Professional Documents
Culture Documents
YAKIMA COUNTY
EMS SYSTEM
5110 Tieton Drive · Yakima WA 98908 · Phone (509) 966-5175 · Fax (509) 966-5176
(2) DISPATCH/COMMUNICATIONS
COP Interagency Radio Communications during Emergency Medical Incidents
COG Prehospital to Hospital Communications
Approved by
Juan Acosta, DO, MS, FACOEP, FACEP
Yakima County Medical Program Director
The Yakima County Prehospital Care Protocols for Basic, Intermediate and Advanced
Life Support represent a compilation of accepted national standards and a historical
perspective of prehospital care in Yakima County. They have been developed to ensure a
standard of prehospital care throughout Yakima County by providing treatment guidelines
for emergency medical service (EMS) providers certified under the scope of authority of
the Yakima County Medical Program Director (MPD). They include those protocols
necessary for EMS personnel certified as First Responders, EMT-B Technicians, EMT-IV
Technicians, EMT-Airway Technicians, EMT-IV/Airway Technicians, EMT-Intermediates
w/King Airway, Combitube, LMA and EMT-Intermediates w/Endotracheal, and EMT-
Paramedics.
EMS personnel are expected to commit the protocols to memory, and have thorough
knowledge and understanding of each of the procedures and assorted pharmacological
interventions. This document does not incorporate all conditions that may be encountered
in the field. For situations not addressed in the protocols, prehospital providers should
perform procedures in accordance with their level of training and currently accepted
Washington State standards, or consult with the on-duty emergency physician at the
designated medical control facility.
Each protocol includes the certification level (FR, EMT-B, EMT-I, EMT-P) for which it is
approved. Throughout the protocols, procedures requiring on-line medical control are
preceded with the phrase “verbal order", which is in BOLD/ITALICS. These procedures
can only be done after consultation and approval of the physician at the facility that will
receive the patient, or the on-duty physician at the designated medical control facility.
All other protocols are considered standing orders (off-line medical control), do not
require a verbal order, and should be performed by all levels of training. Protocols that
require the skill level of the First Responder are typed in black. The protocols that require
the skill level of the EMT-Basic are typed in blue. The protocols that require the skill level
of the EMT-Intermediate are typed in green. If an individual is ILS certified the protocols
should be followed to their level of certification (i.e., IV, Airway, IV/Airway, and EMT-I).
The protocols that require the skill level of the EMT-Paramedic are typed in red.
1. When a competent adult refuses treatment, you must inform the patient of
the risks and consequences involved in refusing care, and be sure the
patient understands you.
2. After you have explained, and are assured that they fully understand the
risks and consequences, you must have the patient sign a "release from
liability" form.
3. If the patient refuses to sign the form, obtain a witness signature of refusal to
sign.
D. See the "Behavioral Emergencies" protocol regarding the use of force in treating a
mentally incompetent patient.
F. We recommend that an EMS provider give honest insight into his/her judgment of
the patients’ condition when asked, however, avoid giving medical “advice” or
“direction” in regard to what medications the patient should or should not take or
home remedy recommendations.
D. EMS personnel who fail to report, or cause failure of a report to be made, shall be
guilty of a gross misdemeanor (in accordance with RCW 26.44.080).
E. On the medical incident report, document known facts only. Include the name of
the law enforcement personnel and agency contacted, along with the date and
time notified.
C. Do not use any of the following restraining techniques that could impair
breathing.
1. "Hog tying," where hands and feet are bound behind the patient.
D. After a patient is under control, use humane techniques to restrain the patient.
Behavioral Emergencies
F. EMT-B – If a patient is still in handcuffs, a police officer must accompany the
patient during transport or remove the handcuffs.
1. Decapitation.
3. Incineration.
4. Rigor mortis.
5. Decomposition.
6. Lividity.
B. For patients who don't meet the criteria in "A," begin initial patient assessment
and resuscitative procedures per normal protocols. Proceed until an EMS-No
CPR form or bracelet is found or Physician Orders for Life-Sustaining Treatment
(POLST) or an advanced directive, living will or DNR order signed by the patient’s
physician is confirmed.
2. If any of the above documents are found and believed to be current and
expressing the patient’s wishes, stop resuscitation.
D. Notify local law enforcement (at least one EMS provider should remain at the
scene until an officer arrives).
Do Not Resuscitate
E. The following individuals can revoke an advanced directive, DNR order, or
EMS- No CPR form or bracelet or POLST form:
1. The patient (by destroying the form, bracelet, or advanced directive).
2. Attending physician.
3. Health care power of attorney.
G. For those patients suffering from a terminal illness who have not reached the
point of cardiac and/or pulmonary arrest, and cannot expect to realize any long-
term benefit from prehospital care, and who have a written DNR order, advanced
directive, or EMS-No CPR form or bracelet or POLST form:
1. Do not perform the following measures (if any of the measures have begun
and valid documentation is produced, the measure(s) should be
discontinued):
a. Cardiopulmonary resuscitation.
b. Endotracheal intubation (leave ET tube in place, but discontinue
ventilation).
c. Defibrillation.
d. Administration of resuscitative medications.
e. Positive-pressure ventilation.
2. The following may be done:
a. Position of comfort.
b. Airway control and suction.
c. IV, IV/Airway, EMT-I, EMT-P – IV line for hydration and/or
analgesics.
d. Oxygen for dyspnea.
H. Clinical judgment and consultation with the patient, patient's family, the patient's
physician, or the on-duty physician at the Medical Control Facility, should
determine what procedures to perform.
J. In the event that a patient expires after life sustaining measures and transport
began the transporting agency will notify the emergency department, preferably
the Charge Nurse, of the situation and continue transport to the hospital.
K. In any case that is questionable, proceed with appropriate protocols, and consult
with the Medial Control Facility physician.
Unlike other forms of penetrating foreign bodies, taser barbed darts because of their shot
length (1/4”) may be safely removed by EMS personnel when requested by law
enforcement. The darts should only be removed in the field if they do not involve the eye,
face, neck, breast, or groin. Patients with retained darts in these areas should be
transported to a hospital for removal by a physician.
B. Ensure that wires are disconnected from the gun or the wires have been cut.
C. Push on the body part that the barbed dart (straight #8 fish hook) is imbedded
and simultaneously pull the dart straight out.
D. Apply alcohol or iodine to the puncture area and dress the wound with a Band- Aid
or other sterile dressing. Inform the patient and police that this may be removed in
24-48 hours.
G. EMT-P – Patient must be placed on a 4-lead cardiac EKG to check for irregular
heart rates. A strip must be run and attached to patient care report.
H. Patient must have a heart rate of <110 bpm, respiratory rate >12, O2 saturation
>94%, systolic blood pressure >100mmHg and <180mmHg.
2. Hypoglycemia
K. Patient has had tetanus booster in last ten years. If tetanus status is unknown, the
patient may be taken to the hospital by police if all other treat and release criteria
are met. (Police are to be informed that it is the responsibility of the police service
to ensure that the patient receives a tetanus booster within 72 hours. This advice
must be documented on the patient care report.)
L. Ask the patient if they would like to be taken to the hospital. If the patient refuses,
document the patient’s refusal as per refusal protocol. If the patient wishes to be
transported to the hospital, transport is to be initiated.
If the patient refuses transport, instruct the patient to seek medical attention
immediately, if he/she develops any signs of infection around one or more of the
wounds (fever, increased pain, redness, heat, swelling, purulent discharge).
Introduction
The following protocols are for use by FR, EMT-B, EMT-I, and EMT-P providers. If an
individual is ILS certified the protocols should be followed to their level of certification
(i.e., IV, Airway, IV/Airway, and EMT-I). In some cases, a protocol will be level specific,
which will be preceded by the level in bold.
A. Conduct scene size-up, scene safety, BSI, and develop action plan.
A. If patient has good gag reflex and adequate respiratory drive, maintain airway
and administer oxygen.
B. Administer oxygen.
F. Verbal Order – If patient has no relief from the epinephrine and has a dual-dose
injector, contact medical control, or receiving hospital for further direction.
A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than
90%.
1. Consider epinephrine, 1:1000, 0.3 – 0.5 mg, IM. Pediatric dose is 0.01 –
0.02 mg/kg, IM.
A. If patient has good gag reflex and adequate respiratory drive, maintain airway
and administer oxygen.
E. EMT-B – If patient has sign and symptoms consistent with a CVA transport
immediately and notify the receiving facility while enroute. You must include
the following information in your radio report and in your MIR narrative:
1. Face: Is it symmetrical? YES or NO
2. Arm: Symmetrical strength? YES or NO
3. Speech: Is it slurred or abnormal? YES or NO
4. Time: What time was the patient last known to be normal?
5. Is the patient on Coumadin (Warfarin)?
6. Glucometry: Glucose should be over 60. (Severe hypoglycemia can
present like a stroke).
7. Glascow Coma Scale: See Appendix G.
E. IV, IV/Airway, EMT-I – Establish peripheral IV with saline lock or TKO NaCl.
B. Instruct patient to blow their nose to expel any clots that may have formed in the
nasal cavity.
C. Using thumb and index finger apply direct pressure to non-bony part of nose for
5 - 10 minutes or until bleeding has stopped.
B. IV, IV/Airway, EMT-I – Consider large bore IV for severe and persistent
bleeding.
A. If patient has a known history of hypoglycemia, a good gag reflex and adequate
respiratory drive, maintain airway and administer oxygen.
EMT-B Optional
1. If the patient has an altered mental status of unknown origin, or has a
history of diabetes and could have an abnormal glucose level, then a
glucose check should be performed.
3. Utilizing universal precautions, the patient has a stick performed and the
blood is tested in the glucometer.
5. If the glucose level is below 80, the patient is awake and has an intact gag
reflex, administer oral glucose.
B. EMT-B – If patient is conscious with a gag and has the ability to swallow,
administer oral glucose or a large amount of (some type of) sugar solution.
F. If alert and competent, patient has the option of transport; thoroughly document
refusal.
B. Administer oxygen and using pulse oximetry, titrate saturation to greater than
90%.
G. IV, IV/Airway, EMT-I – Establish large-bore IV with NaCl, and fluid challenge in
200 mL increments to patient’s BP and clinical findings, up to a total of 1000 mL.
H. IV, IV/Airway, EMT-I – If no improvement with first IV, and no signs of CHF,
establish second large-bore IV with NaCl, and run both as approximately 200 mL
per 5 minutes, up to 2000 mL, or as clinical situation dictates.
EMT-P
A. Determine:
1. Date of expected birth.
2. Onset of contractions/pain.
3. Any bleeding or discharge.
4. Number of pregnancies/births.
5. Duration and frequency of contractions.
2. Have mother lie supine with knees drawn up and spread apart.
4. Prepare OB kit.
5. When the infant’s head appears during crowning, place fingers on bony
part of skull and exert very gentle pressure to prevent explosive delivery.
6. When the head is delivered, suction infant’s nose and mouth with a bulb
syringe. Do not let mother “push” or “bear down” until airway is suctioned.
e. Keep infant level with the vagina until the cord is cut.
10. Estimate time of delivery and blood loss. Treat for shock as necessary.
C. There are three situations where you do not attempt delivery in the field.
1. Prolapsed cord (cord presents through the birth canal before delivery).
a. Place mother in knee-chest position.
2. Limb presentation (an arm or leg is first to protrude from the birth canal).
D. Place patient on left lateral side or position of comfort – except as noted above.
F. EMT-B – If transport time from the scene to Yakima is less than 30 minutes,
transport all third-trimester pregnancy complications, traumas, or premature births
to Yakima Valley Memorial Hospital.
G. For those patients who suffer cardiopulmonary arrest, who are in the third
trimester of pregnancy, full resuscitative measures should be continued, even if it
is obvious that the mother will not survive.
E. If a multiparous patient, and contractions < 2 minutes apart, and transport time
> 15 minutes, prepare to deliver.
1. When infant’s head begins to emerge, support it gently, to prevent
explosive delivery.
C. Administer oxygen.
D. Obtain history.
E. If pediatric patient and temperature > 100 degrees, consider possibility of febrile
seizure. Remove heavy clothing.
A. Administer oxygen and using pulse oximetry, titrate Saturation to greater than
90%.
D. If a grand mal seizure that terminates spontaneously and patient has a history of
previous seizures with ongoing medical management of those seizures, and the
clinical situation dictates – patient has the option of not being transported to the
hospital. If patient is alert, thoroughly document refusal.
B. Gather all containers, bottles, labels, and etcetera, of poisonous agents for
transport with patient to the hospital.
3. Keep limb immobilized below the heart and apply a cold pack (notice).
4. If a snake bite, restrict patient’s movement (do not apply cold pack).
B. EMT-B – Notify Medical Control Facility physician that you are transporting a
patient contaminated with hazardous materials and DO NOT bring patient into the
emergency department until told to do so by the emergency physician or qualified
hospital staff.
D. Administer oxygen and using pulse oximetry, titrate Saturation to greater than
90%.
H. EMT-P – Verbal order – Administer atropine, 2.0 mg, IV, repeat doses
2 – 10 mg every 5 – 15 minutes for copious secretions, altered mental status, or
cardiac dysrhythmias.
A. EMT-B – If patient has a good gag reflex and adequate respiratory drive,
administer oxygen, and using pulse oximetry, titrate Saturation to greater than
90%.
B. Administer oxygen.
A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than
90%.
C. EMT-I – Consider albuterol, 2.5 mg in 2.5 cc NaCl, per nebulizer mask or ET;
repeat immediately if indicated clinically.
D. IV, IV/Airway, EMT-I – Consider peripheral IV with NaCl and administer 100 mL
fluid bolus.
B. Administer oxygen and using pulse oximetry, titrate saturation to greater than
90%.
E. EMT-I – Administer albuterol, 2.5 mg in 2.5 cc NaCl per nebulizer mask, repeat
immediately if clinically indicated.
A. Administer oxygen and using pulse oximetry, titrate saturation to greater than
90%.
B. If there is complete foreign body obstruction, first perform basic life support
procedures for removal.
If a biphasic defibrillator is used, the energy level should be set in accordance with
the manufacturer’s recommendation for defibrillation and cardioversion or as listed
below.
A. If patient has known cardiac history, is suffering from chest pain, has a systolic
blood pressure at least 100, and has his/her own physician prescribed
nitroglycerin (spray or tablet), the EMS provider may:
C. Notify receiving hospital immediately that you are transporting an acute MI patient
who will need emergent cardiac catheterization. If possible, transmit EKG to
hospital.
G. EMT-I – Blood tubes for NSTEMI and STEMI patients shall be drawn in the
following order: Blue, Green, Purple, and Red.
Lower Valley Acute MI – Perform 12-lead ECG and read for MI as listed above. If ECG
is diagnostic of MI, and patient has already requested transport to a Yakima hospital, then
proceed as above. If patient initially requested transport to a Lower Valley hospital, advise
patient of the following:
A. ”Your ECG shows that you are having a myocardial infarction, commonly known
as a heart attack. This occurs because of a blocked artery going to your heart.
The main treatment for an MI is opening this blockage either with medications or
with a procedure called angioplasty, where a wire is put in the artery to open the
blockage. Current medical studies show that angioplasty carries less risk of
bleeding complications and has better short-term results in preventing death and
heart muscle damage. Angioplasty is currently available only at Yakima hospitals.
You have the choice of continuing transport to a Lower Valley hospital or-if you
wish to have emergency angioplasty performed-being transported to a Yakima
hospital of your choice.”
The patient should then be transported to the hospital they choose. If this is a
Yakima hospital, then proceed as above.
B. If the patient has unstable vital signs, altered mental status or airway or respiratory
compromise, he/she should be transported to the closest appropriate hospital.
A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than
90%.
D. If pain unrelieved by NTG, and BP> 100 mmHg systolic, administer Morphine,
4 mg IV. Subsequent doses to be given in 2 mg increments, until pain is relieved
or hypotension occurs, up to a total of 10.0 mg.
1. Should hypotension occur, consider fluid challenge.
2. If allergic to morphine, administer Fentanyl, 50 micrograms IV.
3. Subsequent doses of Fentanyl at 50 micrograms, up to a total of 500
micrograms.
4. If nauseated after analgesic, administer Anzemet 12.5mg IV bolus, or
Zofran 4mg IV bolus over 2-5 min, or Zofran 4mg ODT (if unable to obtain
an IV).
a. A repeat dose of Zofran 4mg ODT or IV may be given.
F. For prolonged transport, consider nitro paste 1”. Remove for systolic blood
pressure less than 100.
G. It is recommended that providers work toward a patient who is free from pain. If
pain is not relieved it is recommended that an attempt be made to transport the
patient straight to a facility with catheterization capability and into the cath. lab
directly when possible.
H. EMT-I – Blood tubes for NSTEMI and STEMI patients shall be drawn in the
following order: Blue, Green, Purple, and Red.
A. Administer oxygen and using pulse oximetry, titrate Saturations to greater than
90%.
ATRIAL FIBRILLATION/FLUTTER
EMT-P
A. If patient unstable with serious signs and symptoms (e.g., chest pain, shortness
of breath, decreased level of consciousness, low BP, shock, pulmonary
congestion, CHF, acute MI):
A. If ECG shows 2nd degree AV block, 3rd degree block, junctional rhythm, or
bradycardia, with a heart rate < 60 per minute, and patient is symptomatic (e.g.,
chest pain, shortness of breath, decreased level of consciousness, low BP,
shock, pulmonary congestion, CHF, acute MI)—administer atropine,
0.5, IV bolus, repeat 0.5 mg every 3-5 minutes, up to a total of 3.0 mg.
B. Initiate external cardiac pacing. Discuss the need for sedation and analgesia.
CARDIOGENIC SHOCK
EMT-I & EMT-P
B. Administer oxygen and using pulse oximetry, titrate Saturations to greater than
90%.
E. IV, IV/Airway, EMT-I – Establish large-bore IV with NaCl and administer fluid
challenge of 200 mL. Do not administer fluid challenge if patient displays signs
and symptoms of pulmonary edema.
A. If patient is unstable with serious signs and symptoms (e.g., chest pain, shortness
of breath, decreased level of consciousness, low BP, shock, pulmonary
congestion, CHF, acute MI):
1. Initiate synchronized cardioversion @ 50 J, biphasic defibrillation @ 100 J.
If patient is conscious, systolic BP > 90 mm Hg and no significant delay would
result; consider midazolam, 2.0 – 10.0 mg, slow IV push.
B. If patient is stable:
2. Have patient perform Valsalva maneuver (deep breath & hold). A carotid
massage may be performed in patients less than 40 years old, to one side
of neck only.
B. In the unstable patient with serious signs and symptoms (e.g., chest pain,
shortness of breath, decreased level of consciousness, low BP, shock, pulmonary
congestion, CHF, acute MI):
D. Initiate CPR and ventilate per pocket mask or BVM with supplemental oxygen at
15 L/min. or by OPVD.
I. Perform resuscitation efforts until patient is breathing and has a pulse, care is
released to a higher authority, or you become too exhausted to continue. If
prolonged time in the field, contact Medical Control for advice.
E. Administer atropine, 1.0 mg, IV (2.0 mg if administered ET), may repeat q 3-5
minutes, up to a maximum of 3.0 mg.
C. If rate < 60/minute, administer atropine, 1.0 mg, IV (2.0 mg if administered ET)
bolus. May repeat q 3-5 minutes, up to 3.0 mg.
1. Attach AED, after 2 minutes and analyze. If shock is indicated, shock once
@ 360 J. Biphasic defibrillation @ 200 J.
EMT-P
B. EMT-P – Verbal Order – Consult with Medical Control Facility for patients that
have not responded to an initial cycle of advanced cardiac life support in
accordance with protocols.
Introduction
The following protocols are not intended to encompass all traumatic incidents the EMS
provider may encounter in the field, but to provide general guidelines for the often-
encountered trauma case.
Rapid transport should be initiated within 10 minutes of arriving at the scene, unless
extenuating circumstances exist (e.g., prolonged extrication, difficult access, multiple-
casualty incident).
Protocols that require the skill level of the First Responder are typed in black. The
protocols that require the skill level of the EMT-Basic are typed in blue. The protocols
that require the skill level of the EMT-Intermediate are typed in green. If an individual is
ILS certified the protocols should be followed to their level of certification (i.e., IV, Airway,
IV/Airway, EMT-I). The protocols that require the skill level of the EMT-Paramedic are
typed in red. In some cases, a protocol will be level specific, which will be preceded by
the level in bold.
A. Conduct scene size-up, scene safety, BSI, and develop action plan.
6. If available, use pulse oximetry and record result, and then administer
oxygen at 15 L/min per non-rebreather mask (NRB) when indicated.
Oxygen by nasal cannula may be used if patient unable to tolerate a mask.
C. IV, Airway, IV/Airway, EMT-I – Administer oxygen and using pulse oximetry,
titrate Saturation to greater than 90%. If pulse oximetry is not available, give
oxygen when indicated by mask or cannula.
6. Contact the transporting agency with patient’s condition, vital signs, and
care rendered.
Conduct scene size-up, scene safety, BSI, and develop action plan.
The first certified EMS provider (or agency) on-scene will determine whether a patient(s)
meets the trauma triage criteria by using the State of Washington Prehospital
Trauma Triage (Destination) Procedures (WSPTTP), refer to Appendix D.
In the event that there is more than one person that qualifies as a Trauma Alert patient the
first arriving paramedic unit will remain on-scene.
In the event that there is more than one EMS transporting agency responding, utilize
OSCCR frequency for inter-ambulance communications regarding, for example, a Trauma
Alert patient’s location, transport destination, or to give a short report. (For larger
incidents, radio frequencies will be determined by the on-scene Incident Command.)
2. Radio contact with the designated trauma facility will be preceded with the
phrase: “This is a Trauma Alert.”
1. Mechanism of injury.
2. Total number of patients’ and the number that qualify as Trauma Alerts.
3. Using Appendix D state how each patient qualifies as a Trauma Alert (i.e.
patient #1 has a penetrating injury to the chest; patient #2 was ejected and
is unresponsive).
4. Later radio reports refer to County Operating Procedures.
If time permits proceed with the following care (acceptable delay exists i.e.,
extended extrication time).
G. The on-scene paramedic unit will advise the second arriving transport unit of its
transport destination be it the Trauma Center for Yakima County, a landing zone
for air transport, the closest Trauma Center by ground transport or the facility
recommended by the Trauma Center that was contacted.
H. While en route to the hospital, the transporting agency must provide a complete
patient status report, via radio or other means, to the receiving trauma facility.
I. In Upper Yakima County (and in Lower Yakima County, if transport time from the
scene to Yakima would be 30 minutes or less, despite the proximity to SCH or
TCH), for the conditions described below, patient destination should be as
follows:
1. Pregnant patients – Yakima Valley Memorial Hospital
2. Pediatric patients less than the age of 10 years – Yakima Valley Memorial
Hospital
3. Hemodynamically stable patients with a severe head injury and a Glasgow
Coma Score of 13 or below – either Yakima Regional Medical Center or
Yakima Valley Memorial Hospital per rotation.
2010 Yakima County
Prehospital Care Protocols
Updated July 2010 Trauma Alert(s)
ABDOMINAL TRAUMA
FR, EMT-B, EMT-I & EMT-P
A. If patient has an evisceration, cover the exposed abdominal organs with saline or
sterile water-soaked dressings.
B. Administer oxygen.
C. Remove patient from a hazardous environment and remove constricting items and
smoldering or non-adherent clothing.
E. Determine the location, extent and depth of burns, and any associated trauma or
complications.
F. Cover minor burns with sterile dressings moistened with normal saline, and
consider cooling if painful.
G. Cover moderate to severe burns with dry sterile dressings. Clean non-sterile
sheets may be used for large BSA.
H. If hands or feet are involved, separate digits with sterile gauze pads.
J. If chemical burns, brush off any dry chemicals and irrigate appropriately.
K. Obtain history to include: mechanism or source of burn; time elapsed since burn;
whether patient was in a confined space with smoke or steam, and how long; and
whether there was a loss of consciousness.
B. Obtain history to include: mechanism or source of burn; time elapsed since burn;
whether patient was in a confined space with smoke or steam, and how long; and
whether there was a loss of consciousness.
EMT-P
H. If there is a chemical burn with hydrofluoric acid (HF), cover with gauze dressing
saturated with calcium gluconate.
I. If patient’s hand is burned with HF, fill a glove with calcium gluconate, place the
burned hand in the glove and tape to wrist.
B. Administer oxygen.
A. Administer oxygen and using pulse oximetry, titrate Saturation to greater than
90%.
B. EMT-P – Place endotracheal tube when indicated. Watch for signs of tension
pneumothorax.
G. If present, stabilize flail chest segment with a pillow splint or other appropriate
splinting device.
5. Insert the needle above the third rib, into the second intercostal space, until
a “pop” is heard.
6. Advance the catheter an additional 1 – 2 cm, and withdraw the needle (or
as recommended by the manufacturer, if using a commercial device).
6. NO distracting injury.
2. Apply appropriate sized cervical collar, consider short board vs. long
backboard, secure to the board with straps, and immobilize head to board
using a head immobilizer.
D. In the event that standard c-collar sizes are not appropriate for your patient(s)
the following may be utilized:
E. DO NOT place a towel around the patient’s neck, as this does not provide
adequate c-spine immobilization.
B. Administer oxygen.
D. If patient has good gag reflex and adequate respiratory drive, maintain airway
and oxygen.
A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than
90%.
3. If a pediatric patient:
a. Administer lidocaine, 1 mg/kg IV.
b. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.5 mg
(minimum of 0.1 mg).
c. Administer etomidate 0.3 mg/kg per IV push.
d. Administer succinylcholine, 1.5 mg/kg IV.
2010 Yakima County
Prehospital Care Protocols
Updated July 2010
Head Trauma
E. If patient has signs/symptoms of hypovolemia secondary to other trauma – treat
shock as per protocols.
C. Administer oxygen.
A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than
90%.
A. Assess pulses, motor function, and sensation before and after immobilization.
B. Consider alignment with gentle traction if distal pulses are absent or gross
deformity is noted.
F. EMT-B – Immobilize mid-shaft femur fractures using a traction splint (Apply the
splint whether an open or closed fracture.) If a pelvic fracture exists, do not
apply the traction splint, immobilize patient to a long-spine board.
A. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than
90%.
B. Control hemorrhaging.
COLD EMERGENCIES
FR, EMT-B, EMT-I & EMT-P
A. Remove patient from inclement environment, move to a warm place, and remove
wet clothing.
B. Handle patient with care, and wrap in blankets to prevent further heat loss.
C. Apply heat packs to the neck, groin, and armpits and attempt to re-warm.
HEAT EMERGENCIES
FR, EMT-B, EMT-I & EMT-P
A. Remove patient from hot environment, move to a cool place and loosen or
remove clothing.
D. EMT-B – If patient is unconscious with pulses, place on left side and transport
immediately.
B. Contact medical control physician with age of victim, time in water and
temperature of the water, to determine the need for rescue vs. body recovery.
D. If no spinal injury is suspected, remove patient from the water, place patient on
left side and allow water, vomitus and secretions to drain from the upper airway.
E. If patient has good gag reflex and adequate respiratory drive, maintain airway
and administer oxygen.
EMT-P
CARDIOPULMONARY ARREST
FR, EMT-B, EMT-I & EMT-P
INITIAL RESUSCITATION
A. Establish and maintain airway.
H. IV, IV/Airway, EMT-I – If peripheral route is not obtained within two attempts or
90 seconds (whichever comes first), attempt intraosseous (IO) route, using the
Vidacare™ EZ-IO™.
I. EMT-P – Place an endotracheal tube and continue ventilations with pediatric bag-
valve-device.
5. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.1 – 0.5 mg, IV,
ET, or Vidacare EZ-IO™ (double dose for ET route).
A. In PEA, identify and treat the following causes: severe hypoxemia, severe
acidosis, severe hypovolemia, tension pneumothorax, cardiac tamponade,
profound hypothermia.
D. Second, and subsequent doses of epinephrine, 1:1000, 0.1 ml/kg, IV, Vidacare
EZ-IO™, or ET, q 3 minutes.
E. Administer atropine, 0.02 mg/kg IV, up to a maximum of 0.1 – 0.5 mg, IV, ET, or
Vidacare EZ-IO™ (double dose for ET route).
B. Administer oxygen and, using pulse oximetry, titrate Saturation to greater than
90%. If mask is not tolerated, administer blow-by oxygen.
C. EMT-I – In severe asthma, administer dose via mask. Doses may be repeated
immediately.
CROUP/EPIGLOTTITIS
EMT-B, EMT-I & EMT-P
E. EMT-P – If BVM unsuccessful, place ET tube using one size smaller than normal
for his/her age.
F. EMT-I – Check blood glucose. If low, administer D25W, 0.5 – 1.0 g/kg.
SUPRAGLOTTIC AIRWAYS
1. Cardiopulmonary arrest.
a. In cardiopulmonary arrest the King LT(S) – D Airway may be used
as the primary airway.
i. Assess ABCs, defibrillation, when indicated, takes precedence over
placement of the King LT(S)-D airway.
ii. Begin chest compression and do not interrupt compressions for
placement of the King LT(S)-D airway.
iii. Follow the Cardiopulmonary Arrest protocol.
2. Respiratory arrest.
B. Airway protection in critical patients with a loss of protective gag reflex when
access to endotracheal intubation is not available.
D. EMT-B - Determining patient's height, choose the correct KING LT(S)-D size.
E. EMT-I & EMT-P – Determining patient’s height for patients less than 4 feet in
height:
H. Test the cuff inflation system by injecting the maximum recommended volume of
air into the cuffs. Remove all air from cuffs prior to insertion.
1. Refer to Sizing Information chart for the maximum recommended volume of
air.
I. Apply a water-based lubricant to the beveled distal tip and posterior aspect of the
tube, taking care to avoid introduction of lubricant in or near the ventilatory
openings.
J. Have a spare KING LT(S)-D ready and prepared for immediate use.
L. Position the patient’s head. The ideal head position for insertion of the
KING LT(S)-D is the “sniffing position”.
1. However, the angle and shortness of the tube also allows it be inserted with
the head in a neutral position.
M. Hold the KING LT(S)-D at the connector with dominant hand. With non-dominant
hand hold mouth open and apply chin lift unless contraindicated by C-spine
precautions or patient position.
N. With the KING LT(S)-D rotated laterally 45-90° such that the blue orientation line
is touching the corner of the mouth, introduce tip into mouth and advance behind
base of tongue.
1. Never force the tube into position.
O. As tube tip passes under tongue, rotate tube back to midline (blue orientation line
faces chin).
P. Without exerting excessive force, advance KING LT(S)-D until base of connector
aligns with teeth or gums.
Q. Fully inflate cuffs using the maximum volume of the syringe included in the kit.
1. For KING LT(S)-D typical inflation volumes see Sizing Information chart.
U. Secure KING LT(S)-D to patient using tape or other accepted means. A bite block
can also be used, if desired.
V. EMT-P – KING LTS-D ONLY – The gastric access lumen allows the insertion of
up to an 18 Fr diameter gastric tube into the esophagus and stomach. Lubricate
gastric tube prior to insertion.
5. Assure that patient's airway is patent and respirations are adequate, and
assist ventilations as necessary.
2. Respiratory arrest
3. Airway protection in critical patients with a loss of protective gag reflex when
access to endotracheal intubation is not available.
B. If vomitus, blood or other foreign material is present in the hypopharynx, rapid and
aggressive suctioning and/or manual removal must be done prior to attempting
intubation with the LMA Supreme™ Airway.
D. Determining patient’s weight, choose the correct LMA Supreme™ Airway size.
1. Adults below 70 kg or 160 pounds size 4
2. Adults above 70 kg or 160 pounds size 5
3. EMT-P – Children 30 – 50 kg or 66 – 110 pounds size 3
E. The LMA Supreme™ airway may be inserted with the patient in virtually any
position.
8. Without holding the LMA Supreme©, inflate the cuff with just enough air to
achieve a seal.
a. A small outward movement is sometimes noticed as the device
seats itself.
9. Use the fixation tab to secure the LMA Supreme© to the patient’s face with
tape or an approved airway fixation device.
H. If patient regains consciousness and/or gag reflex and/or begins to fight the tube,
restrain if necessary, and immediately remove the LMA Supreme™ Airway as
follows:
1. Turn patient on his/her side.
2. Completely deflate cuff.
3. Gently remove the LMA Supreme™ Airway.
4. Be prepared for the patient to vomit, and suction as needed.
5. Assure that the patient’s airway is patent and respirations are adequate.
a. Assist ventilations as necessary.
6. Administer oxygen at 15 L/min per non-rebreather mask.
E. Apply a water-soluble lubricant to the distal shaft of the tube and insert ETC into
the mouth and direct it along the midline. Advance gently until the teeth (or gums)
are aligned between the two black rings on the tube.
F. For patients greater than 5 feet in height, use the regular adult size ETC as
follows:
1. Using the large syringe, inflate Line 1 through the pilot balloon with 100 mL
of air.
2. Using the small syringe, inflate Line 2 through the pilot balloon with 15 mL
of air.
G. For patients between 4 feet and 5 feet in height, use the small adult (SA) size ETC
as follows:
1. Using the large syringe, inflate Line 1 through the pilot balloon with 85 mL of
air.
2. Using the small syringe, inflate Line 2 through the pilot balloon with 12 mL of
air.
I. Using a stethoscope, listen for lung sounds in both lateral lung fields and over the
epigastrium.
1. If lung sounds are present and there are no gastric sounds, continue
ventilations.
2. If lung sounds are absent and gastric sounds are present, tracheal
placement may have been accomplished.
a. Remove the bag-valve-device or OPVD from Tube No. 1 and
continue ventilations through Tube No. 2.
K. If unsuccessful after the second attempt to insert the ETC, discontinue the
procedure and continue ventilations using an alternative method.
L. If esophageal intubation has occurred, consider attaching the mask elbow to Tube
Number 2 to deflect the potential flow of stomach contents.
2. Deflate both the pharyngeal and esophageal cuffs through Lines 1 and 2.
5. Assure that patient's airway is patent and respirations are adequate, and
assist ventilations as necessary.
3. After the endotracheal tube has been successfully placed, deflate the
esophageal cuff through line 2 and gently remove the ETC.
2. Airway obstruction.
Q. Before releasing a patient, with an ETC in place, to another level of care (e.g.,
emergency physician, nurse, paramedic), the EMT performing the procedure
must be certain that the receiving person is knowledgeable about the proper use
and function of the device, and is aware that it is in place.
R. In the event an ETC has been placed, and the ambulance that will transport the
patient is not staffed with personnel trained to use the device, then the EMT who
performed the procedure will remain with the patient throughout transport, or until
personnel with an equal or higher level of certification can assume patient care.
3. Deflate the pharyngeal cuff through Line 1 and move the tube to the left
side of the patient's mouth.
5. After correct placement of the ET tube has been confirmed, deflate the
distal cuff of the ETC through Line 2, and gently remove it.
The following is meant to provide a general protocol for endotracheal intubation (ET) and
other advanced airway management procedures performed by the EMT- Paramedic. This
procedure should be initiated in a short period of time, to prevent delay in the provision of
adequate ventilation.
A. Prior to deciding to intubate, the following questions concerning the patient must
be considered.
C. Ventilate and preoxygenate for approximately 1-2 minutes with pocket mask or
BVM and supplemental oxygen at 15 L/min or more, or OPVD.
2. Visualize the vocal cords and/or glottic opening, and advance endotracheal
tube to the appropriate depth.
3. Capnography reading.
H. Proper tube placement must be reassessed following any point at which a patient
is moved (e.g., floor to stretcher; ambulance to emergency department, etc).
A. Indications for use of C-PAP are a patient who is in respiratory distress with signs
and symptoms consistent with asthma, COPD, pulmonary edema, CHF, or
pneumonia and who is:
1. Awake and able to follow commands.
E. Special Considerations
4. Due to changes in preload and after load of the heart during C-PAP therapy,
a complete set of vital signs must be obtained every 5 minutes.
3. Attach the sensor into the locking bracket on the micro stream cable.
B. While continuing attempts to ventilate, place the patient in a supine position and
hyperextend the head and neck. If a spinal injury is suspected, the head and neck
should be maintained in a neutral, in-line position.
C. Locate the patient's cricothyroid membrane and prep the area with providone-
iodine swabs.
2. Insert the needle/catheter in the midline, through the skin and membrane.
Direct the needle posterior and caudally at a 45° angle to the trachea.
3. Advance the needle and catheter while maintaining negative pressure with
the syringe. Air should readily fill the syringe when the trachea is entered.
4. Advance the catheter over the needle until the hub is flush with the skin,
and then remove the needle and syringe.
C. The straightest and least congested nasal passage should be identified and
prepped with Afrin® nasal spray if possible.
D. A 6.5 or 7.0 endotracheal tube should be coated with Lidocaine jelly and bent
into a “C” shaped curve.
F. Insert the endotracheal tube into the nasal passage and attempt to push it into
the lower pharynx. Do not force the tube if substantial resistance is met.
G. Position the head in the sniffing position if spine injury is not a concern.
H. Listen over the endotracheal tube opening and watch for rise and fall of the
chest, then advance tube into the trachea at the beginning of a spontaneous
breath, and advance it as far as possible.
C. In adult patients with the potential for an elevated ICP (e.g., head injury; IC bleed;
hypertensive crises), or those with ventricular dysrhythmias, premedicate with
lidocaine, 1 mg/kg IV, prior to administration of succinylcholine.
E. In children and adolescents, administer atropine, 0.02 mg/kg (minimum of 0.1 mg,
and a maximum of 0.5 mg) IV push.
Paralytic agents (Succinylcholine) may be used without medical control contact in the
following circumstances:
1. Any trauma patient with a GCS score of 8 or less.
2. Any patient in which the loss of a patent airway could occur in less than 5 minutes
(burn patient with airway edema, anaphylaxis, epiglottitis).
For all other circumstances and conditions, paralytic agents may only be used with the
authorization of Medical Control.
1. If Medical Control leaves the intubation to the discretion of the paramedic, the
paramedic may use paralytics to intubate.
2. Intubation of patients not requiring paralysis may still be performed without Medical
Control contact.
3. Pass guide wire through the cricothyroid needle aimed so that distal end of
the wire may be retrieved from the mouth of patient. Withdraw needle off
the wire.
4. Load ETT over oral end of the wire, passing the wire into the tube through
Murphy's eye.
6. Advance ETT over the wire into the trachea to cricoid area, gradually
relaxing the cricothyroid end of the wire, advance ETT to appropriate
intratracheal location.
7. Release the cricothyroid end of the wire and withdraw the wire out of ETT.
8. Verify placement by use of the EDD and confirm bilateral breath sounds,
then secure the tube.
D. If using the Cook™ retrograde intubation tray, follow the directions included in the
kit.
INTRODUCTION
EMT-I & EMT-P
ASEPTIC TECHNIQUE
GENERAL PROCEDURES
D. Also, if patient already has a central line, consider use of the central line.
E. Consider use of Vidacare EZ-IO™.
A. Blood may be drawn as indicated in the protocols, and must occur at the time
intravenous procedures are being performed.
B. Prior to connecting IV tubing and fluid, attach a Vacutainer® or syringe and fill one
blue-top, one green-top, and one lavender-top, and one red-top blood tube.
C. Label blood tubes appropriately (patient’s name, the date, time, EMS provider's
initials) and tape to the IV bag.
2. Law enforcement must complete and sign the Yakima County Direction to
Take Blood Test form and return it to the provider while at the scene.
3. Attach the completed form to your agency's copy of the medical incident
report (a copy may also be attached to the patient's hospital chart).
A. Paramedics may transport patients with blood or other blood products running, if
the blood products have been running for at least a 1/2 hour before the
interfacility transport.
1. If there is the possibility that the blood product bag will need to be changed
during the transport, then a nurse must accompany the patient.
2. If the drug cannot be discontinued or you are in any doubt contact your
Medical Program Director.
B. Special Considerations
1. Avoid extremities where a dialysis shunt is present. This may be used as a
last and final option if access is important to the patients’ survival.
C. The amount of fluid given to a patient will vary based on the patients’ condition
and needs for fluid, their size, weight and age. The following is meant to be
utilized as a guideline and is not meant to replace the judgment of the EMT-
Intermediate or Paramedic providing care.
1. Trauma Patients
a. Give 1000ml bolus of Normal Saline, repeat at 500ml of NS.
i. Monitor blood pressure every 5 minutes, maintain a systolic
blood pressure of 90.
2. Medical Patients
a. 200ml bolus of Normal Saline, followed by repeat vital signs
including lung sounds
i. Until improved mentation is achieved.
ii. The patient has relief in symptoms (i.e., decreased DT’s,
increased BP or decrease in heart rate if tachycardic)
3. Pediatric patients
a. 20ml/kg bolus of Normal Saline, followed by repeat vital signs
i. It is recommended that a Buretrol 60 drop set containing a
150ml chamber, be utilized on infants & children less than
7.5 kg or 15 lbs.
ii. Any infant or child who is classified as “Pink” or “Grey” inside
the Broselow tape (2007 Version B).
2. Pain:
a. Insertion of the EZ-IO™ in conscious patients causes mild to
moderate discomfort but is usually no more painful than a large bore
IV.
b. IO infusion can cause severe discomfort for conscious patients.
c. EMT-P - Prior to IO flush on alert patients, SLOWLY administer
40 mg (or 2ml) 2% IV Lidocaine through the EZ-IO™ hub.
The procedure is described in the schematic with narrative. Its purpose is to provide the prehospital provider with quick
identification of a major trauma victim. If the patient is a major trauma patient, that patient or patients must be taken to
the highest level trauma facility within 30 minutes transport time, by either ground or air. To determine whether an injury
is major trauma, the prehospital provider shall conduct the patient assessment process according to the trauma triage
procedures.
Explanation of Process
A. Any certified EMS and Trauma person can identify a major trauma patient and activate the trauma
system. This may include requesting more advanced prehospital services or aero-medical evacuation.
B. The first step (1) is to assess the vital signs and level of consciousness. The words “Altered mental
status” mean anyone with an altered neurologic exam ranging from completely unconscious, to someone who
responds to painful stimuli only, or a verbal response which is confused, or an abnormal motor response.
The “and/or” conditions in Step 1 mean that any one of entities listed in Step 1 can activate the trauma system.
Also, the asterisk(*) means that if the airway is in jeopardy and the on-scene person cannot effectively manage
the airway, the patient should be taken to the nearest medical facility or consider meeting up with an ALS unit.
These factors are true regardless of the assessment of other vital signs and level of consciousness.
C. The second step (2) is to assess the anatomy of injury. The specific injuries noted require activation of the
trauma system. Even in the assessment of normal vital signs or normal levels of consciousness, the presence
of any of the specific anatomical injuries does require activation of the trauma system.
Please note that steps 1 and 2 also require notifying Medical Control.
D. The third step (3) for the prehospital provider is to assess the biomechanics of the injury and address
other risk factors. The conditions identified are reason for the provider to contact and consult with Medical
Control regarding the need to activate the system. They do not automatically require system activation by the
prehospital provider.
Other risk factors, coupled with a “gut feeling” of severe injury, means that Medical Control should be consulted
and consideration given to transporting the patient to the nearest trauma facility.
Please note that certain burn patients (in addition to those listed in Step 2) should be considered for immediate
transport or referral to a burn center/unit.
In summary, the Prehospital Trauma Triage Procedure and the Regional Patient Care Procedures are intended to work
in a “hand in glove” fashion to effectively address EMS and Trauma patient care needs. By functioning in this manner,
these two instruments can effectively reduce morbidity and mortality.
If you have any questions on the use of either instrument, you should bring them to the attention of your local or regional
EMS and Trauma council or contact 1-800-458-5281.
Prehospital triage is based on the following 3 steps: Steps 1 and 2 require prehospital EMS personnel to notify Medical
Control and activate the Trauma System. Activation of the Trauma System in Step 3 is determined by Medical Control.**
STEP 1
ASSESS VITAL SIGNS & LEVEL OF CONSCIOUSNESS
• Systolic BP <90*
• HR >120*
*for pediatric (<15y) pts. use BP <90 or capillary refill >2 sec.
*for pediatric (<15y) pts. use HR <60 or >120 1. Take patient to the highest
• Any of the above vital signs associated with signs and symptoms of level trauma center within 30
shock minutes transport time via
• and/or ground or air transport
• Respiratory Rate <10 >29 associated with evidence of distress and/or according to DOH approved
• Altered mental status YES regional patient care
procedures.
**If prehospital personnel are unable to effectively manage airway, consider rendezvous
with ALS, or intermediate stop at nearest facility capable of immediate definitive airway
management.
NO
NO 1. Take patient to
the highest level
trauma center
STEP 3 within 30 minutes
transport time via
ASSESS BIOMECHANICS OF INJURY AND OTHER RISK ground or air
FACTORS CONTACT transport
• Death of same car occupant; OR MEDICAL according to DOH
• Ejection of patient from enclosed vehicle; OR CONTROL approved regional
• Fall ≥20 feet; OR YES FOR YES patient care
• Pedestrian hit at ≥20 mph or thrown 15 feet DESTINATIO procedures.
• High energy transfer situation N DECISION
• Rollover
• Motorcycle, ATV, bicycle accident
• Extrication time of > 20 minutes
• Extremes of age <15 or >60
• Hostile environment (extremes of heat or cold)
• Medical illness (such as COPD, CHF, renal failure, etc.)
• Second/third trimester pregnancy 2. Apply “Trauma
• Gut feeling of EMS provider ID Band” to patient.
NO NO
Activated Charcoal
Class: Adsorbent
Actions: Adsorbs toxins by chemical binding and prevents gastrointestinal adsorption.
Indications: Poisoning following emesis or when emesis is contraindicated.
Contraindications: None in severe poisoning.
Precautions: Should only be administered following emesis, in cases in which it is so indicated. Use with caution in
patients with altered mental status. May adsorb Ipecac before emesis; If Ipecac is administered, wait at least 10 minutes
to administer activated charcoal.
Side Effects: Nausea, vomiting, and constipation.
Dosage: 1 g/kg (typically 50-75 grams) mixed with a glass of water to form a slurry.
Routes: Oral
Pediatric Dosage: 1 g/kg mixed with a glass of water to form a slurry
Adenosine (Adenocard)
Class: Antiarrhythmic
Actions: slows AV conduction
Indications: symptomatic PSVT
Contraindications: second- or third-degree heart block, sick-sinus syndrome, known hypersensitivity to the drug.
Precautions: Arrhythmias, including blocks, are common at the time of cardioversion. Use with caution in patients with
asthma.
Side Effects: Facial flushing, headache, shortness of breath, dizziness, and nausea.
Dosage: 6 mg given as a rapid IV bolus over a 1-2 second period; if, after 1-2 minutes, cardioversion does not occur,
administer a 12-mg dose over 1-2 seconds.
Routes: IV; should be administered directly into a vein or into the medication administration port closest to the patient and
followed by flushing of the line with IV fluid.
Pediatric Dosage: Safety in children has not been established.
Afrin Nasal Spray
Class: Vasoconstrictor
Actions: Decongestant
Indications: Patient meets the indications for nasal intubation.
Contraindications: Recent monoamine oxidase (MAO) inhibitor use such as Marplan, Nardil, Parnate.
Precautions: Use caution if patient is pregnant, has hypertension, heart disease, diabetes, liver or kidney disease
Side Effects: Allergic Reaction, dizziness, hypertension, headache, irregular or fast heartbeat
Dosage: Metered Dose Inhaler: 1-2 sprays
Routes: Nasal Spray
Pediatric Dosage: Do not use with children.
Albuterol (Proventil) (Ventolin)
Class: Sympathomimetic (ß2 selective)
Actions: Bronchodilation
Indications: Asthma reversible bronchospasm associated with COPD
Contraindications: Known hypersensitivity to the drug, symptomatic tachycardia
Precautions: Blood pressure, pulse, and EKG should be monitored use caution in patients with known heart disease
Side Effects: Palpitations, anxiety, headache, dizziness, and sweating
Dosage: Metered Dose Inhaler: 1-2 sprays (90 micrograms per spray)
Small-Volume Nebulizer: 0.5 ml (2.5 mg) in 2.5 ml normal saline over 5-15 minutes
Rotohaler: one 200-microgram rotocap should be placed in the inhaler and breathed by the patient
Routes: Inhalation
Pediatric Dosage: 0.15 mg (0.03 ml)/kg in 2.5 ml normal saline by small volume nebulizer
Amiodarone
Class: Anti-arrhythmic agent
Actions: Anti-dysrrhythmia
Indications: Ventricular and supraventricular arrhythmias.
Contraindications: Patients with history of hypersensitivity to the drug, sinus nodal bradycardia, AV block, 2nd & 3rd
degree heart blocks.
Precautions: Use with caution if the patient is pregnant or nursing. Not to be given with Lidocaine, increases risk of
Asystole. Amiodarone can worsen the cardiac arrhythmia brought on by Digitalis poisoning
Side Effects: Pulmonary toxicity, exacerbation of arrhythmia, and rare serious liver injury
Dosage: 300mg cardiac arrest, 150mg over 10 minutes for ventricular dysrhythmias
Routes: IV, IO
Pediatric Dosage: 5mg/kg
Aspirin (Bufferin)
Class: Platelet inhibitor/anti-inflammatory.
Actions: Blocks platelet aggregation.
Indications: New-onset chest pain suggestive of MI signs and symptoms suggestive or recent CVA.
Contraindications: Patients with history of hypersensitivity to the drug.
Precautions: GI bleeding and upset.
Side Effects: Heartburn, nausea and vomiting, wheezing.
Dosage: 150-325 mg PO or chewed.
Routes: PO.
Pediatric Dosage: not recommended.
Atropine
Class: Parasympatholytic (anticholinergic).
Actions: Blocks acetylcholine receptors, increases heart rate, decreases gastrointestinal secretions.
Indications: Hemodynamically-significant bradycardia, hypotension secondary to bradycardia, asystole,
organophosphate poisoning.
Contraindications: None when used in emergency situations.
Precautions: Dose of 0.04 mg/kg should not be exceeded except in cases of organophosphate poisonings, tachycardia,
hypertension.
Side Effects: Palpitations and tachycardia, headache, dizziness, and anxiety, dry mouth, pupillary dilation, and blurred
vision, urinary retention (especially older males).
Dosage: Bradycardia: 0.5 mg every 5 minutes to maximum of 0.04 mg/kg.
Asystole: 1 mg.
Organophosphate poisoning: 2-5 mg.
Routes: IV, ET (ET dose is 2 - 2.5 times IV dose).
Pediatric Dosage: Bradycardia: 0.02 mg/kg
Maximum single dose (child 0.5 mg) (adolescent 1.0 mg)
Maximum total dose (child 1.0 mg) (adolescent 2.0 mg)
Calcium Chloride (CaCl)
Class: Electrolyte.
Actions: Increases cardiac contractility.
Indications: Acute hyperkalemia (elevated potassium), acute hypocalcemia (decreased calcium), calcium channel
blocker (Nifedipine, Verapamil, etc.), overdose, abdominal muscle spasm associated with spider bite and portuguese
man-o-war stings, antidote for magnesium sulfate.
Contraindications: Patients receiving digitalis.
Precautions: IV line should be flushed between calcium chloride and sodium bicarbonate administration. Extravasation
may cause tissue necrosis.
Side Effects: Arrhythmias (bradycardia and asystole), hypotension.
Dosage: 2-4 mg/kg of a 10% solution; may be repeated at 10-minute intervals.
Routes: IV.
Pediatric Dosage: 5-7 mg/kg of a 10% solution.
Dextrose 50%
Class: Carbohydrate.
Actions: Elevates blood glucose level rapidly.
Indications: Hypoglycemia.
Contraindications: None in the emergency setting.
Precautions: A blood sample should be drawn before administering 50% dextrose.
Side Effects: Local venous irritation.
Dosage: 25 grams (50 ml).
Routes: IV.
Pediatric Dosage: 0.5 g/kg slow IV; should be diluted 1:1 with sterile water to form a 25% solution.
Diltiazem (Cardizem)
Class: Calcium channel blocker.
Actions: Slows conduction through the AV node, causes vasodilation, decreases rate of ventricular response, decreases
myocardial oxygen demand.
Indications: To control rapid ventricular response associated with atrial fibrillation and flutter.
Contraindications: Hypotension, wide complex tachycardia, conduction system disturbances.
Precautions: Should not be used in patients receiving intravenous ß blockers. Hypotension. Must be kept refrigerated or
discarded one month after removal from refrigeration.
Side Effects: Nausea, vomiting, hypotension, and dizziness.
Dosage: 0.25 mg/kg bolus (typically 20 mg) IV over 2 minutes. This should be followed by a maintenance infusion of 5-15
mg/hour.
Routes: IV, IV drip.
Pediatric Dosage: Rarely used.
Dolasetron Mesylate (Anzemet)
Class: Serotonin 5HTe receptor antagonist
Actions: Used to treat nausea and vomiting after chemotherapy. Its main effect is to reduce the activity of the vagus
nerve, which is a nerve that activates the vomiting center in the medulla oblongata.
Indications:
Contraindications:
Precautions:
Side Effects: Headache, dizziness, constipation, prolonged QT interval can occur as well.
Dosage: 12.5 mg
Routes: IV
Pediatric Dosage: 1.2mg/kg
Diphenhydramine (Benadryl)
Class: Antihistamine.
Actions: Blocks histamine receptors, has some sedative effects.
Indications: Anaphylaxis, allergic reactions, dystonic reactions due to phenothiazines.
Contraindications: Asthma, nursing mothers.
Precautions: Hypotension.
Side Effects: Sedation, dries bronchial secretions, blurred vision, headache, palpitations.
Dosage: 25-50 mg.
Routes: Slow IV push deep IM.
Pediatric Dosage: 2-5 mg/kg.
Dopamine (Intropin)
Class: Sympathomimetic.
Actions: Increases cardiac contractility, causes peripheral vasoconstriction.
Indications: Hemodynamically significant hypotension (systolic BP of 70-100 mmhg) not resulting from hypovolemia,
cardiogenic shock.
Contraindications: Hypovolemic shock where complete fluid resuscitation has not occurred.
Precautions: Should not be administered in the presence of severe tachyarrhythmias. Should not be administered in the
presence of ventricular fibrillation, ventricular irritability. Beneficial effects lost when dose exceeds 20 µg/kg/min.
Side Effects: Ventricular tachyarrhythmias, hypertension, palpitations.
Dosage: 2-20 µg/kg/minute. Start low and increase as needed.
Method: 800 mg should be placed in 500 ml of D5W giving a concentration of 1600 µg/ml.
Routes: IV drip only.
Pediatric Dosage: 2-20 µg/kg/minute.
Epinephrine (Adrenalin):
Description: A hormone produced by the adrenal gland (attached to the kidneys) and synthesized commercially. It is
employed therapeutically as a vasoconstrictor, as a cardiac stimulant, and to relax bronchioles. It is also used to treat
asthmatic attacks and treat anaphylactic shock.
Epinephrine 1:1,000
Class: Sympathomimetic.
Actions: Bronchodilation.
Indications: Bronchial asthma, exacerbation of COPD, allergic reactions.
Contraindications: Patients with underlying cardiovascular disease, hypertension, pregnancy, patients with
tachyarrhythmias.
Precautions: Should be protected from light. Blood pressure, pulse, and EKG must be constantly monitored.
Side Effects: Palpitations and tachycardia, anxiousness, headache, tremor.
Dosage: 0.3-0.5 mg.
Routes: Subcutaneous (IV and ET for pediatric cardiac arrest).
Pediatric Dosage: 0.01 mg/kg up to 0.3 mg.
Epinephrine 1:10,000
Class: Sympathomimetic.
Actions: Increases heart rate and automaticity.
Increases cardiac contractile force.
Increases myocardial electrical activity.
Increases systemic vascular resistance.
Increases blood pressure.
Causes bronchodilation.
Indications: Cardiac arrest, anaphylactic shock severe reactive airway disease.
Contraindications: Epinephrine 1:10,000 is for intravenous or endotracheal use; it should not be used in patients who do
not require extensive resuscitative efforts.
Precautions: Should be protected from light. Can be deactivated by alkaline solutions.
Side Effects: Palpitations, anxiety, tremulousness, nausea and vomiting.
Dosage: cardiac arrest: 0.5-1.0 mg repeated every 3-5 minutes.
severe anaphylaxis: 0.3-0.5 mg (3-5 ml); occasionally and Epinephrine drip is required.
Routes: IV, IV drip, ET.
Pediatric Dosage: 0.01 mg/kg initially with subsequent doses, Epinephrine 1:1,000 should be used at a dose of 0.1
mg/kg.
Epinephrine Autoinjector
Class: Adrenaline
Actions: Bronchodilator, vasoconstrictor
Indications: Severe allergic reactions or anaphylactic shock
Contraindications:
Precautions:
Side Effects: Rapid heart rate, ventricular tachycardia, decreased blood flow to the injection site.
Dosage: 0.3mg-0.5mg 1:1000
Routes: IM
Pediatric Dosage: 0.15mg 1:1000
Etomidate
Class: Intravenous anesthetic agent, hypnotic
Actions: General anesthesia, sedative
Indications: Rapid sequence intubation, conscious sedation
Contraindications:
Precautions: Quick acting, patient will become unresponsive in 30-60 seconds after administration.
Side Effects: Adrenal crisis, seizure,
Dosage: 0.3 mg/kg IV, with a typical dose ranging from 20-40 mg, give over 30-60 seconds.
Routes: IV.
Pediatric Dosage: Not recommended
Fentanyl
Class: Opioid, narcotic analgesic
Actions: Fentanyl is 100 times more potent than morphine, with 100 micrograms of Fentanyl approx. equivalent to 10 mg
of morphine.
Indications: Pain management, pain associated with cancer
Contraindications: Hypersensitivity to medication
Precautions: CNS depressant, respiratory depressant, desation
Side Effects: Diarrhea, nausea, constipation, dry mouth, somnolence, confusion, asthenia (weakness), and sweating
Dosage: 25-100mcg slow IVP over 2-3 minutes
Routes: IV, IO
Pediatric Dosage: 2mcg/kg slow IVP
Furosemide (Lasix)
Class: Potent diuretic.
Actions: Inhibits reabsorption of sodium chloride, promotes prompt diuresis, vasodilation.
Indications: Congestive heart failure, pulmonary edema.
Contraindications: Pregnancy, dehydration.
Precautions: Should be protected from light, dehydration.
Side Effects: Few in emergency usage.
Dosage: 40-80 mg.
Routes: IV.
Pediatric Dosage: 1 mg/kg.
Glucagon
Class: Hormone (antihypoglycemic agent).
Actions: Causes breakdown of glycogen to glucose.
Inhibits glycogen synthesis.
Elevates blood glucose level.
Increases cardiac contractile force.
Increases heart rate.
Indications: Hypoglycemia.
Contraindications: Hypersensitivity to the drug.
Precautions: Only effective if there are sufficient stores of Glycogen within the liver. Use with caution in patients with
cardiovascular or renal disease. Draw blood glucose before administration.
Side Effects: Few in emergency situations.
Dosage: 0.25-0,50 mg (unit) IV 1.0 mg, IM.
Routes: IV, IM.
Pediatric Dosage: 0.03 mg/kg.
Haloperidol (Haldol)
Class: Major tranquilizer.
Actions: Blocks dopamine receptors in brain responsible for mood and behavior has antiemetic properties.
Indications: Acute psychotic episodes.
Contraindications: Should not be administered in the presence of other sedatives. Should not be used in the
management of dysphoria caused by Talwin.
Precautions: Orthostatic hypotension.
Side Effects: Physical and mental impairment, Parkinson-like reactions have been known to occur, especially in children.
Dosage: 2-5 mg.
Routes: IM.
Pediatric Dosage: Rarely used.
Heparin
Class: Anticoagulant.
Actions: Functions as an anticoagulant by accelerating neutralization of activated clotting factors.
Indications: Situations where a hypocoaguable state is required (i.e. post MI, post-CVA, pulmonary embolism).
Contraindications: Should not be used unless there is a medical reason to anticoagulate the patient.
Precautions: Sever, urticaria, and anaphylaxis have been reported following heparin administration skin necrosis can
develop at site of subQ injections.
Side Effects: Fever, bruising, oozing of blood.
Dosage: Loading dose: 5,000 iu IV is a typical loading dose although large patients and patients with heparin resistance
may receive larger doses.
Maintenance dose: Infusion therapy is typically started at 800 - 1,000 iu/hour. the dosage is modified based upon the
patient's prothrombin (pt) time.
Routes: IV subQ (for prophylaxis).
Pediatric Dosage: Rarely used.
Ipatropium (Atrovent)
Class: Anticholinergic.
Actions: Causes bronchodilation, dries respiratory tract secretions.
Indications: Bronchial asthma, reversible bronchospasm associated with chronic bronchitis and emphysema.
Contraindications: Patients with history of hypersensitivity to the drug, should not be used as primary agent in acute
treatment of bronchospasm.
Precautions: Blood pressure, pulse, and EKG must be constantly monitored.
Side Effects: Palpitations, dizziness, anxiety, tremors, headache, nervousness, dry mouth.
Dosage: Small-volume nebulizer: 500 µg should be placed in small volume nebulizer (typically administered with a ß
agonist).
Routes: Inhalation only.
Pediatric Dosage: Safety in children has not been established.
Lidocaine (Xylocaine)
Class: Antiarrhythmic.
Actions: Suppresses ventricular ectopic activity, increases ventricular fibrillation threshold, reduces velocity of electrical
impulse through conductive system.
Indications: Malignant PVCs, ventricular tachycardia, ventricular fibrillation, prophylaxis of arrhythmias associated with
acute myocardial infarction and thrombolytic therapy, premedication prior to rapid sequence induction.
Contraindications: High-degree heart blocks, PVCs in conjunction with bradycardia.
Precautions: Dosage should not exceed 300 mg/hr. Monitor for CNS toxicity. Dosage should be reduced by 50% in
patients older than 70 years of age or who have liver disease in cardiac arrest, use only bolus therapy.
Side Effects: Anxiety, drowsiness, dizziness, and confusion, nausea and vomiting, convulsions, widening of QRS.
Dosage: Bolus: Initial bolus of 1.5 mg/kg; additional boluses of 0.5 - 0.75 mg/kg can be repeated at 8-10-minute intervals
until the arrhythmia has been suppressed or until 3 mg/kg of the drug has been administered; reduce dosage by 50% in
patients older than 70 years of age.
Drip: after the arrhythmia has been suppressed a 2-4 mg/minute infusion may be started to maintain adequate blood
levels.
Routes: IV bolus, IV infusion.
Pediatric Dosage: 1 mg/kg.
Lorazepam (Ativan)
Class: Benzodiazepine
Actions: Anziolytic, amnesic, sedative/hypnotic, anticonvulsant and muscle relaxant.
Indications: Anziety, insomnia, acute seizures including status epilepticus and sedation of aggressive patients
Contraindications: Allergy or hypersensitivity, severe respiratory failure, acute intoxication, ataxia, acute narrow-angle
glaucoma, sleep apnea, myasthenia gravis, pregnancy and breast feeding.
Precautions: Use caution when administering to children or the elderly, and liver or kidney failure patients.
Side Effects: Ataxia, sedation, anterograde amnesia and hangover effects.
Dosage: 0.5-2.0 mg IV or 1.0- 4.0 IM
Routes: IV, IM, IO
Pediatric Dosage: 0.05-0.1mg/kg
Magnesium Sulfate
Class: Anticonvulsant/Antiarrhythmic.
Actions: CNS depressant, anticonvulsant, antiarrhyhmic.
Indications: Obstetrical eclampsia (toxemia of pregnancy), pre-eclampsia/PIH, cardiovascular severe refractory
ventricular fibrillation, pulseless ventricular tachycardia, post-MI as prophylaxis for arrhythmias, torsades de pointes (multi-
axial ventricular tachycardia).
Contraindications: Shock, heart block.
Precautions: Caution should be used in patients receiving digitalis. Hypotension. Calcium Chloride should be readily
available as an antidote if respiratory depression ensues. Use with caution in patients in renal failure.
Side Effects: Respiratory depression, drowsiness.
Dosage: 1-4 g.
Routes: IV, IM.
Pediatric Dosage: Not indicated.
Methylprednisolone (Solu-Medrol)
Class: Steroid.
Actions: Anti-inflammatory, suppresses immune response (especially in allergic reactions).
Indications: Severe anaphylaxis, asthma/COPD, possibly effective as an adjunctive agent in the management of spinal
cord injury.
Contraindications: None in the emergency setting.
Precautions: Must be reconstituted and used promptly. Onset of action may be 2-6 hours and thus should not be
expected to be of use in the critical first hour following an anaphylactic reaction.
Side Effects: GI bleeding, prolonged wound healing, suppression of natural steroids.
Dosage: General usage: 125-250 mg.
Spinal cord injury: Initial bolus of 30 mg/kg administered over 15 minutes, followed by a maintenance infusion of 5.4
mg/kg/hr.
Routes: IV, IM.
Pediatric Dosage: 30 µg/kg.
Midazolam (Versed)
Class: Benzodiazepine tranquilizer.
Actions: Hypnotic, sedative.
Indications: Premedication prior to cardioversion/RSI, acute anxiety states.
Contraindications: Patients with known hypersensitivity to the drug, narrow-angle glaucoma, shock.
Precautions: Emergency resuscitation equipment should be available. Flumazenil (Romazicon) should be available.
Dilute with normal saline or D5W prior to intravenous administration. Respiratory depression more common with
Midazolam than with other Benzodiazepines.
Side Effects: Drowsiness, hypotension, amnesia, respiratory depression, apnea.
Dosage: 1.0- 2.5 mg IV.
Routes: IV, IM, intranasal.
Pediatric Dosage: 0.03 mg/kg.
Morphine
Class: Narcotic.
Actions: CNS depressant, causes peripheral vasodilation, decreases sensitivity to pain.
Indications: Severe pain, pulmonary edema.
Contraindications: Head injury, volume depletion undiagnosed abdominal pain, patients with history of hypersensitivity
to the drug.
Precautions: Respiratory depression (narcan should be available), hypotension, nausea.
Side Effects: Dizziness, altered level of consciousness.
Dosage: IV: 2-5 mg followed by 2 mg every few minutes until the pain is relieved or until respiratory depression ensues.
IM: 5-15 mg based on patient weight.
Routes: IV, IM.
Pediatric Dosage: 0.1-0.2 mg/kg IV.
Naloxone (Narcan)
Class: Narcotic antagonist.
Actions: Reverses effects of narcotics.
Indications:
Narcotic overdoses including the following: Codeine, Demerol, Dilaudid, Fentanyl, Heroin, Lortabs, Methadone,
Morphine, Paregoric, Percodan, Tylox, Vicodin, synthetic analgesics,
Overdoses including the following: Darvon, Nubain, Stadol, Talwin, alcoholic coma,
To rule out narcotics in coma of unknown origin.
Contraindications: Patients with a history of hypersensitivity to the drug.
Precautions: Should be administered with caution to patients dependent on narcotics as it may cause withdrawal effects.
Short-acting, should be augmented every 5 minutes.
Side Effects: none.
Dosage: 1-2 mg.
Routes: IV, IM.
ET (ET dose is 2.0-2.5 times IV dose).
Pediatric Dosage: < 5 years old > 5 years old 0.1 mg/kg 2.0 mg.
Nitroglycerin Spray (Nitrolingual Spray)
Class: Antianginal.
Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries.
Indications: Angina pectoris, chest pain associated with myocardial infarction.
Contraindications: Hypotension.
Precautions: Constantly monitor vital signs. Syncope can occur.
Side Effects: Dizziness, hypotension, headache.
Dosage: One spray administered under the tongue; may be repeated in 10-15 minutes; no more than three sprays in a
15-minute period; spray should not be inhaled.
Routes: Sprayed under tongue on mucous membrane.
Pediatric Dosage: Not indicated.
Nitropaste (Nitro-Bid)
Class: Antianginal.
Actions: Smooth-muscle relaxant, decreases cardiac work, dilates coronary arteries, dilates systemic arteries.
Indications: Angina pectoris, chest pain associated with myocardial infarction.
Contraindications: Children younger than 12 years of age, hypotension.
Precautions: Constantly monitor blood pressure, syncope, drug must be protected from light, expires quickly once bottle
is opened.
Side Effects: Dizziness, hypotension.
Dosage: 1/2 to 3/4 inches.
Routes: Topical.
Pediatric Dosage: Not indicated.
Oxygen (O2)
Class: gas.
Actions: Necessary for cellular metabolism.
Indications: Hypoxia.
Contraindications: None.
Precautions: Use cautiously in patients with COPD, humidify when providing high-flow rates.
Side Effects: Drying of mucous membranes.
Dosage: Cardiac arrest: 100%.
Other critical patients: 100%.
COPD: 35%.
Routes: Inhalation.
Pediatric Dosage: 24-100% as required.
Oxytocin (Pitocin)
Class: Mammalian hormone (polypeptide hormone)
Actions: The peripheral actions of oxytocin mainly reflect secretion from the pituitary gland. In lactating mothers, oxytocin
acts at the mammary glands, causing milk to be ‘let down’ into subareolar sinuses, from where it can be excreted via the
nipple. Oxytocin release during breastfeeding causes mild but often painful uterine contractions. This serves to assist the
uterus in clotting the placental attachment point postpartum.
Indications: Post-partum hemorrhage
Contraindications: verify that baby and the placenta have been delivered and that there is not an additional fetus in the
uterus
Precautions: overstimulation of the uterus, uterine rupture, hypertension, cardiac dysrhythmias, anaphylaxis
Side Effects: subarachnoid hemorrhage, seizures, increased heart rate, decreased blood pressure, over stimulated
uterus.
Dosage: 10-20 Units in 1000ml NaCl
Routes: IV
Pediatric Dosage: not recommended.
Plavix (Clopidogrel)
Class: Antiplatelet agent
Actions: Inhibits blood clots in coronary artery disease, peripheral vascular disease, and cerebrovascular disease.
Indications: Prevention of vascular ischaemic events, acute coronary syndrome without ST-segment elevation
(NSTEMI), ST elevation MI (STEMI)
Contraindications: In patient already taking clopidogrel due to increased risk of digestive tract hemorrhage.
Precautions:
Side Effects: Severe neutropenia (low shite blood cells), hemorrhage (increased if co-administration of aspirin)
Dosage: 75 mg oral tablets
Routes: PO
Pediatric Dosage:
Promethazine (Phenergan)
Class: Antihistamine (h1 antagonist).
Actions: Mild anticholinergic activity, antiemetic, potentiates actions of analgesics.
Indications: Nausea and vomiting, motion sickness, to potentiate the effects of analgesics, sedation.
Contraindications: Comatose states, patients who have received a large amount of depressants (including alcohol).
Precautions: Avoid accidental intra-arterial injection.
Side Effects: May impair mental and physical ability, drowsiness.
Dosage: 25 mg.
Routes: IV.
Pediatric Dosage: 0.5 mg/kg.
Sodium Bicarbonate
Class: Alkalinizing agent.
Actions: Combines with excessive acids to form a weak volatile acid, increases ph.
Indications: Late in the management of cardiac arrest, if at all, tricyclic antidepressant overdose, severe acidosis
refractory to hyperventilation.
Contraindication: Alkalotic states.
Precautions: Correct dosage is essential to avoid overcompensation of ph. Can deactivate catecholamines. Can
precipitate with calcium preparations. Delivers large sodium load.
Side Effects: Alkalosis.
Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes as indicated by blood gas studies.
Routes: IV.
Pediatric Dosage: 1 mEq/kg initially followed by 0.5 mEq/kg every 10 minutes.
Succinylcholine (Anectine)
Class: Neuromuscular blocking agent (depolarizing).
Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles.
Indications: To achieve paralysis to facilitate endotracheal intubation.
Contraindications: Patients with known hypersensitivity to the drug.
Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal
intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available.
Paralysis occurs within 1 minute and lasts for approximately 8 minutes.
Side Effects: Prolonged paralysis, hypotension, bradycardia.
Dosage: 1-1.5 mg/kg (40-100 mg in an adult).
Routes: IV.
Pediatric Dosage: 1 mg/kg.
Vasopressin
Class: Peptide hormone, antidiuretic hormone
Actions: Vasopressin is a peptide hormone that controls the reabsorption of molecules in the tubules of the kidneys by
affecting the tissue’s permeability. It also increases peripheral vascular resistance, which in turn increases arterial blood
pressure.
Indications: increase peripheral vascular resistance during CPR (as an alternative to epinephrine or after epinephrine
has been used)
Contraindications: Chronic nephritis, ischemic heart disease, PVC’s, advanced arteriosclerosis
Precautions: epilepsy, migraine, asthma, heart failure, and angina
Side Effects: Blanching of the skin, abdominal cramps, nausea, hypertension, bradycardia, and minor dysrhythmias
Dosage: 40 units
Routes: IV, IO
Pediatric Dosage: Not recommended
Thiamine (Vitamin B1)
Class: Vitamin.
Actions: Allows normal breakdown of glucose.
Indications: Coma of unknown origin, alcoholism, delirium tremens.
Contraindications: None in the emergency setting.
Precautions: Rare anaphylactic reactions have been reported.
Side Effects: Rare, if any.
Dosage: 100 mg.
Routes: IV, IM.
Pediatric Dosage: Rarely indicated.
Vecuronium (Norcuron)
Class: Neuromuscular blocking agent (non-depolarizing).
Actions: Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles.
Indications: To achieve paralysis to facilitate endotracheal intubation.
Contraindications: Patients with known hypersensitivity to the drug.
Precautions: Should not be administered unless persons skilled in endotracheal intubation are present. Endotracheal
intubation equipment must be available. Oxygen equipment and emergency resuscitative drugs must be available.
Paralysis occurs within 1 minute and lasts for approximately 30 minutes.
Side Effects: Prolonged paralysis, hypotension, bradycardia.
Dosage: 0.08-0.10 mg/kg.
Routes: IV.
Pediatric Dosage: 0.1 mg/kg.
Zofran (Ondansetron)
Class: Serotonin, receptor antagonist
Actions: antiemetic
Indications: nausea and vomiting, often followed by chemotherapy, or due to chronic medical illness or acute
gastroenteritis.
Contraindications: Allergy to Zofran
Precautions: HA, Dizziness, Diarrhea
Side Effects: Constipation, dizziness and headache
Dosage: 4-8mg IV
Routes: IV, IO, IM, PO, ODT
Pediatric Dosage: <1 yr 1mg, 1-8yr 2mg, >8yr 4mg
2010 Yakima County
Prehospital Care Protocols
Updated July 2010
How many time Calculation
APPENDIX F ‐ DRIP CHART & CONVERSIONS Drip Set periods does the drip
60 ml/hour
set have in one hour?
1.2 lbs = 1 kg (patient weighs 150lbs, 150/2.2 = 68kg)
5 cc = 1 tsp 60 gtts/ml 1 (there is 1 ‐ 60 minute 60 /1 = 60 gtts/min
15 cc = 1TBS or 3 tsp period in an hour)
Gtts/ml = Drops per milliliter
Gtts/min = Drops per minute
Convert grams to milligrams: __gm X 1000 = ___mg 20 gtts/ml 3 60/3 = 20 gtts/min
Convert liters to milliliters: __L X 1000 = ___ml
Convert milligrams to grams: __mg divided by 1000 = ___gm 15 gtts/ml 4 60/4 = 15 gtts/min
Convert milliliters to liters: __m l X 1000 = ___L
10 gtts/ml 6 60/6 = 10 gtts/min
Lidocaine 2 – 4 mg/min
Dopamine 5 – 7 mcg/kg/min Using a 500 ml of NS and 2 Grams of Lidocaine X 1000 = 2000 mg.
The Math: 7 X 100 X 60 = 4200/1600 = 26 gtts/min For every 15 drops = 1 mg of Lidocaine (a drop every 0.5 seconds)
For every 30 drops = 2 mg of Lidocaine ( a drop every other second)
For every 45 drops = 3mg of Lidocaine (a drop every 1.5 seconds)
APGAR – For Newborn Infants at Time of Birth
APPENDIX G – Glasgow Coma Scale, APGAR, START To be checked at 1min and 5min after birth.
Score 0 1 2
GLASCOW COMA SCALE ‐ For Head Injury Patients
Heart Rate Absent Less Than 100 Over 100
Eye Opening
Respiratory Absent Slow, Irregular Good Cry
Spontaneous 4
Effort
To loud voice 3
Muscle Tone Limp Some Flexion Active Motion
To pain 2
Reflex No Response Grimace Cry Cry
None 1 Irritability
Confused, disoriented 4
Inappropriate words 3
Reference Yakima
Incomprehensible sounds 2 County Operating
Procedure for MCI.
None 1
Best Motor Response
Obeys 6
Localizes 5
Withdraws (flexion) 4
Abnormal flexion posturing 3
Extension posturing 2
None 1