patient has a cardiac history, is

elderly or the Paramedic believes the patient may possibly have an
undesirable cardiac effect from the administration of the drug. (cardiac
monitoring should be done on these patients more often then it is not done).
C. An IV line should be placed if clinically indicated.
PROTOCOL 5.20: Pain Management
Indications:
A. The patient that presents with severe pain/discomfort from an isolated

orthopedic injury. These may include but are not limited to, fractured or
possibly fractured extremities, joint injuries and dislocations.
B. The patient that presents with severe pain/discomfort from thermal, chemical
or electrical burns that are more extensive then can be considered “minor” (a
minor burn is one that can be covered with the hand).
Contraindications:
A. Carefully evaluate and examine the patient and consider the mechanism
of injury. Pain management will be contraindicated in the following patients:
1. Any patient with trauma to the head, chest or abdomen.
2. Any patient with an altered level of consciousness.
3. Any patient that is not hemodynamically stable (systolic BP < 90).
B. Other contraindications and precautions are those found in the Drug

Summaries for Morphine and Fentanyl.
Technique:
A. Administer Fentanyl slow IV 50-100 mcg (1 mcg/kg) slow (over 1-2 min.)
IV/IO. May repeat as necessary to a total of 150 mcg. If IV route not
available, may give single IM dose of 100 mcg. Dose to effect.
OR:
B. Administer Morphine Sulfate slow IVP in 2-4 mg increments to a total of 10

mg. Dose to effect.
C. If using Morphine, also administer 4 mg Zofran (Ondansetron) IV to control

nausea and vomiting.
D. Use caution with narcotic analgesics in any patient > age 65.
PROTOCOL 5.20: Pain Management (cont.)
Special Notes:
A. Contact Medical Control if patient requires more than the maximum allowable
dose of either Morphine Sulfate or Fentanyl.
B. Contact Medical Control for pain management in the pediatric patient.
PROTOCOL 5.21: Peripheral IV line Insertion
Indications:
1. Administer fluids for volume expansion.
2. Administer medications.
Precautions:
A. Do not start IVs distal to a fracture site or through skin damaged with more
than erythema or superficial abrasion.
B. Make certain the IV solution in hand is correct and the expiration date has
not passed.
Technique:
A. Extremity:
1. Explain the procedure to the patient when possible.

2. Connect tubing to IV solution bag.
3. Fill drip chamber one-hall full by squeezing.
4. Use 10 gtt set for trauma or any volume expansion. Use 60 gtt set for
most medical situations and pediatric patients.
5. Tear sufficient tape to anchor IV in place.
6. Apply tourniquet proximal to proposed site. Alternatively, use blood
pressure cuff blown up to 40 mm Hg.
7. Scrub insertion site with alcohol prep.
8. Hold vein in place by applying gentle traction on vein distal to point of
entry.
9. Puncture the skin with the bevel of the needle upward about 0.5 to 1 cm
from the vein and enter the vein from the side or from above.
10. Note blood return and advance the catheter either over the needle into
the vein.
11. Remove needle assembly and connect tubing.
12. Release tourniquet (most frequent cause of IV not flowing).
13. Open IV tubing clamp full to check flow and placement, then slow rate to
TKO or desired rate.
14. Secure tubing with tape, making sure of at least one 180 degree turn in
the taped tubing to be sure any traction on the tubing is not transmitted
to the catheter itself (alternatively, use commercial IV site device).
15. Anchor with arm board or splint if needed to minimize chance of losing
line with movement.
16. Recheck to be sure IV rate is as desired and monitor.
PROTOCOL 5.21: Peripheral IV line Insertion (cont.)
B. External Jugular Vein:
1. Explain the procedure to the patient when possible.

2. Connect tubing to IV solution bag.
3. Fill drip chamber one-half full by squeezing.
4. Use 10 gtt set for trauma or any volume expansion. Use 60 gtt set for
most medical situations and pediatric patients.
5. Tear sufficient tape to anchor IV in place.
6. Position the patient: supine, head down if possible (this may not be
necessary or desirable if congestive heart failure or respiratory distress
present). Turn patient’s head to opposite side from procedure.
7. In trauma patient, open C-Collar, keep head and neck in neutral position.
Do not move patients head. .
8. If not contraindicated, expose vein by having patient bear down.
“Tourniquet” vein with finger pressure just above clavicle.
9. Scrub insertion site with alcohol prep.
10. Align the catheter in the direction of the vein, with the point aimed toward
the shoulder on the same side (it may be useful to bend the catheter
slightly to facilitate alignment).
11. Puncture skin over vein first, then puncture vein itself. Use other hand to
traction vein near clavicle to prevent rolling.
12. Advance catheter well into vein once it is penetrated. Attach IV tubing.
13. Open IV tubing clamp full to check flow and placement, then slow rate to
TKO or rate desired.
14. Secure tubing with tape, making sure of at least one 180 degree turn in
the taped tubing to be sure any traction on the tubing is not transmitted
to the cannula itself.
13. Recheck to be sure IV rate is as desired and monitor.
Complications:
A. Pyrogenic reactions due to contaminated fluids become evident in about 30

minutes after starting the IV. Patient will develop fever, chills, nausea,
vomiting, headache, backache, or general malaise. If observed, stop and
remove IV immediately. Save the solution so it may be cultured.
B. Local: Hematoma formation, infection, thrombosis, phlebitis. Note: The

incidence of phlebitis is particularly high in the leg. Avoid use of lower
extremity if possible.
C. Systemic: Sepsis, catheter fragment embolus, fiber embolus from solution

in IV.
PROTOCOL 5.21: Peripheral IV line Insertion (cont.)
Special Notes:
A. Always use the biggest vein that is accessible. Antecubital veins are useful
access sites, but if possible, avoid areas near joints (or splint well). Given
the choice between a big vein near a joint and a smaller vein elsewhere that
may be harder to access, use the bigger vein and splint.
B. The point between the junction of two veins (bifurcation) is more stable and
often easier to use.
C. Start distally and if successive attempts are necessary, you will be able to
make more proximal attempts on the same vein without extravasating IV
fluid.
D. Venipuncture itself is seldom morbid. The excess fluids inadvertently run

in when nobody is watching can be fatal!
E. One of the most difficult problem with IV insertion is to know when to try and
when to stop trying. IV solutions in the proper setting may “buy time”, but in
the field they may frequently lose time instead. Generally, one attempt at the
scene is worthwhile if there is a delay in loading the patient. Successive
attempts should always be done enroute (especially if the patient is critical).
F. When starting external jugular IV’s, if pressure in vein not sufficient to give
flash-back, attach syringe to catheter assembly and aspirate to confirm entry
into the vein.
Protocol 5.22: Restraint (Physical and Chemical)
Indications:
Use of physical and or chemical restraint on patients is permissible if the patient

poses a danger to himself or others. Only reasonable force is allowable, i.e., the
minimum amount of force necessary to control the patient and prevent harm to
the patient or others. Contact Medical Control for physician direction if there is
uncertainty as to whether or not the use of restraints is warranted to transport the
unwilling or uncooperative patient.
Restraints are to be applied to patients only in limited circumstances:
A. A patient whose medical or mental condition warrants immediate ambulance

transport and who is exhibiting behavior that the pre-hospital provider feels
does or will endanger the patient or others.
B. The pre-hospital provider reasonably believes that the patient’s life or health
is in danger and that delay in treatment and transport would further endanger
the patient’s life or health, and there is no reasonable opportunity to obtain
the necessary consent to provide treatment or obtain informed refusal.
C. The patient is being transported under the direction of a mental health hold,
security hold, or police custody.
Precautions:
A. Restraints shall be used only when necessary to prevent a patient from

seriously injuring himself or others (including the ambulance crew), and only
if safe transportation and treatment of the patient cannot be done without
restraints. They may not be used as punishment, or for the convenience of
the crew.
B. Any attempt to restrain a patient will involve risk to the patient and the pre-
hospital provider. Efforts to restrain the patient should only be done with
adequate assistance present. Obtain law enforcement assistance.
C. Be sure to evaluate the patient adequately to determine the medical

condition, mental status and decision-making capacity of the patient. The
hostile, angry, unwilling patient who is alert, oriented, aware of his condition
and capable of understanding the consequences of his refusal is entitled to
refuse treatment.
D. Be sure that the restraints are in good condition (will not break and will not
injure the patient).
Protocol 5.22: Restraint (Physical and Chemical) (cont.)
Precautions (cont.):
E. Do not transport patients in the prone position or use “hobble” restraints.
F. Ensure that the patient has been searched for weapons.
Technique:
Physical Restraint
A. Determine that the patient’s medical or mental condition warrants ambulance

transport to the hospital and that the patient lacks decision-making capacity,
or there is basis for police custody or a mental health hold to be instituted.
B. Treat the patient with respect. Efforts to verbally calm the patient may avoid
the need for restraints. To the extent possible, explain what is being done
and why.
C. Have all equipment and personnel ready (restraints, suction, a means to

promptly remove restraints, and adequate number of personnel).
D. Use sufficient assistance so that, if possible, one rescuer handles each limb
and one manages the head or supervises the application of restraints.
E. Consider the patient’s strength and range of motion in the need for and
method of applying restraints.
F. Apply restraints to the extent necessary to subdue the patient. Do not use
restraints to punish the patient.
G. After application of restraints, check all limbs for circulation. During the time
that a patient is in restraints, an assessment of the patient’s condition and
vital signs shall be made at least every five minutes, but more frequently if
conditions warrant.
H. During transport and pending the arrival at the hospital, the patient shall be
kept under constant supervision.
Technique (cont.):
I. The Patient Care Report will include: a complete description of the facts
justifying the use of restraints; the type of restraints; a description of the
steps taken to assure that the patient’s needs, comfort and safety; the
condition of the patient during restraint, including re-evaluations during
transport; and the condition of the patient on arrival at the hospital.
J. Removal of restraints should be done with sufficient manpower and caution

to assure protection of the patient and healthcare providers. Utilize law
enforcement assistance if necessary and if possible.
K. Handcuffs or other “hard restraints” are not to be applied by pre-hospital

providers. If police apply handcuffs the officer should be requested to stay
with the patient and ride in the ambulance during transport. A handcuff key
may be needed if patient deteriorates suddenly.
L. The patient that spits or attempts to bite will have an infection control mask or
a non-rebreather mask at 8-10 lpm placed. Do not “gag” such a patient or
put a covering such as a sheet or towel over their face. It may interfere with
an already compromised respiratory effort.
M. The use of chemical restraints should be considered if the patient continues

to struggle against physical restraint and remains uncooperative, violent or
combative.
Chemical Restraint
A. NOTE: CHEMICAL RESTRAINT IS A LEVEL II INTERVENTION AND

MEDICAL CONTROL MUST BE CONTACTED.
B. Chemical restraint will be used in conjunction with physical restraint for the
purpose of additional control of agitation, violence or combativeness during
treatment and transport.
C. Continuous monitoring will be done of the patient’s respiratory rate, O2

saturation and ECG. That monitoring will continue on arrival at the hospital
during the transfer of the patient from the ambulance to the hospital bed.
Technique / Chemical Restraint (cont.):
D. Administer:
1. Haldol: Adult – 2.5 mg IM or IV, up to 5 mg
Pediatric – 0.1 mg IM or IV
2. Ativan (Lorazepam) – 0.5 – 2 mg IM or IV
Special Notes:
A. Aspiration can occur, particularly if the patient is supine. It is the

responsibility of the Paramedic to continually monitor the patient’s airway. If
the patients condition does not contraindicate it, a low semi-fowlers position
or lateral position may be the best for transport.
B. Nerve injury can result from hard restraints (handcuffs).
C. Do not overlook the medical causes for combativeness, such as hypoxia,

hypoglycemia, stroke, hyperthermia, hypothermia, or drug ingestion.
D. Contraindications, precautions, and special considerations regarding the

use of chemical restraints are those found in the Drug Summary for Haldol.
PROTOCOL 5.23: SALINE LOCK INSERTION
Indications:
A. To administer medications.
B. Precautionary IV access.
Precautions:
A. Do not start IV s distal to fracture site or through skin damaged with more
than erythema or superficial abrasion.
B. Do not use saline locks on trauma patients or any hypotensive patient that
may require fluid replacement, use a regular peripheral IV with a bag of NS.
Technique:
A. Explain procedure to the patient whenever possible.
B. Prepare extension set by flushing with normal saline.
C. Perform venipuncture as stated in Peripheral IV Line Insertion Protocol 5.20.
D. Attach extension set cap to IV catheter.
E. Flush with approximately 3 ml normal saline. As the plunger is still moving

forward and the last ½ ml is being injected, withdraw the needle (or blunt
cannula from the extension set. Maintaining a positive pressure in the
catheter will prevent backflow of blood.
F. Tape in place (alternatively, use commercial IV site device).
G. Administering medications:
1. Wipe extension set site with alcohol prep.

2. Flush with 3 ml normal saline.
3. Administer medication.
4. Flush with 3 ml normal saline. Maintain positive pressure on syringe
while last ½ ml is injected and needle is withdrawn from cap.
PROTOCOL 5.24: Spinal Immobilization
Indications:
A. Cervical or upper one-third thoracic spinal tenderness, pain on palpation,

pain with movement, or neurological deficit (associated distal weakness,
numbness, tingling, or paralysis).
B. Swelling or deformity of the spine which may be due to fracture, dislocation,

or ligamentous instability.
C. All trauma patients who are unconscious or present with an altered level of
consciousness due to traumatic head injury or drug and/or alcohol ingestion.
D. Patients with significant head trauma or who have experienced a significant

mechanism of injury that cannot be ruled out by an accurate exam or history
that present with the potential for unrecognized co-existent spinal trauma.
Note: Perform and document a complete neurologic exam prior to and after
movement of the patient. Re-document a complete exam after splinting and
upon delivery to the hospital.
Technique:
A. Use assistant to apply neutral in-line stabilization while completing primary

survey.
B. Assess and document neurologic findings.
C. Advise the patient of the procedure and purpose before and during
application.
D. Apply a rigid cervical collar to immobilize the cervical spine.
E. Prepare to move the patient to a long back board or to apply a KED as the
situation dictates.
Note: Because a patient has been ambulatory prior to the arrival of EMS
does not preclude the need for spinal immobilization. If a patient that
has been ambulatory needs to be immobilized, it should be performed
as the patient is found (sitting, standing, lying). Under no
circumstances will a patient be allowed to walk to a backboard and lay
down on it.
PROTOCOL 5.24: Spinal Immobilization (cont.)
Technique (cont.):
F. Use the KED for seated patients provided they are stable and rapid
extrication is not required.
1. Slide the KED behind the patient and position chest panels up into the
armpits.
2. Apply chest straps.
3. Apply leg straps.
4. Secure the head using padding where necessary to ensure a neutral in-
line position.
G. Prepare to move the patient to a long spine board ensuring that adequate
manpower, straps and a cervical immobilization device (CID) are at hand.
1. Logroll or lift the patient to the board as a unit.

2. Release the leg straps if a KED was used.
3. Use appropriate padding behind the neck, back, or knees in order to
ensure proper in-line immobilization.
4. Apply straps to secure the chest, thighs and lower legs to the board
(minimum of 3 straps, 4 are preferred)
5. Secure the head using a cervical immobilization device (CID) and tape.
H. Helmets:
1. Remove helmets only when they prevent proper in- line immobilization
and or airway control
a. Football helmets: Leave football helmets in place if the patient is

also wearing shoulder pads, that will provide neutral in-line
immobilization. Removal of the facemask portion of the helmet will in
most cases allow for airway control (can be done with Phillips
screwdriver or trainers tool). If required, complete removal of the
helmet will also necessitate removal of shoulder pads and other
protective equipment.
b. Motorcycle/and other sporting helmets: In most cases these helmets

will need to be removed to provide for airway control and in-line
immobilization unless other auxiliary protective equipment
(Motocross pads) are in place or appropriate padding can be applied
to ensure a neutral in-line position. When removing a helmet always
use an approved BTLS / PHTLS technique.
Technique (cont.):
I. When immobilizing the pediatric patient, use pediatric specific equipment,

don’t try to make adult equipment fit.
J. Re-assess and re-document neurologic findings.
Spinal Immobilization Exclusion Criteria:
A. Assess and document neurologic findings.
B. Spinal immobilization may not be required in all situations and may be

deferred in the patient who meets the following criteria:
1. Is able to present a complete and reliable history.
2. Is without cervical or thoracic pain and/or tenderness and deformity on

palpation.
3. Is able to exhibit, upon a complete spinal assessment, a full range of

motion without pain, and/or associated distal weakness, numbness,
tingling, or paralysis.
4. Is without an event related altered mental status or loss of

consciousness.
5 Is not under the influence of intoxicating medications, alcohol, or drugs.
6. Does not have a “distracting injury” (is not distracted by another painful
injury or emotional condition that may mask the potential for injury to the
spine).
7. Does not present with a language or other communication barrier that

inhibits a reliable exam and history.
C. Re-assess and re-document neurologic findings.
Complications:
A. Spinal immobilization is not a benign procedure. Be aware of the possibility

of increasing chronic lower back injuries and pain and the potential for
decubitus ulcers in patients with spinal compromise.
B. Complete airway control is assumed and immobilization must be secure

enough to allow rolling and other movement of the patient.
C. Injuries below the level of cord damage will be difficult to diagnose and
special care must be taken in your primary and continued assessment.
Special Notes:
A. Application of a cervical collar by itself does not constitute adequate spinal

immobilization. Cervical collars are to be used in conjunction with long back
boards and cervical immobilization devices; with the addition of the KED
when appropriate.
B. When fitting a cervical collar to a patient, take care to see that you have the
right size collar, it is adjusted and applied properly. A poorly fit, poorly
applied cervical collar can be worse than none at all.
C. When immobilizing a patient on a long backboard, take care that the patient
is “straight” and even on the board, both lengthwise and side to side. Assure
that the patients head and neck are fixed in the cervical immobilization
device in a neutral, “straight” manner as well and not pulled to one side or the
other. Again, poor immobilization can be worse than none at all.
PROTOCOL 5.25: Splinting, Extremity
Indications:
A. Pain, swelling or deformity in an extremity which may be due to fracture or

dislocation.
B. In an unstable extremity injury: to reduce pain, limit bleeding at the site of

injury, and prevent further injury to soft tissues, blood vessels or nerves.
Precautions:
A. Transport of critically injured trauma patients should not be delayed by

lengthy evaluation of possible non-critical extremity injuries. Prevention of
further damage is accomplished by securing the patient to a long back board
when other injures demand prompt treatment.
B. The patient with an altered level of consciousness from head injury or drug
ingestion should be carefully examined and conservatively treated, because
their ability to recognize pain and injury is impaired.
C. Check to make sure the obvious injury is also the only one. It is very easy to
miss fractures proximal to the most visible one.
D. In a stable patient in which no environmental hazard exists, splinting should

be done prior to moving the patient.
E. Never deliberately test for crepitus or instability.
Technique:
A. Assess pulse, movement, and sensation distally prior to splinting or

movement.
B. Remove bracelets, watches, or other constricting bands prior to splint

application.
C. Identify and dress open wounds. Note wounds which contain exposed bone
or lie near fracture sites.
D. Avoid sudden or unnecessary movement of fracture site to minimize pain and

soft tissue damage.
E. Choose splint to immobilize joint above and below injury. Rigid cardboard
splints are best for long bones, pillow splint can be used for wrists, ankles,
etc. Pad rigid splints to prevent pressure injury to extremity.
PROTOCOL 5.25: Splinting, Extremity (cont.)
Technique (cont.):
F. Apply gentle continuous traction to extremity and support to fracture site

during splinting operation.
G. Re-assess distal pulses, movement and sensation after splinting.
Traction Splinting Technique (for suspected femur fractures):
A. Use two persons for splint application procedure.
B. Immobilize the affected extremity. Remove sock and shoe and check for
distal pulse and sensation.
C. Identify and dress open wounds, note exposed bone or wounds overlying
fracture sites.
D. Measure and adjust splint length prior to application for the Hare. If using
Sager, make sure it is not too long. Use pediatric models where necessary.
E. Hare application:
1. Apply ankle hitch and pull gentle traction, reducing angulation or open
fractures. Support calf and thigh throughout the application of the Hare.
2. Position ischial pad under buttocks, up against bony prominence (ischial

tuberosity) for the Hare. Empty pockets if needed.
3. Secure groin strap.
4. Maintain continuous traction for the Hare, and support to fracture site
throughout procedure.
5. Apply traction to the Hare without losing the traction the assistant is
holding with the ankle hitch. Adjust the traction until the assistant no
longer needs to hold the ankle hitch and the patient experiences an
improvement in comfort (movement at the fracture site will cause some
pain, but increased traction continues to cause increased pain, do not
proceed. Splint and support leg in position of most comfort).
6. Adjust support straps to appropriate positions under leg.
7. Secure support straps after traction properly adjusted
PROTOCOL 5.25: Splinting, Extremity (cont.)
Traction Splinting Technique (cont.):
F. Sager application:
1. Position the ischial pad into the groin avoiding the genitals.
2. Apply the ankle hitch for the Sager.
3. Maintain continuous stabilization and support to fracture site throughout

procedure.
4. Apply traction by extending the Sager to achieve a force of 10% of body

weight utilizing the same principles as the Hare for comfort.
5. Place and adjust support straps to appropriate positions under leg.
6. Secure support straps after traction properly adjusted.
G. Re-assess distal pulses and sensation after splinting with both devices.
H. Do not apply Hare or Sager traction devices if pelvic, knee or lower extremity
fractures exist or are suspected.
PROTOCOL 5.26: Stroke (CVA) “Stroke Alert”
Rationale:
In the past, there was not much available in the way of acute care for the stroke
patient. All that was really able to be accomplished was supportive care and to
make attempts to prevent recurrence.
More aggressive stroke treatment programs are starting to be seen. These
include more advanced assessment, diagnostic and treatment modalities, to
include consideration of the use of thrombolytic therapy.
EMS providers can help reduce the morbidity and mortality of the stroke patient
by identifying those stroke patients who may benefit from newer treatment
modalities, and making early notification to the receiving medical facility so they
can prepare to implement treatment.
Technique:
A. If patient meets “stroke alert” criteria, treat with the same urgency as AMI
or head trauma.
B. Treat patient using the treatment protocol that best addresses the signs and
symptoms they present with. If unconscious, hyperventilate and consider
intubation using Lidocaine 1mg/kg to reduce increased intracranial pressure.
C. Obtain as thorough and complete a history as is possible of both the present

event and past medical history. The patient that falls within a 3 hour time
frame from first onset of symptoms initially meets “stroke alert” criteria.
Complete the Stroke Exclusionary Criteria for Thrombolytics Survey
(below) as completely as possible without delaying transport..
D. Maintain head/neck in neutral alignment, do not use pillows.
E. Bradycardia may be present due to increased intracranial pressure. Atropine

is not to be given if the systolic BP is above 90.
F. If altered mental status, seizure activity, or focal neurological deficit: obtain

and record blood glucose level. If glucose <70, administer D50 IVP. Note
response.
G. If seizure occurs: Valium or Ativan as needed per Seizure Protocol 2.24.
H. If patient does not have any criteria that would exclude them from the use of
thrombolytics per the Stroke Exclusionary Criteria Survey, notify receiving
hospital and advise that you have a patient that meets stroke alert criteria.
Transport patient red lights and siren (hot) to hospital.
PROTOCOL 5.26: Stroke (CVA) “Stroke Alert” (cont.)
Stroke Exclusionary Criteria for Thrombolytics Survey
Greater than three (3) hours from symptom onset. (KEY QUESTION)
1. Stroke symptoms that are improving rapidly.
2. On repeated measurement, BP systolic greater than 185 or BP diastolic

greater than 110.
3. Isolated minor neurological deficits (i.e. ataxia alone, sensory loss alone,
minimal weakness).
4. Within 3 months of intracranial surgery, serious head trauma, or previous

stroke.
5. Within 14 days of major surgery or serious trauma.
6. History of prior intracranial hemorrhage, aneurysm or arteriovenous

malformation.
7. Recent AMI.
8. GI or urinary tract bleeding within last 3 weeks.
9. Known bleeding diathesis, including but not limited to low platelet counts,
Heparin use within the last 48 hours or recent use of anticoagulants such as
Coumadin.
10. Witnessed seizure at stroke onset or known active seizure disorder.
11. Recent arterial puncture at a non-compressible site or a lumbar puncture

within the last 7 days.
12. Blood glucose less than 70 or greater than 400.
13. Severe neurological deficits such as coma, severe obtundation.
14. Any other seriously advanced illness or terminal condition.
PROTOCOL 5.27: Tension Pneumothorax Decompression
Indications:
A. Increasing respiratory insufficiency in a susceptible patient:
1. Neglected spontaneous pneumothorax.
2. Cardiac arrest with CPR in progress and appearance of PEA with

increased difficulty ventilating patient.
3. Sucking chest wound which has been covered completely.
4. Chest trauma with suspected pneumothorax.
B. Patient must also have three or more of the below (signs of tension):
1. Systolic blood pressure less than 90 mm Hg
2. Cyanosis and progressively more severe respiratory distress
3. Decreased or absent breath sounds with hyper-expanded chest
4. Jugular venous distension
5. Tracheal shift
6. Subcutaneous emphysema
Precautions:
A. Be sure to understand the difference between the two types of

pneumothorax. A SIMPLE pneumothorax causes some degree of respiratory
difficulty and possibly chest pain. It MAY be associated with a decrease or
absent breath sounds on the side of the collapse (not necessarily!!) and
subcutaneous air if the cause is traumatic. Most patients will tolerate a
simple pneumothorax rather well in the short term and it should not be
treated in the field.
TENSION pneumothorax is associated with progressive respiratory difficulty,

dropping blood pressure, a “drum-like” hyper-expanded chest, distended
neck veins, and general patient deterioration. Tracheal shift may or may not
be present.
Signs of pneumothorax as well as signs of tension must be present before

treatment is undertaken. Accurate diagnosis is critical!
PROTOCOL 5.27: Tension Pneumothorax Decompression (cont.)
Precautions (cont.):
B. Pneumothorax rarely presents with tension on initial assessment. Be

particularly suspicious with deterioration during transport and with patients
requiring assisted ventilation.
Technique:
A. NOTE: CHEST DECOMPRESSION IS A LEVEL II INTERVENTION AND

MEDICAL CONTROL MUST BE CONTACTED BEFORE BEING
ATTEMPTED
B. If covered sucking chest wound is present, remove the seal and allow chest
pressures to equilibrate. No further treatment may be necessary.
C. Needle decompression (Cook Pneumothorax Kit):
1. Expose the entire chest.
2. Clean area for insertion vigorously: alcohol or iodine/Betadine.
3. Attach 20 ml syringe to catheter/introducer needle.
4. Attach blue Molnar disc to catheter/introducer needle and slide up to hub

of catheter (Molnar disc is used to adjust depth of catheter).
5. Insert catheter/introducer needle into the pleural space by entering the

chest in the second intercostal space in the mid-clavicular line. The
catheter should be inserted on the top of the rib so as to avoid the
intercostal vessels and nerve. If rib is struck, slid over top of rib.
5. When tension is present, plunger will blow back out of the syringe, or an
immediate hiss of air escaping will be heard.
6. If no hiss or evidence of tension is seen, remove catheter/introducer

needle and reassess reason for patient deterioration.
7. If air under pressure is demonstrated, remove the introducer needle

(trocar) and advance the catheter. Fix catheter at the desired depth with
the Molnar disc and the enclosed pull-tie.
PROTOCOL 5.27: Tension Pneumothorax Decompression (cont.)
Technique (cont.):
8. Attach one-way stopcock, clear connecting tube and Heimlich flutter

valve to catheter hub. (see Illustration 5.I below). Orient to direction of
airflow and tape assembly securely to patients chest. Leave one-way
petcock OPEN.
D. If pediatric or small adult patient, 14 - 18 gauge unprotected angiocath may

be used. Attach syringe or leave angiocath open and follow above
procedure. Flutter valve and 1-way stopcock from Cook kit may be used if
desired.
A second catheter may be needed for severe air leak.
E. If patient deteriorates after needle decompression, be prepared to assist

ventilation (if not already doing so) and continue hyper-oxygenating.
Complications:
A. Creation of pneumothorax if none existed previously.
B. Pulmonary edema from release of collapsed lung, particularly in spontaneous

pneumothorax.
C. Laceration of the lung.
D. Laceration of blood vessels: slide above rib (intercostal vessels run in the
groove under each rib).
E. Infection: clean rapidly but vigorously; use sterile gloves if available.
Special Notes:
A. Sudden onset of chest pain and shortness of breath in a normal individual

may be caused by a pneumothorax (particularly in patients with chronic lung
disease or asthmatics). These rarely do, but can also progress to a “tension”
state.
ILLUSTRATION 5.I.
COOK EMERGENCY PNEUMOTHORAX KIT
Unassembled
CATHETER W / INTRODUCER NEEDLE
HEIMLICH FLUTTER VALVE
CONNECTING TUBE ONE-WAY

STOPCOCK
20 ML SYRINGE
MOLNAR DISC
WITH PULL-TIE
Assembled
PROTOCOL 5.28: TRAUMA ALERT
Indications:
The morbidity and mortality of the seriously injured trauma patient can be
reduced by decreasing the amount of time between the time the patient is
injured, and the time the patient receives definitive, in-hospital evaluation and
treatment.
The purpose of the Trauma Alert system is to bring together in a timely manner,
the necessary trauma services resources to quickly and definitively evaluate and
treat the seriously injured trauma patient.
Technique:
A. Trauma Alerts are not “called” in the field. When a patient is encountered
that meets Trauma Alert criteria, as soon as is possible, (preferably before
transport) the Paramedic (or the Paramedic’s designee) either by phone or
radio, will contact the RCRH ED and advise that you have a patient that
meets Trauma Alert criteria. This should be followed by a short report
detailing the patient’s condition and the nature of their injuries. Trauma Alert
criteria found should specifically be included in this short report. A more
detailed report should be given later enroute to the hospital as time allows.
B. A Trauma Alert notification will be made to RCRH for a patient who

demonstrates any of the following:
1. Respiratory compromise (persistent manifestation of respiratory rate less

than 10/min. or more than 29/min).
2. Glasgow Coma Scale at or below 12, attributable to trauma.
3. Systolic blood pressure below 90.
4. Penetrating injury to any of the following:
a. head
b. neck
c. chest
d. abdomen
PROTOCOL 5.28: TRAUMA ALERT (cont.)
Technique (cont.):
5. Severe burns
a. Total body surface area > 20%
b. Face/airway involvement
6. Spinal cord injury with hypotension
7. Physician discretion
C. All patients that meet Trauma Alert criteria will be transported red lights and
siren (hot) to the hospital.
Special Notes:
A. All patients that meet Trauma Alert criteria should receive rapid transport to
the hospital; with as short scene times as are possible and most definitive
pre-hospital treatment performed enroute.
PROTOCOL 5.29: 12 LEAD ECG
Indications:
A. A 12-lead ECG should be obtained whenever possible on the patient that

exhibits signs and symptoms of an acute coronary syndrome (ACS). These
syndromes include ST elevation, Acute Myocardial Infarction and unstable
angina. This will typically be patients who are suffering from chest pain of
probable cardiac origin.
B. Patients who have a significant cardiac arrhythmia, but not the usual
presentation of an acute coronary syndrome may be good candidates as
well. Examples are patients with A-Fib vs SVT, those with wide complex
tachycardia of uncertain origin and those with symptoms of congestive heart
failure.
C. Other patients with an atypical presentation of an ACS, such as a syncopal

episode, unexplained diaphoresis and weakness may be candidates for a 12-
lead ECG as well.
Precautions:
A. While the acquisition of a 12-lead ECG can prove to be a valuable diagnostic

tool, excessive time should not be spent in the field obtaining one if the
patient is gravely ill. If necessary, try to obtain and send (if necessary) the
12-lead while the patient is being packaged for transport or enroute to the
hospital.
Technique:
A. Explain the procedure to the patient whenever possible.
B. Preparation of the skin to remove oils and dead skin cells and the elimination
of muscle tension are important in obtaining a noise-free 12-lead.
1. Cleanse the skin at the electrode sites with alcohol preps and rub with a
towel or gauze. Shave excessive hair.
2. Position the patients arms and legs in a comfortable position in which the
extremities are resting on a supportive surface. Any self-support of the
limbs by the patient may introduce fine muscle artifact even though the
patient does not appear to be moving.
C. Any patient that is going to have a 12-lead done should have had a standard
3, 4 or 5-lead ECG reading done first.
PROTOCOL 5.29: 12 LEAD ECG (cont.)
Technique (cont.):
D. If the Paramedic believes the patient may require a 12-lead to be obtained,

the limb lead electrodes from the 3-lead reading should NOT be placed on
the torso, they should be placed on the limbs (or replaced to the limbs if
originally on the torso). Typical placement is on the inside of the wrists and
the inner aspects of the legs near the ankles, but they may also be placed
more proximally on the deltoids and upper legs. Proximal placement rather
than distal placement of limb leads may result in a more noise-free ECG.
Placement of limb leads on the torso may result in a non-standard 12-lead.
E. Attach the MRX precordial lead attachment cable to the patient monitoring
cable .
F. Precordial lead placement: (see Illustration 5.J. below)
1. V1 Fourth intercostal space to the right of the sternum.
2. V2 Fourth intercostal space to the left of the sternum.
3. V3 Directly between leads V2 and V4.
4. V4 Fifth intercostal space a midclavicular line.
5. V5 Level with V4 at left anterior axillary line.
6. V6 Level with V5 at left midaxillary line.
G. Assure that all limb leads and precordial leads are firmly attached to the
proper electrodes.
H. Turn Therapy Knob to Monitor (if not already on).
I. Encourage the patient to remain as still as possible during to reduce artifact.
J. Press the 12 LEAD button. The 12-lead preview screen will be displayed,
check the signal quality on each lead and if necessary, make adjustments to
improve signal quality.
K. Press the START ACQUIRE button. The message “Acquiring 12-Lead” will
be displayed while the MRX acquires 10 seconds of ECG data. Encourage
the patient to remain still while the “Acquiring 12-Lead” message is
displayed.
Technique (cont.):
L. If patient age and sex were not previously entered, you are prompted to enter
the information. Use the NAVIGATION and MENU SELECT buttons to enter
the information. Pre-entered default is 55 y/o male.
M. Once ECG acquisition is complete, ECG analysis begins automatically and is

accompanied by the message “Analyzing 12-Lead”. The patient does not
need to remain still during this time.
N. Following analysis, a 12-lead ECG report is displayed, automatically printed

and stored internally.
Note: Do not depend on the MRX’s printed interpretive statements to

diagnose the presence or absence of AMI. Interpret yourself and or send 12-
Lead to hospital for interpretation.
O. To acquire another 12-Lead, press the NEW 12-LEAD button. To exit the
12-Lead function, press the EXIT 12-LEAD button.
P. A 12-lead should be transmitted to the hospital when any of the following

conditions exist:
1. Medical Control requests.
2. An ST elevation MI is suspected.
3. When a cardiac rhythm is unclear and physician interpretation may help

facilitate needed treatment in the field or enroute to the hospital.
4. Anytime transmitting the patients 12-Lead ECG to the hospital will help
expedite the patients treatment once they arrive.
This list should not be considered all inclusive, there may be other situations
under which it may be appropriate to transmit a 12-lead to the hospital.
Q. To transmit a 12-lead to the hospital printer:
1. Acquire 12-Lead (12-Lead Report View will be displayed).
2. Press the MENU SELECT button and using the NAVIGATION buttons,
select SEND from the menu. Press MENU SELECT again.
Technique (cont.):
3. Destination site will come up next, RCRH will be pre-configured

(highlighted). Press MENU SELECT button.
4. Transmission device will come up next, MOTOROLA PHONE will be pre-

configured (highlighted). Press MENU SELECT button.
5. Transmission will start, on screen displays will advise of the progress
ILLUSTRATION 5.J.
12-LEAD PRECORDIAL LEAD PLACEMENT
V1 Fourth intercostal space to the right

of the sternum
V2 Fourth intercostal space to the left

of the sternum
V3 Directly between leads V2 and V4
V4 Fifth intercostal space at left midclavicular line
V5 Level with lead V4 at left anterior axillary line
V6 Level with lead V5 at left midaxillary line
Pre-hospital Advanced Life Support Protocols Operational Protocols
Protocol 6.1: Advanced Directives / DNR Orders
General Principles:
A. This protocol is for the pre-hospital management of the statutory “Advanced

Directive/Do Not Resuscitate (DNR) document. This document expresses
the patients legally recognized right to have CPR and or certain types of
advanced care withheld in the event they are dying. This document is a
specifically identifiable form that is signed by the patient or the patients
authorized agent and is also signed by the patient’s physician.
B. In addition to the written Advanced Directive/DNR document, the patient or

authorized agent may have an Advanced Directive/DNR (Comfort One)
necklace or bracelet. This necklace or bracelet carries the same legal weight
as the document.
C. CPR and or certain types of advanced care shall be withheld or terminated if

the Advanced Directive/DNR document is readily accessible or if the
necklace or bracelet is worn by the patient.
D. An Advanced Directive/DNR order does not only apply to patients in full

cardiac arrest, but should also be honored in patients who are gravely ill and
near death.
Procedures:
A. Perform initial patient assessment.
B. Verify that the Advanced Directive/DNR order is a signed copy and is

unaltered (not defaced or altered physically in some manner).
C. Verify that the information on the document or, if present, on the back of the
necklace or bracelet reasonably appears to match the patient (name, age,
sex, etc.). If possible, try to verify the patient’s identity from a readily
available additional source such as a family member, drivers license, etc.
D. Upon verification of the patient’s identity, withhold CPR and or certain types
of advanced care (as noted below). If CPR or the noted advanced care has
already been started, it should be stopped.
E. If there is any question as to the validity of the Advanced Directive/DNR

order or the identity of the patient, initiate full resuscitative measures and
contact Medical Control for guidance.
Protocol 6.1: Advanced Directives / DNR Orders (cont.)
Procedures (cont.):
F. If the death occurs outside of a health care facility and the patient is not
under Hospice care, the coroner shall be contacted immediately, (see
Protocol 6.5: Field Determination of Death).
G. Provide appropriate emotional and customer service support to the family

wherever possible.
H. The following resuscitative measures are to be withheld or withdrawn from a

patient who has a valid Advanced Directive/DNR order:
1. CPR.
2. Endotracheal intubation or other advanced airway management.
3. Artificial ventilation.
4. Defibrillation.
5. Cardiac resuscitation medications and measures.
I. The following interventions may be administered or provided:
1. Assist in maintenance of the airway (non-advanced airway management

such as positioning).
2. Suctioning.
3. Oxygen.
4. Pain medication.
5. Control bleeding.
J. In addition to the standard patient care documentation, the following

information will be documented in the Patient Care Report:
1. Patients status when found.
2. Type of Advanced Directive/DNR order (document, bracelet, or

necklace).
Protocol 6.1: Advanced Directives / DNR Orders (cont.)
Procedures (cont.):
3. Any identifying number that appears on the document necklace or

bracelet.
4. Name of patients physician, if known.
5. Any special circumstances which justify initiating resuscitation, if this was

done despite the presence of the Advanced Directive/DNR order.
6. Cardiac monitor strips in at least two leads.
Additional Considerations:
A. The patient may revoke the Advanced Directive/DNR order at any time by
oral expression of revocation or by destruction of the Advanced
Directive/DNR order document, bracelet, or necklace. If the Advanced
Directive/DNR order was executed by a guardian, agent or proxy decision-
maker, then the Advanced Directive/DNR order may be revoked by the
guardian, agent, or proxy decision-maker.
B. CPR and or advanced measures are to be initiated if the Advanced

Directive/DNR order document, bracelet, or necklace is not readily available
(bedside with or being worn by the patient). The bracelet or necklace is only
available to the patient after the Advanced Directive/DNR order document
has been properly executed. Removal of the bracelet or necklace may be
construed as revocation. Therefore, if the necklace or bracelet is readily
accessible but not on the patient, any question as to whether the order has
been revoked should result in resuscitation until the situation is clarified.
Consult with Medical Control if there are questions about terminating care
and or transport.
C. If not in full cardiac arrest, patients with Advanced Directive/DNR orders may
still be transported to provide comfort measures.
D. In the absence of an Advanced Directive/DNR order, patients consent to

CPR/advanced care will typically be presumed. However, the statutorily
authorized Advanced Directive/DNR order is only one manner for a patient to
demonstrate resuscitation preferences. If no Advanced Directive/DNR order
is present and responsible family members present do not wish to have a
resuscitation performed on an adult patient, BLS measures shall be initiated
and Medical Control shall be contacted to discuss options. See Protocol
6.5: Field Determination of Death for further guidance.
Protocol 6.2: Confidentiality
General Principles:
A. EMS agencies are direct providers of health care to patients and generate
what is known as “Protected Health Information” (PHI).
B. PHI consists of records that contain information that identifies an individual

(such as name, social security number and address), as well as medical
information about that individual such as injury or illnesses and treatments
provided. PHI can exist electronically or in hard copy.
C. Personal medical or identifying information known to an EMS provider about

a patient that does not yet exist in electronic or hard copy form is also
considered PHI.
D. Federal law and City of Rapid City policy stipulate that EMS providers shall
make reasonable efforts to see that PHI be kept private and confidential and
not be disclosed outside the context of necessary and proper workplace
operations.
Procedures:
A. EMS providers can use PHI for treatment, billing, clinical review and
training/education purposes.
B. EMS providers can also share and disclose PHI with other entities that are
directly involved in the patients care, such as receiving hospitals and other
pre-hospital providers in a tiered response system – as long as it is for
legitimate treatment, payment or health care operation purposes.
C. Generally, EMS providers must limit the PHI used or disclosed to only that
which is necessary to accomplish the intended purpose for which the
information is needed. For example, in QI review of cases (health care
operations), there would typically be no need to disclose the patients name
or other identifying information.
D. EMS providers shall not discuss or disclose any patients PHI with persons
outside the context of necessary and proper workplace operations.
E. EMS providers shall assure that both electronic and hard copy Patient Care
Reports are kept secure. Printed copies of reports shall not be left
unattended on counters, vehicles or other places where they may be
improperly viewed.
Protocol 6.2: Confidentiality (cont.)
Procedures (cont.):
F. Computers with Patient Care Reports in process shall not be left unattended,
if the EMS provider has to leave before completing the report it should be
closed.
G. Copies of Patient Care Reports will be generated only for Patient Billing
Services and the receiving hospital. Other requests for copies of Patient
Care Reports will be forwarded to the EMS Chief or Patient Billing Services.
H. When students/observers are riding with EMS providers, the attending

Paramedic will assure that the proper confidentiality documents are signed
by the rider and they are thoroughly aware of patient confidentiality practices
and policy.
I. Radio communications shall not include disclosure of patient’s names.
Protocol 6.3: Controlled Substance Documentation
General Principles:
A. The complex legalities of narcotic distribution and storage require strict

enforcement concerning the use of these types of medications. Narcotics
have an ever-present risk of abuse and misuse that can and will be
minimized by constant administrative and field personnel oversight and
proper documentation of their use. The Medical Director is legally
responsible for the storage, disbursement and subsequent record keeping for
all narcotics associated with the system’s provision of EMS. It is our
responsibility to document all activity associated with narcotic medications to
minimize any legal risks.
Descriptions:
A. Each narcotic kit is labeled in 4” black numbering with its own individual
container number. This number will match the Medic unit number to which it
is assigned.
B. There are 2 narcotic kits for every unit that is assigned narcotics, one orange
and one yellow. One full audited set (either orange or yellow) of all the
narcotic kits is kept at the RCRH pharmacy.
C. Each narcotic kit contains a single RCRH Controlled Drug Administration

Record (see Illustration 6.A. below) for all narcotics stored within the kit.
D. The narcotics kits contain the following narcotics in the noted quantities.
1. (2) Morphine Sulfate, 10 mg each.
2. (2) Demerol, 100 mg each.
3. (2) Valium, 10 mg each.
4. (2) Ativan, 2 mg each.
Procedures:
Daily Narcotic Audit and Exchange Procedure
A. At every shift change, the oncoming and outgoing Paramedic will facilitate a
proper exchange of narcotics.
Protocol 6.3: Controlled Substance Documentation (cont.)
Procedures (cont.):
Daily Narcotic Audit and Exchange Procedure (cont.)
B. The oncoming Paramedic will visually inspect the narcotic kit and verify that
the lock number matches the previous lock number documented in the
Ambulance Controlled Substance Log (see Illustration 6.B. below). Any lock
change during the previous shift should be noted in the comments section of
the Ambulance Controlled Substance Log and in the Usage and
Disbursement Log. If there is an undocumented change in lock numbers,
the outgoing Paramedic will not leave until the discrepancy is accounted
for.
C. After visual inspection of the lock and the container, the outgoing Paramedic
will document the following in the Ambulance Controlled Substance Log.
1. Date
2. Time
3. From (printed name of the outgoing Paramedic)
4. To (printed name of the oncoming Paramedic)
5. Container # (narcotic kit number)
6. Then each Paramedic will sign to verify the exchange
7. Any other comments that are pertinent to the exchange should be noted
in the comments section (lock changes, etc.)
8. Lock #
D. If during the daily audit (or at any time) an undocumented lock number
change or an unexplained broken lock is encountered, the narcotic kit will be
opened and checked to assure that all the narcotics are present in the proper
quantities and the seals are intact. If narcotics are missing or all seals are
not intact, the EMS Chief, Operations Chief and the on-duty Battalion Chief
will be notified immediately.
Usage and replacement of a narcotic
A. Any time that a patient is given a narcotic, after arrival at the hospital the
RCRH Controlled Drug Administration Record (found in the narcotics kit) will
be completed with all of the following information:
1. Date
2. Time (of administration)
3. Patient Name
4. Who the drug was administered by
Procedures (cont.):
Usage and replacement of a narcotic (cont.)
5. Amount Administered
6. Amount Wasted
7. If an amount is wasted, it must be witnessed, and then documented, with
signature by the person who witnessed the wasting
B. Double check to make sure the information filled in on the RCRH Controlled
Drug Administration Record corresponds to the type of drug given.
C. Make a copy of the RCRH Controlled Drug Administration Record (to turn in
with daily paperwork).
D. Take the entire narcotic kit and the filled out RCRH Controlled Drug
Administration Record to the pharmacy located on 1st floor just off elevators.
E. The pharmacy staff will take the narcotic kit and the filled out RCRH
Controlled Drug Administration Record and give you a completely stocked,
audited and locked narcotic kit with the proper unit number of the opposite
color (yellow if you gave them orange and vice versa).
F. Document usage and replacement in the proper Controlled Substance Usage

Log (there is a separate sheet for each of the different drugs) in the back of
the Narcotics Log book in the medic unit. The Usage Log is self-
explanatory and ALL sections must be filled out. The new lock number
must also be noted in the Controlled Substance Usage Log (see Illustration
6.C. below).
G. It is a legal requirement (DEA) that there be a separate file kept of all

narcotics dispensed. To meet this requirement, make sure your copy of the
RCRH Controlled Drug Administration Record is included with the daily
paperwork for filing. This, along with the documentation in the Usage Log
will meet that requirement.
Narcotics Storage
A. Narcotics will be stored in the built-in refrigerators in the 3 primary duty medic
units and the peak-load unit.
B. Nothing other than drugs will be kept in medic unit refrigerators.
Procedures (cont.):
Narcotics Storage (cont.)
C. Narcotics kits are available for all medic units, those narcotic kits not stored
in the primary duty medic units and the peak-load unit will be kept in a locked
refrigerator in the EMS Chief’s office. In the event a transfer or similar duty
requires a set of narcotics for one of the other medic units, they can be
checked out from the Operations Chief, the EMS Chief, the on-duty Battalion
Chief or the Paramedic in charge of medical supply. When that duty is
concluded, the narcotics kit must be checked back in with one of the above
mentioned personnel. Documentation will be the same as noted above.
Narcotics Log books for the other medic units are in the EMS Chiefs office.
ILLUSTRATION 6.A.
RCRH CONTROLLED DRUG ADMINISTRATION RECORD
ILLUSTRATION 6.B.
AMBULANCE CONTROLLED SUBSTANCE LOG
ILLUSTRATION 6.C.
CONTROLLED SUBSTANCE USAGE LOG
Protocol 6.4: Crime Scene Operations
General Principles:
A. Response by EMS providers to a known or suspected crime scene, including

a crime scene that is not discovered until after arrival will require specific
procedures to be followed. These procedures are designed to minimize
possible threats to EMS providers and to avoid unnecessary contamination
of a crime scene. These crime scene situations may include but are not
limited to:
1. Assaults including domestic violence situations and sexual assault
2. Reported gunshot wounds
3. Stabbings
4. Hangings
5. Suicide gestures or completed suicides
6. Homicides
7. Unexplained explosions, WMD/terrorist acts
8. Any situation where an unattended death has occurred
Procedures:
A. Dispatched response to a known or suspected crime of violence or suicide

will typically be a cold response to stage in the area until Law Enforcement
has secured the scene. This response will always be followed in the
absence of compelling reasons to the contrary. In the absence of being
notified, do not assume a scene is secure and take precautions as necessary
to assure personnel safety.
B. If a crime scene is not discovered until after responding to an incident, and

Law Enforcement is not present, Law Enforcement shall be called to the
scene immediately. An assessment will be made of the possible threat to
responders and if a threat exists, personnel will exit the scene immediately to
a safe distance and wait for Law Enforcement assistance. If there is no
immediate threat, necessary patient treatment may begin, being mindful of
potential returning threats.
Protocol 6.4: Crime Scene Operations (cont.)
Procedures (cont.):
C. When responding to a known crime scene, entry to the scene should be

made with the minimum number of personnel necessary to provide effective
patient evaluation and treatment. Other personnel not required for treatment
shall remain outside the scene. This reduces the possibility that evidence
will be disturbed or contaminated.
D. When responding to a crime scene where an alleged violent death has

occurred and Law Enforcement is already present, one (1) EMS provider
shall be allowed access to the victim to evaluate life status (see Protocol
6.5: Field Determination of Death for further procedures). Check with the
officer in charge for entry and any special circumstances. If Law
Enforcement will not allow access, explain politely to the officer in charge that
it is local Law Enforcement policy that an evaluation of life status by medical
providers be made. Involve the Law Enforcement duty supervisor if
necessary. If access is still not allowed, leave the scene and document the
exchange very completely, including names of all persons involved.
E. While performing patient evaluation and treatment, precautions should be

taken not to remove, move or otherwise disturb anything in the crime scene
environment except as is absolutely necessary to perform effective patient
evaluation and care activities. If it becomes necessary to move anything
(weapons, furniture, etc.), it should carefully be moved out of the way, using
caution to avoid unnecessary handling of the object. (when weapons have to
be moved, try to get Law Enforcement assistance).The original position of
the object should be mentally noted so investigators can reconstruct the
scene as accurately as possible.
F. Personnel shall avoid moving about a structure or crime scene unnecessarily

or touching any object at the scene unnecessarily. Remaining in close as
possible proximity to the patient will avoid the risk of contaminating other
areas within the crime scene. If medications must be looked for to assist in
providing treatment, it should be done by one person, exercising care to note
their original locations and to try to avoid handling or touching other objects
not associated with the medications.
G. When removing clothing from patients that have sustained gunshot wounds,
stab wounds or other assaults, avoid cutting through garments at or near
bullet or stab wound holes. The bullet/stab wound hole, powder residue or
powder smudges around a hole can have considerable investigative value as
evidence and should not be modified if at all possible.
Procedures (cont.):
H. If the patient has ligature or binding items around the neck, arms, feet or any
other part of the body, do not remove them unless necessary to provide
treatment. If the item must be removed, do not untie, but cut off taking care
not to cut through any knot that may have been tied in the item. The original
position and placement of the item should be mentally noted.
I. If the patient is wearing jewelry, do not remove unless necessary to provide

treatment. If items must be removed, the original position and placement of
the item should be mentally noted.
J. The clothing the patient was wearing should always be kept track of. Give
removed clothing directly to Law Enforcement whenever possible and leave
at scene. Where clothing is bloody, if possible try to avoid having blood or
debris on one area or garment transfer to another area or garment (do not
wad up into a ball). Do not put wet or bloody garments in plastic (red) bags.
Handle clothing as little and as carefully as possible.
K. Avoid stepping in pools of blood or other fluids. If there is blood/fluid spatter

on walls, furniture or other objects, try to avoid smearing the spatter.
L. In the instance of a crime scene involving a motor vehicle accident, check

with Law Enforcement before any clean up of vehicle fluids on the roadway,
they may have investigative value as evidence. The only exception to this
would be if the fluids (gasoline, HazMat) present an immediate significant
hazard. Even then, notify Law Enforcement about what you feel is necessary
to do. Diking may be sufficient in the short term to prevent fluids from
entering waterways, sewer, etc.
M. When IV’s need to be established, try to start them above the hands if there
is a possibility the patient fired or may have fired a weapon. Law
Enforcement may wish to bag a patients hands, this should be allowed if it
will not interfere with treatment or delay treatment and transport.
N. Disposable medical supplies and their wrappers/boxes used at a crime scene

should not be cleaned up as is typically done. They should be left in place
where they were used to avoid “cleaning up” any possible evidence.
O. If a cricothyrotomy or chest decompression must be performed, do not place

needles or tubes through pre-existing gunshot or stab wound holes.
Procedures (cont.):
P. Anytime the physical environment in and around a crime scene must be

disturbed by EMS providers, it should be documented completely and fully in
the Patient Care Report.
Q EMS providers may become custodians of verbal evidence while operating at

a crime scene. An “excited utterance” or a statement made in the heat of the
moment is often times valuable and many times overlooked. Throughout
contact with a patient involved in a crime, keep in mind that such statements
can be key evidence in the event the patient is not able to repeat them in the
future. These statements should be noted and included in the Patient Care
Report. When charting these statements use exact quotes, do not add or
change wording.
R. EMS providers should be prepared to give their names to Law Enforcement

before departing a crime scene whenever possible.
Protocol 6.5: Field Determination of Death
General principles:
A. Situations will arise in which EMS personnel will encounter a patient in whom
resuscitative efforts should be withheld or in some cases terminated after a
trial course of treatment. This protocol is designed to provide guidelines
under which the PARAMEDIC may choose to discontinue or not initiate
resuscitative efforts.
Indications:
A. The obviously deceased patient (cause trauma OR medical) that meets

specific criteria.
B. The cardiac arrest patient in whom resuscitation has begun, but remains
without cardiac electrical activity (asystole) after a full regiment of first-line
ACLS procedures.
Procedures:
A. In all cases where ALS resuscitation has already begun, Medical Control will
be contacted for permission to cease resuscitative efforts. The Paramedic
should be prepared to provide the following information for Medical Control:
1. Brief history of event
2. Patients presenting clinical condition and cardiac rhythm.
3. Procedures preformed and drugs administered.
4. Patients total elapsed down time.
5. Patients present clinical condition and cardiac rhythm.
B. The PARAMEDIC may withhold or terminate resuscitative efforts in the

patient that meets the following criteria:
Initial Criteria:
1. No spontaneous respirations AND
2. No palpable pulse AND
3. No evidence of cardiac electrical activity (asystole) AND
Protocol 6.5: Field Determination of Death (cont.)
Procedures (cont.):
Initial Criteria (cont.):
4. Pupils fixed and dilated AND
One or more of the following additional criteria:
1. Rigor Mortis
2. Extensive post-mortem dependent lividity
3. Decapitation
4. Decomposition of the body
5. Blunt trauma cardiac arrest
6. Legal Advanced Directive/DNR order in place (see Protocol 6.1:

Advanced Directives/DNR orders)
C. Apneic and pulseless penetrating trauma patients will have resuscitative

efforts begun and be rapidly transported unless signs of prolonged, obvious
death as noted above (1-4, additional criteria) are present. See Protocol
3.10: Trauma Cardiac Arrest for further information.
D. Resuscitation should not be withheld or terminated on hypothermic patients

or cold water drowning patients. If drowning patient has more than one and
a half hours submersion time, contact Medical Control for direction.
E. Resuscitation should not be withheld or terminated on electrocution or

lightning strike patients unless signs of prolonged, obvious death as noted
above (1-4, additional criteria) are present.
F. All patients in whom a resuscitation is either withheld or terminated will have

a cardiac rhythm strip run whenever possible and attached to the Patient
Care Report. If it is not possible to obtain a rhythm strip, the reason will be
documented in the Patient Care report.
G. In all cases where resuscitation has either been withheld or terminated

outside of a medical facility, these are considered by law to be unattended
deaths and the coroner will be called to the scene immediately. If transport
has already begun, the coroner will be called to the receiving facility.
Procedures (cont.):
H. Patient Care Report documentation on these cases will always include the
following information:
1. Complete history of event
2. Complete description of patients presenting clinical condition (pupils,

color, rigor, lividity, decomposition, etc.) and cardiac rhythm with
accurate times.
3. Any procedures preformed and drugs administered with accurate times.
4. Conversations with Medical Control to include names, orders given or

denied and accurate times.
5. Patients total elapsed down time as is best obtainable.
6. Complete description of patient’s clinical condition and cardiac rhythm

when resuscitation terminated.
7. Document any Law Enforcement involvement, including names if

possible and accurate times.
8. Cardiac rhythm strips.
I. If situations arise outside the scope of this protocol, or the Paramedic is

unsure whether resuscitative measures are warranted or should be
terminated, contact Medical Control for direction.
J. If the situation appears to be a crime scene, see Protocol 6.4: Crime Scene
Operations for further information.
A. Mass Casualty Incidents involving death are not covered in detail by this
protocol and have somewhat different guidelines, see Protocol 6.10: Mass
Casualty Incidents for further information.
B. There may be situations where the EMS provider feels compelled to begin or
continue a resuscitation when it normally otherwise might not be done
(hostile scene environment, family members adamant that “everything be
done”, or other highly emotional or volatile situations). In such
circumstances, the EMS provider should attempt to contact Medical Control
for direction. If that is not possible, the EMS provider should use his or her
best judgment in deciding what is reasonable and appropriate for the
situation, including possibly starting basic resuscitative measures and
transport. Medical Control should be contacted as soon as is possible.
Protocol 6.6: Hazardous Materials / WMD Incidents
Indications:
A. Response to reported and or known chemical/biological Hazardous Materials

or Weapon of Mass Destruction (WMD) incident.
B. Response to situations including but not limited to vapor/gas clouds, leaking

substances, numbers of sick or deceased people or animals and noxious
odors present on or near scene.
Definitions:
A. For adequate and uniform scene control, a system of zones is established.

There are 3 control zones: the Hot (Exclusion) Zone, the Warm
(Contamination Reduction) Zone, and the Cold (Support) Zone. See
Illustration 6.D: HazMat Zones below.
1. Hot Zone: An area immediately surrounding an incident that is the

primary area of contamination. May also include areas that are not
immediately contaminated, but that HazMat Operations/IC believes the
contamination will predictably spread.
2. Warm Zone: Immediately outside the Hot Zone and acts as a buffer
area between the Cold and Hot Zones. It contains the Decontamination
area (Contamination Reduction Corridor), which is the pathway to and
from the Hot Zone.
3. Cold Zone: A clean or non-contaminated zone where support and

control functions are operating or staged.
General Principles:
A. If you are first on scene and a HazMat/WMD situation is suspected, request

a HazMat Team and engine company response. Keep yourself and your unit
at a safe distance. This may require you to leave the scene for some
distance, leaving patients and bystanders in a hazardous situation. This is
necessary, your safety comes first. Seek a location uphill and upwind from
the incident. Relay pertinent observations to in-bound units and Dispatch.
B. If the HazMat Team/engine companies are already on scene, on arrival

report in where/as requested (Command Post, HazMat Operations, Staging,
etc.). Initial EMS operations should be established in the Cold Zone.
Protocol 6.6: Hazardous Materials / WMD Incidents (cont.)
General Principles (cont.):
C. Initial assessment, treatment and decontamination will be performed by

HazMat Team/engine company personnel in the proper level of Personal
Protective Equipment (PPE). Decontaminated patients will typically then be
brought to EMS personnel in the Cold Zone (outer limit of Warm Zone) for
definitive treatment and transport. EMS personnel will not participate in
Hot/Warm Zone operations or patient decontamination unless trained and
equipped to do so. HazMat Operations/IC and the nature and scope of the
contamination will dictate the level and location of EMS operations in all
zones.
D. EMS personnel may be required to drape the interior of ambulances with

plastic and don some level of PPE to transport patients even after they have
been decontaminated. Decontamination may not be complete. This will be
done or not done based on recommendations from HazMat Operations/IC.
Consider the potential need for secondary decontamination at the receiving
facility
E. Once the situation has been assessed, notify the receiving hospital(s) of the
following information:
1. Location of the incident.
2. Name of the chemicals/materials involved (if known). If not known,

description of signs/symptoms common to patients.
3. Number of injured/contaminated.
4. Extent of injuries/contamination.
5. Extent that patients will be decontaminated in the field.
6. Estimated time of arrival of first patients.
7. Any other pertinent information that is available.
F. This protocol is designed for rendering the maximum appropriate care to

each patient affected by these situations. In Mass Casualty Incident
situations, not all of these assessments and treatments may be able to be
performed on each patient. EMS providers should follow established MCI
procedures and attempt to do the greatest good for the greatest number of
patients. See Protocol 6.10: Mass Casualty Incidents for further
information.
General Principles (cont.):
G. Remember that patients in potential HazMat/WMD incidents may also have

non-poison related problems such as head trauma, hypoglycemia, asthma
exacerbation, etc. Refer to pertinent protocol for assessment and treatment
strategies related to these complaints if time and situation allows.
Procedures:
A. The first priority for patients in a Hot Zone will typically be evacuation to a
decontamination area. Any assessment of a patient in the Hot Zone will
have to be provided by personnel in the appropriate complete PPE. This will
make complete exposure of the patient and utilization of assessment tools
such as a stethoscope impossible. Hot Zone assessments are limited to
those that can be conducted rapidly through PPE. These may include:
1. Observation of the patient’s mental status.
2. Observation of the patient’s skin signs.
3. Observation/testing of neurologic response, including GCS and pupils.
4. Observation of the patient’s airway, secretions, and any vomiting or other

bodily fluids.
5. Pulse check.
B. Patients should be removed from the contaminated environment as soon as

is practical to prevent further contamination.
C. The order of assessment and supportive care may be affected by incident-

specific considerations, e.g., primary survey may be followed by evacuation
and decontamination, or in the case of entrapped live patients, supportive
care performed by personnel in PPE may be followed by decontamination in
place. In all cases, decontamination of contaminated patients should be
considered a vital part of their treatment.
D. The removal of contaminating materials, such as clothing, from the patient is

at the discretion of HazMat Operations/IC. This should be done as rapidly as
is practically feasible and should include full patient decontamination where
indicated.
Procedures (cont.):
E. Assessments and treatments in the Warm/Cold Zone will typically include

those that need patient exposure, such as stethoscope exam or initiation of
IV therapy.
F. Identification of the material released for the receiving hospital may be

difficult. Utilize all resources at your disposal, These include (but are not
limited to) Hazmat Databases, Poison Control Center, and Base Station
Physician consultation.
G. These protocols include Fact Sheets on some common Biologic and

Chemical agents and Radiation injury. Fact Sheet for the Biologic agents
and Radiation is generic, for Chemical agents it is specific to the agent.
For the listed Biologic agents there are Summary Charts and treatment
information for both field and hospital treatment. Hospital treatment
information is included for additional background information for the EMS
provider. It should be noted that field treatment of Biologic agent affected
patients is usually supportive care only and is not typically specific. Infection
control and decontamination information is included where necessary.
For the listed Chemical agents and Radiation injury there is an Information
Needed section reference history and exposure, an Objective Findings
section on physical signs, a Treatment section divided into BLS and First
Responder actions, ALS provider actions in the Hot Zone, or contaminated
area (if properly equipped and trained), ALS provider actions in the
Warm/Cold Zone or decontamination area, as well as hospital treatment
information for additional background information.
Table Of Contents
BIOLOGICAL AGENTS
Fact Sheet (Generic).................................................................................................. 6-26
Summary Chart of Biologic Agents ............................................................................ 6-27
Treatment Protocols for Biologic Agents.................................................................... 6-30

Anthrax ................................................................................................................ 6-30
Botulism............................................................................................................... 6-32
Brucellosis ........................................................................................................... 6-33
Cholera................................................................................................................ 6-34
Encephalitis (Venezuelan, Eastern, Western) ..................................................... 6-35
Plague ................................................................................................................. 6-36
Q Fever ............................................................................................................... 6-38
Ricin .................................................................................................................... 6-39
Smallpox.............................................................................................................. 6-40
Staphylococcal Enterotoxin B.............................................................................. 6-41
Tricothecene Mycotoxins..................................................................................... 6-41
Tularemia ............................................................................................................ 6-42
Viral Hemorrhagic Fevers.................................................................................... 6-44
References ................................................................................................................ 6-45
CHEMICAL AGENTS
Chlorine ............................................................................................................... 6-46

Hydrogen Cyanide and Cyanogen Chloride ........................................................ 6-49
Methylene Diphenyl Isocyanate (MDI), Methylene Diisocyanate and Methyl
Isocyanate (MIC) ................................................................................................. 6-52
Mustard (Sulfur Mustard)..................................................................................... 6-55
Nerve Agents....................................................................................................... 6-58
RADIATION INJURY................................................................................................. 6-62
DRUG SUMMARIES
Drug Summaries for all drugs referenced in this section can be found in Section 7
with other standard protocol drug summaries.
BIOLOGICAL AGENTS
Fact Sheet (Generic)
1. Military Designation: None
2. Description: There are many potential biological agents that can be used as
Weapons of Mass Destruction. Ideal properties of such agents include rapid
dispersion, high rate of infectivity, high degree of virulence, short incubation
time, low resistance among the population, and high rate of morbidity and
morality. Examples are listed in the charts below along with their health
effects.
3. Non-military Uses: Biological agents are used in a wide variety of medical

research and some types are easily available from biological supply
warehouses. Other biologic agents occur endemically (in normally small
numbers in certain patient populations), making the early detection of biologic
agent use as a weapon potentially difficult.
4. Military Use: Biologic agents were allegedly used during the Gulf War by the
Iraqis against the Kurdish population. While no country currently admits to
the use or storage of biologic agents, defensive research occurs at the US
Army Medical Research Institute at Fort Detrick, Maryland.
5. Health Effect: see chart.
6. Environmental Fate: Varies by nature of agent. Most are not persistent

outside of their natural reservoirs. Refer to source document for further
information.
Summary Chart of Biologic Agents
Agent Type/ Primary Signs and Likely Mode of

AGENT
Incubation Period Symptoms Acquisition
Anthrax Bacteria/ Biphasic illness: Inhalation

(Inhalational) 1-60 days Influenza-like illness (ILI) then
abrupt onset of fever, chest
pain, respiratory distress,
cyanosis, occasional stridor,
occasional meningismus,
progression to shock and
death within 24-36 hours.
Botulism Toxin from bacteria/ Acute bilateral descending Inhalation or

24-36 hours flaccid paralysis beginning ingestion
with cranial nerve palsies:
ptosis, dry mouth, blurry
vision, diplopia, dysarthria,
dysphagia. (Do not confuse
with nerve agent poisoning,
which has copious secretions
and miotic pupils or atropine
overdose, which has CNS
excitation with dry mucous
membranes & mydriasis).
Brucellosis Bacteria/ Fever, sweats, malaise, Inhalation, oral

2-8 weeks anorexia, headache and back ingestion
pain; sometimes “undulant”
fever, sometimes focal
complications.
Cholera Bacteria/ Vomiting, watery “rice water” Oral ingestion

24-48 hours diarrhea, dehydration and
shock; abdominal cramps and
anxiety in proportion to
dehydration.
Encephalitis Virus/ Encephalopathy with fever Inhalation

(Venezuelan, 1-14 days and seizures and/or focal
Eastern, neurologic deficits.
Western)
Summary Chart of Biologic Agents (cont.)

AGENT Incubation Period Symptoms Acquisition
Plague Bacteria/ Fever, cough, dyspnea, Inhalation

(Pneumonic) 1-6 days hemoptysis, cyanosis, often
prominent GI symptoms,
rapid deterioration to shock
and death.
Q Fever Bacteria/ Fever, headache, myalgias, Inhalation

14-29 days possibly cough, pleuritic
chest pain
Ricin Biologic toxin/ Immediate nausea/vomiting, Inhalation,

Dependent on dose: aphthous-like oral lesions. ingestion
some immediate Then, acute onset of fever,
symptoms, then chest pain and cough,
18-36 hours progressing to respiratory
distress and hypoxemia (18-
36 hours); not improved with
antibiotics; hepatic and
renal failure (24-48
hours); death in 36-72
hours.
Smallpox Virus ILI then continued fever and Inhalation

12-14 days popular rash that begins on
the face and extremities and
uniformly progresses to
vesicles and pustules;
headache, vomiting, back
pain and delirium are
common.
Staphylococcal Toxin from bacteria/ Fever, chills, headache, Inhalation or

Enterotoxin B 3-12 hours myalgia, non-productive ingestion
cough, dyspnea, chest pain
ILI, can progress to shock.
Summary Chart of Biologic Agents (cont.)

AGENT Incubation Period Symptoms Acquisition
T-2 Biologic toxin/ Abrupt onset of Inhalation,

Mycotoxins minutes mucocutaneous and airway ingestion, skin
irritation including skin (pain, exposure
blistering, sloughing), eye
(pain and tearing),
gastrointestinal (bleeding,
vomiting and diarrhea), and
airway (dyspnea and
cough), can progress to
shock.
Tularemia Bacteria/ 1-21 days Fever, chills, headache, Inhalation

malaise, sore throat, cough,
chest pain, abdominal pain,
anorexia, vomiting, diarrhea,
often a pulse-temperature
deficit.
Viral Virus/ 2-19 days Fever with mucous Inhalation and

Hemorrhagic membrane bleeding, ingestion
Fever petechiae, and hypotension (fomites)
(e.g., Ebola) in a patient without
underlying malignancy
Treatment Protocols for Biologic Agents
Anthrax
FIELD:
Supportive care (for shock and hypoxia)
HOSPITAL:
*Adult: Pediatric:
IV Ciprofloxacin 400 mg q 12 hrs 10-15 mg/kg q 12 hrs

IV Doxycycline 100 mg q 12 hrs Not recommended in children
IV Penicillin G 4 million Uq 4 hrs < 12 yrs: 50,000 U/kg q 6 hrs
> 12 yrs: 4 million U q 4 hrs
MASS CASUALTY and PROPHYLAXIS:
*Adult: Pediatric:
PO Ciprofloxacin 500 mg q 12 hrs 10-15 mg/kg q 12 hrs

PO Doxycycline 100 mg q 12 hrs Not recommended in children
PO Amoxicillin 500 mg q 8 hrs < 20 kg: 13 mg/kg q 8 hrs
> 20 kg: 500 mg q 8 hrs
Vaccine:
Therapy should be continued for 60 days. Oral therapy should be substituted for
IV when patient condition improves. Ideally post-exposure prophylaxis will
include vaccine. In this case, antibiotics should be given for 30 days concurrent
with vaccination. If no vaccine is available, antibiotic therapy should continue for
60 days for post-exposure prophylaxis.
*Immunosuppressed persons receive the same as non-immunosuppressed

persons.
The appropriate regimens for pregnant women should be determined at the
time using the consensus recommendations published in JAMA 1999;
281(18):1735-1745.
(Ciprofloxacin is the only drug with an FDA indication for prophylaxis against
aerosol Anthrax. It has been studied in animals but little experience in humans
exists; other fluoroquinolones are also assumed to be effective.)
Treatment Protocols for Biologic Agents (cont.)
Anthrax (cont.)
INFECTION CONTROL:
Transmission via direct contact is possible; however, there is no data to suggest

patient-to-patient transmission occurs. Observe standard barrier precautions.
Measures for airborne protection are not indicated. Use standard disinfectants to
clean surfaces. Notify laboratory of suspicion of anthrax so safe specimen
handling can occur under Bio-Safety Level 2 conditions. Cremate bodies if
possible.
DECONTAMINATION:
With announced threats, any person coming in direct physical contact with a
substance alleged to be Anthrax should perform thorough washing of the
exposed skin and articles of clothing with soap and water. Further
decontamination of directly exposed persons or of others is not necessary.
Botulism
FIELD:
Supportive care
HOSPITAL:
Supportive care
Polyvalent antitoxin, 10 ml over 20 minutes after skin testing.

If wound botulism: débride wound
Administer appropriate antibiotics (e.g., Penicillin)
PROPHYLAXIS:
Consider antitoxin for those who have been exposed to toxin.
INFECTION CONTROL:
Observe standard barrier precautions. Wash hands after handling soiled

clothes/diapers.
Brucellosis
FIELD:
Supportive Care
HOSPITAL:
Adult:
Doxycycline 200 mg q day

Tetracycline 500 mg QID
Rifampin 600-900 mg q day
Streptomycin 1 gm q day
Gentamicin 3-5 mg/kg in 3 doses q day
Trimethoprim/
Sulfamethoxazole (TMX)
Combination therapy is recommended (e.g., Doxycycline + Rifampin). Therapy

should be continued for 6 weeks.
The appropriate therapy for pediatric, Immunosuppressed and pregnant patients
should be determined at the time using current references. Consider TMX +
Rifampin for children < 8 years of age.
PROPHYLAXIS:
None recommended at present.
INFECTION CONTROL:
Transmission via direct contact is possible. Observe standard barrier

precautions, drainage and secretion precautions for open lesions. Clean or
decontaminate rooms with standard disinfectants. Launder clothing and linens as
per hospital protocol. Notify laboratory of suspected infection so safe specimen
handling can occur.
Cholera
FIELD:
Supportive care, oral hydration (electrolyte replacement drink if possible)
HOSPITAL:
Continue hydration (oral or IV) and
Adult*: Pediatric:
Ciprofloxacin 1 gm or 250 mg QD Not recommended for children

Doxycycline 300 mg x 1 day Not evaluated
Tetracycline 500 mg QID 500 mg/kg in 4 doses QD
Therapy should be continued for 3 days unless indicated otherwise.

* Immunosuppressed persons receive the same as non-immunosuppressed
persons.
The appropriate regimens for pregnant women should be determined at the time.
PROPHYLAXIS: Possibly oral vaccination
INFECTION CONTROL:
Transmission via direct or indirect contact with feces. Identify cases and
implement proper enteric precautions. Disseminate information about enteric
precautions (especially proper hand washing) to the public. Identify and assess
contacts of cases. Provide prophylaxis (similar to treatment but use current
references) to contacts if there is a high likelihood of transmission. Implement
contact surveillance.
Encephalitis (Venezuelan, Eastern, Western)
FIELD:
Supportive care
HOSPITAL:
Supportive Care
PROPHYLAXIS:
None
INFECTION CONTROL:
Observe standard barrier precautions. Clean or decontaminate with standard

disinfectants. Launder clothing and linens as per hospital protocol.
Plague
FIELD:
Supportive care (strict respiratory isolation)
HOSPITAL:
Adult*: Pediatric:
IM Streptomycin 1 gm q 12 hrs 5 mg/kg q 12 hrs (max = 2 g)

IM or IV Gentamicin 5 mg/kg QD or
2 mg/kg then 1.7 mg/kg q 8 hrs
IV Ciprofloxacin 400 mg q 12 hrs 15 mg/kg q 12 hrs
IV Doxycycline 200 mg IV QD or < 45 kg: 2.2 mg/kg q 12 hrs
100 mg q 12 hrs >45 kg: give adult dosage
IV Chloramphenicol 25 mg/kg q 6 hrs 25 mg/kg q 6 hrs
Therapy should be continued for 10 days. Oral therapy should be substituted for
IV when patient condition improves.
MASS CASUALTY or PROPHYLAXIS:
*Adult: Pediatric
PO Doxycycline 100 mg q 12 hrs < 45 kg: 2.2 mg/kg q 12 hrs

> 45 kg: give adult dosage
PO Ciprofloxacin 500 mg q 12 hrs 20 mg/kg q 12 hrs
PO Chloramphenicol 25 mg/kg q 6 hrs 25 mg/kg q 6 hrs
Therapy for mass casualty should be continued for 10 days; for post-exposure
prophylaxis therapy should be continued for 7 days.
* Immunosuppressed persons receive the same as non-immunosuppressed

persons.
The appropriate regimens for pregnant women should be determined at the time
using the consensus recommendations published in JAMA 2000; 283(17):2281-
2290.
Plague (cont.)
INFECTION CONTROL:
Transmission via respiratory droplets is possible. Identify and isolate all cases in
whom pneumonic plague is suspected. Identify contacts of cases and provide
prophylactic antibiotics and contact surveillance (especially those refusing
antibiotics). Provide antibiotic prophylaxis to all health care workers and all other
essential disaster response personnel (police, firefighters, transit workers, public
health, medical examiner and mortuary staff) that might encounter close contact
(< 2 meters) with patients with confirmed pneumonic plague. Personnel with
close contact to cases should observe strict respiratory droplet precautions
(gown, gloves, mask (surgical or HEPA mask), and eye protection). Patients
should be in isolation rooms with negative pressure and high-efficiency
particulate air filtration during the first 48 hours of therapy. If patient isolation is
not possible, cohort patients to contain respiratory droplets. Clean or
decontaminate with standard disinfectants. Launder clothing and linens as per
hospital protocol. Notify laboratory of suspected plague so safe specimen
handling can occur. Cremate bodies if possible.
DECONTAMINATION:
substance alleged to be plague should perform thorough washing of the exposed
skin and articles of clothing with soap and water. Further decontamination of
directly exposed persons or of others is not necessary. The plague bacillus is
sensitive to sunlight and heating does not survive long outside the host. In a
World Health Organization analysis, a plague aerosol was estimated to be
effective and infectious for as long as 1 hour.
Q Fever
FIELD:
Supportive care
HOSPITAL:
Adult:
Doxycycline 100 mg bid

Tetracycline 500 mg QID
Alternative agents include: Rifampin, Chloramphenicol, Fluoroquinolones, and

Trimethoprim.
Duration of therapy varies depending on disease manifestation and patient

condition. Determine appropriate therapy and duration at the time using current
references.
PROPHYLAXIS:
Currently none recommended; consider Doxycycline, Tetracycline, or

Fluoroquinolones.
INFECTION CONTROL:
Transmission via direct contact is possible. Observe standard barrier

precautions. Disinfect fresh concentrations of blood, sputum and emesis with
bleach solutions. Clean or decontaminate routinely with standard disinfectants.
Launder clothing and linens as per hospital protocol.
Ricin
FIELD:
Supportive care
HOSPITAL:
Supportive care, if toxin was ingested, decontamination of GI tract.
PROPHYLAXIS:
None recommended
INFECTION CONTROL:
None recommended
Smallpox
FIELD:
Supportive care
HOSPITAL:
Supportive care, antibiotics as indicated for secondary bacterial infections
PROPHYLAXIS:
Vaccination
INFECTION CONTROL:
Person-to-person transmission possible via aerosol. Immediately isolate all

individuals in whom smallpox is suspected, preferably at home. Vaccinate and
place under contact surveillance all household and other face-to-face contacts of
smallpox cases. Vaccinate all health care workers at clinics or hospitals that
might receive patients and all other essential disaster response personnel, such
as police, firefighters, transit workers, public health staff and medical examiner
and mortuary staff. Furlough employees for whom vaccination is contraindicated.
If admitted to a hospital, confine patients to negative pressure rooms with high-
efficiency particulate air filtration. Consider designating a specific hospital for
patients requiring hospitalization. Observe standard barrier precautions using
gloves, gowns and masks. Adopt a special protocol for decontaminating rooms
using consensus recommendations in JAMA 1999; 281(22):59-69. Place all
laundry and waste in biohazard bags and autoclave before laundering or
incinerating. Launder in hot water with added bleach. Clean surfaces with
standard disinfectants. Cremate bodies.
DECONTAMINATION:
substance credibly alleged to be smallpox should perform thorough washing of
the exposed skin. Articles of clothing and other contaminated objects should be
autoclaved or washed in hot water with bleach.
Staphylococcal Enterotoxin B
FIELD:
Supportive care
HOSPITAL:
Supportive care
PROPHYLAXIS:
None recommended
INFECTION CONTROL:

Tricothecene Mycotoxins (T2)
FIELD:
Supportive care, eye irrigation if needed
HOSPITAL:
Supportive care
PROPHYLAXIS:
None recommended
INFECTION CONTROL:

Tularemia
FIELD:
Supportive care
HOSPITAL:
Preferred: Adult: Pediatric:
IM Streptomycin 1 gm bid 15 mg/kg bid

IM or IV Gentamicin 5 mg/kg QD 2.5 mg/kg IM/IV tid
Alternatives:
IV Doxycycline 100 mg bid > 45 kg: 100 mg bid

< 45 kg: 2.2 mg/kg bid
IV Chloramphenicol 15 mg/kg QID 15 mg/kg QID
IV Ciprofloxacin 400 mg bid 15 mg/kg bid
Therapy with Streptomycin, Gentamicin, or Ciprofloxacin should continue for 10

days. Therapy with Doxycycline or Chloramphenicol should continue for 14-21
days. The treatment of pregnant women is similar to other adults excepting the
use of Chloramphenicol. See consensus recommendations in JAMA 2001;
285(21):2763-73 for additional information and for treatment of
immunosuppressed persons.
MASS CASUALTY or POSTEXPOSURE PROPHYLAXIS:
Preferred: Adult: Pediatric:
PO Doxycycline 100 mg bid > 45 kg: 100 mg bid

< 45 kg: 2.2 mg/kg bid
PO Ciprofloxacin 500 mg bid 15 mg/kg bid
Therapy with all agents should continue for 14 days.
Tularemia (cont.)
INFECTION CONTROL:
Transmission via direct contact is possible. Observe standard barrier precautions

and drainage and secretion precautions for open lesions. Clean or
decontaminate with standard disinfectants. Launder clothing and linens as per
standard hospital protocol. Notify laboratory of suspected Tularemia so safe
specimen handling can occur. Cremate bodies if possible.
DECONTAMINATION:
substance alleged to be Tularemia should perform thorough washing of the
exposed skin and articles of clothing with soap and water. Further
decontamination of directly exposed persons or of others is not necessary.
Viral Hemorrhagic Fevers
FIELD:
Supportive care
HOSPITAL:
IV Ribavirin 1st dose: 30 mg/kg, then 15 mg/kg q 6 hrs x 4 days

(experimental) then 8 mg/kg q 8 hrs x 6 days
PROPHYLAXIS:
None recommended
INFECTION CONTROL:
Transmission via direct contact with blood, secretions, organs and semen.
Airborne transmission among humans has not been documented. Implement
immediate strict barrier precautions with patient in isolation. Restrict contact with
non-essential staff and visitors. Restrict testing to the minimum required. Alert
laboratory staff of the nature of specimens. Laboratory tests should be done with
maximum possible precautions using gloves and biological safety cabinets.
Patients’ secretions, sputum, blood and all objects with which the patient has had
contact, including laboratory equipment used to carry out tests on blood, should
be disinfected with 0.5% sodium hypochlorite solution or 0.5% phenol with
detergent and as far as possible with appropriate heating techniques (e.g.,
autoclaving, incineration or boiling). Identify contacts of cases and place under
contact surveillance. Cremate bodies.
References:
1. The Working Group on Civilian Bio-defense. Anthrax as a Biological

Weapon: Medical and Public Health Management. JAMA. 1999;
281(18):1735-45.
2. The Working Group on Civilian Bio-defense. Smallpox as a Biological
281(22):59-69.
3. The Working Group on Civilian Bio-defense. Plague as a Biological
283(17):2281-90.
4. The Working Group on Civilian Bio-defense. Tularemia as a Biological
285(21):2763-73.
5. Control of Communicable Diseases Manual, American Public Health
Association, 17th Edition, 2000, Edited by James Chin, MD, MPH.
6. Principles of Practice of Infections Diseases, Edited by G.L. Mandell, J.E.
Bennett, R. Dolin, 5th Edition, 2000.
7. Medical Management of Biological Casualties Handbook, US Army
Medical Research Institute of Infectious Diseases, Third Edition, July
1999.
CHEMICAL AGENTS
Chlorine
FACT SHEET
1. Military Designation: None
2. Description: Chlorine is found as an amber liquid or greenish-yellow gas with

a very characteristic irritating, pungent odor. Chlorine is severely irritating to
the skin, eyes, and respiratory tract. Although generally stored as a liquid,
when released, the resulting gas is about two times heavier than air.
3. Non-military Uses: Chlorine is used widely in industrial settings. These may

include the organic synthesis and manufacture of antifreeze agents, solvents,
refrigerants, resins, bleaching agents, and other inorganic chemicals. There is
an exceptionally wide use of chlorine in non-commercial and home settings
as a cleaning agent, bleaching agent, bacteriostatic, and disinfecting agent.
Storage of this substance in a variety of liquid and granular forms is
widespread.
4. Military Use: Chlorine was first used by the German military on 22 April 1915
in a cylinder-released gas attack that resulted in an estimated 15,000 Allied
wounded and 5,000 Allied deaths. Because of its tendency to dissipate
rapidly, very large concentrations were required. Chlorine was weaponized in
projectiles, mortars and bombs. There is no current chlorine weaponry.
5. Health Effects: Chlorine exposure causes an immediate severe irritation to

the eyes and mucous membranes. The upper airways are first involved with
nose, throat, and sinus irritation. The lower airways are irritated with severe
cough and chest pain. There may be nausea, vomiting, and fainting. Very
high doses may cause significant pulmonary edema. Wheezing is likely to
occur in individuals with a history of pre-existing asthma. Bronchitis often
occurs, sometimes progressing to pneumonia. High concentrations also
irritate the skin, causing burning, itching and occasional blister formation.
There is no animal or human epidemiological data to suggest that chronic
chlorine exposure may cause cancer or the occurrence of adverse
developmental effects in the unborn fetus.
6. Environmental Fate: Chlorine is not persistent in surface water, ground

water, or soil. Oxidation of environmental organic materials occurs rapidly,
reducing its concentration rapidly. Dispersal of chlorine gas is rapid into the
atmosphere.
CHEMICAL AGENTS (cont.)
CHLORINE TREATMENT PROTOCOL
1. Information Required:
• History: exposure to a greenish-yellow gas with a pungent, acrid odor
• Symptoms: low dose; cough, eye irritation and lacrimation, chocking
sensation
Higher dose; hoarseness, wheezing, severe cough, sudden collapse due
to laryngospasm
2. Objective Findings:
• Lacrimation
• Voice hoarse
• Skin erythema
• Increased work of breathing
• Wheezing
• Cough
• Cyanosis
3. Treatment:
BLS/FIRST RESPONDER • Supportive Care.

• Eyes: flush with copious amounts of water.
• Skin: flush with copious amounts of water.
• High flow O2 if respiratory symptoms.
ALS HOT ZONE • If bronchospasm present, administer

Epinephrine (1:1,000) 0.3 mg IM or SQ x 1 in
severe cases.
ALS WARM/COLD ZONE • Albuterol nebulizer treatment if evidence of

bronchospasm; repeat as necessary.
• Consider intubation for stridor/severe
dyspnea/hypoxia/chest pain.
• Consider surgical/needle cricothyrotomy for
laryngospasm if unable to maintain airway with
BLS maneuvers or intubation.
• Continue Albuterol nebulizer therapy.
• IV access with NS TKO.
CHLORINE TREATMENT PROTOCOL (cont.)
HOSPITAL • Continue Inhalational Beta-2 agonist

bronchodilator therapy.
• If hypoxia continues, consider intubation.
• Be prepared for Adult Respiratory Distress
Syndrome (ARDS); treat pulmonary edema with
intubation and consider Positive End Expiratory
Pressure (PEEP). Use diuretic therapy with
caution due to risk of hypotension.
4. Precautions and Comments:

• All patients who have had a moderate or high level of exposure
(respiratory distress or airway symptoms upon exam by EMS personnel)
should be referred to a medical facility for examination and treatment.
• If utilized, the ETT’s placement and patency must be strictly maintained at
all times. Confirm ETT position (reassessed and documented) with any
patient transfer. Confirm by direct visualization and/or end-tidal CO2
detection device.
Hydrogen Cyanide and Cyanogen Chloride
FACT SHEET
Military Designation: AC (hydrogen cyanide) and CK (cyanogen chloride)
Description: Both of these substances are liquids, but they vaporize (evaporate)
at about 73 degrees F, so they will be in gaseous under most temperate
conditions. AC has an odor of bitter almonds (which a percentage of the US
population cannot smell); CK is pungent. AC is lighter than air, whereas CK is
heavier than air. Cyanogen chloride is quickly metabolized to cyanide once
absorbed into the body, and causes the same biological effects as hydrogen
cyanide. In addition, CK is irritating to the eyes, nose and throat (similar to riot
control agents), whereas AC is nonirritating.
Non-military Uses: Large amounts of cyanide (most in the form of salts) are
produced, transported and used by US industry. Cyanide is used in fumigation,
photography, extraction of metals, electroplating, metal cleaning, tempering of
metals, and the synthesis of many compounds. Hydrogen cyanide is released
when wool, synthetic fibers and plastic burns.
Military Use: The French and English used small amounts of cyanide during
World War I, but the compound was not effective as a weapon because the
amount needed is large and because cyanide, being lighter than air, drifted away
from the target. Japan allegedly used cyanide against China before World War II
and Iraq allegedly used cyanide against the Kurds in 1988. The US once had
cyanide munitions, but all known stocks are believed to have been destroyed.
Health Effects: Cyanide blocks the use of oxygen in cells of the body and thus
causes cellular asphyxiation. The cells of the brain and heart are most
susceptible to its effect. High concentrations of vapor may cause a brief increase
in rate and depth of respirations (in 15 seconds), seizures (30 seconds) and
cessation of breathing (3-5 minutes) and cardiac arrest and death (4-10 minutes).
A smaller concentration will cause headaches, flushing, lightheadedness and
other non-specific complaints. In addition, CK produces irritation of the eyes,
nose and airway. Antidote (Sodium Thiosulfate) can be effective if administered
in time. A large exposure may result in prolonged neurologic damage, secondary
to hypoxia.
Environmental Fate: Because of their volatility, these substances are not

expected to persist in surface water or soil.
HYDROGEN CYANIDE AND CYANOGEN CHLORIDE TREATMENT PROTOCOL
1. Information Needed:
Exposure to a vapor or liquid that some patients may complain had a “bitter
almond” smell or upper airway and eye irritation. Other patients may not
notice anything unusual in their environment and may complain of:
• nausea
• headache
• anxiety
• agitation
• weakness
• muscle tremors
• Altered LOC: anxiety, agitation, stupor, coma
• Transient hyperpnea, followed by seizures, apnea and cardiovascular
collapse
• Tremor
• Normal pupils
• Cough
• Diaphoresis
3. Treatment:
ALS HOT ZONE • High flow of O2 if available.
ALS WARM/COLD ZONE • Cardiac monitor.

• NS IV access.
• Sodium Thiosulfate IV:
Adult dose: 12.5 grams (50 ml)
Pediatric dose: 0.4 mg/kg
• Intubate and ventilate if apneic.
HOSPTIAL • Supportive care, including:

Intubation & ventilation if necessary.
Sodium Bicarbonate for acidosis
ABG monitoring.
HYDROGEN CYANIDE AND CYANOGEN CHLORIDE TREATMENT

PROTOCOL (cont.)
4. Precautions and Considerations:

• Do not remove PPE to check for “bitter almond” smell.
• Pulse oximetry is of limited use in Cyanide poisoning. If the patient is
symptomatic and O2 saturation is high, this may indicate either severe
poisoning or the absence of Cyanide. If the patient is symptomatic and the
O2 saturation is low, this may indicate another co-intoxicant or concurrent
medical problem along with Cyanide that may be amendable to other
treatment, such as bronchodilation.
• Nitrate therapy, such as Amyl Nitrate or Sodium Nitrate, has significant

side effects and is not useful in empiric treatment. Most Cyanide treatment
kits contain these drugs. Do not use them.
Methylene Diphenyl Isocyanate (MDI), Methylene Diisocyanate, and Methyl

Isocyanate (MIC)
FACT SHEET
Military Designations or Military Unique Use: None
Description: MDI is found as a solid in white to yellow flakes. Various liquid

solutions are used for industrial purposes. There is not odor to the solid or liquid
solutions. The vapor is approximately eight times heavier than air. This chemical
is a strong irritant to the eyes, mucous membranes, skin and respiratory tract. It
is also a very potent respiratory sensitizer.
Non-military Uses: Very large quantities of MDI are produced, transported, and
used annually in the US. Various industrial processes utilize MDI in production of
polyurethane foams, lacquers and sealants. MDI is a commonly used precursor
in the industrial production of insecticides. Noncommercial uses of
polyurethanes, such as in isocyanate paints or in cutting of uncured urethanes,
may also cause exposure. Thermal degradation of these substances may
produce MDI as a byproduct of combustion
Health Effects: MDI as either a solid or liquid solution is a strong irritant to the
eyes and the skin, resulting in discomfort and burning sensation. Severe
inflammation may occur, along with irritation of the respiratory tract and
bronchospasm. Very high concentrations may result in severe respiratory
distress and pulmonary edema. MDI vapor is a strong sensitizer of the
respiratory tract and may result in an asthma manifestation in individuals both
with and without prior history of the disease. This sensitization may persist
indefinitely. Repeated or long term exposure may result in permanent respiratory
or skin problems.
Environmental Fate: MDI / MIC is expected to remain almost entirely in vapor

phase when released into the atmosphere.
MDI / MIC TREATMENT PROTOCOL
• Exposure to a white or yellow solid, or a heavier than air vapor
• Eye, mucous membrane or skin irritation
• Allergic symptoms such as wheezing, shortness of breath or urticaria
• Increased work of breathing
• Wheezing
• Cough
• Increased secretions and lacrimation
• Erythema of skin
3. Treatment:

• Eyes or skin irritation: flush with copious
amounts of water as is feasible.
• High flow O2 if respiratory symptoms.
ALS HOT ZONE • If bronchospasm present, administer

Epinephrine (1:1,000) 0.3 mg IM or SQ x 1 in
severe cases
ALS WARM/COLD ZONE • Albuterol nebulizer treatment if evidence of

bronchospasm; repeat as necessary.
• Consider intubation for stridor/severe dyspnea/
chest pain.
• Consider surgical/needle cricothyrotomy for
laryngospasm if unable to maintain airway with
BLS maneuvers or intubation.
• Continue Albuterol nebulizer therapy.
• IV access with NS TKO.
MDI / MIC TREATMENT PROTOCOL (cont.)
HOSPTIAL • Continue Inhalational Beta-2 agonist

bronchodilator therapy.
• Solu-Medrol 125 mg IV.
• If hypoxia continues, Intubate and maintain
oxygenation.
• Be prepared to treat ARDS; treat pulmonary
edema with PEEP. Use diuretic therapy with
caution due to risk of hypotension.
• Utilize Morphine Sulfate or Codeine for
pain/cough suppression.

• All patients who have had a moderate or high level of exposure
(respiratory distress, GI or cardiovascular signs or symptoms on exam by
EMS personnel) should be referred to a medical facility for examination
and treatment.
• If utilized, the ETT’s placement and patency must be strictly maintained at
all times. Confirm ETT position (reassessed and documented) with any
patient transfer. Confirm by direct visualization and/or end-tidal CO2
detection device.
Mustard (Sulfur Mustard)
FACT SHEET
Military Designations: H; HD; HS
Description: Mustard is a “blister agent” that causes cellular damage by

interfering with DNA function. It is a colorless to light yellow to dark brown oily
liquid with the odor of garlic. It is not derived from, or chemically related to edible
mustard. It does not evaporate readily, but may pose a vapor hazard in warm
weather. It is a vapor and liquid hazard to skin and eyes, and a vapor hazard to
airways. Its vapor is five times heavier than air.
Non-military Uses: Sulfur mustard has been used as a research tool to study
DNA damage and repair. A related compound, nitrogen mustard, was the first
cancer chemotherapeutic agent and is still used for some purposes.
Military Uses: Mustard was used extensively in World War I and was the largest
producer of chemical agent casualties during that war. Mustard was used by Iraq
against Iran in the 1980’s. The US has a variety of munitions filled with sulfur
mustard, including projectiles, mortars and bombs.
Health Effects: Mustard damages DNA in cells, which leads to degradation of

cellular function and cell death. Mustard penetrates skin and mucous membranes
very quickly, and cellular damage begins within minutes. Despite this cellular
damage, clinical effects may not become apparent until hours later; the range is
2 to 24 hours. The initial effects are in the eyes, skin and airways. After high
doses, the effect is progressive from irritation to ulceration (cornea), blistering
(skin), alveolar damage (lungs), gastrointestinal tract (vomiting & diarrhea) and
suppression of bone marrow (pancytopenia). There is no specific antidote.
Mustard may produce carcinogenic, developmental damage, airway stenosis and
other long term effects.
Environmental Fate: Persistence of mustard may last for weeks in the soil;
deeper levels may be contaminated for years. Mustard is relatively insoluble in
water; once dissolved, however, it breaks down into nontoxic byproducts.
MUSTARD TREATMENT PROTOCOL
• Exposure to a colorless to light yellow or dark brown oily liquid
• Odor of garlic
• Onset of signs and symptoms usually 4 to 8 hours after exposure
• Eyes: irritation, redness, foreign body “gritty” sensation
• Skin: erythema progressing to clear vesicles and blisters
• Cough
• Mucous membranes/airway: hoarseness/stridor
4 Sinus pain
4 Cough
4 Dyspnea
3. Treatment:
ALS HOT ZONE • None.
ALS WARM/COLD ZONE • Thorough decontamination especially important.

• Intubation, ventilation if needed.
• Flush eyes if symptomatic.
• Standard burn treatment for blistered areas.
• Preserve body temperature if blistered areas are
large.
HOSPITAL • Utilize mydriatic with sunglasses if photophobia

is present. Topical antibiotic if evidence of
significant conjunctivitis or keratitis may be
useful.
• Control pain with systemic analgesic such as
Morphine Sulfate or Codeine.
• Continue burn treatment for blistered areas.
• Humidified O2, bronchodilators, Codeine for
cough suppression if symptomatic. Intubation
and preservation of oxygenation if chemical
pneumonitis develops.
• Monitor CBC for bone marrow suppression.
MUSTARD TREATMENT PROTOCOL (cont.)

• Liquid or vapor mustard penetrates the skin and mucous membranes and
damages cells within minutes of exposure, so decontamination must be
done immediately after exposure.
• Mustard agent can be very persistent; all surfaces with potential
contamination must be carefully cleaned before assumed to be
decontaminated.
Nerve Agents
FACT SHEET
Military Designations: GA (Tabun); GB (Sarin); GD (Son): GF and VX.
Description: Nerve agents are very toxic organophosphorus compounds that

have biological activity similar to that of many insecticides. There is variable
volatility, with some agents more likely than others to pose a toxic hazard by
inhalation, and some agents likely to persist longer than others. All are well-
absorbed across the skin. Under temperate conditions, the liquids are clear,
colorless, and mostly odorless. They cause biologic effects by inhibiting
acetylcholinesterase, thereby allowing acetylcholine to accumulate and cause
hyperactivity in the muscles, glands and nerves.
Non-military Use: None.
Military Use: Nerve agents were first synthesized pre-World War II, but were not
used during that war. They were allegedly used by Iraq in its war with Iran. The
US has a large stockpile of GA and VX weapons that are in the process of being
destroyed.
Health Effects: Nerve agents are among the most toxic chemical agents. Initial
effects from small amounts of agent differ depending on the route of exposure.
After a small vapor exposure, there is the immediate onset of effects in the eyes
(miosis), the nose (rhinorrhea), and the airways (dyspnea due to wheezing and
increased secretions). After a small skin exposure, there may be an
asymptomatic interval of a few minutes to a few hours before the onset of
sweating and fasciculations at the site of the droplet, which may be followed by
nausea, vomiting and diarrhea. After exposure to a large amount of nerve agent
by either route, there may be sudden loss of consciousness, fasciculations,
seizures, copious secretions, paralysis, apnea and death. There is usually an
asymptomatic interval of minutes after liquid exposure before these occur; effects
from vapor occur almost immediately. The antidotes Atropine and Pralidoxime (2-
Pam) are effective if administered before circulation fails.
Environmental Fate: GB will react with water to produce toxic vapors. Most GB
spilled will be lost to evaporation. VX is moderately persistent in soil, and
because it has low water solubility and low volatility, it could be mobile in surface
and ground water systems.
NERVE AGENT TREATMENT PROTOCOL
• Eyes: blurry or dim vision
• Nausea, abdominal pain, cramps, diarrhea
• Dyspnea
• Tremors
• Weakness
• Mild:
4 Miosis
4 Rhinorrhea
4 Excess secretions
4 Diaphoresis
4 Vomiting
4 Diarrhea
• Severe:
4 Decreased level of consciousness
4 Fasciculations and muscle weakness
4 Seizures
4 Muscle paralysis leading to apnea and death
3. Treatment:
MILD EXPOSURE SEVERE EXPOSURE
BLS/FIRST RESPONDER • Supportive Care. • Supportive Care.
ALS HOT ZONE • Atropine:

Adult: 2 mg IM
Infant: 0.05 mg/kg IM
Repeat as needed
• 2-PAM 1 gram IM
• Ativan 2 mg IM for
seizures
NERVE AGENT TREATMENT PROTOCOL (cont.)
MILD EXPOSURE SEVERE EXPOSURE
ALS WARM/COLD ZONE • IV access • IV access

• Atropine: • Repeat Atropine as
Adult: 1 mg IV or IM needed IV
Infant: 0.02 mg/kg, • 2-PAM Adult: 1-2
repeat q 5 min. gram IM or IV; Infant
Repeat Atropine as & child: 20-40 mg/kg
needed IV • Treat seizures with
• Pralidoxime (2-PAM) Ativan (admin. over 2-
Adult: 1-2 gram 5 min. slow IV): Adult
Infant & child: 20-40 1-2 mg, repeat as
mg/kg needed; Infant & child
0.1 mg/kg, repeat at
0.05 mg/kg in 10 min.
if needed.
HOSPITAL • Continue Atropine and • Continue Atropine

2-PAM as needed (2- and 2-PAM as
PAM infusion is needed
preferred over repeat • Treat acidosis as
boluses; give 200-500 needed
mg/hr titrated based
on improvement in
muscle weakness)
4. Precautions and Comments

• Nerve agent poisoning can be very toxic. Large amounts of Atropine may
need to be utilized (in the 100’s of mg’s). If the patient is initially
symptomatic and no response is seen to the initial doses of medication,
continue giving until a response is achieved.
• If the patient has enough symptoms to require Atropine treatment, they

should also receive 2-PAM.
• In MCI nerve agent poisoning, consider the following dosage scheme

for Atropine (and possibly 2-PAM) administration via auto-injectors
in the hot zone:
NERVE AGENT TREATMENT PROTOCOL (cont.)
* USE 3 AUTO- USE BETWEEN 1 AND 3 DO NOT USE AUTO-

ATROPINE AUTO- INJECTORS IF:
INJECTORS IF:
INJECTORS IF:
(attempt to titrate dose)
One or more signs of life, 2

or more signs of poisoning
and:
At least one sign of life Elderly appearing No sign of life

(breathing, pulse, or
conscious)
Exhibiting 2 or more signs Children appearing under Ambulatory

of poisoning (in addition to age 14
miosis)
Non-ambulatory Prolonged extrication (if not Fits non-resuscitation group

expected to die). May need (expected to die) due to other,
more than 3 auto-injectors concomitant injury.
and possibly 2-PAM.
Seizures No seizures No seizures
• Bronchospasm and respiratory secretions are the best acute symptoms to

monitor for response to Atropine/2-PAM therapy.
• * If symptoms are severe, 3 Atropine auto-injectors and 3 2-PAM auto-

injectors should be administered in rapid succession (stacked).
Radiation Injury
FACT SHEET
Military Designations: None.
Description: Radiation injury situations can be classified into two distinct

scenarios: Detonation of a nuclear bomb (fission or fusion device) and
contamination of people with radioactive material by a mechanism other than a
nuclear bomb (e.g. a conventional explosive with radioactive covering or spilled
radioactive materials).
Non-military Use: Radioactive materials (isotopes) are utilized by hospitals and

other health care facilities in many medical procedures, such as bone scans and
research laboratory functions. Nuclear fission materials are utilized for power
generation in electrical generating plants. Isotope materials are generally more
readily accessible than fissionable materials.
Military Use: Nuclear bombs utilize fission or fusion to rapidly produce an

enormous release of energy from a small amount of material. The resulting blast
devastates both the physical environment and the human population that is
exposed to it. The only wartime uses of these devices were during World War II
on Hiroshima and Nagasaki. Multiple nuclear device testing has been done
since that time, much of it underground to minimize health effects.
Health Effects:
• Nuclear Bomb: Health effects would be cataclysmic, and proportional to the
explosive power of the device expressed as equivalent tons of TNT. Most
current devices are in the 1 to 100 kiloton range (1,000 to 100,000 tons of
TNT). Detonation of such a device would result in large numbers of
immediate deaths with vaporization of many human remains. Blast injuries
(pneumothoraces, closed head injuries, blunt abdominal trauma, spine and
limb injuries) would be common along with severe burns all due to the
thermal energy released by the device. Health effects due to radiation would
be profound and are related to the amount of radioactive energy absorbed by
the body, expressed as “RADS”, which are units of energy absorbed.
Radioactive energies released by nuclear bombs are primarily gamma rays,
which are short lived (they do not cause residual contamination once the
blast is over) but are very powerful and can penetrate most materials.
Protective factors are distance from the center of the explosion, material
between the patient and the explosion (the more solid, the better) and the
parts of the body exposed to radioactive effects.
Radiation Injury (cont.)
Health Effects (cont.):
• Contamination: Health effects from exposure to radioactive contamination

are more variable, and likely to be more survivable. Most radioactive
contaminants are isotopes; these materials give off some gamma radiation,
but more commonly alpha and beta rays, which are easily stopped by
physical barriers such as clothing. Radioactive contaminants may be
persistent however, and may pose a threat to the rescuer. Examples would
be shrapnel wounds from a bomb that are contaminated with isotopes, or
liquid radioactive material on the skin. Strict decontamination procedures,
similar to those described in the Chemical Agent protocols, are an important
part of therapy along with isolating any bodily secretions that may contain
contaminants (such as vomitus).
Environmental Fate: Radiation may persist in the ground water and soil for a
number of years. The predictable threat level is yet to be determined.
The symptoms of radiation exposure are outlined in the following chart:
AMOUNT OF ORGAN SYSTEM SYMPTOMS

RADIATION PREDOMINANTLY
EXPOSURE AFFECTED
800 Rads and above Central nervous system Coma and rapid death
600-800 Rads Central nervous system Altered LOC, seizures,

coma
400-600 Rads GI tract Nausea, vomiting,

diarrhea
200-400 Rads Skin Partial and full-thickness

burns
200 Rads This is the LD 50, or 50% of See above and below
the patients exposed to this
amount of radiation will
eventually die
Health Effects (cont.):
100-200 Rads Hematopoietic system (bone Anemia, easy bruising

marrow, blood cells) and bleeding (including
internal bleeding),
secondary infection due to
immuno compromise
several dys after exposure
Less than 100 Rads Endocrine and other systems Tumor development
(carcinogenesis, or excessive months to years after
development of cancers) exposure; thyroid cancer
particularly common
0.1 Rad Exposure from a typical chest

X-Ray
RADIATION INJURY TREATMENT PROTOCOL
• History: Type of exposure (bomb or contamination scenario)
4 Pre-existing medical condition
4 Time since exposure
4 Type of decontamination performed (decontaminate prior to treating
patient in contamination situation
4 Age and pregnancy status
• Symptoms: as outlined in chart above
4 Low-dose – Skin and mild GI findings, or no acute symptoms
4 Higher-dose – Severe skin destruction, severe GI findings, altered
LOC
• Burns
• Blast injuries
• Spine injury
• Long bone fractures
• Vomiting (may be bloody)
• Diarrhea
• Altered LOC
RADIATION INJURY TREATMENT PROTOCOL (cont.)
3. Treatment:

• Skin: cover any burned areas with clean
dressings if available.
• High-flow O2 if respiratory symptoms.
ALS HOT ZONE • Decontamination of skin per

Chemical/HazMat procedures.
• Respiratory support.
ALS WARM/COLD ZONE • Consider intubation for stridor/severe

dyspnea/ hypoxia/chest pain.
• Consider needle decompression of chest if
blast injury and S/S of tension
pneumothorax.
• Continue burn and other wound dressing.
• IV access with NS, bolus.
HOSPITAL • Institute appropriate wound and burn care

(be aware of possible radioactive
contamination of penetrating trauma
wounds).
• Potassium Iodide 130 mg PO for all
symptomatic patients, or those exposed to
significant radiation per HazMat personnel.
Also treat all children < 8 y/o and all
pregnant females with Potassium Iodide.
• Pain management.
• CBC, including absolute lymphocyte count.
• Supportive treatment for CNS and GI
symptoms.
• Prophylactic antibiotics not recommended.
RADIATION INJURY TREATMENT PROTOCOL (cont.)

• Follow HazMat radiation exposure plan for decontamination and disposal
of all contaminated waste.
• In the nuclear bomb scenario, the casualty load will likely be excessive.
Utilize austere care and mass casualty techniques with strict triaging to
maximize available resources.
ILLUSTRATION 6.D.
HAZMAT ZONES
WARM ZONE
HOT ZONE
PROTOCOL 6.7: HELICOPTER UTILIZATION
Indications:
A. It is the purpose of this procedure to detail the actions of Rapid

City/Pennington County EMS personnel (both ALS and BLS) when
considering a request for a scene response by a helicopter during medical
and rescue incidents. It is imperative that these requests for scene response
are appropriate and operations involving them are conducted safely. This
procedure will primarily be directed toward the use of the LifeFlight helicopter
resource, but can apply to military helicopters as well.
General Principles:
A. It is a medically accepted fact that the rapid transport capabilities of the

helicopter can potentially reduce the morbidity and mortality of the seriously
injured or ill patient in the pre-hospital setting. This is especially true in a
primarily rural setting such as western South Dakota.
B. Following are some pertinent points to consider, and some guidelines that
shall be followed if you find yourself considering requesting a scene
response by the LifeFlight or National Guard helicopters.
Procedures:
A. The LifeFlight helicopter will not always be available for scene response on
an immediate basis; it will occasionally be out of the area transferring
patients into RCRH from the outlying localities.
B. The National Guard Aviation unit is not a 24-hr. on-call service. At times
they can fly almost immediately, at other times it may take them two hours or
more to put a helicopter in the air. This being dependent on the time of day,
day of week, time of year, weather, etc.
C. Whenever a response by the LifeFlight or National Guard helicopter is

considered, the first piece of information that should be gathered is whether
or not the helicopter is immediately available and the time required to launch
the helicopter and fly to the scene. This information can be obtained through
Dispatch. This estimated time should be compared to the time it will take to
utilize ground transport. If a rescue can be affected and ground transport
take place in a shorter period of time, a helicopter should not be called.
Under no circumstances should transport of a patient be delayed to use
a helicopter for transport.
PROTOCOL 6.7: HELICOPTER UTILIZATION (cont.)
Procedures (cont.):
D. A request for a scene response by a helicopter should only be considered for

the patient with a life-threatening injury or illness requiring rapid
transportation in order to sustain life, or prevent aggravation of the injury or
illness.
E. A request for a response by a helicopter may be considered in the instance

of a patient in a remote, difficult to access by ground, area. This patient’s
injuries or illness may or may not be life-threatening, but a removal by ground
may take such an extended period of time that removal by air is a better
option for the patient.
F. In situations where rescue personnel are considering a vertical extraction by

helicopter and a hoist may be needed, keep in mind that the Guard
helicopters are not always set up with a hoist. If Guard personnel have to
install a hoist before a helicopter is put in the air, it may take an extended
period of time and a ground extraction and transport may be more expedient.
G. Dispatch launch of the LifeFlight helicopter will be automatic on selected

trauma cases (see LifeFlight automatic launch criteria below) outside a 20-
minute ground travel zone calculated from the geographical center of Rapid
City (see Illustration 6.E. 20-Minute Ground Travel Zone below). Ground
EMS units will still be dispatched and respond per standard Dispatch
protocol. If LifeFlight arrives on scene and ground EMS units are not
needed, LifeFlight will cancel them and ground EMS units will return. If
LifeFlight requires assistance from ground EMS units, they will continue and
assist LifeFlight as needed.
H. There will be no automatic Dispatch launch of the LifeFlight helicopter inside

the city limits of Rapid City or inside the 20-minute ground travel zone from
the center of the city. In most cases, a ground ambulance will be able to
transport in a shorter time frame inside this zone.
I. A scene response by the LifeFlight helicopter will not be precluded inside the
city limits of Rapid City or inside the 20-minute ground travel zone. The
senior Paramedic on scene at an incident or responding, may at their
discretion, request a scene response by the LifeFlight helicopter. Any such
request will be made through Dispatch, keeping in mind the parameters
mentioned above. The most likely scenarios for any close-in scene
responses will be multiple patient situations (serious MCI) and entrapment
with prolonged extrication.
Procedures (cont.):
Any request for a scene response for the LifeFlight helicopter inside the city
limits or inside the 20 minute ground travel zone will be examined post-
incident to assure that request for a scene response was appropriate.
J. Outside of the 20-minute ground travel zone, first response agencies may
make the decision to request a scene response by a helicopter. This may
occur when first response agencies are called to an incident and find a
situation that meets the criteria for an automatic launch, and initial
information to Dispatch was unclear or incomplete to the point of not causing
the automatic launch to occur. Any such request will be made through
Dispatch, once again, keeping in mind the parameters mentioned above.
The outside 20-minute zone automatic launch criteria list should be used as
a guideline to determine what types of patients and situations that it would be
appropriate to request a scene response for. In all situations where a scene
response by a helicopter is being considered, the responding Paramedic
should be consulted. In most cases these ALS personnel will usually be in
the best position to make an accurate judgment of the time required to affect
their own ground transport and help decide if transport by helicopter is or is
not in the best interests of the patient.
K. Consideration should be given to possibly utilizing helicopter transport during

a Mass Casualty Incident (MCI) keeping in mind the same time frame
parameters mentioned previously. The use of helicopters during a MCI will
be at the discretion of the IC (Incident Commander) or his designee.
L. The transition of patient care from the attending Paramedic on scene to

LifeFlight personnel will be the same as any other situation where patient
care is transferred. The Paramedic on scene will give a complete face-to-
face verbal report to the LifeFlight crewmember that will be responsible for
the patient’s continued care. In the instance of National Guard helicopter
usage, the attending Paramedic will typically accompany the patient to the
hospital in the helicopter.
M. All circumstances surrounding a request for a scene response by a helicopter

will be fully documented in patient care reports (PCR’s) and FD incident
report narratives.
Landing Zone (LZ) Procedures:
A. Ground EMS units, when requesting a scene response by a helicopter,

should not concern themselves with an LZ unless they know of a suitable
location at or very near the incident site. In all cases where a scene
response has been requested, a Fire Dept engine company (from the
jurisdiction where the incident occurred) should be detailed to LZ operations.
B. A safe landing zone should be established prior to the helicopter’s arrival by

LZ operations. In the event that the unit assigned to LZ operations
experiences difficulties finding a suitable LZ, they should wait until the
helicopter arrives. The helicopter may have a better vantage point in
choosing an LZ and they will advise LZ operations. In the event that the LZ
is remotely located and appears to be safe for landing, the pilot may elect to
land without the assistance of LZ operations. This does not mean the unit
assigned to LZ operations should be cancelled; they will be utilized for
security, safety, and possible assistance with patient loading once the
helicopter is on the ground.
C. When setting up an LZ there are several things to keep in mind:
1. The pilot will generally determine how small an area he can safely land in,
the bigger and freer of obstructions the area is, the better. Keep in mind
that wires are very difficult to see from the air, especially at night. An
area 100’ larger than the rotor tips in all directions is a good starting
point.
2. The LZ should be set up as to facilitate takeoffs and landings into the

wind. Do not rely on Dispatch for correct wind direction, use visual
indicators.
3. The approach and departure ends of the LZ should be clear of

obstacles (any object > 40 feet tall that is within 100 feet of the LZ).
4. Any and all loose articles (wood, cans, plastic, sheets, blankets, etc) in
the vicinity of the LZ that potentially could be affected by rotor down
wash need to be secured or removed. Flying debris can damage both
the helicopter and personnel on the ground.
5. If the LZ will be on a surface other than pavement, to minimize the

hazard of blowing dirt, dust and sand, the LZ should be wet down as
necessary. If the LZ will be on snow, an attempt should be made to clear
the snow from the area to prevent it from obscuring the vision of the pilot.
Landing Zone (LZ) Procedures (cont.):
6. No unauthorized person will be permitted to approach the helicopter.

This will be the general responsibility of LZ operations.
7. It is not necessary to have a hose line pulled and charged. In the event
of a catastrophic event involving the helicopter, strategy and tactics will
be left up to the IC (Incident Commander).
8. The pilot is both legally and operationally responsible for the safety of
the aircraft. Therefore, the final decision on the suitability of the LZ is
that of the pilot.
Safety Procedures:
A. Safety should always be of paramount concern when addressing operations

involving helicopters. The first question you should ask yourself when you’re
considering the use of a helicopter is, “can this be done safely?” The
helicopter is not inherently dangerous. The danger manifests itself in the
form of people not understanding the potential hazards that exist on or near
the helicopter. Following are a few basic safety rules to impart a basic
understanding of where the potential dangers exist, and how to work around
helicopters safely and effectively. Above all: Stay Alert!!!
B. Absolutely no personnel will approach the helicopter until given an “all clear”
by a helicopter crewmember, and then approach only in the pilot’s field of
vision.
C. Unless required to be closer, persons should stay 100’ away from large
helicopters at all times. When approaching nearer than this distance, always
approach the helicopter from the side and near the front in full view of the
pilot. NEVER approach a helicopter from the rear (tail rotor!). Note: The
Blackhawk helicopter used by the National Guard should never be
approached from the front, only the side. The main rotor pitches down in
front.
D. Keep clear of the main rotor and tail rotor at all times. The greatest threat
when operating around a helicopter is the turning rotor blade. When the
blades are turning, the high-speed tail rotor is virtually invisible! Physical
contact with either of the blades while they are turning is almost always fatal.
Safety Procedures (cont.):
E. Never approach the helicopter from any side where the ground is higher than
where the helicopter is standing or hovering. On uneven ground, always
approach and depart the helicopter from the DOWNHILL side if possible.
Keep in the pilot’s field of vision at all times.
F. Do not face helicopters when they are landing, taking off, or hovering unless
goggles are worn or visor is down. Fire Dept personnel involved in helicopter
operations will wear full bunker gear, with collar up, gloves and helmet.
Helmets will have chinstraps fastened.
G. Avoid approaching a helicopter with long tools, rods, etc. If this is

unavoidable, carry such objects horizontally to avoid possible contact with
the rotor blades.
H. Patients will be secured to backboards with a minimum of three (3) straps

unless contraindicated by their medical condition. The feet must be secured
at the ankles. If the patient is combative, place an additional strap above the
knees.
I. All bandages and dressing shall be affixed security. Coverings like sheets
and blankets are potential hazards and will be secured or placed underneath
straps.
J. A minimum of four (4) personnel, one of which will be a helicopter

crewmember, will carry the patient to the helicopter. Loading of the patient
into the helicopter will be at helicopter crewmember’s direction.
K. The pilot or crewmember’s approval shall be obtained first before any gear or
personnel are placed in or on the helicopter.
L. The pilot is responsible for the safety of his aircraft at all times; his decisions
are final in this respect.
Automatic launch criteria – Regional LifeFlight Helicopter
911 Dispatch generated, Delta/Echo level trauma, outside 20 min. ground

ambulance response zone
Animal bites/Attacks
• Severe CENTRAL injuries
• Attacks or multiple animals
• Known poisonous snake
• Unconscious, not alert
Assault
• Multiple patients (MCI)
• DANGEROUS injuries (abdomen, chest w/abnormal breathing, head/not
alert)
• Unconscious
Burns/Explosions
• Large burns (>18% BSA)
• Face, airway involvement
• SEVERE RESPIRATORY DISTRESS
• Explosion
Carbon Monoxide/Inhalation/HazMat
• SEVERE RESPIRATORY DISTRESS
Drowning (near)/Diving/Scuba Accident
• Not breathing
• Neck/back injury with neuro deficit
Electrocution/Lightning
• Not breathing
Automatic launch criteria – Regional LifeFlight Helicopter (cont.):
Falls
• DANGEROUS injuries (chest w/abnormal breathing, head/not alert
• Fall >20 feet
Heat/Cold Exposure
Hemorrhage/Lacerations
• DANGEROUS hemorrhage (armpit, groin, neck, rectal (serious), vomiting
bright red blood)
Industrial/Machinery/Farm Accidents
• LIFE STATUS QUESTIONABLE (existence of any information suggesting:
abnormal breathing, cardiac arrest, major injury, unconsciousness,
uncontrollable bleeding)
• Trapped or caught in machinery
Stab/Gunshot/Penetrating Trauma (Law Enforcement must secure scene)

• Multiple wounds
• CENTRAL wounds
Traffic/Transportation Accident
• MAJOR INCIDENT (MCI, any evidence suggesting serious injuries to multiple
patients. This includes aircraft, bus, train)
• Auto vs. pedestrian/bicycle/motorcycle
• Ejected from vehicle
• Trapped in vehicle > 20 minutes
• Vehicle off bridge/height
• Unconscious
Traumatic Injuries (Specific)

• DANGEROUS injuries (chest w/abnormal breathing, head/not alert,
neck/back injury with neuro deficit)
• Amputation excluding fingers, toes
ILLUSTRATION 6.E.
20 MINUTE GROUND TRAVEL ZONE
Protocol 6.8: Infectious / Communicable Disease
General Principles:
A. Contact with patients carrying communicable diseases must be taken

seriously and the appropriate protective measures taken to substantially
reduce or eliminate the potential risk. This will assure not only the continued
health and safety of EMS providers, but their families and other patients.
B. If an exposure to a communicable disease does occur, the proper follow-up

and treatment will minimize any possible effects of the exposure.
C. Infection control measures will be addressed by following specific procedures

in the following areas:
1. Body substance Isolation and barrier protection.
2. Equipment usage, maintenance and cleaning.
3. Hygiene.
4. Post-exposure follow-up.
Definitions:
A. Significant Exposure:
1. Direct mouth-to-mouth contact.
2. Any body fluids (including airborne droplets from a cough or sneeze) that
come in contact with your:
a. Mouth
b. Eyes
c. Nose (or other mucosal surface)
d. Open sore, cut, or rash
3. Needle stick (by contaminated needle or other sharp) or a laceration by

any object potentially contaminated with body fluids.
Protocol 6.8: Infectious / Communicable Disease (cont.)
Procedures:
Body substance isolation and barrier protection
A. Body substance isolation practices dictate that all body fluids are to be
considered potentially infectious agents and EMS providers will make every
effort to avoid being exposed to same. Body substance isolation will
primarily be accomplished with barrier protection through the use of personal
protective equipment (PPE). The following items of PPE are to be used
when and as described.
1. Gloves
a. Disposable gloves (non-latex) shall be worn for all patient contacts.
b. Gloves shall be changed after each patient contact.
c. Cuts, rashes or sores on the hands shall be bandaged in addition to

wearing gloves.
d. Structural firefighting gloves shall be worn over disposable gloves

(whenever possible) when patient care is combined with extrication
activities or any other contact with sharp or rough surfaces.
2. Eye protection
a. Eye protection (protective eyeglasses or surgical-type masks with

eye shields) shall be worn whenever there is a possibility that blood
or other body fluids could be splashed into the provider’s eyes (e.g.
intubation attempts, suctioning, combative patient, etc.).
3. Masks
a. Surgical-type masks shall be worn whenever there is a possibility

that blood or other body fluids could be splashed into the provider’s
mouth and nose (e.g. intubation attempts, suctioning, combative
patient, etc.). These will suffice in situations where no airborne
infection threat is suspected.
Procedures (cont.):
Body substance isolation and barrier protection (cont.)
b. Disposable HEPA-filter type masks shall be worn whenever treating

patients suspected of possibly carrying infectious airborne disease
(TB, Meningitis, etc.) to avoid inhalation of airborne droplets. Any
patient with fever, vomiting, cough or known history should be
suspect.
c. A non-rebreather O2 mask at a minimum of 8-10 LPM may also be

put on a patient (if clinical condition and treatment allows) suspected
of possibly carrying infectious airborne disease to further contain the
threat.
d. A BVM with one-way valve shall be used for patient ventilation when
needed. Mouth-to-mouth ventilation will not be done and is
considered a Significant Exposure.
4. Gowns, shoe covers
a. Gowns and shoe cover shall be worn when conditions permit and
there is significant possibility that blood or body fluids could be
splashed onto the provider’s clothes.
Equipment usage, maintenance and cleaning
A. Disposable equipment shall not be re-used or cleaned, if it is contaminated

with body fluids it will be disposed of in a red bio-hazard bag. Red bio-
hazard bags will be disposed of in the larger, red plastic bio-hazard
containers found in the stations. Contaminated disposable equipment will
not be put in with the regular station trash.
B. Used, disposable equipment (including gloves) shall not be left anywhere in

vehicles or stations unless disposed of properly in a red bio-hazard bag.
C. Needleless supplies will be used whenever possible. Needles will not be re-
capped; used needles and all sharps will be placed in an approved sharps
container after use. When sharps containers are full, they will be disposed of
in the larger, red plastic bio-hazard containers found in the stations.
Procedures (cont.):
Equipment usage, maintenance and cleaning (cont.)
D. Hard, non-disposable equipment that becomes contaminated with body fluids

will be cleaned with a commercial disinfectant and left to air dry in an area
designated for that purpose. Equipment will not be cleaned in the living
quarters of stations.
E. When equipment is cleaned, it should generally be left to air dry. If it must be

wiped off for immediate re-use, paper towels should be used whenever
possible and not cloth towels.
F. When the patient compartments of ambulances are cleaned, they should be

cleaned with a commercial disinfectant and left to air dry with the doors open.
Final cleaning may be done with an all purpose cleaner and towels.
Cleaning supplies (mops, etc.) used in ambulances should only be used for
that purpose.
G. Appropriate PPE shall be used whenever cleaning equipment. This will at a

minimum include gloves, and possibly a mask and gown if there is a
significant splash hazard.
H. If cloth towels or blankets become heavily contaminated with body fluids,

they should be disposed of properly in bio-hazard bags or containers. If cloth
towels and blankets are only lightly contaminated they may be put in linen
bags in the stations for commercial cleaning (linen bags are considered to
contain bio-hazard materials).
I. Porous, non-disposable equipment (backboard straps, cot straps, etc.) that

becomes heavily contaminated with body fluids will not be cleaned; it will be
disposed of in the larger, red plastic bio-hazard containers found in the
stations. When this is done, the Paramedic in charge of medical supply must
be notified.
Hygiene
A. Hands should be washed as soon as possible after removing gloves after

any patient contact (immediately after with a waterless hand cleaner if
possible, and then thoroughly with soap and water when available).
B. Treat all cuts, rashes or abrasions promptly and cover or bandage them.
Procedures (cont.):
Hygiene (cont.)
C. Vehicles shall not be operated, radio microphones or computers used while

wearing gloves used during patient contact.
D. In the event of a needlestick type injury, the area should be cleaned with an
antiseptic cleaner, then washed thoroughly with soap and water and
bandaged. If the injury is a single needlestick, it may be cleaned initially with
an alcohol prep, bandaged and then cleaned with soap and water when
available. This is a Significant Exposure.
E. In the event of body fluids being splashed into a providers face, mouth or
nose, the face should be washed thoroughly with soap and water and
possibly a shower taken. Eyes should be flushed with water or saline. This
is a Significant Exposure.
F. Uniforms should be changed and a shower taken if the arms, legs or trunk of
the body are significantly exposed to body fluids.
G. Uniform items that become contaminated with body fluids will be taken out of
service as soon as possible. Items that are lightly contaminated should be
sprayed with a commercial disinfectant and either commercially laundered or
laundered in a Department washing machine intended for that purpose.
Items that are heavily contaminated should have the gross contamination
sprayed off (into a sanitary sewer drain), then sprayed with a commercial
disinfectant. Those items should then be isolated in bio-hazard bags and
referred to the Department Infection Control Officer for disposal or
commercial cleaning.
Post-exposure follow-up
A. Following a Significant Exposure, the exposed individual will report the

incident to their direct supervisor immediately, or as soon as is reasonably
possible.
B. If the exposed individual is actively engaged in patient care, whenever

possible, care should be referred to another provider (of the same skill level
or higher) so treatment can begin immediately. It is recognized this may not
always be possible.
Procedures (cont.):
Post-exposure follow-up (cont.)
C. In all cases of Significant Exposure, the exposed individual will present to the
RCRH Emergency Department for evaluation as soon as possible. This will
be facilitated by the individual’s direct supervisor. In no case should this be
delayed any longer then is absolutely necessary. If this situation creates a
staffing shortage, the shift commander will shift personnel or hire-back to
resolve the shortage.
D. The exposed individual will check in at the RCRH Emergency Department

and be evaluated by an ED physician. The physician will determine if a
Significant Exposure has in fact occurred, and if it has, what the potential
threat is. If the exposed individual was determined to have had a Significant
Exposure to a confirmed communicable disease, the individual shall undergo
whatever treatment and post-exposure prophylaxis (PEP) is deemed
advisable by the ED physician and/or the Department physician.
E. If information about a source patients communicable disease status becomes

available to the ED and the physician, that will be communicated to the
exposed individual and the Department Infection Control Officer.
F. At all times, information about the source patient’s identity and the exposed
individual’s communicable disease status will be kept strictly confidential.
That information is protected by law.
G. As soon as possible after the exposed individual’s initial treatment, the

proper paperwork will be completed to document the exposure and provide
for follow-up care if needed. The paperwork to be completed will include:
1. Blood/Body Fluid Exposure Notice

2. South Dakota Employers First Report of Injury
3. Workers Compensation Form
4. Supervisors investigation Report
All of these forms will be completed by the end of the exposed individuals
shift and forwarded to the Department Operations Chief within 24 hours.
H. The Patient Care Report (PCR) pertinent to the exposure will include a
description of events relating to the exposure. A copy of the PCR will be
included with the other paperwork and copies of all documents will become
part of the exposed individual’s confidential medical file.
A. All EMS providers should maintain a high level of awareness and base
knowledge relative to common blood borne and airborne diseases. This
knowledge should include particular information about the diseases, their
symptoms, means of exposure and potential follow-up care that might be
provided in the event of a Significant Exposure.
B. Vaccination is an important part of disease prevention. The Department

provides Hepatitis B vaccination for all new employees, Hepatitis B titer
checks and TB checks. Participation in these programs is mandatory if the
employee has not already been vaccinated or checked. Documentation of
vaccinations and checks will also become part of the employee’s confidential
medical file.
Protocol 6.9: Inter-facility Transport (Critical Care)
Under Construction
Indications:
General principles:
Definitions:
Procedures:
Protocol 6.9: Inter-facility Transport (Critical Care) (cont.):
Under Construction
Protocol 6.10: Multiple Casualty Incidents (MCI)
Indications:
A. Medical or trauma situation involving multiple patients where the combination

of numbers of patients and types of injuries exceeds the capabilities of the
EMS systems normal on-duty resources.
General principles:
A. The very nature of the MCI will typically dictate either multi-company and or
multi-agency responses. This will require that some degree of Incident
Command (IC) structure be established. IC structure should be set up
rapidly and efficiently, and only that IC structure that is required to mitigate
the incident should be set up. These incidents can deteriorate and patients
can die while boxes are being filled in a chart.
Note: RCFD Paramedics will seldom be required to fill General Staff IC

positions in an incident that is within the city or in close proximity to it. Those
positions will typically be filled by RCFD or VFD officers. (This does not
preclude the necessity for RCFD Paramedics to be intimately familiar with all
levels of IC structure). Dependent on the scope of the incident, RCFD
Paramedics may be required to fill positions at the level of Medical Group
Supervisor or below. (See Illustration 6.F., MCI IC Flowchart, below).
B. The MCI with Biological, Chemical or Radiological implications and

contaminated patients will require that patients are decontaminated prior to
triage, treatment and transport. If patients are suspected or known to be
contaminated, triage should only be accomplished by personnel in the proper
level of personal protective equipment (PPE). PPE required for treatment
and transport will generally be dictated by the level of decontamination that is
able to be done. Haz-Mat operations will be consulted to determine the
proper levels of PPE for all operational phases. See Protocol 6.6:
Hazardous Materials / WMD Incidents for further information.
C. The location of a triage/treatment area is very important; it should fulfill the

following criteria as much as is possible:
1. It should be in a relatively safe area, away from the objective dangers of

the incident.
2. It should be close enough for access from incident with stretchers.
3. It should be configured to be accessible by multiple transport vehicles,

for both ingress and egress. Close coordination should be done with
staging (if staging area is established) to assure that vehicles move
smoothly in and out of the triage/treatment area.
Protocol 6.10: Multiple Casualty Incidents (MCI) (cont.)
General principles (cont.):
D. The MCI requires discipline within the team, be sure that leadership and
individual roles are well identified and adhered to. Free-lancing only leads to
poor patient outcomes and delays.
E. The MCI will many times require that treatment decisions be made that fall
outside of the normal parameters of EMS operations and ALS protocol. Time
and resources should not be expended on patients that have a very poor
chance of survival, START triage guidelines (see definition and Illustration
6.G. START Triage algorithm below) should be followed strictly.
Definitions:
A. For purposes of notification and response, Multiple Casualty Incidents will be

classified into three (3) different levels. Level 1 incidents do not need to be
declared. Level 2 and level 3 incidents will be declared.
Note:
When classifying Multiple Casualty Incidents, consideration should be given
to the type of incident and the kinds of patients involved. For instance, an
incident involving 16 patients and above where all patients are GREEN may
not require some actions normally required by the Level 3 MCI classification.
Perform those actions that the incident requires.
1. Level 1 MCI:
a. Does not need to be declared.
b. This will be an incident with a threshold of 5-8 patients.
c. Local on-duty resources will be adequate.
d. First-due units will make medical facility notification of numbers and

condition codes of patients (Priority, 1, 2, 3) as soon as numbers are
known. Routine radio contact with medical facility by transport
vehicles will apply.
Definitions (cont.):
2. Level 2 MCI:
a. Does have to be declared.
b. This will be an incident with a threshold of 9-15 patients.
c. Local resources will be impacted, may require all physical RCFD

Medic Units to be in service.
d. Dispatch will notify medical facility immediately of possible Level 2

MCI
e. IC or designee, (Transport officer/Dispatch) will make medical facility

notification of numbers and types of patients as soon as numbers are
known.
f. Individual transport vehicles will not contact medical facility when

transport has begun, IC or designee, (Transport officer) will make
medical facility notification of numbers and types of patients being
transported.
3. Level 3 MCI:
a. Does have to be declared.
b. This will be an incident with a threshold of 16 patients and above.
c. Local resources will be inadequate; all physical RCFD Medic Units

will be in service and outside resources will have to be utilized.
d. Dispatch will notify medical facility immediately of possible Level 3

MCI.
e. Dispatch will set off a “Medical Strike Team” page (list below), advise
of a Level 3 MCI and request a response to staging.
f. IC or designee, (Transport officer/Dispatch) will make medical facility

notification of numbers and types of patients as soon as numbers are
known.
g. Medical facility may request transport of some patients to alternative

medical facilities.
Definitions (cont.):
h. Individual transport vehicles will not contact medical facility when

transport has begun, IC or designee, (Transport Officer) will make
medical facility notification of numbers and types of patients being
transported.
B. Medical Strike Team resource list:
1. Hill City – 1 ALS ambulance
2. Keystone – 1 BLS ambulance
3. Piedmont – 1 BLS ambulance
4. Rapid City – 2 ALS ambulances, 2 BLS ambulances (if incident is in city

or in very close proximity, all physical RCFD Medic Units may be sent.
5. Pennington County Search and Rescue Mass Casualty Trailer.
C. START Triage:
(Simple Triage And Rapid Treatment) will be the triage method used in the
Rapid City/Pennington County EMS system. The START method of triage is
designed to assess a large number of patients quickly, and can be used
effectively by personnel with limited medical training. The START system
triages patients into the following categories:
1. RED (Priority 1) – Immediate transport

(critical, life-threatening injuries, may survive if treated within 30 minutes)
2. YELLOW (Priority 2) – Delayed transport

(serious injuries, may be life threatening. Very likely to survive if treated within 30
minutes to several hours)
3. GREEN (Priority 3) – Ambulatory (minor), alternative transport

(minor injuries, not considered life-threatening. Care may be delayed several hours or
in some cases days)
4. BLACK (Priority 0) – Deceased (non-salvageable)

(dead, mortally wounded and expected to die)
For explanation of patient sorting through the START triage system see
Illustration 6.G. START Triage algorithm below.
Procedures:
MCI Operations Procedures are generally broken down into three (3) categories,
Triage, Treatment and Transport that typically follow one another chronologically:
Triage:
A. First due-units of any skill level should begin START triage as soon as
immediate threats are mitigated. First-due ALS personnel should assist and
supervise this process as necessary. First due-Paramedic will assume role
of Triage Officer (this Paramedic may also assume role of Medical Group
Supervisor, Treatment Officer and or Transportation Officer depending on the
scope of the incident. When span of control is exceeded, these positions
should be assigned to other personnel). (See Illustration 6.F., IC Flowchart,
below).
B. Triage team should be deployed in an organized fashion to save time and

avoid duplication of effort. Incidents covering a larger geographical area may
be broken down into divisions or sectors with members of the team assigned
to triage patients in a certain division.
C. As soon as an approximate number of total patients can be obtained,

sufficient transport resources should be ordered through Command if they
are not already enroute. Consider alternative transport for GREEN patients.
D. All GREEN patients (ambulatory / walking wounded / minor) should be

separated from other patients and assembled together in a safe area.
Assign minimal personnel (can be non-medical personnel initially) to keep
them together and notify Command of their location. Do not forget these
patients, they should be re-triaged as soon as is possible.
E. Initial triage of all non-ambulatory patients should be performed where they

lay if the area is safe, if a hazard exists, patients should be moved to a safe
triage area. Triage should take 30 seconds or less, No treatment should be
performed during the triage phase other than opening airways and inserting
OPA’s or NPA’s.
F. Initial triage should be performed utilizing Triage Ribbons (color coded plastic
strips). One should be tied to an upper extremity in a VISIBLE location (wrist
if possible). A short strip of the color ribbon utilized may be retained to assist
in documentation of numbers and types (priority) of patients.
Procedures (cont.):
Triage (cont.):
G. Independent decisions should be made for each patient. Do not base triage
decisions on the perception of too many REDs, not enough GREENs, etc. If
borderline decisions are encountered, always triage to the most urgent
priority (eg. GREEN /YELLOW patient - tag YELLOW).
H. Once a patient reaches a triage level in the START algorithm, triage of this
patient should stop and the patient should be tagged accordingly.
I. Patients tagged BLACK should not be moved if at all possible until Law
Enforcement has been consulted. (Note: Per National Transportation
Safety Board (NTSB) regulations, aviation crash fatalities should not be
moved until cleared to do so by a NTSB representative) If absolutely
necessary, they can be moved to facilitate ingress and egress, but advise
Law Enforcement as soon as possible if this has to be done (try to remember
patients original position if possible).
Treatment:
A. After initial triage is complete, secondary triage will be performed on all

patients before they are transported.
Secondary triage is typically performed when patients are moved to a

triage/treatment area, but the scope of the incident will determine this. If the
incident dictates there is no separate triage/treatment area, then all phases
of triage and treatment may be performed on patients where they lay.
During secondary triage, the patient will be re-assessed using the same
START triage method (30 seconds or less). Triage Tags (METTAGs) (See
Illustration 6.H., METTAG Triage Tag, below) will be utilized and affixed to
the patient.
Note:
Once RED tagged patients are found at any level of triage, they should
be transported immediately as transport units become available. These
patients should not be delayed with prolonged secondary triage or
treatment, they should have Triage Tags affixed and be transported
expeditiously.
Procedures (cont.):
Treatment (cont.):
METTAG use:
1. Affix Triage Tag to one of the patient’s extremities (preferably a wrist if

possible) and remove the ribbon. Do not affix Triage Tags to a patients
clothing.
2. The ends of the METTAG Triage Tag will be removed to leave the
colored portion matching the patient’s condition (ie. if the patient is
determined to be in Priority 1 or RED condition, the green and yellow
portions of the tag will be removed, leaving the red portion).
3. One corner of the triage tag that contains the triage tag number will be
removed and retained by the Triage Officer (or the person fulfilling that
role). The Triage Officer or his designee will document numbers of
patients, their triage tag numbers and condition codes. This
documentation will be duplicated by the Transportation Officer if the
incident dictates there is one.
4. If during an assessment or reassessment a patient changes condition

codes from lower to higher, the bottom colored portion of the tag will be
removed to show the updated higher condition code.
5. If during an assessment or reassessment, a patient changes condition

codes from higher to lower, a second triage tag must be added. All color
coded sections should be removed from the bottom of the first tag, but
the first tag (with its number) should remain on the patient along with the
second tag that shows the status of a lower priority. Both triage tag
numbers shall be documented and shall show as being assigned to the
same patient.
6. Secondary triage will include a brief secondary exam with the

assessment documented on the Triage Tag (if time permits). The
information documented will include but is not limited to date, time,
patient’s vitals signs and a brief description of the patient’s injuries.
Procedures (cont.):
Treatment (cont.):
METTAG use (cont.):
7. A second corner of the Triage Tag is available with the same triage tag
number on it that can be removed and retained by the Transport Officer if
the incident is of sufficient scope to require one. The Transport Officer is
required to document numbers of patients, their triage tag numbers and
condition codes. This documentation will duplicate the documentation
performed by the Triage Officer, and numbers should be compared with
the Triage Officers numbers for correctness. In all cases however, the
documentation must be completed so patients can be tracked
accurately.
B. The Treatment phase is typically where patients are physically separated and
moved into priority category (RED, YELLOW, GREEN, etc.) areas. It is
important to physically separate these patients by priority wherever possible
so transport priorities can be maintained. Moving the patients will be one of
the most labor-intensive parts of the incident and will require the most
personnel.
C. Considerations for a Treatment area should include its capability to

accommodate the number of patients, rescuers and equipment required. It
should also consider weather, safety and HazMat implications.
D. Treatment area ingress and egress areas should be set up to make the
Treatment area a funnel. Ingress and egress areas (funnel points) should be
designated which are readily accessible and relatively easy to move vehicles
in and out of.
E. The priority category areas (RED, YELLOW, GREEN, etc.) should be marked
with colored tarps, flags or whatever equipment is available. Excessive
amounts of time and manpower should not be spent setting up elaborate
area marking, set up and mark the areas as quickly and efficiently as
possible.
F. Medical treatment should only be provided in the Treatment phase as time

before transport allows. Do not delay a patient’s transport to provide
extended treatment. Treatment provided should be only what is necessary
to save life and preserve or possibly improve the patient’s condition while
enroute to the medical facility. The endpoint of treatment should be to
provide the greatest amount of good for the greatest number of patients in
the shortest possible time.
Procedures (cont.):
Transport:
A. The Transport Officer (if one is designated) shall document numbers of

patients, their triage tag numbers and condition codes. This documentation
will duplicate the documentation performed by the Triage Officer, and
numbers should be compared with the Triage Officers numbers for
correctness.
B. The coordination of the loading and transport of patients shall be done by

priority (RED, YELLOW, GREEN, etc.). RED patients shall always be
transported first, YELLOW patients shall be transported next and GREEN
patients shall be transported last. Patients that are trapped and need to be
extricated should be the only variable that changes this order.
C. The very nature of a Multiple Casualty Incident will require that normal EMS
transport parameters be changed. Multiple RED patients may have to be
transported in one transport vehicle, possibly with a single caregiver. ALS
patients can and should be transported with BLS personnel if ALS personnel
are limited or unavailable.
D. Strongly resist the urge to “fill up” transport vehicle space with GREEN
patients mixed in with RED and or YELLOW patients. GREEN patients
should be transported last and in alternative modes of transport (bus, etc.)
whenever possible.
E. When transport vehicles arrive, every effort should be made to keep the
drivers of those units with their vehicles. If that is not possible due to those
personnel being needed to perform other tasks (triage, etc.) then very close
track should be kept of where those personnel are so when the vehicles are
loaded with patients, they can leave without delay. Keys should always be
left in unattended vehicles.
F. The Transport Officer (if one is designated) shall coordinate air transport
resources. The scope of the incident will dictate the expansion of any Air
Operations Group, but a Landing Zone (LZ) Officer shall always be required
when air resources are involved. This will be required to address operational
and safety concerns involving establishing landing zones, and the safe
landing and departure of aircraft.
Procedures (cont.):
Transport (cont.):
G. With Level II and III MCI’s, individual transport units will not contact medical
facilities with patient information. The Transport Officer (if one is designated)
shall contact receiving medical facilities with the following information:
1. Units transporting;
2. Number of patients being transported;
3. Their priority or condition codes (RED, YELLOW, GREEN, etc.);
4. Any special needs (eg. burns, trauma alert, etc.)
H. Transport units should always be given specific instructions to drop off their
patients at the receiving medical facility and then return immediately back to
the incident. This should be done until it has been verified that there are no
more patients to transport.
Note:
If this is not done, personnel may be easily caught up in assisting medical
facility personnel when they and their transport vehicle are badly needed at
the incident.
A. All units will respond to staging unless otherwise directed by Command.

First-due vehicles need to be parked in a safe place
B. Ensure that all areas around the MCI scene have been checked for any
possible missed patients, walking wounded, ejected/trapped patients, etc.,
and that all patients have been triaged.
EMS MCI Command Structure Responsibilities:
A. EMS Group Supervisor shall be responsible for:
1. Overall EMS operations at the incident
EMS MCI Command Structure Responsibilities (cont.):
2. Filling EMS Group positions as needed
a. Triage Officer
b. Treatment Officer
c. Transportation Officer
d. LZ officer
3. Notifying IC as to needs of EMS Group
B. Triage Officer shall be responsible for:
1. Management of patients where they are found at the incident site
2. Sorting (triage) and moving all patients to treatment/transportation areas
3. Ensuring coordination between extrication teams and medical care

providers to provide appropriate care for entrapped patients
4. Performing initial documentation on numbers and condition codes of

patients
C. Treatment Officer shall be responsible for:
1. Establishing treatment areas
a. RED
b. YELLOW
c. GREEN
d. BLACK
2. Patient care and triage decisions for patients in the treatment areas
3. Overseeing all aspects of patient care in the treatment areas
D. Transport Officer shall be responsible for:
1. Arranging and coordinating appropriate transport (ALS, BLS, helicopter,

etc.) for patients forwarded to treatment/transport areas
2. Coordinating and maintaining communication with medical facilities as to

numbers, condition codes of patients and where they will be transported
EMS MCI Command Structure Responsibilities (cont.):
3. Performing documentation on numbers and condition codes of patients
4. Coordinating air transport resources and operations
E. Landing Zone (LZ) Officer shall be responsible for:
1. Establishing safe landing zones for air transport resources
2. Coordinating with Transport Officer to safely move patients to landing

zones for transport
3. Coordinating with air transport crews to safely and expeditiously load

patients for transport
ILLUSTRATION 6.F.
MCI IC FLOWCHART
ILLUSTRATION 6.G.
START TRIAGE ALGORITHM
ILLUSTRATION 6.H.
METTAG TRIAGE TAG
Protocol 6.11: No-Transport (Refusal, Cancel)
General Principles:
A. Non-transport of a patient when EMS is called to a scene is one of the

greatest areas of exposure to legal liability that EMS agencies and individual
EMS providers face. The EMS provider is responsible for a reasonable
assessment of the patient and situation to determine if there is injury or
illness, or a reason to treat and/or transport. When a non-transport situation
occurs, care must be taken to assure that procedures are followed correctly
and the encounter is documented fully.
B. An adult patient that has decision making capacity has the legal right to
refuse treatment, evaluation and transport in spite of the fact they may be
injured or ill. The minor patient does not have that same legal right to refuse,
a parent or legal guardian must represent them.
C. Non-transport situations generally fall into two primary categories: Cancel

and Refusal.
Definitions:
A. Cancels are calls where the response is discontinued prior to patient contact
being made (by EMS personnel).
B. Refusals are calls where patient contact is made by EMS personnel, but the
patient(s) refuse treatment and or transport.
C. When EMS personnel arrive on the scene of a call originally dispatched as

an EMS call and after investigation find that no medical situation exists, these
will also be categorized as Refusals for purposes of this protocol.
D. A minor in SD is any patient less than 18 years of age.
E. An emancipated minor in SD is any patient less than 18 years old that:
1. Has entered into a valid marriage, whether or not such marriage was
terminated by dissolution; or
2. Is on active duty with any of the armed forces of the United States; or
3. Has been declared an emancipated minor by the courts.
An emancipated minor is treated the same as an adult.
Protocol 6.11: No-Transport (Refusal, Cancel) (cont.)
Procedures:
Cancel:
A. A response may be cancelled enroute to a call when a first-response Fire

and or EMS agency already on scene advises to cancel. These
cancellations may encompass a number of different situations, to include but
are not limited to:
1. MVA or other trauma call with no patients claiming injuries.
2. Medical call where patient is refusing treatment and or transportation.
3. Man down/unknown problem call where first response agency has

determined patient to be public inebriate only and Law Enforcement will
handle.
4. Medical or trauma call where no patient has been found or patient has
left the area.
Note: Use extreme care in the “no patient found” or “patient left the
area” scenarios. It is not uncommon for even a seriously ill or injured
patient to wander a short distance from the area where they were initially
reported to be. As much as is possible, assure that a thorough search
for the patient was done before cancelling. This is particularly true in the
rollover MVA and assault situation.
B. Response to a MVA shall not be cancelled only on advice from Law

Enforcement or civilians when they report no injuries. An evaluation must be
done by a first response Fire and or EMS agency and they must advise no
injuries before cancelling. An initial hot response may however, be
downgraded to cold in this scenario.
C. Response may be cancelled on advice from Law Enforcement in the

following scenarios:
1. Reported MVA and LE has found no accident.
2. Reported MVA and LE has found no one around the vehicle or patient
has apparently left the area.
3. Reported MVA turns out to be accident previously reported and already

investigated.
Protocol 6.11: No-Transport (Refusal, Cancel)
Procedures (cont.):
Cancel (cont.):
4. “Man down” or unknown problem is determined to be a public inebriate

by LE and they will handle.
D. EMS personnel shall have the discretion to continue a response to a scene in

spite of a first response Fire and or EMS agency request to cancel if the
request to cancel seems inappropriate or if the information appears to be
incomplete, incorrect or inaccurate. Communication is the key, if you are
uncomfortable cancelling based on what you’ve heard, continue and try to
get more information.
Refusal:
A. In all refusal situations, EMS personnel shall perform as complete an

assessment as the situation and the patient(s) will allow (see assessment
/documentation guidelines below). The results of the assessment (or the
patients refusal to allow one) shall be documented fully in the Patient Care
Report (PCR). A refusal with no assessment and accompanying
documentation is an area of extreme legal risk for EMS personnel.
B. When EMS personnel reach the scene of a MVA or other trauma call where
patients are refusing service and:
1. There are no patients claiming injuries or with any visible injuries.
2. There are no patients requesting treatment and or transportation to a

medical facility.
3. There is no significant mechanism of injury to suggest a possible hidden

injury.
4. All affected patients at the scene are mentally competent, with decision
making capacity.
If an assessment reveals no problems, EMS personnel may treat these

patients as “involved not injured” and clear the scene, no Refusal of
Ambulance Services form is required (this includes all minors). If an
assessment reveals injuries, patient(s) shall be offered treatment and
transport to a medical facility.
Procedures (cont.):
Refusal (cont.):
C. When EMS personnel reach the scene of a MVA or other trauma call where
patients are refusing service and:
1. There are patients claiming injuries or that have any visible injuries.
2. There is any significant mechanism of injury to suggest a possible hidden

injury.
3. All affected patients at the scene are mentally competent, with decision
making capacity.
EMS personnel shall fully advise the patient(s) of the results of the
assessment and of the risks of refusing treatment and transport and obtain a
signed Refusal of Ambulance Services form for each affected patient
before clearing the scene.
If the patient(s) refuses to sign the Refusal of Ambulance Services form, it

should be witnessed and documented fully in the Patient Care Report (PCR).
D. If a non-emancipated minor at the scene of a MVA or other trauma call is

attempting to refuse service and has:
1. Any visible/discovered on assessment injury ; or
2. Claims any injury; or
3. Is involved in a situation where there is any significant mechanism of

injury to suggest a possible hidden injury;
That minor may not refuse service and may not sign a Refusal of
Ambulance Services form. The parent or a legal guardian of a minor must
refuse treatment and or transport for their minor children in person and the
minor left in their custody.
If a parent or legal guardian is not able to arrive in an expedient manner to

handle the refusal and take custody of the minor, that minor must be
transported to a medical facility. Do not wait on scene for extended periods
of time waiting for a parent/legal guardian to arrive.
Procedures (cont.):
Refusal (cont.):
E. When EMS personnel reach the scene of a medical call where a mentally
competent adult patient(s), with decision making capacity that had or has a
chief complaint is refusing service; EMS personnel shall fully advise the
patient(s) of the results of the assessment and of the risks of refusing
treatment and transport and obtain a signed Refusal of Ambulance
Services form for each affected patient before clearing the scene.
If the patient(s) refuses to sign the Refusal of Ambulance Services form, it

should be witnessed and documented fully in the Patient Care Report (PCR).
F. A non-emancipated minor at the scene of a medical call that had or has a

chief complaint may not refuse service and may not sign a Refusal of
Ambulance Services form. The parent or a legal guardian of a minor must
refuse treatment and or transport for their minor children in person and the
minor left in their custody.
If a parent or legal guardian is not able to arrive in an expedient manner to

handle the refusal and take custody of the minor, that minor must be
transported to a medical facility. Do not wait on scene for extended periods
of time waiting for a parent/legal guardian to arrive.
G. EMS personnel may treat and release an adult hypoglycemic diabetic

patient, given that the following conditions are met:
1. The patient must be a diagnosed diabetic being treated with a form of

insulin.
2. The patient must not be taking any oral agents for the control of their
blood sugar.
3. The patient must have had an initial blood glucose <70 before treatment,
and a blood glucose >100 after treatment.
4. The patient must not have exhibited any focal neurologic deficits before
treatment with glucose.
5. After treatment the patient must be exhibiting completely normal
neurologic signs and have a Glasgow coma scale score of 15.
6. The patient must have access to food, or a source of food must be
provided to the patient before releasing the patient from care.
Obtain a signed Refusal of Ambulance Services form before clearing the

scene. See Protocol 2.19: Diabetic Emergencies for further information.
Procedures (cont.):
Refusal (cont.):
H. In circumstances where a patient, parent or legal guardians mental

competency is obviously in question; or the obvious presence of alcohol or
chemical intoxication is interfering with decision making capacity, contact
with Medical Control to help sort out the situation is strongly suggested. Seek
the assistance of Law Enforcement when necessary.
I. When EMS personnel respond to a scene where a verified suicide gesture

has taken place, the patient(s) involved may not refuse service, they must be
transported to a medical facility. If there is some dispute about whether or
not the suicide gesture has actually taken place, investigate carefully and
seek the assistance of Law Enforcement where necessary. Remember,
patients that engage in suicide gestures many times have a reason to be
untruthful, so do not rely on their word alone that a suicide gesture has not
taken place.
J. When EMS personnel respond to the scene of a reported illness or injury and
after an investigation and assessment find that no medical situation exists, a
Refusal of Ambulance Services form is not appropriate.
Assessment / Documentation Guidelines:
A. In refusal situations, particularly those with patients refusing against medical

advice (AMA), EMS personnel wherever possible, shall assess and
document:
1. Mental status i.e., orientation to person, place and time, and patients
comprehension of the nature/severity of illness/injury and comprehension
of the nature of treatment.
2. Vital signs (ECG also if potentially cardiac related).
3. Glasgow Coma Scale score.
4. Any plan for alternative care.
5. Risks of refusal up to and including death (inform patient).
Assessment / Documentation Guidelines (cont.):
B. In adult patients refusing an assessment who have a chief complaint, have

sustained an injury or might reasonably be suspected to have sustained an
injury:
1. Evaluate the patient’s mental status as to coherency/decision making

capacity.
2. Explain the significance of the mechanism of injury (if there is one).
3. Explain the possible related complications of the illness or injury.
4. Explain the possible consequences of the illness or injury if left
untreated, up to and including death.
5. Have patient read (or read it to them) and sign a Refusal of Ambulance
Services form and document discussion in Patient Care Report (PCR)
narrative. If patient will not sign, document the refusal to sign in the
narrative as well
A. EMS personnel should err on the side of contacting Medical Control in

Refusal situations that are unclear or are not covered by this protocol.
B. Obtaining a signature on a Refusal of Ambulance Services form is always

strongly encouraged when appropriate, because signing may be evidence of
the patients decisional capacity and physical ability. However, remember
that a signature does not relieve EMS personnel of the responsibility for a
reasonable assessment and possibly treatment of the patient.
C. For the patient who is refusing treatment/transport against medical advice

(AMA), providing the patient with clear instructions and warnings is
imperative (having them read or reading to them the Refusal of Ambulance
Services form is recommended). Having this form co-signed by a witness
that is not an employee of the RCFD is also recommended.
D. For Cancel situations that are unclear or not covered by this protocol, contact
the on-duty Battalion Chief or the EMS Chief.
Protocol 6.12: Patient Care Report (PCR) Requirements
General principles:
A. The Patient Care Report (PCR) is an integral component of patient care, the
quality improvement process and is a professional responsibility of the EMS
provider.
B. The Patient Care Report (PCR) is many times the sole source of information
regarding the patients condition and any pre-hospital treatment they
received. It is imperative that the information is accurate, complete and
provided to the receiving hospital in an expedient manner in order to provide
for an efficient and safe transfer of care.
C. The Patient Care Report (PCR) is the legal record of the EMS providers
encounter with the patient, and the treatment and transport that patient
received. The PCR is discoverable in a court of law and can be (and
frequently is) subpoenaed. Given that fact, the PCR must be complete and it
must be accurate in all respects.
D. The Patient Care Report (PCR) is also the primary tool used by patient billing
services to collect fees for ambulance services, which are the primary finding
source for the EMS system. The PCR must be complete and it must be
accurate to allow the billing process to take place in an expedient manner
and to satisfy federal regulations regarding ambulance billing.
Procedures:
A. The procedures detailed herein apply to both the handwritten (paper) PCR
and any electronic charting method the Department uses.
B. The following minimum information shall be gathered and documented

relative to the patient and their personal information:
1. Patient name
2. Patient age and birth date
3. Patient sex
4. Patient social security number
5. Patient residential address
6. Patient phone number
7. Patient health insurance company(s) and numbers (to include
Medicare/Medicaid)
8. Patient next of kin or responsible party
Protocol 6.12: Patient Care Report (PCR) Requirements (cont.)
Procedures (cont.):
Note: It is understood that at the time of the call, some of the above
information may be difficult to obtain in the event a patient is unconscious,
intoxicated, etc. Every effort should be made to obtain the information in a
timely manner if at all possible. Family members, friends, law enforcement
and the hospital face sheet are all good potential sources for this information.
C. The following minimum information shall be gathered and documented

relative to the incident itself:
1. Incident number
2. Date incident occurred
3. Run/call type and or reason for dispatch
4. Incident location
5. Response mode to the call and back to the hospital (hot/cold and any
changes)
6. Location patient transported to
7. Times:
a. Dispatch
b. Enroute
c. On Scene
d. First Paramedic on scene (if applicable)
e. Enroute to hospital
f. Out at hospital
g. Clear of call
h. Cancelled (if pertinent)
8. Patient loaded mileage
9. Medic Unit number and station
10. Receiving physician
11. Crew names (signature) and skill level
D. The following minimum information shall be gathered and documented

relative to the patient and the medical care they received:
1. Patient chief complaint

2. Nature of the incident and or mechanism of injury
3. Results of physical exam/assessment to include but not limited to:
a. Vital signs (BP, RR, HR, O2 Sat.) repeated every 10 minutes if

transport > 10 min.
b. LOC – Mentation - GCS
c. Skin signs
Protocol 6.12: Patient Care Report (PCR) Requirements (cont.)
Procedures (cont.):
d. ECG. (Where pertinent, copy of ECG shall be attached to all copies

of report whenever an ECG is done)
e. Lung sounds (where pertinent)
f. End –Tidal CO2 (where pertinent)
g. Glucose (where pertinent)
h. Motor function
i. Any visible trauma or abnormality
j. Pupil size and reactivity
k. Temperature (where pertinent)
4. Condition patient first found in.

5. History of present event (brief).
6. Known patient past medical history, medications, allergies.
7. All treatment rendered (including treatment rendered prior to arrival).
Treatment times shall be noted. Medication administrations shall include
times and dose(s).
8. Any changes in patient condition noted, and specifically those changes
noted as a result of treatment (including lack of changes).
9. Any orders requested and whether granted or denied (include physicians
name).
10. Any special circumstances (weather, facility divert, violence, prolonged
extrication, etc.).
11. Patient condition on arrival at medical facility.
E. For specific PCR requirements in refusal cases, see Protocol 6.11: No-
Transport (Refusal, Cancel).
F. Patient Care Reports for patients who have had invasive airway procedures
done and or IV medications administered, shall be completed at the hospital
and left there with the patient. All other ALS reports shall be printed out or
copies left at the hospital within 12 hours of the call. All BLS reports shall be
printed out or copies left at the hospital before the end of the shift.
A. In all circumstances, Patient Care Reports shall be completed in sufficient

detail to allow the receiving medical facility and system Medical Director to
easily determine the nature and extent of the patients injury or illness and
any treatment rendered.
Protocol 6.13: Public Inebriate Disposition
General Principles:
A. Medic Units and Engine Companies will at times receive requests from Law
Enforcement to perform a medical evaluation of the public inebriate. These
requests are valid due to the fact that the public inebriate population has a
statistically higher incidence of serious medical problems than most other
segments of society.
B. Law Enforcement agencies and other allied agencies like the Pennington
County Jail, Juvenile Services and Detox typically use an arbitrary BAC
number of .400 or .500 as a limiting factor to determine whether a subject is
suitable for transport to that particular facility. While these numbers may be
suitable to determine if a subject is suitable for a particular facility, they are
not suitable to determine if a subject requires transport to a medical facility by
an ALS ambulance. The determination of whether or not one of these
subjects will be transported to a medical facility by ambulance will be based
on a clinical evaluation by the attending Paramedic and not on the BAC
number generated by a portable breath tester.
C. This protocol pertains only to the encounter with the public inebriate in public.
When a facility (Pennington County Jail, Juvenile Services, Detox, etc.)
requests transport for a subject/patient in their facility, those patients shall be
transported immediately.
D. When requests for an evaluation of the public inebriate are received, refer to
the following:
Procedures:
A. These requests will be processed through Dispatch and will receive a cold
(immediate) response unless triaged to a higher response by Dispatch.
B. In times of system overload, these requests will be triaged to a delayed

response and will be handled as soon as resources become available. If at
any time, Dispatch indicates a need for a higher level of response, that will
place the call higher in the queue and it will be responded to as appropriate.
C. Representatives from agencies making these requests will be treated with

the same courtesy and respect you would expect from them. These requests
for medical evaluation are not an unnecessary interruption of our daily
operations; they are a very necessary part of the public safety net for a
segment of the population that is unable or unwilling to seek mainstream
medical care.
Protocol 6.13: Public Inebriate Disposition (cont.):
Procedures (cont.):
D. On arrival at one of these incidents, the Paramedic will obtain a complete

history of the requesting agencies contact with the subject (who, what, when,
where, how long) make no assumptions.
E. The determination of whether or not the subject will be transported by

ambulance to a medical facility will be based on the following evaluation and
parameters.
1. Complete history and exam finding the following:
a. Subject must be easy to arouse
b. Must have a minimum GCS of 14
c. Must be ambulatory with minimal assistance and have no focal motor

or sensory deficits
2. Complete set of vital signs within the following parameters:
a. Pulse 60-110
b. SBP 90-160
c. RR 12-25
d. O2 Sat > 94%
e. Glucose 70-200
3. Subject not requesting transport to a medical facility.
F. If the above parameters are not met, the subject will be transported to the
appropriate medical facility by ambulance.
G. If the above parameters are met, politely explain to the requesting agency
representative that the subject does not meet our criteria for transport by
ambulance. Brief them completely on your findings and your basis for
declining to transport the subject. Further explain that if they still wish to
have the subject transported to a medical facility after your evaluation, they
will need to find alternative means to do so. All of this will be accomplished
in a polite, professional, non-confrontational manner.
Protocol 6.13: Public Inebriate Disposition (cont.):
Procedures (cont.):
H. If at any time during one of these encounters, the subject requests transport
to a medical facility because of an injury or illness, they will be transported by
ambulance immediately.
I. If the above vitals signs assessment and evaluation are not performed (or
are not able to be performed), the subject will be transported to a medical
facility by ambulance immediately.
J. Document the encounter completely with vitals signs, see Protocol 6.11:
No-Transport (Refusal, Cancel) for additional details.
A. Remember, always err on the side of caution in questionable or unclear

circumstances, it is medically-legally safer to transport someone to a
medical facility that doesn’t need to go than to not transport someone
that does need to go.
B. In situations where there is unresolved disagreement between a requesting

agency and the attending Paramedic reference whether a subject should be
transported by ambulance, contact the on-duty Battalion Chief or the EMS
Chief.
Protocol 6.14: Radio Reports
General Principles:
A. The primary purpose of contacting the receiving medical facility is to provide

them with enough information to allow the ED staff to decide what
preparations they will need to make for the patient. This assures a safe,
efficient transfer of care.
B. Radio contact should only include essential, relevant information.

Remember, the ED staff may be very busy and a report that isn’t brief and to
the point may be misunderstood or disregarded.
C. This protocol applies to reports that are given over the phone as well as by
radio.
Procedures:
Notification to Receiving Facility
REGIONAL HOSPITAL / This is Medic ____
We are enroute with a :

____ Y/O Male_____ Female_____ with a Chief Complaint of ______________
____________________________________________________________
Brief description of problem / situation / mechanism of injury (MVA, etc.)
Pt. is: awake, alert, confused, unresponsive – (describe LOC)
Vitals Signs: BP:____/____ HR:_____ RR:____O2 Sat:_____ (on room air, O2)
Glucose: ____ Skin is: color__________ temp_________ moisture__________
ECG shows:_______________________ Lung Sounds:___________________
Any visible trauma, abnormality: _______________________________________

_________________________________________________________________
Treatment being provided: Airway:___________O2:_________IV’s:_________
Meds administered :___________________C-Spine?______ Other:___________
Will relate further information on arrival if no questions or orders:
ETA is:___________
Medic ____ Clear
Protocol 6.14: Radio Reports (cont.):
Procedures (cont.):
Notification to Receiving Facility (cont.):
A. The above format and information shall be used to notify the receiving facility
of arrival. Information shall only be given to the extent it is pertinent.
B. A response code to the facility only needs to be given when it is ”emergent”

and that is the term that should be used.
Requests for Treatment Orders
Note: Only a physician may provide authorization to a Paramedic to perform a

procedure or administer a medication pursuant to these protocols. The
requesting Paramedic shall be clear and concise in requesting that a
physician be available for consultation or orders.
A. Request to speak to a physician to obtain the order.
B. Identify yourself and Medic Unit number to the physician and clearly state the
order you are requesting. Be clear, concise and brief, many times the reason
for declined orders can be traced back to the Paramedics failure to paint a
clear picture relative to what is going on.
C. Provide pertinent information that is the basis of the request, such as:
1. Enroute (emergent or not,) or still on scene.

2. ETA to hospital.
3. Patient age and sex.
4. Chief complaint.
5. Past medical history (only if pertinent).
6. Level of consciousness.
7. Vitals signs (include ECG if pertinent).
8. Physical assessment findings.
9. Treatment already in progress
10. Restate or clarify order requested, if drug order, dosage and route to be
administered.
D. In the event a request is for termination of cardiac arrest resuscitation,

include information about the initial and present cardiac rhythm, response to
resuscitation (or lack thereof), mechanism and duration of resuscitation
efforts. If terminated, note exact time.
Protocol 6.14: Radio Reports (cont.):
Procedures (cont.):
Requests for Treatment Orders (cont.):
E. Communication with Medical Control is appropriate if you are not sure

whether or not a treatment, procedure or destination is appropriate for a
patient. Medical Control contact should be considered as a consultation, not
just a source of authorization for medications or procedures.
F. Whenever treatment orders are requested, the Patient Care Report (PCR)
narrative shall include the nature of the order requested, the name of the
physician contacted and whether the order was granted or declined.
Special Circumstances:
A. In the event a communications failure does not allow Medical Control

contact for an order request; or a physician is not able to come to the
phone/radio in a timely manner, the Paramedic shall adhere to the
treatment guidelines as defined by these protocols.
Under no circumstances shall a Paramedic exceed their scope of
practice as defined by their South Dakota State Board of Medical
Examiners license/South Dakota state law and practice privileges
authorized by the system Medical Director.
Protocol 6.15: Rules of Engagement
Emergency Stuff
• When dealing with a single call, closest unit always goes regardless of whose
district it’s in, even with a call dispatched as “cold”. Only exception is a transfer.
• When dealing with multiple calls, units will always take the most critical call
that is the closest. This will be based on dispatch information.
• In times of “call overload”, ALS engine companies and Medic 1 will handle calls as
possible and necessary until ambulances are available.
• “Hot” and “cold” response modes from dispatch will always be followed unless
there is a compelling reason to the contrary
• Two-tiered responses will remain as they always have, an ambulance and an

engine in the same house will not change that.
• “Two Paramedic” response and treatment policy applies on cardiac arrests in the
city or in very close proximity to the city. ALS engine or Medic 1 can satisfy policy.
Incidents outside the city will have one unit respond and second unit will meet them
inbound.
• With a known, significant trauma alert case, “two Paramedic” treatment policy will
apply on cases in the city or in very close proximity to the city. ALS engine or
Medic 1 can satisfy policy. Incidents outside the city will have one unit respond
and second unit will meet them inbound.
• Response to seemingly significant trauma calls will be as dispatched (typically 1

ambulance) unless dispatch information or early-arriving engine companies make it
very clear that more units are needed.
• If after responding to a 911 call, a patient (or patients family) requests transport to
Ft. Meade or Hot Springs VA, that patient will not be transported to the VA unless it
can be accurately determined that the VA has approved the transport. The patient
(or their family) should be reminded that neither of the VA facilities has ED facilities
and are not set up to accept patients without prior notice and approval. If the VA
has not approved the transport, the patient will be offered transport to RCRH, if the
patient wishes to refuse rather than accept transport to RCRH, that is their right.
• Units will notify out at the hospital just before backing in, not down the street.
• Units will call clear from the hospital immediately upon leaving.
• ALL copies of PCR's for patients transported to Regional Hospital will be at

Regional Hospital before your shift ends. No reports will be left until the following
day. Reports for patients that were intubated or given any IV medications will
be done on the spot and left at the hospital before you leave. This essentially
means you are out of service to do that report with the only exception being if while
Protocol 6.15: Rules of Engagement (cont.):
Emergency Stuff (cont.):
at the hospital you are the closest unit to an ALS call or the only unit available, that
only makes good sense. Reports for all other ALS patients must be at the hospital
within 12 hours (within your shift), reports for BLS patients can wait longer, but in
all cases will be at the hospital before your shift ends.
Transfer Stuff
• Anything that goes to the hospital (RCRH or SS) is not a transfer, it’s a call and is
handled like any 911 call.
• A transfer is a transport that goes anywhere besides the hospital (RCRH or SS).
• Use caution doing more than one transfer at a time with duty units, two duty units
should not be tied up doing transfers unless ALS overload units are available. If
ALS overload units are available, it may be possible to do 2 transfers at one time.
If ALS overload units are not available, only one transfer should be done at a time.
• If the system is extremely busy, transfers should be temporarily postponed until

sufficient resources are free to handle the call volume. Notification should always
be made to the requesting facility that the transfer is being postponed, what the
reason is and an approximate time that the transfer may potentially be done.
• Transfers by duty units should be done by the unit in whose area the destination is.
This will keep the ambulances in their respective response areas more often.
• 911 calls that result in a transport to Ft. Meade or Hot Springs VA will be handled
by the duty unit that originally responded to the call. Have dispatch notify Battalion
1 that you will be out of the area.
• ALS transfers that originate at RCRH (or another medical facility) that are going to
Ft. Meade or the Hot Springs VA can be handled by a duty unit as long as the rest
of the transfer “rules” are satisfied. If the three duty units are extraordinarily busy,
an overload unit should handle these if one can be staffed with ALS personnel. A
duty unit could handle these if on-duty manpower allows another ALS ambulance
to be staffed immediately. If none of the above scenarios is possible, the facility
requesting the transfer should be told it will have to wait until hire-back personnel
can be brought in. These transfers (if they come in late at night) can sometimes
wait until shift change when more personnel may be available.
• BLS transfers that originate at RCRH (or another medical facility) that are going to
Ft. Meade or the Hot Springs VA should be assigned to a BLS crew whenever
possible (either by hire-back or utilizing available on-duty manpower). ALS duty
crews should not be used for these, but an ALS crew consisting of hire-back
personnel or other available on-duty personnel could be utilized.
Transfer Stuff (cont.):
• BLS transfers that originate at RCRH (or another medical facility) that are going to
Ft. Meade or the Hot Springs VA that are solely at the patients request (the
patients paperwork will prominently say that) should be referred to Medic 1 or
Patient Billing Services before they are done. These transfers are commonly going
to psych or re-hab. type units at the VA and are not paid for by the VA. Payment
will typically have to be guaranteed before these are done.
• BLS transfers may be assigned to overload ambulances at the discretion of the

Battalion Chief even if duty units are not all busy.
• A call that originates at Ft. Meade that is emergent or “needs to be done

immediately” (per Ft. Meade) will be handled by a duty unit and we will back-fill as
necessary.
• If overload ambulances are to be used for longer out of town transfers (> 3 hrs.),
the on-duty Battalion Chief will attempt to hire-back personnel to maintain
manpower levels. Hire-back personnel could also be used for the transfer if it can
wait that long.
Everyday Stuff
• Narcotics will be checked, documented and audited per administrative rule and
protocol.
• Copies of Patient Care Reports will not be left lying on the dashes of vehicles or on
a desk in a station. All copies of PCR’s will be secured and taken to the hospital as
soon as possible considering the rule noted above in “Emergency Stuff” about
paperwork. Substations shall bring Billing PCR copies to Patient Billing Services
every weekday morning as soon as is possible.
• Remote computers with Field Data collection software shall be data-linked

(downloaded) a minimum of once a day at the start of the shift. It is recommended
to download as much as 2-4 times a day to ensure that data is not lost in the event
of a computer hard drive failure.
• All communications with Dispatch and other units will be acknowledged. Every
time Dispatch or another unit gives you a piece of information, you shall
acknowledge that you heard it.
• Anytime you respond to a scene where you have to go some appreciable distance
from your vehicle to where the patient is (apartment house, elderly high rise,
motel/hotel, private residence set back a considerable distance from the street,
etc.). Take your cot, airway box, drug box and cardiac monitor with you. That will
make the entire patient care process go quicker and smoother. Don’t make the
engine companies run (and your patient wait) for your equipment when you should
have brought it with you in the first place.
Everyday Stuff (cont.):
• Each ambulance has its own primary response area (district). Ambulances will not
be taken out of their primary response area for personal reasons unless three rules
are satisfied:
First: Battalion 1 and or Medic 1 will be consulted to obtain permission to do so.

The Company Officer in the station the ambulance is stationed at must also be
brought into the “permission loop”.
Second: the other two ambulances must be notified and asked if they will cover
the uncovered area (one way and probably the best way) to do this is to
temporarily “exchange” areas with another Medic Unit.). If one of the other two
ambulances cannot or will not cover the uncovered area, then the ambulance will
not be taken out of its area.
Third: Dispatch shall be notified and told what is going on.
• Any time a unit is taken out of service for any length of time, Dispatch, Battalion 1
and the other duty units shall be notified. The notification shall include the reason
the unit is being taken out of service and the expected time it will be out (or back in
service). This can be accomplished with phone calls to the interested parties or
airing the information to Dispatch on the EMS frequency.
• Duty ambulances and overload ambulances will both be kept clean (interior and
exterior) in the same manner as the engines are.
• Drugs and other equipment in overload ambulances will be checked everyday.
• Overload ambulances will not have supplies or equipment “scavenged” to stock

duty units.
• Off-going shifts will insure that duty units are fully stocked, have reasonable levels
of oxygen, have at least ¾ tank of fuel and the interiors are clean. Failure to do
this will result in immediate discipline.
• Sub stations will insure that dirty linen and medical waste is brought to Station 1
once weekly for pick up.
Pre-hospital Advanced Life Support Protocols Drug Summaries
DRUG SUMMARIES
This section contains a description of those drugs approved for use (or
transport) in the Rapid City/Pennington County EMS System. This
description includes Actions, Indications, Contraindications, Side Effects,
Dosages (adult and pediatric if applicable) and available forms of these
drugs.
RAPID CITY FIRE AND EMERGENCY SERVICES PARAMEDICS APPROVED

DRUG LIST:
Adenocard (Adenosine) (6 mg/2 ml) or (12 mg/4ml)

Albuterol (Proventil) (2.5 mg in 3 ml unit dose)
Amiodarone (Cordarone) (150 mg/3 ml)
Aspirin (Acetylsalicylic Acid) (81 mg tabs)
Ativan (Lorazepam) (2 mg/1 ml)
Atropine Sulfate (as a cardiac agent) (1 mg/10 ml)
Atropine Sulfate (as an antidote for poisoning) (8 mg/20 ml)
Benadryl (Diphenhydramine) (50 mg/1 ml)
Calcium Gluconate (4.65 mEq/10 ml)
Cyanokit (Hydroxycobalamin) (5 gm)
Dextrose 50% (25 gm/50 ml)
Dextrose 25% (2.5 gm/10 ml)
Dopamine (Intropin) Infusion (400 mg/250ml)
Epinephrine, (1:10,000) (1 mg/10 ml)
Epinephrine, (1:1000) (1 mg/1 ml)
Epinephrine, (1:1000) multi-dose, (30 mg/30 ml)
Etomidate (Amidate) (40 mg/20 ml)
Fentanyl (Sublimaze) (100 mcg/2 ml)
Glucagon (1 mg (unit)/ 1 ml)
Haldol (Haloperidol) (5 mg/1 ml)
Haz-Mat / WMD drugs (Mark I Kit, (not stocked)
• Pralidoxime (2 Pam) Chloride
• Atropine Sulfate (as an antidote for poisoning)
RAPID CITY FIRE AND EMERGENCY SERVICES PARAMEDICS APPROVED

DRUG LIST (cont.):
Inter-facility Transport drugs (not stocked)

• Heparin Infusion
• Nitroglycerin Infusion
• Integrilin Infusion
IV Fluids: D5W, Normal Saline
Lasix (Furosemide) (40 mg/4 ml)
Lidocaine (100 mg/5 ml)
Lidocaine Infusion (1 gm/250 ml)
Lidocaine 2% viscous gel
Morphine Sulfate (10 mg/1 ml)
Narcan (Naloxone) (2 mg/2 ml)
Neo-Synephrine (Nasal Spray)
Nitroglycerin Spray/Tablet (0.4 mg/unit dose)
Procainamide (1 gm/10 ml)
Sodium Bicarbonate (50 meq/50 ml)
Succinylcholine (Anectine) (200 mg/10 ml)
Thiamine Hydrochloride (100 mg/2 ml)
Valium (Diazepam) (10 mg/2 ml)
Zemuron (Rocuronium) (50 mg/5 ml)
Zofran (Ondansetron (4 mg/2 ml)
ADENOCARD (ADENOSINE)
A. ACTIONS:
Adenocard slows conduction time through the A-V node, can interrupt the
reentry pathways through the A-V node and can restore normal sinus rhythm
in patients with paroxysmal supraventricular tachycardia (SVT), including
SVT associated with Wolff-Parkinson-White Syndrome. The half-life is
estimated to be less than 20 seconds. In controlled clinical trials, 92 % of
patients with SVT were converted after a bolus dose of 12 mg. Adenocard is
not effective in converting rhythms other than SVT, such as atrial flutter, atrial
fibrillation or ventricular tachycardia. However, administration of Adenocard
in such patients has not had adverse consequences.
B. INDICATIONS:
Conversion of SVT to Sinus rhythm including that associated with accessory

bypass tracts (WPW).
C. CONTRAINDICATIONS:
1. Second or third degree A-V Block (except in patients with a functioning

artificial pacemaker).
2. Sick Sinus Syndrome (except in patients with a functioning artificial

pacemaker).
3. Rhythms other than SVT, such as atrial flutter, atrial fibrillation or

ventricular tachycardia.
4. Known hypersensitivity to adenosine.
D. SIDE EFFECTS AND ADVERSE REACTIONS:
CNS - lightheadedness, dizziness, tingling, numbness.
CV - facial flushing, headache, sweating, palpitations – there may be a long

sinus pause prior to conversion.
GI - nausea, tightness in throat.
Note: The more proximal the IV, the more likely this drug will convert the
rhythm.
ADENOCARD (ADENOSINE) - (cont.)
E. DOSAGE:
Adult: Initial dose: 6 mg IV/IO administered rapidly over a 1-2 second

period followed by a rapid saline flush.
Repeat administration: If the first dose does not convert the SVT within 1-2
minutes, a second rapid 12 mg IV dose should be given. This 12 mg dose
may be repeated a second time if required. Doses greater than 12 mg are
not recommended.
Pediatric: 0.1 mg/kg IV or IO rapid IV push followed by 10 ml NS IV flush.
Repeat administration: Second dose if necessary and possible may be

doubled (0.2 mg/kg). Maximum first dose: 6 mg; maximum second dose: 12
mg.
F. HOW SUPPLIED:
6 mg in 2 ml pre-filled syringe or 12 mg in 4ml pre-filled syringe.
ALBUTEROL (PROVENTIL, VENTOLIN)
A. ACTIONS:
Albuterol is primarily a beta-2 sympathomimetic and as such, produces

bronchodilatation. Because of its greater specificity for beta-2 adrenergic
receptors, it produces fewer cardiovascular side effects and more prolonged
bronchodilatation than some other drugs. Onset is within 15 minutes; peaks
in 60-90 minutes. Therapeutic effects may be active up to 5 hours.
B. INDICATIONS:
Nebulized Albuterol is indicated for relief of bronchospasm in patients with

reversible obstructive airway disease, including asthma.
Albuterol is contraindicated in patients with a history of hypersensitivity to

Albuterol.
CNS - Nervousness, tremor, headache, dizziness, insomnia.
CV - Tachycardia, hypertension, angina.
GI - Drying of oropharynx, nausea, vomiting, unusual taste.
E. WARNINGS:
1. Use cautiously in patients with coronary artery disease, hypertension,

hyperthyroidism, diabetes.
2. Epinephrine should not be used at the same time as Albuterol, however,

either may be used subsequent to a failure of the other.
3 Administer cautiously to patients on MAO inhibitors or tricyclic

antidepressants.
4. Beta-Blockers and Albuterol will inhibit each other.
ALBUTEROL (PROVENTIL, VENTOLIN)-(cont.)
F. DOSAGE:
Each unit dose delivers 2.5 mg of Albuterol Sulfate in 3 ml total solution.

Administer full unit dose in adults and children over 2 years of age. May be
repeated twice if necessary.
In children less than 2 years of age, administer half a unit dose. May be
repeated once if necessary.
G. HOW SUPPLIED:
3 ml unit dose (2.5 mg Albuterol Sulfate in 3 ml).
AMIODARONE (CORDARONE)
A. ACTIONS:
Amiodarone is generally considered a class III antiarrhythmic drug, but it

possesses electrophysiologic characteristics of all four other classes of
antiarrhythmic drugs.
Like class I drugs, amiodarone blocks sodium channels at rapid pacing
frequencies, and like class II drugs, it exerts a non-competitive
antisympathetic action. One of its main effects is to lengthen the cardiac
action potential, a class III effect. In addition to blocking sodium channels,
amiodarone blocks myocardial potassium channels, which contributes to
slowing of conduction and prolongation of refractoriness.
Its vasodilatory action can decrease cardiac workload and consequently
myocardial O2 consumption.
B. INDICATIONS:
1. Shock refractory pulseless ventricular tachycardia / ventricular fibrillation.
2. Wide-complex tachycardia of uncertain origin.
1. There are no contraindications to Amiodarone use in the treatment of

ventricular fibrillation and pulseless ventricular tachycardia.
2. In other situations, Amiodarone is contraindicated in patients with known

hypersensitivity to any of the components of Amiodarone, or in patients
with cardiogenic shock, marked sinus bradycardia, and second or third
degree AV block unless a functioning pacemaker is available.
D. DOSAGE:
Adult: 300 mg IV/IO, consider repeat dose of 150 mg IV in 3-5 minutes.
In the setting of wide-complex tachycardia of uncertain origin, 150 mg IV

over 10 minutes.
Pediatric: 5mg/kg IV/IO in the setting of refractory VF/VT, (if Epinephrine

and Lidocaine have been ineffective).
AMIODARONE (CORDARONE) (cont.)
The use of Amiodarone in the setting of wide-complex tachycardia in the

pediatric patient has not been fully studied, but it may have some use.
E. HOW SUPPLIED:
150 mg in 3ml ampuls.
ASPIRIN (ACETYLSALICYLIC ACID
A. ACTIONS:
Aspirin is an over the counter non-narcotic analgesic with antipyretic and

anti-inflammatory properties. It is used in the pre-hospital setting for its
potential effectiveness as an anti-thrombotic agent.
When an atherosclerotic plaque ruptures or erodes, within seconds platelets
adhere to the damaged lining of the vessel and to each other, forming a plug.
“Sticky platelets” secrete several chemicals, including thromboxane. These
substances stimulate vasoconstriction, further reducing blood flow at the site.
At this stage, antiplatelet agents are most effective. Aspirin blocks the
synthesis of thromboxane, inhibiting platelet aggregation.
B. INDICATIONS:
1. Chest pain or other signs / symptoms highly suggestive of acute

coronary syndrome.
2. Unstable angina.
3. ECG changes highly suggestive of acute MI.
1. Hypersensitivity to aspirin and / or non-steroidal anti-inflammatory

agents.
2. Recent history of GI bleed.
3. Bleeding disorders (hemophilia).
4. Asthma and active ulcer disease are relative contraindications to the use
of aspirin.
D. DOSAGE:
324 mg, have the patient chew and swallow (4) 81 mg tablets as soon as
possible after onset of symptoms.
E. HOW SUPPLIED:
81 mg tablets (baby aspirin) in bottle.
ATIVAN (LORAZEPAM)
A. ACTIONS:
Ativan (Lorazepam) is a member of the benzodiazepine family. It has a

tranquilizing action on the central nervous system to produce an anti-anxiety
and sedative effect. No appreciable effect is noted on the respiratory or
cardiovascular systems.
B. INDICATIONS:
1. Status epilepticus or recurrent seizures.
2. Pre-medication prior to cardioversion or other procedures where a

calming and anti-anxiety effect is desired
1. Ativan is contraindicated in patients with known sensitivity to

benzodiazepines.
2. Ativan is contraindicated in the patient with acute narrow-angle

glaucoma.
Confusion, muscular weakness, blurred vision, drowsiness and slurred

speech.
E. DOSAGE:
Adult: 1-2 mg, IV or IM. IV route administer slowly over 1 minute.
Pediatric: .05-0.2 mg/kg slow IV or IM (for IV use, dilute 1:1 in NS).
F. HOW SUPPLIED:
2 mg in1ml vial.
ATROPINE SULFATE (as a cardiac agent)
A. ACTIONS:
Atropine is a potent parasympatholytic anticholinergic that reduces vagal

tone and thus increases automatically the SA node and increases A-V
conduction.
B. INDICATIONS:
1. Symptomatic bradycardia.
2. Asystole / bradycardic PEA.
None in emergency situations
CNS - Restlessness, agitation, confusion, psychotic reaction, pupil dilation

blurred vision, headache.
CV - Tachycardia, may worsen ischemia or increase area of infarction,

ventricular fibrillation.
GI - Dry mouth, difficulty swallowing.
GU - Urinary retention.
Other – Worsened pre-existing glaucoma
E. WARNINGS:
Too small a dose (< 0.5 mg) or if normal dose pushed too slowly, may initially
cause the heart rate to decrease. Atropine is potentiated by antihistamines
and antidepressants. A maximum dose of 3 mg should not be exceeded.
F. DOSAGE:
Adult: Symptomatic bradycardias: 0.5-1.0 mg IV/IO or ET, may repeat

every 3-5 minutes until heart rate increased or total dose of 3 mg has been
reached.
ATROPINE SULFATE (as a cardiac agent) - (cont.)
Asystole: 1 mg IV/IO or ET, may repeat every 3-5 minutes to maximum dose
of 3 mg (0.04 mg/kg). (ET dose 2-2.5 mg if IV access delayed or
Bradycardic PEA: 1 mg IV or ET, may repeat every 3-5 minutes to maximum

dose of 3 mg (0.04 mg/kg). (ET dose 2-2.5 mg if IV access delayed or
Pediatric: Symptomatic bradycardias: 0.02 mg/kg IV/IO; may repeat once.
1. 0.1 mg minimum dose

2. Maximum single dose 0.5 mg in child; I mg in adolescent
3. Maximum total dose 1 mg in child; 2mg in adolescent
Asystole/Bradycardic PEA: Atropine is not indicated in the pediatric patient

in cardiac arrest.
G. HOW SUPPLIED:
Pre-filled syringes containing 1 mg in 10ml of solution.
ATROPINE SULFATE (as an antidote for poisoning)
A. ACTIONS:
Atropine is a potent parasympatholytic that bonds to acetylcholine receptors

thus diminishing the actions of acetylcholine. Atropine stops the effect of the
nerve agent by blocking the effects of over-stimulation and effectively
counters the actions of the nerve agent at nerve receptors.
Atropine also relieves the smooth muscle constriction in the lungs (wheezing,
respiratory distress) and GI tract (diarrhea, cramps) and dries up respiratory
tract secretions.
B. INDICATIONS:
1. Organophosphate poisoning (e.g. parathion, malathion, sevin, diazinon

and many common roach and ant sprays).
2. Nerve gas poisoning (Sarin gas, VX gas) with symptoms of excessive

cholinergic stimulation.
POISONING SIGNS ARE:
Salivation Pinpoint pupils Rhinorrhea

Tearing (lacrimation) Bradycardia
Urination Vomiting
Abdominal cramping Airway secretions
None when used in the management of severe organophosphate or nerve

gas poisoning.
Victims or organophosphate poisoning can tolerate and may require large

doses of Atropine. Signs of atropinization (flushing, pupil dilation, dry mouth,
tachycardia) are the end point of treatment. Reduction of secretions is most
important.
E. WARNINGS:
It is important that the patient be adequately oxygenated and ventilated prior

to using Atropine, as Atropine may precipitate ventricular fibrillation in a
poorly oxygenated patient.
ATROPINE SULFATE (as an antidote for poisoning)-(cont)
F. DOSAGE:
Adult: 2-5 mg IV/IO, repeat with 2-5 mg q 15 minutes until atropinization

occurs.
Pediatric: 0.05-0.1mg/kg, repeat q 15 minutes if necessary.
G. HOW SUPPLIED:
1. Pre-filled syringes containing 1mg in 10ml.
2. Multi-dose bottles containing 8 mg in 20 ml.
BENADRYL (DIPHENHYDRAMINE)
A. ACTIONS:
Benadryl (Diphenhydramine) is an antihistamine with anticholinergic (drying)

and sedative side effects. Antihistamines appear to compete with histamine
for cell receptor sites on effector cells. Benadryl prevents, but does not
reverse histamine mediated responses, particularly histamines effects on the
smooth muscle of the bronchial airways, gastrointestinal tract, uterus, and
blood vessels.
B. INDICATIONS:
1. Dystonic reactions from phenothiazines.
2. Anaphylaxis.
Benadryl is not to be used in newborn or premature infants or in nursing

mothers. Benadryl is also not to be used in patients with lower respiratory
tract symptoms, including asthma.
CNS - (most noted in elderly) Drowsiness, confusion, insomnia, headache,

vertigo, hyperactivity in children.
CV - Palpitations, tachycardia, PVC’s, hypotension.
GI - Nausea, vomiting, diarrhea, dry mouth, constipation.
GU - Dysuria, urinary retention.
RESP - Thickening of bronchial secretions, tightness of the chest,

wheezing, nasal stuffiness.
E. WARNINGS:
1. In infants and children especially, antihistamines in overdose may cause

hallucinations, convulsions, or death.
2. Antihistamines may diminish mental alertness in both adults and children.

In young children, they may produce excitation.
BENADRYL (DIPHENHYDRAMINE) - (cont.)
3. Benadryl has additive effects with alcohol and other CNS depressants
(hypnotics, sedatives, tranquilizers, etc).
4. Antihistamines are more likely to cause dizziness, sedation, and

hypotension in the elderly (60 years or older) patient.
F. DOSAGE:
Adult: 25-50 mg IV or deep IM.
Pediatric: 1 mg/kg IV or IM.
G. HOW SUPPLIED:
50 mg diphenhydramine HCL in 2 ml pre-filled syringe or vial
CALCIUM GLUCONATE
A. ACTIONS:
Calcium is essential for maintenance of the functional integrity of nervous,

muscular, skeletal system and cell-membrane and capillary permeability.
The cation is essential in the transmission of nerve impulses, contraction of
cardiac, smooth and skeletal muscles; renal function; respiration; and blood
coagulation.
B. INDICATIONS:
Calcium Gluconate may be a consideration during resuscitation attempts

when the following are suspected or known:
1. Acute hyperkalemia.
2. Hypocalcemia.
3. Calcium Channel Blocker toxicity.
4. Hypermagnesemia.
It may be used as a temporizing measure to prevent and/or treat cardiac

arrythmias in the face of hyperkalemia.
Calcium salts are not indicated during routine cardiopulmonary resuscitation

(except as noted as above). It is suspected that high levels of Calcium may
induce reperfusion injury and adversely affect the neurologic outcome of the
patient.
Rapid IV injection of Calcium salts may cause vasodilation, decreased blood

pressure, bradycardia, cardiac arrhythmias, syncope and cardiac arrest.
E. WARNINGS:
Calcium salts should not be injected IM, SQ, or into any perivascular tissue.
They may cause mild to moderate local reactions.
CALCIUM GLUCONATE (cont.)
F. DOSAGE:
Adult – in cardiopulmonary resuscitation: 2.3 - 3.7 mEq IV injected over

10-20 seconds, repeated at 10 minute intervals if necessary.
Adult – for treatment of hyperkalemia with secondary cardiac toxicity:

2.25 – 14 mEq IV injected over 1-2 minutes while monitoring ECG.
Pediatric: Not indicated in the pediatric patient. If Calcium is required in

the resuscitation of the pediatric patient, Calcium Chloride should be used.
G. HOW SUPPLIED:
4.65 mEq in 10 ml bottle.
CYANOKIT (Hydroxycobalamin)
A. DESCRIPTION:
Cyanokit is an antidotal treatment for acute intoxication by hydrogen cyanide

and its derivatives.
B. ACTIONS:
The active ingredient in the Cyanokit, hydroxocobalamin, is a precursor of

vitamin B12. Hydroxocobalamin works by binding directly to the cyanide,
creating cyanocobalamin, a natural form of vitamin B12, which is excreted in
the urine. Methemoglobin is not produced and the oxygen carrying capacity
of the patients blood is not lowered, making it suitable and safe for use in
smoke inhalation patients.
C. INDICATIONS:
NOTE: Use of the Cyanokit is a Level II procedure and contact must be

made with Medical Control before it’s use is considered.
Indicated in the treatment of known or suspected hydrogen cyanide

poisoning and its derivatives. If history is suggestive and clinical suspicion of
cyanide poisoning is high, Cyanokit should be administered without delay.
Note: Cyanide exposure occurs relatively frequently in patients with smoke

inhalation secondary to being confined in residential or commercial structure
fires. Cyanide poisoning may also occur in industry, particularly in the metal
trades, mining, electroplating, jewelry manufacture and x-ray film recovery. It
is also encountered in the fumigation of ships, warehouses flour mills and
other similar large structures. Cyanides can also be used as suicidal agents,
particularly among health care and laboratory workers.
None.
The most common side effect seen is injection site redness and a temporary
pink or red discoloration of the skin, urine and mucous membranes. Allergic
reactions can occur, but are rare. Rises in blood pressure have been noted,
but are transient.
CYANOKIT (Hydroxycobalamin) (cont.):
E. WARNINGS:
Hydroxocobalamin is known to be incompatible with a number of other drugs

in the same IV line, so it should be administered in its own dedicated IV line.
F. DOSAGE AND ADMINISTRATION:
Adult: Starting dose is 5 gm (both 2.5 gm vials) administered as an IV drip

over 10-15 minutes. Depending on the severity of the poisoning and the
clinical response, a second 5 gm dose may be needed later.
Pediatric: The use of hydroxocobalamin in the pediatric patient has not

been studied in the U.S., but in Europe a common starting dose is 70 mg/kg.
Each 2.5 gm vial of hydroxocobalamin is to be reconstituted with 100 ml NS

using the supplied sterile transfer spike. Following the reconstitution of the
powder, each vial should be rocked for 30 seconds prior to infusion.
G. HOW SUPPLIED:
Each Cyanokit contains:
1. (2) 250 ml glass vials, each containing 2.5 gm lyophilized

hydroxocobalamin dark red crystalline powder for injection.
2. (2) sterile transfer spikes.
3. (1) sterile IV infusion set.
4. Quick use reference guide and package insert.
DEXTROSE 50% (D50)
A. ACTIONS:
A monosaccharide, which provides calories for metabolic needs, spares body

proteins and loss of electrolytes. Readily excreted by kidneys producing
diuresis. It is a hypertonic solution.
B. INDICATIONS:
Hypoglycemia.
Intracranial or intraspinal hemorrhage; Delirium Tremens’ with dehydration.

Hyperglycemia, CVA, head injury, low perfusion states (unless hypoglycemia
is confirmed).
CV – Potential thrombosis, sclerosing if given in small peripheral vein.
INTEG - Tissue damage, irritation if infiltrates.
OTHERS - Acidosis, alkalosis, hyperglycemia, hypokalemia.
E. WARNINGS:
1. May theoretically cause Wernicke-Korsakoff syndrome in acute alcohol

intoxication. Perform a glucose check prior to administering dextrose.
2. Do not give D50 to pediatric patients < 2 y/o, use D25 or D10.
3. Do not give if glucose level > 70.
F. DOSAGE:
Adults: 50 ml of a 50% solution (25gms) IV.
Pediatrics: See D25.
G. HOW SUPPLIED:
Pre-filled syringes containing 25 gm of glucose in 50 ml of solution.
DEXTROSE 25% (D25)
A. ACTIONS:
A monosaccharide, which provides calories for metabolic needs, spares body

proteins and loss of electrolytes. Readily excreted by kidneys producing
diuresis. It is a hypertonic solution.
B. INDICATIONS:
Hypoglycemia.
Intracranial or intraspinal hemorrhage, hyperglycemia, CVA, head injury, low

perfusion states (unless hypoglycemia is confirmed).
CV – Potential thrombosis, sclerosing if given in small peripheral vein.
INTEG - Tissue damage, irritation if infiltrates.
OTHERS - Acidosis, alkalosis, hyperglycemia, hypokalemia.
E. WARNINGS:
1. Do not give D25 to pediatric patients < 1 month, use D10.
2. Do not give if glucose level > 60.
F. DOSAGE:
Pediatrics: 2 ml/kg of 25% solution.
Adults: See D50.
G. HOW SUPPLIED:
Pre-filled syringes containing 2.5 gm of glucose in 10 ml of solution.
DOPAMINE INFUSION (INTROPIN)
A. ACTIONS:
Dopamine stimulates dopaminergic beta-adrenergic and alpha-adrenergic

receptors of the sympathetic nervous system. It exerts an inotropic effect on
the myocardium resulting in an increased cardiac output. Dopamine
produces less increase in myocardial oxygen consumption than does
isoproterenol and its use is usually not associated with a tachyarrhythmia.
Dopamine dilates renal and mesenteric blood vessels at low loses that may
not increase heart rate or blood pressure. Therapeutic doses have
predominant beta-adrenergic receptor stimulating actions that result in
increases in cardiac output without marked increases in pulmonary occlusive
pressure. At high doses, Dopamine has alpha receptor stimulating actions
that result in peripheral vasoconstriction and marked increases
in pulmonary occlusive pressure.
B. INDICATIONS:
1. Hemodynamically significant bradydysrhythmias that have not responded

to Atropine and/or when pacing is not available.
2. Hypotension that occurs after return of spontaneous circulation.
3. Hemodynamically significant hypotension in the absence of hypovolemia

(cardiogenic shock).
1. Hypovolemia.
2. Uncorrected tachydysrhythmias or VF.
3. Patients with pheochromocytoma.
4. Patients on MAO inhibitors.
5. Known hypersensitivity to sulfites or Dopamine.
CNS - Headache.
CV - Ectopic beats, tachycardia, anginal pain, palpitations, hypotension.
DOPAMINE INFUSION (INTROPIN) (cont.)
SIDE EFFECTS AND ADVERSE REACTIONS: (cont.)
GI - Nausea, vomiting.
LOCAL - Necrosis and tissue sloughing with extravasation.
OTHER - Piloerection, dyspnea.
E. WARNINGS:
Do not add Dopamine to any alkaline dilutent solution since the drug is
inactivated in alkaline solution.
F. DOSAGE:
Adults: Dose range 5 to 20 mcg/kg/min. Begin infusion at 5 mcg/kg/min.
Pediatrics: Dose range 2 to 20 mcg/kg/min. Use 40 mg/ml solution, to mix:

add 30 mg (2.4 ml) to 250ml D5W.
G. HOW SUPPLIED:
Premixed solution containing 400 mg of Dopamine in 250 ml of D5W yielding

a concentration of 1600 mcg/ml.
EPINEPHRINE (1:10,000)
A. ACTIONS:
Epinephrine is a sympathomimetic which stimulates both alpha and beta

receptors. As a result of its effects, myocardial and cerebral blood flow are
increased during ventilation and chest compression. Epinephrine increases
systemic vascular resistance and thus may enhance defibrillation.
B. INDICATIONS:
1. Cardiac arrest: asystole, ventricular fibrillation, pulseless VT, pulseless

electrical activity (PEA),
2. Anaphylaxis with hypotension.
3. Symptomatic (unstable) bradycardia in the pediatric patient.
None in the cardiac arrest situation.
D. SIDE EFFECTS:
CNS - Anxiety, headache, cerebral hemorrhage.
CV - Tachycardia, ventricular dysrhythmias, hypertension, angina,

palpitations.
GI - Nausea and vomiting.
E. WARNINGS:
Epinephrine is inactivated by alkaline solutions - never mix with sodium

bicarbonate. Action of catecholamines depressed by acidosis - attention to
ventilation and circulation is essential. Antidepressants potentiate the effect
of Epinephrine.
F. DOSAGE:
Adults - cardiac arrest: 1 mg IV/IO every 3-5 minutes for duration of

pulselessness (ET dose 2-2.5 mg if IV access delayed or unavailable.
Adults - anaphylaxis with hypotension: 1 ml slow IV/IO over 3-5 min.
EPINEPHRINE (1:10,000) (cont.)
DOSAGE (cont.)
Pediatrics - cardiac arrest: 0.01 mg/kg, IV/IO every 3-5 minutes for
duration of pulselessness.
Pediatrics - anaphylaxis with hypotension: 0.01 mg/kg slow IV/IO over 3-

5 min. (not to exceed 1 ml dose).
Pediatrics - unstable bradycardia: 0.01 mg/kg IV repeated every 3-5

minutes at same dose
G. HOW SUPPLIED
Pre-filled syringes containing 1 mg/10ml.
EPINEPHRINE (1:1000)
A. ACTIONS:
Epinephrine is a sympathomimetic which stimulates both alpha and beta

adrenergic receptors causing immediate bronchodilatation, increase in heart
rate and an increase in the force of cardiac contraction. Subcutaneous dose
lasts 5 - 15 minutes.
B. INDICATIONS:
1. Anaphylaxis.
2. Pediatric asthma, adult asthma in extremis.
3. Cardiac arrest in pediatric patients.
4. May be used for ET dose in adult cardiac arrest (after diluting to 10 ml).
5. May be used for ET administration in pediatric symptomatic bradycardia

if unable to start IV or IV delayed.
C. CONTRAINDICATION:
Hyperthyroidism, hypertension, cerebral and coronary artery arteriosclerosis.
Same as Epinephrine 1:10,000.
E. WARNINGS:
Same as Epinephrine 1:10,000. 1:1000 Epinephrine should not be given

intravenously to adults or intravenously for pediatric asthma and anaphylaxis.
F. DOSAGE:
Adults - anaphylaxis: 0.3 - 0.5 mg (0.3 - 0.5 ml) SQ or IM. May be

repeated every 15 minutes x 3 if necessary.
Adults - asthma (in extremis): 0.3 - 0.5 mg (0.3 - 0.5 ml) SQ (requires
contact with Medical Control).
Adults - cardiac arrest (ET dose): Give 2 - 2.5 mg ET diluted to 10 ml until

IV established.
EPINEPHRINE (1:1000) (cont.)
Pediatrics - anaphylaxis/asthma: 0.01 mg/kg (up to 0.3 mg) SQ for both

asthma and anaphylaxis.
Pediatrics - cardiac arrest: 0.1 mg/kg for ET dose if IV delayed or

unavailable. 0.1 to 0.2 mg/kg for second and subsequent doses after first
dose of 1:10,000.
G. HOW SUPPLIED:
Ampule containing 1 mg/1 ml.

Pre-filled syringe containing 1 mg/1 ml.
Multi-dose vial in a concentration of 30 mg/30 ml.
ETOMIDATE (AMIDATE)
A. ACTIONS:
Etomidate is a imidazole sedative-hypnotic agent that causes sedation

through enhanced GABA receptor activity. It produces rapid, deep sedation
within one minute (many times within 15-30 seconds) with minimal
cardiovascular effects. The duration of the sedation is approximately 5-10
minutes.
B. INDICATIONS:
1. Used as an induction agent for Rapid Sequence Intubation.
2. Can be used for procedural sedation during painful procedures

(cardioversion).
C. CONTRAINDICATION:
There is no contraindication to the use of Etomidate in the setting of Rapid

Sequence Intubation. For procedural sedation, the only contraindication is
the patient who has shown a hypersensitivity to the drug.
CNS – Transient muscle contractions or twitching (Myoclonus).
GU – If used without concomitant paralytics, nausea and vomiting can occur.
LOCAL – Can cause transient mild local burning and venous irritation on
administration.
E. WARNINGS:
Can cause rapid and deep sedation within 15-30 seconds. Should only be
used when personnel and equipment are ready for appropriate airway and
ventilatory management.
F. DOSAGE:
Adults – Rapid Sequence Intubation: 0.3 mg/kg IV/IO
Adults – procedural sedation: 0.1 mg/kg IV
ETOMIDATE (AMIDATE) (cont.)
F. DOSAGE (cont.):
Pediatrics: Etomidate should not be used in the patient ≤ 10 years of age.

If patient > 10 years of age, adult dose is used.
G. HOW SUPPLIED:
Pre-filled syringe containing 40 mg/20 ml (2mg/ml).
FENTANYL (SUBLIMAZE)
A. ACTIONS:
Fentanyl is a potent narcotic analgesic that suppresses pain by inhibiting

ascending pathways in the central nervous system. It increases pain
threshold, and alters pain reception via binding at opioid receptors in the
brain.
Onset of action if given IV is 1-2 minutes. Peak effects are seen within 3-5
minutes Duration of action is typically 30-60 minutes.
Onset of action if given IM is 7-15 minutes. Peak effects are seen within 20-
30 minutes. Duration of action is typically 1-2 hours.
B. INDICATIONS:
1. Severe pain from burns and isolated extremity injuries/fractures.
2. Chest pain from acute MI when patient allergic to Morphine.
1. Patients with pain due to multi-system trauma or acute abdomen.
2. Patients with volume depletion or hypotension.
3. Patients with head, chest or abdominal trauma.
4. Alcoholism or antidepressant ingestion.
5. Any respiratory difficulty. Note: Fentanyl is a potent respiratory

depressant.
6. Myasthenia Gravis and in those patients who have received MAO

inhibitor therapy in the last 14-21 days as well as those who have a
known hypersensitivity to the drug.
CNS - Euphoria, drowsiness, dizziness, pupillary constriction, respiratory

depression and arrest.
CV - Bradycardia, hypotension.
FENTANYL (cont.):
D. SIDE EFFECTS AND ADVERSE REACTIONS (cont.):
GI - Nausea and vomiting.
RESP – Apnea, respiratory depression, Broncho and laryngospasm,

decreased cough/gag reflex.
E. WARNINGS:
1. Rapid administration may cause skeletal muscle (chest wall) rigidity.

This may inhibit or make ventilation impossible. Administer slow (over 1-
2 min.) IV.
2. Fentanyl should be used with great caution in patients who are

concurrently using other narcotic analgesics, phenothiazines,
benzodiazepines, sedative-hypnotics (including barbiturates), tricyclic
anti-depressants and other CNS depressants (including alcohol).
Respiratory depression or arrest, hypotension and profound sedation or
coma may result.
3. May be reversed with Narcan (may require more than usual dose of
Narcan).
F. DOSAGE:
Adults: 50-100 mcg (1 mcg/kg) slow (over 1-2 min.) IV/IO. May repeat as
necessary to a maximum total dose of 150 mcg. If IV route not available,
may give single IM dose of 100 mcg.
Pediatrics: 1 mcg/kg IV/IO.
G. HOW SUPPLIED:
Pre-filled cartridges containing 100 mcg/2 ml.
GLUCAGON
A. ACTIONS:
Glucagon, produced in the pancreas by the alpha cells of the Islets of

Langerhans, can cause an increase in blood glucose concentrations. It
releases stores of glucose from the liver, causing blood glucose to rise.
B. INDICATIONS:
Glucagon is indicated for the treatment of hypoglycemia when a peripheral IV

is either impractical or cannot be obtained.
Since glucagon is a protein, hypersensitivity is a possibility.
GI: Occasional nausea and vomiting.
E. WARNINGS:
1. Glucagon should be administered with caution in patients with a known

history of Insulinoma and/or Pheochromocytoma.
2. If patient has no stores of glucose, Glucagon may be ineffective.
F. DOSAGE:
Adults: 1.0 unit (1.0 mg.) of Glucagon IM.
Pediatrics: Children under 20 kg should receive 0.5 mg (.5 unit) IM. If child
over 20 kg may use adult dose.
G. HOW SUPPLIED:
Vial with 1.0 unit (1.0 mg) glucagon (dry powder) and pre-filled syringe
containing 1 ml of diluting solution.
Inject diluting solution into vial, mix together and draw back into syringe to
administer.
HALDOL (HALOPERIDOL)
A. ACTIONS:
Haldol is an antipsychotic whose precise mechanism is not known.

Competitively blocks dopamine receptors in the brain responsible for mood
and behavior. Also known to have antiemetic properties.
B. INDICATIONS:
1. Short-term management of acute, violent psychotic episodes.
2. Short-term management of aggressive, agitated and combative patients

to facilitate transport.
1. Patients in comatose states or experiencing CNS depression due to

alcohol or other depressant drugs.
2. Patients with Parkinson’s syndrome.
3. Do not administer to females who may be pregnant or nursing.
4. Any patient with known hypersensitivity to the drug.
CNS – Extrapyramidal symptoms, especially akathisia and dystonias.

Confusion, vertigo, seizures,
CV – Tachycardia, orthostatic hypotension, hypertension, ECG changes

(torsades) with IV use.
EENT – Blurred vision.
GI – Dry mouth, diarrhea, nausea, vomiting.
E. WARNINGS:
If Extrapyramidal symptoms occur, treat with 50 mg Benadryl IV.
HALDOL (HALOPERIDOL) (cont.)
F. DOSAGE:
Adults: 5 mg IM or IV
Pediatrics: Not indicated in the patient < 8 years of age.
G. HOW SUPPLIED:
Ampule containing 5 mg/1ml
Pralidoxime (2 Pam) Chloride (Mark I Kit, Auto-Injector)
A. ACTIONS:
Pralidoxime Chloride is a cholinesterase reactivator. It’s principal action is to

reactivate cholinesterase which has been inactivated by phosphorylation due
to organophosphates or nerve gas compounds. The destruction of
accumulated acetylcholine can then proceed and neuromuscular junctions
will again function normally.
B. INDICATIONS:
The auto-injector for Pralidoxime Chloride is specifically indicated for

intramuscular use as an adjunct to Atropine in the treatment of poisoning by
organophosphates or nerve agents (Sarin gas, VX gas) having
anticholinesterase activity.

Urination Vomiting

gas poisoning.
It is very difficult to differentiate between any adverse effects of Pralidoxime

Chloride and Atropine and the toxic effects of organophosphate/ nerve gas
poisoning.
E. WARNINGS:
When Atropine and Pralidoxime Chloride are administered together, the

signs of atropinization (flushing, tachycardia, dryness of mouth and nose)
may occur much earlier then might be expected when Atropine is used alone.
This is especially true if the total dose of Atropine has been large and the
administration of Pralidoxime Chloride has been delayed.
Pralidoxime (2 Pam) Chloride (Mark I Kit, Auto-Injector) (cont.)
F. DOSAGE:
Adults: For optimal effects, Atropine and Pralidoxime Chloride should be

administered together as soon as possible after exposure. Depending on the
severity of symptoms, immediately administer 1 Atropine auto-injector,
followed by 1 Pralidoxime Chloride auto-injector.
Atropine must be given first until its effects become apparent, and only then
should Pralidoxime Chloride be administered. If nerve agent symptoms are
still present after 15 minutes, repeat injections. If symptoms still exist after
an additional 15 minutes, repeat injections for third time. If symptoms remain
after third set of injections, do not give any more injections. If symptoms
are severe, 3 Atropine auto-injectors and 3 Pralidoxime Chloride auto-
injectors should be administered in rapid succession (stacked)
See directions for use and picture below.
Pediatrics: Safety and effectiveness in the pediatric patient has not been
established. Do not use in the patient < 8 years of age.
G. HOW SUPPLIED:
Pralidoxime Chloride is supplied in aqueous solution pre-filled and pre-

measured in the auto-injector, 600 mg/2ml.
Directions for Use:
1. Remove gray safety cap.
2. Place black end against outer thigh and

push hard until the injector functions.
3. Hold firmly in place for 10 seconds, then

remove. Massage the injection area.
4. Dispose of properly. Place in sharps container

or bend needle into a hook.
Atropine Sulfate (Mark I Kit, AtroPen Auto-Injector)
A. ACTIONS:
Atropine is a potent parasympatholytic that bonds to acetylcholine receptors

thus diminishing the actions of acetylcholine. Atropine stops the effect of the
nerve agent by blocking the effects of over-stimulation and effectively
counters the actions of the nerve agent at nerve receptors.
Atropine also relieves the smooth muscle constriction in the lungs (wheezing,
respiratory distress) and GI tract (diarrhea, cramps) and dries up respiratory
tract secretions.
B. INDICATIONS:
The auto-injector for Atropine is specifically indicated for intramuscular use in

conjunction with Pralidoxime Chloride for the treatment of poisoning by
organophosphates or nerve agents (Sarin gas, VX gas) having
anticholinesterase activity.

Urination Vomiting

gas poisoning.
Victims of organophosphate/nerve gas poisoning can tolerate and may

require large doses of Atropine. Signs of atropinization (flushing, pupil
dilation, dry mouth, tachycardia) are the end point of treatment. Reduction of
secretions is most important.
E. WARNINGS:
It is important that the patient be adequately oxygenated and ventilated prior

to using Atropine, as Atropine may precipitate ventricular fibrillation in a
poorly oxygenated patient.
Atropine Sulfate (Mark I Kit, AtroPen Auto-Injector) (cont.)
F. DOSAGE:
Adult: For optimal effects, Atropine and Pralidoxime Chloride should be

administered together as soon as possible after exposure. Depending on the
severity of symptoms, immediately administer 1 Atropine auto-injector,
followed by 1 Pralidoxime Chloride auto-injector.
Atropine must be given first until its effects become apparent, and only then
should Pralidoxime Chloride be administered. If nerve agent symptoms are
still present after 15 minutes, repeat injections. If symptoms still exist after
an additional 15 minutes, repeat injections for third time. If symptoms remain
after third set of injections, do not give any more injections. If symptoms
are severe, 3 Atropine auto-injectors and 3 Pralidoxime Chloride auto-
injectors should be administered in rapid succession (stacked)
See directions for use and picture below.
Pediatrics: Safety and effectiveness in the pediatric patient has not been
established. Do not use in the patient < 8 years of age.
G. HOW SUPPLIED:
Atropine is supplied pre-filled and pre-measured in the auto-injector,

2mg/2ml.
1. Yellow
Directions for Use: Safety
Cap
1. Remove yellow safety cap.
2. Place green end against outer thigh and

push hard until the injector functions.
3. Hold firmly in place for 10 seconds, then

remove. Massage the injection area.
4. Dispose of properly. Place in sharps container

2. Green
or bend needle into a hook.
End
3. Thigh
HEPARIN INFUSION (transport only, not stocked)
A. ACTIONS:
Heparin inhibits reactions that lead to the clotting of blood and the formation
of fibrin clots. Heparin acts at multiple sites in the normal coagulation
system. Small amounts of Heparin in combination with antithrombin III
(Heparin co-factor) can inhibit thrombosis by inactivating active factor X and
inhibiting the conversion of prothrombin to thrombin.
Heparin does not have fibrinolytic activity, so it will not dissolve existing clots.
B. INDICATIONS:
1. Prevention of clotting in arterial and heart surgery.
2. Anticoagulant therapy in prophylaxis and treatment of venous thrombosis
3. Prophylaxis and treatment of pulmonary embolism.
4. Atrial fibrillation with embolization.
1. Heparin should not be used in patients with severe thrombocytopenia

(abnormal decrease in the number of platelets in the blood) in whom
suitable blood coagulation tests cannot be performed at appropriate
intervals (this contraindication refers to full-dose Heparin, there is usually
no need to monitor coagulation parameters in patient receiving low-dose
Heparin.
2. Heparin should not be used in patients with an uncontrollable active

bleeding site.
3. Patients with documented hypersensitivity to Heparin should only be

given the drug in clearly life-threatening circumstances.
Hemorrhage is the chief complication that may result from Heparin therapy.
Bleeding can occur at virtually any site, but it should be appreciated that
internal bleeding that is hard to detect can occur, and any unexplained fall in
blood pressure or other symptoms of hypotension may be caused by a
hemorrhagic event that is related to the Heparin therapy.
HEPARIN INFUSION (transport only, not stocked) (cont.)
E. WARNINGS:
1. Heparin is not intended for intramuscular use.
2. Heparin should be used with extreme caution in disease states in which

there is increased danger of hemorrhage. If patient develops signs of
hemorrhaging, infusion should be discontinued.
F. DOSAGE
Loading dose: 80 units/kg (Loading dose usually given prior to starting

maintenance drip)
Maintenance Dose: 500-1500 units/hour to maintain PTT 1.5-2.5 times

control.
Weight Based Dosing: 80-100 units/kg loading dose, followed by 15-25

units/kg/hour to maintain target PTT.
G. HOW SUPPLIED:
25,000 units in 250 ml NS (pre-mixed)
NITROGLYCERIN INFUSION (transport only, not stocked)
A. ACTIONS:
Nitroglycerin is a direct vasodilator which acts primarily on the venous

system, although it also produces direct coronary artery vasodilatation.
There is a decrease in venous return which decreases the workload on the
heart and decreases myocardial oxygen consumption, preload and afterload.
Nitroglycerin is metabolized by the liver, excreted in urine and has a half-life

of 1-4 minutes. IV onset of action is immediate, duration is variable.
B. INDICATIONS:
1. Acute, unstable myocardial ischemia (Angina).
2. Acute Myocardial Infarction.
3. Relief of persistent chest pain that does not respond to first-line

medications.
4. Congestive heart failure.
1. Known sensitivity to nitrates.
2. Increased intracranial pressure (ICP) from head trauma, hemorrhagic

CVA or other cerebral hemorrhage.
3. Hypotension.
4. Uncorrected hypovolemia.
5. Use of Viagra (Sildenafil Citrate) within 24 hrs.
CNS – Headache, dizziness, pallor or flushing, sweating.
CV – Hypotension, reflex tachycardia.
GI – Nausea, and vomiting.
NITROGLYCERIN INFUSION (transport only, not stocked) (cont.)
E. WARNINGS:
1. Use with caution in patients with the following conditions:

a. Pregnant or lactating.
b. Hepatic or renal disease.
c. Pericarditis
d. Postural hypotension.
2. Glass infusion bottles and non-polyvinyl tubing must be used as plastics

will absorb Nitroglycerin. Plastic IV infusion bags may be used for short-
term transports.
3. Do not use in-line filters.
4. Do not mix with any other medications in same bag/bottle.
F. DOSAGE:
Rate of administration is titrated to patient pain relief response, typically

starting at 10mcg/min. and increasing in 5 mcg increments every 3-5 minutes
until response is noted (Be alert for developing hypotension).
G. HOW SUPPLIED:
Nitroglycerin infusion encountered at a facility will either be
full strength: 50 mg/250 ml of NS or D5W or:
half strength: 25 mg/250 ml or 50 mg/500 ml of NS or D5W.
Pre-mixed will be in glass bottles. Teams will occasionally mix vials of

Nitroglycerin (25 or 50 mg) in 250 ml bags of D5W for short transports.
INTEGRILIN INFUSION (transport only, not stocked)
A. ACTIONS:
Integrilin (Eptifibatide) is a cyclical heptapeptide that reversibly prevents

platelet aggregation by preventing the binding of fibrinogen and other
adhesive ligands to specific platelet receptors. The effects are specific to
platelets, avoiding interference with other normal cardiovascular processes.
The effects are reversed upon Integrilin discontinuation.
Integrilin has a half-life of 2.5 hours and is cleared renally.
B. INDICATIONS:
1. As an adjunct to aspirin and Heparin, for the prevention of acute cardiac

ischemic complications in patients with acute coronary syndrome
(unstable angina or non Q-wave myocardial infarction).
2. For the treatment of patients undergoing (PCI) percutaneous coronary

intervention (balloon angioplasty, intracoronary stent placement).
1. History of bleeding diathesis, or evidence of active abnormal bleeding

within the last 30 days.
2. Uncontrolled hypertension (SBP > 200 and/or DBP > 110).
3. Major surgery or trauma within the preceding 6 weeks.
4. History of stroke within 30 days or any history of hemorrhagic stroke.
5. Known hypersensitivity to any component of the drug.
CV – Bleeding is the most common complication encountered during

Integrilin therapy, it is associated with an increase in major and minor
bleeding. Most major bleeding has been at the arterial access site for
cardiac catheterization or from the gastrointestinal or genitourinary tract.
INTEGRILIN INFUSION (transport only, not stocked) (cont.)
E. WARNINGS:
1. If bleeding cannot be stopped with pressure, infusion of Integrilin and

concomitant Heparin should be stopped immediately.
2. Use with caution in patients with concomitant Warfarin use and

hemorrhagic retinopathy.
F. DOSAGE:
Typical recommended dosing of Integrilin for acute coronary syndromes is a

bolus of 180 mcg/kg, followed by a continuous infusion of 2 mcg/kg/min.
Dosing for PCI may be different.
G. HOW SUPPLIED:
Supplied in 10 ml vials containing 20 mg and 100 ml vials containing 75 mg.
Requires vented IV tubing and may share same line with NTG or Heparin.
10 ml vial typically used for bolus dose. 100 ml vial typically used for infusion
with IV set spiked directly to vial.
LASIX (FUROSEMIDE)
A. ACTIONS:
Lasix is a sulfonamide derivative and potent diuretic which inhibits the

reabsorption of sodium and chloride in the proximal and distal renal tubules,
as well as in the loop of Henle. This results in an increase in the urinary
excretion of sodium, chloride and water, creating a profound diuresis. It also
has a significant vasodilatory effect not related to its renal actions.
With IV administration, onset of diuresis is within 5-10 minutes; peaks in 30

minutes; and has a duration of 2 hours. Onset of vasodilatory effects can be
within 2 minutes.
B. INDICATIONS:
1. Pulmonary edema.
2. Congestive heart failure.
1. Hypersensitivity to Furosemide or sulfonamides.
2. Hypovolemia/hypotension.
3. Electrolyte depletion.
4. Anuria.
CNS - Dizziness, tinnitus, hearing loss (with rapid administration), headache,

blurred vision, weakness.
CV - Hypotension.
GI - Anorexia, vomiting, nausea.
OTHER - Pruritus, urticaria, muscle cramping.
E. WARNINGS:
1. Can cause excessive fluid loss and dehydration, resulting in hypovolemia

and electrolyte imbalance.
LASIX (FUROSEMIDE) (cont.)
E. WARNINGS (cont.):
2. Use with caution in patients with Diabetes mellitus, dehydration and

severe renal disease.
3. Lasix should be protected from light.
F. DOSAGE:
Adults: 0.5-1.0 mg/kg (20-40 mg) IV slowly over 1-2 minutes. If the patient
is on oral Lasix therapy, consider an initial IV dose that is twice the daily oral
dose.
Pediatrics: 1.0 mg/kg IV slowly over 1-2 minutes.
G. HOW SUPPLIED:
Vials or pre-filled syringes containing 40 mg/4ml (10 mg/1 ml).
LIDOCAINE (XYLOCAINE)
A. ACTIONS:
Inhibits the influx of sodium through the fast channels of the myocardial cell
membrane and decreases conduction in ischemic cardiac tissue. This
decreases the excitability in ischemic tissue and suppresses ventricular
irritability. Raises the ventricular fibrillation threshold.
B. INDICATIONS:
1. Control of hemodynamically compromising PVC’s.

Note: Treatment of PVC’s with Lidocaine can be controversial.
Lidocaine should only be considered in the symptomatic patient with
significant ventricular irritability after other AMI treatments have been
given (O2, ASA, NTG, Morphine).
2. Ventricular fibrillation / pulseless V-tach.
3. Prior to intubation in the setting of the head-injured trauma patient

(suspected increased intracranial pressure).
1. Hypersensitivity to Lidocaine or amide-type local anesthetics.
2. Severe sinoatrial, atrioventricular or intraventricular block (2nd and 3rd

degree).
3. Stokes-Adams syndrome.
4. Wolff-Parkinson-White syndrome.
CNS – Seizures, drowsiness, numbness, dizziness, blurred vision, tinnitus,

euphoria, muscle twitching, tremors.
CV - Rare, but with toxic levels - hypotension, widening of QRS complex,

bradycardia, cardiac arrest.
RESP - At toxic levels - respiratory depression and/or arrest.
LIDOCAINE (XYLOCAINE) (cont.)
E. WARNINGS:
1. Lidocaine may be lethal in a bradycardia with a ventricular escape

rhythm.
2. If PVC’s occur in conjunction with sinus bradycardia or incomplete heart

clock, the bradycardia must be treated first.
3. Lidocaine is metabolized in the liver. Bolus dosage should be decreased

by half in patients with liver disease and low cardiac output states, e.g.,
acute MI, shock, congestive heart failure, patient more than 70 years old.
F. DOSAGE:
Adults – cardiac arrest: 1-1.5 mg/kg/IV/IO bolus, repeat with 1-1.5 mg/kg q
5 - 10 minutes if necessary, not to exceed a total of 3 mg/kg.
Pediatrics – cardiac arrest: 1 mg/kg IV/IO bolus. Repeat bolus of 1 mg/kg

q 5 - 10 min. if needed, to a total of 3 mg/kg.
Maintenance Infusion: Lidocaine infusion containing 1 gm Lidocaine in 250

ml D5W given at a rate of 2-4 mg/min. (30-60) microdrops/min.). See
Infusion Charts, Page 7-0.
Note:
Infusions are rarely necessary in pediatrics; treatment of ectopy should focus
on maximization of oxygenation and ventilation and bolus doses of
antiarrhythmic if needed.
ET dose: Double IV dose.
PVCs: 1mg - 1.5mg/kg IV or ET, subsequent doses 0.5 - 0.75 mg/kg not to
exceed 3 mg/kg.
Head Trauma: 1 mg/kg IV/IO.
G. HOW SUPPLIED:
Pre-filled syringes: 2% = 100 mg/5ml.
Pre-mixed infusion solution: 1 gm/250 ml D5W.
LIDOCAINE 2 % VISCOUS GEL (Xylocaine)
A. ACTIONS:
Lidocaine stabilizes the neuronal membrane by inhibiting the ionic fluxes

required for the initiation and conduction of impulses, thereby causing local
anesthetic action.
B. INDICATIONS:
Lidocaine Gel is indicated as an anesthetic lubricant of accessible mucous

membranes of the nasopharynx and oropharynx. It is useful for nasotracheal
intubation and placement of nasopharyngeal airways.
Lidocaine is contraindicated in patients with a known history of

hypersensitivity to local anesthetics of the amide type or to other components
of Lidocaine 2% Gel.
D. WARNINGS:
Lidocaine 2% Gel should be used with extreme caution in the presence of

sepsis or severely traumatized mucosa in the area of application, since such
conditions have the potential for rapid systemic absorption.
E. DOSAGE:
A single application should not exceed 50 mg of Lidocaine 2% Gel.
F. HOW SUPPLIED:
2% viscous gel in tubes or pre-filled syringes of 100 mg/5 ml (20 mg/ml).
MORPHINE SULFATE
A. ACTIONS:
Morphine is a narcotic (opiate) analgesic which depresses the central

nervous system and suppresses pain via binding at opioid receptors of the
brain. It increases venous capacitance, decreases venous return, and
produces mild peripheral vasodilatation. Morphine also decreases
myocardial oxygen demand and reduces anxiety.
B. INDICATIONS:
1. Pain from acute myocardial infarction.
2. Pain from isolated extremity fractures.
3. Pain from burns.
4. Pulmonary edema.
1. Multi-systems trauma or acute abdomen.
2. Volume depletion or hypotension.
3. Head trauma, acute alcoholism and acute asthma (relative).
4. Anyone with a known hypersensitivity to the drug.
D. SIDE EFFECTS AND ADSVERSE REACTIONS:
CNS - Euphoria, drowsiness, pupillary constriction, respiratory arrest.
CV - Bradycardia, hypotension.
GI - Decreases gastric motility, nausea and vomiting.
RESP - Bronchoconstriction, decrease cough reflex.
E. WARNINGS:
Morphine is detoxified by the liver. It is potentiated by alcohol, antihistamines,

barbiturates, phenothiazines, and other sedatives.
MORPHINE SULFATE (cont.)
F. DOSAGE:
Adults: 2-4 mg in 2 mg increments, slow IV. May repeat if necessary to a

total of 10 mg.
Pediatrics: 0.1 mg/kg slow IV.
G. HOW SUPPLIED:
Pre-filled syringe containing 10 mg/2 ml.
NARCAN (NALOXONE)
A. ACTIONS:
Narcan antagonizes the effects of opiates by competing at same receptor

sites. Prevents or reverses the effects of narcotics/opiates, including
respiratory depression, sedation and hypotension. When given IV, the action
is apparent within (2) minutes. IM or SQ administration is somewhat less
rapid.
B. INDICATIONS:
Narcan is indicated to rule out or reverse coma and/or respiratory depression

secondary to narcotics/opiates:
1. Heroin.
2. Meperidine (Demerol).
3. Codeine.
4. Morphine.
5. Methadone.
6. Lomotil.
7. Hydromorphone (Dilaudid).
8. Pentazocine (Talwin).
9. Propoxyphene (Darvon or Darvocet).
10.Percodan.
Narcan is contraindicated in patients known to be hypersensitive to the drug

(rare).
CNS - Tremors, agitation, belligerence, pupillary dilation, seizures, increased

tear production, sweating.
CV - Hypertension, hypotension, ventricular tachycardia, pulmonary edema,

ventricular fibrillation.
GI - Nausea, vomiting.
NARCAN (NALOXONE) (cont.)
E. WARNINGS:
1. Narcan should be administered cautiously to persons (including

newborns of mothers) who are known or suspected to be physically
dependent on narcotics/opiates. May precipitate acute withdrawal
syndrome.
2. May need to repeat Narcan if patients LOC and respiratory status start to
decline, since duration of action of some narcotics may exceed that of
Narcan.
3. Rapid administration can cause projectile vomiting,
4. Use caution during administration as patient may become agitated or

violent as level of consciousness increases.
5. Higher doses of Narcan may be indicated for certain synthetic narcotic

overdoses such as Talwin or Darvocet.
F. DOSAGE:
Adults: 2 mg slow IV. IM, SQ or ET may also be used. Consider larger

dose with synthetic narcotic.
Pediatrics: 0.1 mg/kg slow I. IO, IM, SQ or ET may also be used.
G. HOW SUPPLIED:
Pre-filled syringe with 2 mg/2ml.
NEO-SYNEPHRINE
A. ACTIONS:
12-hour nasal decongestant. Causes vasoconstriction of superficial blood

vessels in the nasal mucosa, which decreases the possibility of bleeding.
B. INDICATIONS:
Used to minimize bleeding during nasotracheal intubation.
C. WARNINGS:
Do not exceed recommended dosage because untoward symptoms may

occur such as burning, stinging, sneezing, or increase of nasal discharge.
D. DOSAGE:
Adults and children 8 years of age and over: Spray two or three times in
each nostril.
NITROGLYCERIN SPRAY / TABLET
A. ACTIONS:
Nitroglycerin is a direct vasodilator which acts primarily on the venous

system, although it also produces direct coronary artery vasodilatation as a
result. There is a decrease in venous return which decreases the workload
on the heart and decreases myocardial oxygen demand. Sublingual
Nitroglycerin spray is preferred as it is more easily absorbed and bio-
available.
B. INDICATIONS:
1. Myocardial ischemia (angina).
2. Acute myocardial infarction.
2. Hypertensive crisis.
3. Pulmonary edema.
1. Known sensitivity to nitrates.
2. Increased intracranial pressure (ICP) from head trauma, hemorrhagic

CVA or other cerebral hemorrhage.
3. Hypotension.
4. Uncorrected hypovolemia.
5. Use of Viagra (Sildenafil Citrate) or other ED drugs within 24 hrs.
CNS – Headache, dizziness, pallor or flushing, sweating.
CV – Hypotension, reflex tachycardia.
GI – Nausea, and vomiting.
NITROGLYCERIN SPRAY / TABLET (cont.)
E. WARNINGS:
1. Use with caution in patients with the following conditions:

a. Pregnant or lactating.
b. Hepatic or renal disease.
c. Pericarditis
d. Postural hypotension.
2. Because of an easily developed tolerance, patients on chronic nitrate

therapy may require larger doses of nitroglycerin during acute anginal
episodes.
3. Nitro tablets are inactivated by light, air and moisture. Must be kept in
amber glass containers with tight-fitting lids. Do not leave cotton in
container.
4. Consumption of alcohol will accentuate vasodilatation and hypotensive

effects.
F. DOSAGE:
Adults: 1 tablet or 1 puff sublingually. May repeat q 5 minutes to a total of 3

doses if necessary. Hold spray canister upright, do not shake.
Note: Advise patient to open mouth and bring the canister as close as
possible, press button firmly with forefinger to release spray onto or under
tongue. Advise patient not to inhale spray. Tablet should be placed under
tongue.
Pediatrics: Not indicated.
G. HOW SUPPLIED:
Spray canister that dispenses 0.4 mg/metered dose per spray.
Bottles with 0.4 mg tabs.
PROCAINAMIDE (PRONESTYL)
A. ACTIONS:
Ventricular and supraventricular antiarrhythmic. Slows conduction through

myocardium, elevates ventricular fibrillation threshold, suppresses ventricular
ectopic activity.
B. INDICATIONS:
1. Recurrent V-Fib, pulseless V-Tach refractory to Lidocaine.
2. Stable, wide-complex tachycardia refractory to Lidocaine.
1. Complete AV block in the absence of an artificial pacemaker.
2. Patients hypersensitive to Procaine or other ester-type local anesthetics.
3. Digitalis toxicity.
CNS – Anxiety, nausea, convulsions (monitor for CNS toxicity).
CV – Hypotension. Widening of QRS.
E. WARNINGS:
Procainamide should be discontinued when/if any of the following occurs:
a. Dysrhythmia is suppressed.
b. QRS is widened by 50% of original width.
c. Hypotension ensues.
d. Total of 17 mg/kg has been given.
F. DOSAGE:
Adults: 20 mg/min slow IV/IO bolus until one of the above occurs. If
successful conversion of V-Tach occurs with bolus Procainamide, a
maintenance infusion of 1-4 mg/min. may be used. See Infusion Charts,
Page 7-0.
SODIUM BICARBONATE
A. ACTIONS:
An alkalizing agent used to buffer acids present in the body during and after
severe hypoxia. Bicarbonate combines with excess acids (usually lactic
acid) present in the body to form a weak, volatile acid. This acid is broken
down into CO2 and H2O. Sodium bicarbonate is effective only when
administered with adequate ventilation and oxygenation.
B. INDICATIONS:
1. Tricyclic antidepressant overdose with widening of the QRS to 0.10

seconds or longer.
2. Cardiac arrests associated with overdoses of tricyclic antidepressants or

Phenobarbital.
3. Dialysis patient in cardiac arrest due to suspected hyperkalemia.
When used for situations above, there are no absolute contraindications. In

the absence of the above situations, congestive heart failure and alkalotic
states are contraindications.
CV - Metabolic alkalosis, hypernatremia, sodium and H20 retention which

can cause CHF, hypotension, tachycardia.
CNS – Syncope, headache and flushing.
E. WARNINGS:
1. Excessive bicarbonate therapy inhibits the release of oxygen and may

result in alkalosis. Alkalosis is very difficult to reverse and may cause as
many problems in resuscitation as acidosis.
2. Sodium Bicarbonate does not improve the ability to defibrillate. The

most effective treatment for acidosis associated with cardiac arrest is
effective ventilation.
SODIUM BICARBONATE - (cont.)
E. WARNINGS (cont.):
3. May inactivate simultaneously administered catecholamines and will

precipitate if mixed with calcium chloride. Administration should be
guided by arterial blood gases and ph.
F. DOSAGE:
Adults: 1 mEq/kg (1 ml/kg) IV. Repeat with 0.5 meq/kg IV q 10 minutes.
Pediatrics: 1 mEq/kg (I ml/kg) IV. Repeat with 0.5 meq/kg IV q 10 minutes.
G. HOW SUPPLIED:
Pre-filled syringes containing 50 meq/50 ml (I mEq/ml).
SUCCINYLCHOLINE (ANECTINE)
A. ACTIONS:
Succinylcholine is a short-acting, depolarizing-type skeletal muscle relaxant.

It combines with the cholinergic receptors of the motor end plate to produce
depolarization. This depolarization may initially be observed as
fasciculations. Onset of flaccid paralysis with apnea is rapid (usually less
than one minute after IV administration), and with single administration lasts
approximately 4-6 minutes.
B. INDICATIONS:
Paralyzing agent to facilitate endotracheal intubation of primarily the

combative, head-injured patient. Other candidates for RSI may include:
1. Patients with potential or actual airway compromise due to depressed

LOC (GCS of 8 or less) or whose combativeness threatens the airway or
spinal cord.
2. Patients who demonstrate a very high probability of airway compromise

during transport (i.e. severe smoke inhalation injury).
3. Patients who need ventilatory assistance or airway protection.
1. Persons with personal or familial history of malignant hyperthermia.
2. Presence of neuromuscular disease (i.e. myasthenia gravis or multiple

sclerosis).
3. Severe burns or multiple trauma greater than 48 hours old.
4. Penetrating eye injury.
1. Adverse reactions to succinylcholine consist primarily of extensions of its

pharmacological actions. Profound muscle relaxation resulting in apnea
may be prolonged.
2. Increased intraocular pressure.
3. Muscle fasciculations.
SUCCINYLCHOLINE (ANECTINE) (cont.)
E. WARNINGS:
1. Succinylcholine should be administered with great caution to patients

suffering from electrolyte abnormalities and those who may have
massive digitalis toxicity, because in these circumstances,
Succinylcholine may induce serious cardiac arrythmias or cardiac arrest
due to hyperkalemia.
2. Succinylcholine is not a sedative! Do not administer to the patient who is

awake or partially awake. Sedate first with Morphine, Valium or
Etomidate.
F. DOSAGE:
2mg/kg , both adult and pediatric.
Contact with MEDICAL CONTROL required BEFORE administering

Succinylcholine!
G. HOW SUPPLIED:
200 mg/10 ml (20 mg/ml) multi-dose vials.
THIAMINE HYDROCHLORIDE
A. ACTIONS AND INDICATIONS:
1. Thiamine is indicated and is effective in the treatment of Wernicke’s

Encephalopathy. Wernicke’s Encephalopathy, also known as
Wernicke’s Syndrome is an inflammatory, hemorrhagic, degenerative
condition of the brain, characterized by lesions in several parts of the
brain. The condition is characterized by double vision, involuntary and
rapid movements of the eyes, lack of muscular coordination, and
decreased mental function, which may be mild or severe to the point of
unconsciousness. Wernicke’ s encephalopathy is caused by a Thiamine
deficiency and is seen in association with chronic alcoholism.
2. Thiamine is also effective in the treatment of beriberi (Thiamine

deficiency), whether of the dry (major symptoms related to the nervous
system) or wet (major symptoms related to the cardiovascular system)
variety.
B. CONTRAINDICATIONS:
History of sensitivity to thiamine or to any of the components of the drug.

Anaphylactic/allergic reactions are possible, but exceedingly rare.
C. DOSAGE:
100mg IV or IM.
D. HOW SUPPLIED:
100mg/2ml (50 mg/ml) vial.
E. ADDITIONAL:
Patients with marginal thiamine status (chronic alcoholic) to whom

dextrose is being administered should also be considered for
administration of IV or IM Thiamine.
(Vitamin B1) (Vitamin B1)
THIAMINE HYDROCHLORIDE (Vitamin B1)
VALIUM (DIAZEPAM)
A. ACTIONS:
Valium is a tranquilizer and is a member of the benzodiazepine family. It

depresses the limbic system, thalamus, and hypothalamus resulting in
calming effects. Valium produces an amnestic effect and is also an
anticonvulsant and skeletal muscle relaxant.
B. INDICATIONS:
1. Status epilepticus and generalized seizures.
2. Pre-medication prior to cardioversion or other painful procedures.
3. Acute anxiety states
1. Patient with acute alcohol intoxication.
2. Do not use in pregnant patient or in neonates.
CNS - Confusion, muscular weakness, blurred vision, drowsiness, respiratory

depression, respiratory arrest, slurred speech.
CV - Bradycardia, hypotension, cardiovascular collapse.
E. WARNINGS:
1. Do not mix Valium with any other solutions or drugs. When injecting IV,
administer slowly through the IV tubing as close as possible to the IV site
to prevent precipitation with the IV fluid.
2. Do not administer into small veins such as those on the dorsum of the
hand – may cause local irritation and possibly venous thrombosis in
small veins.
VALIUM (DIAZEPAM) (cont.)
F. DOSAGE:
Adults: 5-10 mg IV or IM. IV route should be administered slowly - no faster

than 5 mg/min. (acute anxiety if ordered by Medical Control – 2-5 mg).
Pediatrics: 0.2 mg/kg IV, not to exceed 10 mg. IV route should be

administered slowly no faster than 1 mg/min. May be administered rectally.
To administer Valium rectally, draw up 0.5 mg/kg of valium in tuberculin

syringe. Lubricate end of syringe (without needle) and insert into rectum past
sphincter, 4-5 cm (often done most easily with child prone).
G. HOW SUPPLIED:
Pre-filled syringes containing 10 mg/2ml (5 mg/ml).
ZEMURON (ROCURONIUM)
A. ACTIONS:
Zemuron (Rocuronium) is a non-depolarizing neuromuscular blocking agent

that acts by competing for cholinergic receptors at the motor end plate.
Onset of flaccid paralysis with apnea is rapid to intermediate at
approximately 1 minute with a duration of approximately 30 minutes.
B. INDICATIONS:
1. Paralyzing agent for prolonged paralysis during longer transports of the

patient that has already been intubated.
2. Per physician request only, may be used as an alternative for

Succinylcholine in Rapid Sequence Intubation.
1. Contraindicated in patients with a known hypersensitivity to the drug.
2. Zemuron will be contraindicated as an initial paralyzing agent in Rapid

Sequence Intubation in the patient who presents as a difficult oral
intubation. The drugs intermediate to long duration of 30 minutes or
more dictates the patient will require prolonged airway support.
Adverse reactions to Zemuron consist primarily of extensions of its

pharmacological actions (prolonged neuromuscular blockade).
E. WARNINGS:
Zemuron is not a sedative! Do not administer Zemuron to the patient who is

awake, partially awake or starting to awaken from the administration of
Succinylcholine. Sedate first with Morphine, Valium or Etomidate, then
administer Zemuron.
F. DOSAGE:
.6 mg/kg IV or IO, both adult and pediatric.
Contact with MEDICAL CONTROL required BEFORE administering

Zemuron!
ZEMURON (ROCURONIUM) (cont.)
G. HOW SUPPLIED:
50 mg/5 ml (10 mg/ml) multi-dose vial.
ZOFRAN (ONDANSETRON)
A. ACTIONS:
Antiemetic, the antiemetic properties of Zofran appear to be the result of it

being a selective blocking agent of the serotonin 5-HT3 receptor type.
Onset of action:
Intravenous - 5 min.
Intramuscular - 6-8 min.
Oral dose - TBA
Pharmacological effects persist for - 6 - 8 hrs.
B. INDICATIONS:
1. Patients experiencing significant nausea and/or vomiting during

transport.
2. To control nausea and vomiting in the patient that has had narcotic
analgesics administered to control pain.
Contraindicated in patients with a known hypersensitivity to the drug.
None.
E. WARNINGS:
None.
F. DOSAGE:
Adults: 4 mg IV/IM. 2nd dose of 4 mg may be administered after 15 minutes

if first dose ineffective.
Pediatrics .1 mg/kg to max of 4 mg.
G. HOW SUPPLIED:
4 mg/2 ml (2 mg/ml).
Infusion Charts
(Adult, Pediatric, Critical Care)
INFUSION CHARTS
Table 7.A. Dopamine Drip
Dose: 2 - 20 mcg/kg/minute
Preparation: 400 mg in 250 ml D5W Concentration: 1600 mcg/ml (pre-mix)
mcg/kg/ Patient weight in kg
min. 2.5 5 10 20 30 40 50 60 70 80 90 100
2 mcg * * * 1.5 2 3 4 5 5 6 7 8
5 mcg * 1 2 4 6 8 9 11 13 15 17 19
10 mcg 1 2 4 8 11 15 19 23 26 30 34 38
15 mcg 1.4 3 6 11 17 23 38 34 39 45 51 56
20 mcg 2 4 8 15 23 30 38 45 53 60 68 75
Microdrops per minute (also ml/hr)
Table 7.B. Epinephrine Drip
Dose: 1 - 10 mcg/minute.
Preparation: 1 mg in 250 ml D5W or NS Concentration: 4 mcg/ml
Epinephrine Drip
mcg/min 1 2 3 4 5 6 7 8 9 10
drops 15 30 45 60 75 90 105 120 135 150
Table 7.C. Lidocaine Drip
Dose: 1 - 4 mg/minute
Preparation: 1 gm in 250 ml D5W Concentration: 4 mg/ml (pre-mix)
Lidocaine Drip
mg/minute → 1 mg 2 mg 3 mg 4 mg
drops/minute (ml/hr)→ 15 30 45 60
INFUSION CHARTS (cont.)
Table 7.D. Procainamide Drip
Dose: 1 - 4 mcg/minute.
Preparation: 1 gm in 250 ml D5W Concentration: 4 mg/ml
Procainamide Drip
mg/minute → 1 mg 2 mg 3 mg 4 mg
drops/minute (ml/hr) → 15 30 45 60
Table 7.E. Pediatric Infusions
PEDIATRIC MEDICATION INFUSIONS

DOPAMINE (use 40 mg/ml solution) DOSE 2 – 20 µg/kg/minute. To mix: add 30 mg
(2.4 ml) to 250ml D5W. 1 microdrop /kg/minute of this solution = 5 mcg/kg/minute.
EPINEPHRINE (use 1:1000 solution, 1 mg/ml) DOSE: 0.1 – 1 mcg/kg/minute. To mix: add
1.5 mg (1.5 ml) to 250 ml D5W. 1 microdrop /kg/minute of this solution = 0.1 mcg/kg/minute.
LIDOCAINE Drip use 2% solution, 20 mg/ml) DOSE: 20–50 mcg/kg/minute. To mix: add 300
mg (15 ml) to 250 ml D5W. 1 microdrop /kg/minute of this solution = 20 mcg/kg/minute.
“Rule of 6” for Dopamine or Dobutamine infusions: 6 mg x wt in kg;
Add this amount to 100 ml. 1 ml/hr = 1 mcg/kg/minute.
“Rule of 6” for Epinephrine, Norepinephrine, or Isoproterenol infusions: 0.6 mg x wt in
kg; Add this amount to 100 ml. 1 ml/hr = 0.1 mcg/kg/minute.
INTERFACILITY TRANSPORT INFUSIONS
Table 7.F. Heparin Drip
µ drops/minute, or ml/hr
Mix 25,000 IU in 500 ml D5W (50 U/ml) & run at:
Heparin Drip
Patient weight 50 kg 60 kg 70 kg 80 kg 90 kg 100 kg
IV drip: 12 IU/kg/hr 12 gtt 14 gtt 17 gtt 19 gtt 20 gtt 20 gtt
Table 7.G. Nitroglycerin Drip
10 - 12 µ / minute.
Increase by 5 - 10 µg/minute q
¯¯ 5 minutes until desired effect.
Mix 25 mg in 250 ml D5W (100 µg/ml) & run at:
Dose in µgtts/minute Dose in µgtts/minute

(µg/min) (or ml/hr) (µg/min) (or ml/hr)
5 µg = 3 µgtts/min. 110 µg = 66 µgtts/min.
100 µg = 60 µgtts/min.
Note: use glass IV bottle and non-PVC IV tubing.

Rapid City (Pennington Co) (SD) Protocols (2008)

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Rapid City (Pennington Co) (SD) Protocols (2008)

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RAPID CITY

ADVANCED LIFE SUPPORT

These protocols are effective as of January 2007

RECEIPT OF PROTOCOL ACKNOWLEDGEMENT

Name (please print) Date

Rapid City Department of Fire and Emergency Services Paramedics

Section 1. contains the Patient Assessment Protocols.

Section 2. contains the Medical Treatment Protocols.

Section 3. contains the Trauma Treatment Protocols.

Section 4. contains the Environmental Injury Treatment Protocols.

I. Level I. treatment is an intervention that can performed without contacting

Section 5. contains the Procedure Protocols. The Procedure protocols where

Section 7. contains Drug Summaries. The Drug Summaries include a description of

Section 8. contains a full list of tables and illustrations.

Rapid City Department of Fire and Emergency Services Paramedics

Definitions .................................................................................................................... 1-1

2. Treatment Protocols - Medical

Protocol 2.11: Airway Obstruction ................................................................... 2-28

4. Treatment Protocols – Environmental Injury

8. Tables and Illustrations

Table 2.A. APGAR Score................................................................................. 2-16, 2-52

Illustration 3.A. Rule of Nines Chart .......................................................................... 3-15

8. Tables and Illustrations (Cont.) Page

Illustration 6.A. RCRH Controlled Drug Administration Record................................. 6-10

Table 7.A. Dopamine Drip......................................................................................... 7-70

Level I treatment is denoted by a Roman numeral I. It is defined as an

Level II treatment is denoted by a red Roman numeral II. It is defined as an

It is necessary to make a differentiation between neonatal, infant and adult

C. Pediatric and Adult:

The term “pediatric” is used in these protocols as a collective term, including

For medical purposes, differences between neonates, infants and children

A more subtle distinction, from a medical perspective, is made between

Thomas, CL (Ed.): Taber’s Cyclopedic Medical Dictionary, F.A. Davis

ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY

A. Recognize environmental hazards to rescuers, and secure area for

B. Recognize hazard to patient, and protect from further injury.

C. Identify number of patients. Initiate a triage system if appropriate.

D. Observe position of patient, mechanism of injury, surroundings.

E. Initiate communications if hospital resources require mobilization; call for

F. Identify self. Consider TRAUMA ALERT.

Note initial level of responsiveness (awake, verbal, pain, unresponsive).

1. Observe the mouth and upper airway for air movement.

1. Look for jugular venous distention and tracheal deviation.

a. Open or sucking chest wound - Seal.

5. Auscultate for crackles (wet sounds), wheezes, or decreased

ASSESSMENT-TRAUMA PATIENT PRIMARY SURVEY (cont.)

a. Radial pulse - systolic BP > 90

2. Check capillary refill time in fingertips: ≤ 2 sec is typically normal.

1. Reassess level (awake, responsive to voice or pain, no response).

ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY

Secondary survey is the systematic assessment of the entire patient. The

A. Initial Vital signs.

C. Head and Face:

1. Observe for deformities, asymmetry, bleeding.

1. Re-check for deformity or tenderness if not already immobilized.

1. Observe for wounds, symmetry of chest wall movement

ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).

3. Re-auscultate for crackles (wet sounds), wheezes, and decreased

1. Observe for wounds, bruising, distention.

1. Observe for angulation, protruding bone ends, symmetry.

1. Observe for angulation, protruding bone ends, symmetry.

1. If patient is stable, logroll, observe and palpate for wounds,

ASSESSMENT-TRAUMA PATIENT SECONDARY SURVEY (cont).