Polk State College
EMS Protocols
Paramedic Certificate Treatment Parameters
Polk State EMS Program
Clinical Education Office
Revised: February 7th, 2013
Polk State College
EMS Protocols
Cardiac 1. Angina / Myocardial Infarction
2. Supraventricular Bradycardia and A.V. Blocks
3. A - Fib / Flutter
4. Supraventricular Tachycardia
5. Ventricular Tachycardia with a Palpable Pulse
6. Torsades de Pointes
Cardiac Arrest 7. Asystole
8. PEA
9. V-Fib / Pulseless V-Tachycardia
Medical Emergencies
10. Abdominal Pain
11. Allergic Reaction / Anaphylactic Shock
12. Altered Mental Status
13. Asthma / COPD
14. Behavioral Emergency
15. Rapid Sequence Intubation (RSI) - Adult
16. Pulmonary Edema
17. Seizure
18. Overdose and Poisonings
19. Overdose Tricyclic and Tetracyclic Antidepressant
Anticholergenic Poisoning/Organophosphates Overdose
20. Overdose Antipsychotic / Acute Dystonic Reaction, Carbon Monoxide,
Cocaine & Sympathomimetic Overdose
21. Overdose Beta Blocker Toxicity
22. Overdose Calcium Channel Blocker Overdose
Trauma Emergencies
23. Adult Trauma Transport
24. Adult Pain Management
Pediatric Emergencies
Polk State College
EMS Protocols
25. Rapid Sequence Intubation (RSI)
26. Allergic Reaction / Anaphylactic Shock
27. Altered Mental Status
28. Bronchospasm
29. Supraventricular Bradycardia
30. Supraventricular Tachycardia (SVT)
31. Ventricular Tachycardia with a Palpable Pulse
32. Overdose, Poisoning or Ingestion
33. Seizure
Pediatric Cardiac Arrest
34. Asystole
35. Pulseless Electrical Activity (PEA)
36. Ventricular Fibrillation / Pulseless Ventricular Tachycardia
Pediatric Trauma Emergencies
37. Pain Management
38. Trauma Transport
Polk State College
EMS Protocols
1
Angina / Myocardial Infarction
Initial Medical Care (Oxygen, IV, Monitor)
Record and monitor vital signs
Initiate cardiac monitoring, record and evaluate EKG strip.
AMI (STEMI) is indicated if 12 Lead indicates > 1mm ST elevation in: • Lead II, III, AVF (Inferior Wall MI) (Check V4R)
• V1, V2 (Septal Wall MI)
• V3, V4 (Anterior Wall MI)
• V5, V6, Lead I, AVL, or (Lateral Wall MI)
• Any 2 contiguous leads Do not interpret ST elevation in ECGs presenting with right or left BBB.
Baby ASA (4) 324 mg, chewed. (81 mg each)
Nitroglycerin (Nitrostat) 0.4 mg SL spray, at 5 minute intervals until Nitroglycerin Drip established.
Contraindicated in patients:
Systolic BP < 90 mm Hg / Viagra use in past 24 hrs
Use with caution in acute Inferior Wall MI, (Assess V4R to rule out RVI)
NOTE: Ensure IV line started, SBP < 110 mm Hg and be prepared to administer IV NS boluses at 200-300
ml if hypotension develops)
Nitroglycerin Drip at 10 mcg / minute via infusion regulator. Titrate and increase at 5 mcg / minute
increments every 3 - 5 minutes until relief of discomfort or systolic B/P <100 mm Hg.
If pain unrelieved by Nitro Drip, Morphine Sulfate 2 mg slow IVP every 5 minutes (Maximum 10 mg)
Contraindicated in patients: Systolic BP < 90 mm Hg / Use with caution in acute Inferior Wall MI,
(Assess V4R to rule out RVI)
Promethazine (Phenergan) 12.5 mg diluted with 9 ml of NS or RL slow IVP for severe vomiting.
If BP < 90 mm Hg systolic, administer 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg
Polk State College
EMS Protocols
2
Bradycardia / A.V. Blocks
Basic Life Support
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Do not delay treatment by obtaining EKG unless diagnosis is in question
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock
If systolic BP < 90 mm/ Hg, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg
Symptomatic (B/P <90 AND altered mental status AND signs of shock)
Atropine 0.5 B 1.0 mg fast IVP repeat every 3 minutes as needed (Maximum 3mg)
(Consider TCP before Atropine if 2nd II or 3 AV Blocks)
Administer sedation if needed
Midazolam (Versed) 2.5mg slow IVP
Initiate transcutaneous pacing using Demand Mode
Start at lowest MA=s until electrical capture with pulses achieved.
Verify mechanical capture, if not, continue increase in MA until mechanical capture
Start rate at 70 or default and increase rate to achieve systolic BP > 90mm Hg
(Maximum 100 beats/minute)
If above unsuccessful
Dopamine (Intropin) infusion at 5-20 mcg/kg/minute IV titrated to maintain systolic
BP > 90 mm/Hg
If drug induced, treat as per specific drug overdose
Calcium Chloride 1 gram IV for calcium channel blocker OD
Avoid if patient on digoxin/Lanoxin
Asymptomatic
Place Transcutaneous Pacing on standby and use in demand mode if needed
Medical Control
Contact medical control for Epinephrine (Adrenalin) infusion at 2-10 mcg/minute IV.
NOTE: Epinephrine (Adrenalin) 2mg in a 250 ml bag equates to 15 gtts / 2 mcg
Polk State College
EMS Protocols
3
Atrial Fibrillation / Atrial Flutter
Basic Life Support
Secure airway - Administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG
Heart Rate > 150 beats/minute
Do not delay treatment if patient is unstable by obtaining EKG unless diagnosis is in question
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock
Stable (BP > 90 mm Hg)
Rate > 150 beats/minute B and wide complex or WPW history
Advise ED physician if patient has had rhythm > 48 hours
Unstable (BP < 90 mm Hg AND altered consciousness AND Heart Rate > 150 beats/minute.
Sedation if needed
Midazolam (Versed) 2.5mg slow IVP
Synchronized Cardioversion
1st energy level 100 J Biphasic
If no response 150 J Biphasic
If no response 200 J Biphasic
Additional Drugs to consider:
Diltiazem (cardizem) 0.25 mg/kg slow IVP
Verapamil (Calan, Isoptin) 2.5 mg slow IVP
Polk State College
EMS Protocols
4
Supraventricular Tachycardia
SVT
Basic Life Support
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Do not delay treatment by obtaining EKG unless diagnosis is in question
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock - Initiate in Antecubital fossa if possible
(E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)
NOTE: Assess etiology – Only treat if cardiac related
Stable or borderline (Rate >150):
Vagal maneuvers (Valsalva or cough)
Adenosine phosphate (Adenocard) 6 mg rapid IVP over 1-3 seconds with 10cc flush
If no response in 2 minutes, 12 mg rapid IVP over 1-3 seconds with 10cc flush
Additional Drugs to consider:
If no response in 2 minutes, repeat 12 mg IVP over 1-3 seconds with 10cc flush (Total of 30 mg)
Unstable with serious signs and symptoms ((B/P <90 AND altered mental status AND signs of shock)
(Ventricular rate > 150):
May give brief trial of Adenosine (Adenocard) 6mg rapid IVP over 1-3 seconds with 10 cc flush
Sedation if needed
Midazolam (Versed) 2.5mg slow IVP
Synchronized Cardioversion
First energy level 50 J Biphasic
If no response 100 J Biphasic
If no response 150 J Biphasic
If no response 150 J Biphasic
If no response 150 J Biphasic
Polk State College
EMS Protocols
5
Ventricular Tachycardia with Pulse
Basic Life Support
Secure airway - Administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Do not delay treatment by obtaining EKG unless diagnosis is in question
In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are
unreliable in excluding VT as cause of wide complex tachycardia
Record & monitor oxygen saturation
IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)
Stable
Amiodarone (Cordarone) 150 mg IV over 10 minutes every 10-15 minutes (Maximum of 450 mg
total.)
Additional Medication to consider: Procainamide (Pronestyl) 20 mg / min until:
1) A maximum of 1 gram or 17mg/kg
2) Rhythm subsides
3) QRS widens by greater than 50%
4) Hypotension ensues
Unstable wide complex tachycardia (B/P <90 AND altered mental status AND signs of shock)
Sedation if needed: Midazolam (Versed) 2.5mg slow IVP
Synchronized Cardioversion
o 1st energy level 100 J Biphasic
o If no response, 150 J Biphasic
o If no response 150 J Biphasic
o If no response 150 J Biphasic
o If delays in synchronization occur and clinical condition is critical, go immediately to
unsynchronized shocks.
Following electrical Cardioversion
o If no antiarrythmic agent was given: Amiodarone (Cordarone) 150 mg IV over 10 minutes
o If Amiodarone (Cordarone) was given:
VT Reoccurs repeat at 150 mg IV over 10 minutes every 10-15 minutes (Maximum 450 mg
cumulative total dose)
Polk State College
EMS Protocols
6
Torsades de Pointes
Basic Life Support
Secure airway - Administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Do not delay treatment by obtaining EKG unless diagnosis is in question
In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are
unreliable in excluding VT as cause of wide complex tachycardia
Record & monitor oxygen saturation
IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)
Magnesium Sulfate 2 g slow IV in 10 ml NS over 1-2 minutes
If no response, perform Cardioversion - if clinical condition permits sedate before Cardioversion
Sedation if needed
Midazolam (Versed) 2.5mg slow IVP
Synchronized Cardioversion
o 1st energy level 100 J Biphasic
o If no response, 150 J Biphasic
o If no response 150 J Biphasic
o If no response 150 J Biphasic
If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks
Synchronized Cardioversion
o 1st energy level 100 J Biphasic
o If no response, 150 J Biphasic
o If no response 150 J Biphasic
o If no response 150 J Biphasic
Polk State College
EMS Protocols
7
Asystole
Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses
NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS
arrival, provide effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200
high quality compressions/rate of 100 /min with Interposed ventilation at a rate of 10 bpm)
Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated
Advanced airway/ventilatory management as needed
Endotracheal Intubation (Max 2 attempts)
Combitube if unable to intubate in appropriate patients
Confirm airway device placement with assessment and detection device (ETCO2) and capnography.
Continue CPR with no pause for ventilation.
IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV)
Epinephrine (Adrenalin) 1:10,000 1 mg IVP or IO (2 mg ETT) repeated every 3-5 minutes
Consider and treat possible causes
1. Hypoxia / Acidosis - (Hyperventilate)
2. Hypothermia – Warm Patient
3. Hypovolemia – Fluid bolus (200-300 cc up to 1-2 liters)
4. Hyperkalemia
5. Tablet (Drug) overdoses (see specific drug OD/toxicology section)
a. Beta blocker OD - Glucagon 2 mg IVP
b. Calcium channel blocker OD - Calcium Chloride 1 gram IV
i. Avoid if patient on Digoxin / Lanoxin
c. Narcotic OD - Naloxone (Narcan) 2 mg slow IVP
Polk State College
EMS Protocols
8
Pulseless Electrical Activity
(PEA)
Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses
NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS
arrival, provide effective CPR for 2 minutes. (200 high quality compressions/rate of 100 /min with
interposed ventilation at a rate of 10 bpm)
Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated
Advanced airway/ventilatory management as needed
Endotracheal Intubation (Max 2 attempts)
Combitube if unable to intubate in appropriate patients
Confirm airway device placement with assessment and detection device (ETCO2) and capnography.
Continue CPR with no pause for ventilation.
IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV
Epinephrine (Adrenalin) 1:10,000 1 mg fast IVP or IO (2 mg ETT) repeated every 3-5 minutes
Potential PEA cause Treatment
Hypovolemia (most common cause) Normal Saline 200 – 300cc Bolus up to 1-2 Liters IV
Hypoxia / Hydrogen ion – acidosis Open/secure airway and ventilate
Hyperkalemia Call for orders
Hypothermia Active core rewarming
Tablets (drugs) Beta blocker OD - Glucagon 2 mg IVP
Calcium channel blocker OD - Calcium Chloride 1 gram IV
Avoid if patient on Digoxin / Lanoxin
Narcotic OD - Naloxone (Narcan) 2 mg IVP
Tamponade, cardiac Normal Saline 1-2 Liters IV
(In hospital pericardiocentesis)
Tension pneumothorax Plural Decompression
Thrombosis (Coronary / Pulmonary) (In hospital thrombolytics, cardiac cath.)
Polk State College
EMS Protocols
9
V-Fib / Pulseless V-Tach
Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses
NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide
effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200 high quality compressions/rate of
100 /min with Interposed ventilation at a rate of 10 bpm
Apply monitor/defibrillator
If V-Fib / Pulseless V-Tachycardia identified:
Defibrillate at 150J biphasic (360 J monophasic) followed by immediate CPR beginning with
compressions. Perform 200 high quality compressions/rate of 100 p/m with ventilations at a rate of 10
bpm (2) minute cycles
Repeat defibrillation x1 at 150 J biphasic (360j mono-phasic) as indicated at end of each CPR cycle
Continue rescue breathing with BVM (100% oxygen) without CPR if pulse present
Advanced airway/ventilatory management as needed
- King Airway (If available)
- Endotracheal Intubation (Max 2 Attempts)
- Combitube if unable to intubate in appropriate patients
Confirm airway device placement with exam and detection device (EtCO2 and Capnography)
IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV)
Epinephrine 1mg (Adrenalin) fast IVP/IO every 3- 5 minutes (2 mg ETT if no IV or IO access.)
Defibrillate 150 J Biphasic (or 360 J Monophasic) Bfollowed by immediate CPR for two minutes. This
step may be repeated as indicated at end of two minute CPR cycles.
Antiarrythmic/additional medications B administer sequentially (in the order listed) and defibrillate as indicated at
end of 2 minute CPR cycles-followed with immediate CPR.
Amiodarone (Cordarone) 300 mg IVP/IO may repeat 1 time at 150mg after 10 minutes,
Reassess patient for conversion between each intervention above.
Polk State College
EMS Protocols
10
Abdominal Pain / GI Bleeding
Basic Life Support
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Nothing by mouth (NPO)
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO (if condition warrants)
If BP < 90 mm / Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic
BP > 90 mm Hg
Record and evaluate 12-lead EKG
For patients with severe vomiting:
Promethazine (Phenergan), 12.5 mg slow IVP
Polk State College
EMS Protocols
11
Allergic Reaction / Anaphylactic Shock
Basic Life Support
Secure airway and administer supplemental oxygen (100%)
Record and monitor vital signs
Nothing by mouth (NPO)
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock
Mild Reaction (Itching/Hives)
Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) May be administered IM if no IV access
Additional Drugs to consider:
Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes
Moderate Reaction (Dyspnea, Wheezing, Chest tightness)
Albuterol 2.5 mg (Proventil) and Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft
May repeat once in 20 minutes
Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
May be administered IM if no IV access available
Additional Drugs to consider:
Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes
Severe systemic reaction (BP < 90 mm Hg, stridor, severe respiratory distress)
Administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg
Epinephrine (Adrenalin) 1:1,000 0.3 mg SQ
Albuterol 2.5 mg (Proventil) and Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft
May repeat once in 20 minutes
Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
May be administered IM if no IV access available
Additional Drugs to consider:
Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes
Methylprednisolone (Solu-Medrol) 125 mg slow IVP
Imminent Cardiac Arrest or Cardiopulmonary Arrest:
Epinephrine (Adrenalin) 1:10,000 0.5 mg IVP (instead of 1:1,000 SQ)
Albuterol 2.5 mg (Proventil) and Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft
Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)
Polk State College
EMS Protocols
12
Altered Mental Status Basic Life Support
Secure airway and administer supplemental oxygen
Record / monitor vital signs and Blood Glucose level
Nothing by mouth, unless patient is a known diabetic and is able to self-administer Glucose paste, orange
or apple juice
Assess for etiology
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG
Record & monitor oxygen saturation & end-tidal C02 (if available)
IV 0.9% NaCl KVO or IV lock
If Hypoglycemic (Blood glucose < 60 mg/dL) with IV access
Additional Drugs to consider:
If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose
Dextrose 50% 25 gm Slow IVP
May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dL
If Hypoglycemic (Blood glucose < 60 mg/dL) without IV access
Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to
self-administer oral agent or
Glucagon 1 mg IM
If Drug (narcotic) overdose suspected
Naloxone (Narcan) 2 mg slow IVP
If no IV access has been established, administer Naloxone (Narcan) 2.0mg IM.
Polk State College
EMS Protocols
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Asthma / COPD
Basic Life Support
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock
If Acute Bronchospasm (wheezing)
Note: Patient may present with CLEAR diminished lung sounds due to the inability to move air because
they are so constricted.
If Asthma History - Albuterol (Proventil) 2.5 mg via updraft.
Additional Drugs to consider:
Repeat Albuterol (Proventil) 2.5 mg via updraft x2 as needed
Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/ 2.5 ml via updraft
Methylprednisolone (Solu-Medrol) 125 mg slow IVP
If COPD History - Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide 0.02% (Atrovent) 0.5
mg/2.5 ml via updraft
o May repeat in 20 minutes x2
o If patient condition deteriorates, Utilize CPAP at 5.0 cmH20
Additional Drugs to consider:
Methylprednisolone (Solu-Medrol) 125 mg slow IVP
If patient experiences decreased level of consciousness with respiratory failure OR poor ventilatory effort (with
hypoxia unresponsive to supplemental 100% oxygen) OR unable to maintain patent airway, intubation is indicated.
If conscious sedation needed proceed with RSI protocol
Polk State College
EMS Protocols
14
Behavioral Emergencies
Basic Life Support
Secure airway and administer supplemental oxygen
Record / monitor vital signs and Blood Glucose level
Restrain as needed for patient/crew safety
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and evaluate 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO (if condition warrants)
o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic
BP > 90 mm Hg
For patients with extreme agitation resulting in interference with patient care or patient/crew safety
o Midazolam (Versed)
< 70 kg 5 mg IM
> 70 kg 10 mg IM
Select MAO inhibitors
Nardil (Phenelzine)
Parnate (Tranylcypromine)
Additional Drugs to consider:
Haloperidol (Haldol) < 60 kg 5 mg IM
> 60 kg 10 mg IM.
Medical Control
Call Medical Control if further sedation needed
Repeat Haloperidol (Haldol) 5 mg IV or IM
Polk State College
EMS Protocols
15
Rapid Sequence Induction (RSI)
Adult
REMEMBER – ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES
PRECEDENT OVER TRAUMA SCENE TIME!!!
This protocol is only to be utilized under the following circumstances:
TRAUMA
BMR <= 4 (UNCONSCIOUS – withdraws to painful stimulus)
Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS – localizes painful stimulus)
Unstable traumatic airway condition as assessed by the Paramedic
MEDICAL - As specified in specific protocols
Basic Life Support
Secure airway - Administer supplemental oxygen 100% via BVM device
Record and monitor vital signs
Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history)
Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before
utilizing King Airway
Advanced Life Support
Begin cardiac monitoring, record and evaluate EKG strip
Visually evaluate oropharynx for indications of difficult intubation situation. If no visual indications present,
then proceed with RSI.
IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV)
If no seizure:
o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched) o If clenched induce paralysis with Succinylcholine 1.5 mg/kg IV
o Confirm tube placement with CO2 detector color change
o Provide oxygenation between intubation attempts (Maximum of 2 attempts, then SALT or Combitube)
o Midazolam (Versed) 5 mg IV if Succinylcholine is given or needed for continued sedation.
May repeat for a Midazolam (Versed) 5 mg IV for sedation
If seizure: o Lidocaine (Xylocaine) 1mg/kg IV if Head Injury
o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation
o Midazolam (Versed) 5 mg IV for sedation if needed.
o Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO2
detector color change
o If two (2) endotrachael attempts fail, begin BCLS procedures, control airway and ventilate with BVM
and airway adjunct
Polk State College
EMS Protocols
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Pulmonary Edema
Basic Life Support
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO or IV lock
Only if Wheezing is present:
Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft
May repeat once in 20 minutes
Contraindicated if: HR > 150 or systolic BP > 180 mm Hg
Nitroglycerin (Nitrostat) 0.4 mg spray SL every 5 minutes, until Nitroglycerin drip established at 10mcg/min via
infusion regulator. Contraindicated if: Systolic BP < 90 mm Hg
Viagra taken within 24 hrs
Additional Drugs to consider:
Furosemide (Lasix) 1 mg / kg to a maximum of 100mg
Utilize CPAP at 10.0 cm H2O. Evaluate effectiveness and need for intubation If patient experiences decreased level of
consciousness with respiratory failure OR
poor ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) OR
unable to maintain patent airway, intubation is indicated.
If conscious sedation needed to effect intubation proceed with RSI protocol
Dopamine (Intropin) infusion at 5-20 mcg/kg/min titrated as needed if systolic BP < 90 mm Hg
Polk State College
EMS Protocols
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Seizure Basic Life Support
Secure airway and administer supplemental oxygen
Record / monitor vital signs and Blood Glucose level
Protect patient from injury
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip
Record and evaluate 12-lead EKG if seizure has stopped
Record & monitor oxygen saturation
Blood Glucose measurement
IV 0.9% NaCl KVO or IV lock (medications only for active seizures)
If Hypoglycemic (Blood glucose < 60 mg/dL) with IV access
Additional Drugs: If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose
NOTE: Must be given PRIOR to or in conjunction with Dextrose.
Dextrose 50% 25 gm Slow IVP
May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dL
If Hypoglycemic (Blood glucose < 60 mg/dL) without IV access
Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to self
administer oral agent or
Glucagon 1 mg IM
Midazolam (Versed) 2.5 mg slow IVP repeat once for a maximum of 5 mg
If NO IV access:
Midazolam (Versed) 5 mg slow IVP repeat once for a maximum of 10 mg
Polk State College
EMS Protocols
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Overdose and Poisonings
NOTE: General considerations for any overdose or poisoning include determining the particular agent(s) involved, the
time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc., to the receiving facility.
See HAZMAT protocol for exposure to hazardous materials.
Basic Life Support
Secure airway and administer supplemental oxygen (100%)
Record / monitor vital signs and Blood Glucose level
Nothing by mouth (depending on agent, patient may be at risk for seizure or rapid loss of consciousness with
subsequent aspiration)
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
Record & monitor 02 saturation
IV 0.9% NaCl KVO
o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90
mm Hg
Antidepressants Category Drugs Overdose Effects
Tricyclic
antidepressants
Amitriptyline (Elavil, Endep, Etrafon,
Vanatrip, Levate)
Hypotension
Anti-cholinergic effects (tachycardia,
seizures, altered mental status,
mydriasis)
AV conduction blocks, prolonged
QT interval, wide QRS, VT and VF
Clomipramine (Anafranil)
Doxepin (Sinequan, Zonalon, Triadapin)
Imipramine (Tofranil, Impril)
Nortriptyline (Aventyl; Pamelor, Norventyl)
Desipramine (Norpramin)
Protriptyline (Vivactil)
Trimipramine (Surmontil)
(Limbitrol) Amitriptyline + chlordiazepoxide
Other Cyclic
Antidepressants
Maprotiline (Ludiomil) Ludiomil is similar to tricyclics,
Asendin produces mostly seizures Amoxapine (Asendin)
Bupropion (Wellbutrin) Minimal-moderate seizures
Trazodone (Desyrel, Trazorel) Less seizures and cardiac effects than
tricyclics
Selective
Serotonin Reuptake
Inhibitors (SSRI’s)
Citalopram (Celexa) Hypertension, tachycardia, agitation,
diaphoresis, shivering, tremor,
muscle rigidity
Malignant Hyperthermia
Fluoexitine (Prozac)
Fluvoxamine (Luvox)
Paroxetine (Paxil)
Sertraline (Zoloft)
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Overdose
Tricyclic and Tetracyclic Antidepressant
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO
If wide QRS, hypotension, or arrhythmias present:
Consider: Sodium Bicarbonate 1mEq / kg IVP
Anticholinergic Poisoning/Organophosphates
Basic Life Support
Wear protective clothing including masks, gloves, and eye protection.
Toxicity to ambulance crew may result from inhalation or topical exposure.
Any traces of contamination must be removed from the vehicle prior to the next transport.
Secure airway and administer supplemental oxygen
Record and monitor vital signs
Decontaminate patient
o Remove clothing
o Irrigate with normal saline – may also use soap and water
o Contain run-off of toxic chemicals when flushing
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO o Remember SLUDGE: Salivation, Lactation, Urination, Defecation, GI, Emesis
o If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory secretions – do
not rely on pupil constriction to diagnose or to titrate medications)
o Atropine 2.0 mg fast IVP every 5 min – titrate until respiratory secretions/distress begins to
decrease
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Antipsychotic/Acute Dystonic Reaction
Commonly used Antipsychotic and Antipsychotic related medicines (e.g. antiemetics) in medical practice include, but are not
limited to the following: Prochlorperazine (Compazine) Promethazine (Phenergan) Thorazine
Prolixin Haloperidol
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO
For Dystonic reactions, administer
Diphenhydramine (Benadryl) 25 mg IVP.
Repeat Diphenhydramine (Benadryl) 25 mg IVP if inadequate response, in 10 minutes
Carbon Monoxide
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO
Draw blood and place with cold pack
Consider transport to hyperbaric chamber
Cocaine and Sympathomimetic Overdose
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO
For patients with Sympathomimetic toxidrome (hypertension, tachycardia, agitation):
o Midazolam (Versed) < 70 kg - 2.5 mg slow IVP
> 70 kg - 5 mg slow IVP
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Beta Blocker Toxicity
Commonly used Beta Blockers(lol) in medical practice include but are not limited to the following:
Propranolol (Inderal) Atenolol (Tenormin) Metroprolol (Lopressor) Nadolol (Corgard)
Timolol (Blocadren) Labetolol (Trandate) Esmolol (Brevibloc) Acebatolol (Sectral)
In addition beta-blockers are contained in many combination drugs. It is the beta-blocker component that leads to
specific toxicity. Combination beta-blocker drugs include, but are not limited to the following:
Corzide (Nadolol/bendroflumethlazide) Inderide (Propranolol/HCTZ)
Inderide LA (Propranolol/HCTZ) Lopressor HCT (Metoprolol/HCTZ)
Tenoretic (Atenolol/Chlorthalidone) Timolide (Timolol/HCTZ)
Ziac (Bisoprolol/HCTZ)
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at 200-300ml until systolic BP > 90
mm Hg
For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) with
(1) bradycardia with rate < 60 or
(2) Heart block, including third degree heart block and high grade second degree heart blocks i.e. Mobitz Type II
second degree
Administer the following agents
Atropine 0.5 mg IV, may repeat X 2
If no response, begin Transcutaneous Pacing
Medical Control
Dopamine (Intropin) infusion, or additional orders if cardiovascular toxicity persists
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Calcium Channel Blockers
Calcium Channel Blockers include:
Amlodipine (Norvasc) Felodipine (Plendil, Renedil) Isradipine (DynaCirc) Nicardipine (Cardene)
Verapamil (Calan) Nifedipine (Procardia, Adalat) Diltiazem (Cardizem)
Basic Life Support
Secure airway and administer supplemental oxygen 100%
Record and monitor vital signs
Advanced Life Support
Advanced airway/ventilatory management as needed
Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG
Record & monitor oxygen saturation
IV 0.9% NaCl KVO o If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at 200-300ml until systolic
BP > 90 mm Hg
For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) (1)
bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree
heart blocks i.e. - Mobitz Type II second degree
Administer the following agents
o Atropine 0.5 mg fast IV, may repeat X 2
o If no response, Calcium Chloride 1 gram IV
Avoid if patient taking digoxin (Lanoxin)
o If no response, may repeat Calcium Chloride 1 gram IV
o If no response, begin transcutaneous pacing
Medical Control
Dopamine (Intropin) or epinephrine infusion, or additional orders if cardiovascular toxicity persists
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Adult Trauma Triage Criteria
COMPONENT
BLUE
RED
AIRWAY
RESPIRATORY RATE > = 30 / MINUTE
Active Airway Assistance Beyond Administration of
Oxygen
CIRCULATION
Sustained Heart Rate
> 120
(1) Lack of Radial Pulse With Sustained H/R > 120
OR (2) B/P < 90 mm / hg
BEST MOTOR
RESPONSE
(Pinch of the inner thigh)
BMR = 5
(1) BMR < = 4
OR (2) EXHIBITS PRESENCE OF PARALYSIS
OR (3) Suspicion of Spinal Cord Injury OR Loss of
Sensation
CUTANEOUS
(1) Soft Tissue Loss via Degloving Injuries
OR (2) Major Flap Avulsions > 5 Inches
OR (3) GSW To Extremities of The Body
(1) Amputation Proximal To Wrist / or Ankle
OR (2) 2nd / 3rd Degree Burns To > 15 % TBSA
OR (3) Penetrating Injury To Head, Neck, Torso
( Excluding superficial wounds where the depth of the
wound can be determined) LONG BONE FRACTURE
S/S of Single Long Bone FX Site Resulting
From a MVC OR Fall > 10 Feet
S/S of 2 OR more Long Bone FX Sites
(SEE LONG BONE DEFINITION BELOW)
AGE
> 55
MECHANISM OF
INJURY
(1) Ejection From Vehicle
(EXCEPT: ATVS, Motorcycles, Bicycles,
Open Body of Pick-ups, Mopeds
OR (2) Driver Impact of Steering Wheel
Causing Deformity
LONG BONES ARE DEFINED AS
1. Radius AND Ulna,
2. Humerus
3. Femur
4. Tibia AND Fibula
Adult Pain Management
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Basic Life Support
Establish patient responsiveness
If trauma suspected, stabilize spine
Assess Airway/Breathing/Oxygenation
Assess perfusion and circulation , obtaining a baseline blood pressure
Assess mental status
Assess baseline pain level (0-10 scale), (0 = no pain, 10 = worst pain)
Administer nothing by mouth (NPO)
Advanced Life Support
Assess airway/breathing and ensure no airway intervention or ventilation needed
Begin cardiac monitoring
Record and monitor oxygen saturation
IV 0.9% NaCl KVO
Perform a focused history and detailed physical examination en route to the hospital if patient status and
management of resources permit.
Analgesic agents may be administered if patient has severe pain and one of following
o Extremity injury including long bone fracture in the presence of multi-system trauma. (Pt must be
alert, normotensive)
o Burn without airway, breathing, or circulatory compromise
o Medical Control Contact required for Sickle crisis with pain that is typical for that patient’s sickle
cell disease
o Acute chest pain – see chest pain protocol for management
Agents for pain control
Phenergan (Promethazine) 6.25 mg diluted in 5ml 0.9% NaCl slow IVP
Morphine Sulfate 2 mg slow IVP every 5 minutes until pain relief achieved (Maximum 10 mg)
(Maximum 20 mg for burns)
Reassess the patient frequently
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Rapid Sequence Induction (RSI)
Pediatric
REMEMBER – ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES
PRECEDENT OVER TRAUMA SCENE TIME!!!
This protocol is only to be utilized under the following circumstances:
TRAUMA
BMR <= 4 (UNCONSCIOUS – withdraws to painful stimulus)
Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS – localizes painful stimulus)
Unstable traumatic airway condition as assessed by the Paramedic
MEDICAL - As specified in specific protocols
Basic Life Support
Secure airway - Administer supplemental oxygen 100% via BVM device
Record and monitor vital signs
Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history)
Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before
utilizing King Airway
Advanced Life Support
Begin cardiac monitoring, record and evaluate EKG strip
IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV)
If no seizure:
Atropine 0.02 mg/kg fast IVP
Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP
Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched)
Induce paralysis with Succinylcholine 2.0 mg/kg slow IVP over 15-30 seconds
Confirm tube placement with CO2 detector color change
Provide oxygenation between intubation attempts (Maximum of 2 attempts, then OPA/NPA)
Midazolam (Versed) 0.1 mg/kg slow IVP if Succinylcholine has been given or for continued sedation. May
repeat once to a maximum of 5 mg.
If seizure:
Atropine 0.02 mg/kg IV
Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP
Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched)
Fentanyl (Sublimaze) 6 mcg/kg IV for sedation if needed
Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO2 detector
color change
Provide oxygenation between intubation attempts (Maximum of 2 attempts, then BVM and airway adjunct
Midazolam (Versed) 0.1 mg/kg slow IVP for continued sedation. May repeat once to a maximum of 5 mg. .
Medical Control
Contact medical control for continued sedation or higher dosage of medication to facilitate intubation
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Allergic Reaction / Anaphylactic Shock
(Pediatric)
Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed
Assess perfusion and circulation
Advanced Life Support
Advanced airway/ventilatory management as needed
Initiate cardiac monitoring, record and evaluate EKG strip
IV 0.9% NaCl KVO or IV lock
If patient meets criteria for anaphylactic shock
Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg SQ (max individual dose 0.3 mg)
o Massage the injection site vigorously for 30-60 seconds
Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg is equal to 0.01cc/kg SQ
If bronchospasm is present in a patient with adequate ventilation,
o Albuterol (Proventil) 2.5 mg via nebulizer over a 10-15 minute period
If bronchospasm persists,
o Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes
Reassess patient for signs of anaphylactic shock. If criteria are still present repeat
o Epinephrine (Adrenalin) 1:1,000 solution at 0.01 mg/kg (0.01cc/kg)
(Maximum individual dose 0.3 mg) via SQ injection.
Additional Drugs to consider:
Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml
Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP
IV 0.9% NaCl KVO or IV lock
If evidence of shock,
If IV access cannot be obtained, place intraosseous needle (IO).
Administer fluid bolus of 0.9% NaCl at 20 ml/kg set to maximum flow rate IV or IO
After reassessment, if shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.
Diphenhydramine (Benadryl) 1.0 mg/kg IV or deep IM (maximum individual dose 50 mg)
Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature
throughout the examination
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Altered Mental Status
Pediatric
This protocol is intended for pediatric patients with an altered mental status of unknown etiology.
Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed
Assess perfusion and circulation
Advanced Life Support
Advanced airway/ventilatory management as needed
If signs or respiratory distress, failure or arrest are present refer to the appropriate protocol
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% as necessary.
Use a non rebreather mask or blow-by as tolerated
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO, if IV access cannot be obtained after 2 attempts proceed with E/Z IO
Determine blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)
(NOTE: The following dosages are equivalent to 0.5g/kg)
D10W 5 ml/kg for neonates
D25W 2 ml/kg for children 2 years
D50W 1 ml/kg for children > 2 years
IF IV or IO access is unavailable:
< 20 kg, Glucagon 0.5 mg IM
> 20 kg, Glucagon 1.0 mg IM
Repeat Dextrose once if
Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood glucose and no change
in mental status
If patient has continued altered mental status
Naloxone (Narcan) 0.1 mg/kg (Maximum individual dose 2.0 mg) via IV or IO route
If IV or IO unavailable administer same dose endotracheally or IM
If evidence of shock
If IV access cannot be obtained, and 5 years place intraosseous needle (IO)
Fluid bolus 0.9% NaCl at 20 ml/kg
If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.
Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature
throughout the examination
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Bronchospasm
Pediatric
Basic Life Support
Assess airway and breathing and administer oxygen
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Assess circulation and perfusion
Advanced Life Support
Obtain and record pulse oximetry reading
Assist breathing/ventilation if needed
If bronchospasm
Albuterol (Proventil) 2.5 mg via nebulizer over 10-15 minutes
If bronchospasm persists, repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes
If patient shows signs of respiratory distress or failure with clinical evidence of bronchospasm or a history of
asthma and inadequate ventilation
Epinephrine (Adrenalin) 1:1,000 at 0.01 mg/kg (max 0.3 mg) subcutaneously
Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20 minutes AND Epinephrine every 15
minutes as needed x 2. NOTE: May administer at same time nebulizer is being administered
Additional Drugs to consider:
Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml
Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP
Magnesium Sulfate 50mg/kg IV over 5-10 minutes
Initiate transport and perform focused history and detailed physical examination en route to the hospital if patient status
and management of resources permit.
Reassess the patient frequently
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Bradycardia
Pediatric
Advanced Life Support
Advanced airway/ventilatory management as needed / Obtain and record pulse oximetry reading
Initiate cardiac monitoring and determine rhythm
Initiate chest compressions if signs of severe cardiopulmonary compromise are present in an infant (< 1 year)
or neonate and the heart rate remains slower than 60 beats per minute despite oxygenation and ventilation
Identify and treat possible causes of bradycardia
If hypoxia open airway - assist breathing If hypothermic – rewarm
If signs of severe cardiopulmonary compromise
IV 0.9% NaCl KVO – NOTE: If IV cannot be obtained after 2 attempts, AND the patient shows signs
of severe cardiopulmonary compromise, proceed with E/Z IO access.
Do not delay transport to establish access
*Check blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)
(NOTE: The following dosages are equivalent to 0.5g/kg)
D10W 5 ml/kg for neonates
D25W 2 ml/kg for children 2 years
D50W 1 ml/kg for children > 2 years
If signs of severe cardiopulmonary compromise persist: Use 1st route available
Epinephrine (Adrenalin) 1:10,000 at 0.01 mg/kg (Max 1 mg) via IV/IO
Repeat dose every 3-5 minutes until either the bradycardia or severe cardiopulmonary compromise
resolves
If signs of severe cardiopulmonary compromise persist despite epinephrine and above measures
Atropine at 0.02 mg/kg via IV, IO, (0.2cc/kg)
Minimum dose is 0.1 mg and Maximum individual dose is 0.5 mg / child and 1.0 mg / adolescent
May repeat once after 3-5 minutes until maximum dose reached.
If severe cardiopulmonary compromise persists despite epinephrine/atropine
If weight is < 15 kg apply pediatric external pads, 15 kg apply adult external pacer pads use lowest
energy that causes every pacer impulse to result in ventricular capture (pulse)
If severe cardiopulmonary compromise persists despite pacing
Dopamine (Intropin)infusion at 5-20 mcg/kg/minute IV
Medical Control
Repeated administration of Epinephrine (Adrenalin) and Atropine
Polk State College
EMS Protocols
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Supraventricular Tachycardia
Pediatric Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation
Assess perfusion and circulation
Assess patient to ensure etiology and this is cardiac in nature!
Advanced Life Support
Assist airway, ventilation if needed
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO
If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary
compromise, proceed with E/Z IO access.
Do not delay transport to obtain vascular access
*Check blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)
(NOTE: The following dosages are equivalent to 0.5g/kg)
D10W 5 ml/kg for neonates
D25W 2 ml/kg for children 2 years
D50W 1 ml/kg for children > 2 years
Supraventricular tachycardia (HR > 220 Infants, >190 Child) with severe cardiopulmonary compromise
Adenosine (Adenocard) 0.1 mg/kg (0.1cc/3kg)
Max individual dose 6.0 mg via rapid IV/IO bolus at the port closest to the IV hub.
Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (Maximum individual dose 12 mg)
If Adenosine is unsuccessful and patient still has severe cardiopulmonary compromise
See Medical Control box for possible sedation orders
Medical Control
Sedate the patient before Cardioversion as permitted by Medical Direction
Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg)
Synchronized Cardioversion at 0.5 - 1.0 joules/kg
May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules)
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Ventriclular Tachycardia (With Pulse)
Pediatric Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation
Assess perfusion and circulation
Advanced Life Support
Assist airway, ventilation if needed
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO
If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary
compromise, proceed with E/Z IO access.
Do not delay transport to obtain vascular access
*Check blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)
(NOTE: The following dosages are equivalent to 0.5g/kg)
D10W 5 ml/kg for neonates
D25W 2 ml/kg for children 2 years
D50W 1 ml/kg for children > 2 years
Amiodarone (Cordarone) 5mg/kg IV over 10 minutes (Mix in a 100cc bag – 1ml/kg)
If vascular access is not readily available AND the patient is poorly perfused
See Medical Control box for possible sedation orders
Medical Control
Sedate the patient before Cardioversion as permitted by Medical Direction
Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg)
Synchronized Cardioversion at 0.5-1.0 joules/kg
May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules)
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Overdose / Poisoning or Ingestion
Pediatric Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation
Assess perfusion and circulation
Advanced Life Support
Assist airway, ventilation if needed
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO
If respiratory depression is present and a narcotic overdose is suspected,
Administer Naloxone (Narcan) at 0.1 mg/kg (Maximum dose 2.0 mg) via IV, IO, or IM route
Treatment for specific toxic exposures:
Organophosphates
Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg)
Calcium channel and B-blocker overdose
Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg if inadequate response
Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg) for symptomatic bradycardia, if
inadequate response
Calcium Chloride 0.3 ml/kg slow IV over 2 minutes for calcium channel blocker overdose
Dystonic reactions –acute uncontrollable muscle contractions
Diphenhydramine (Benadryl) 1 mg/kg IV or deep IM (Maximum dose 50 mg)
Medical Control
Contact Medical Control for questions concerning individual toxic exposures and treatments.
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Seizure
Pediatric
Basic Life Support
Establish responsiveness
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation
Assess perfusion and circulation
Advanced Life Support
Assist airway, ventilation if needed
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO
If IV access cannot be obtained AND patient in shock, proceed with E/Z IO access
*Check blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)
(NOTE: The following dosages are equivalent to 0.5g/kg)
o D10W 5 ml/kg for neonates
o D25W 2 ml/kg for children 2 years
o D50W 1 ml/kg for children > 2 years
o Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg
Repeat dextrose once if Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood
glucose and no change in mental status.
Administer anticonvulsants IV slowly over 1-2 minutes if patient in status epilepticus
(More than 10 minute seizure, or more than 1 seizure without awakening)
Midazolam (Versed) 0.1 mg/kg IV (Max. individual dose 5 mg) OR if no IV
Midazolam (Versed) 0.2 mg/kg IM (Max. individual dose 10 mg)
Medical Control
Contact Medical Control for any further orders, questions, or assistance.
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Asystole
Pediatric
Establish patient responsiveness - If spine trauma suspected, stabilize spine
Confirm Cardiac Arrest: Begin CPR (Two minute cycles of 30:2 or 15:2 with two rescuers)
NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective
CPR for 2 minutes while preparing to evaluate rhythm. (200 high quality compressions/rate of 100 per minute with
Interposed ventilation)
Apply heart monitor as soon as available.
Follow Non-traumatic Cardiac Arrest Protocol
Confirm the presence of Asystole in two leads
Maintain adequate ventilation via BVM with 100% oxygen
o Endotracheal Intubation (Max 2 attempts)
o Assess effective ventilations with exam, and ETCO2/capnography
o If unable to intubate, maintain adequate ventilations via BVM with airway adjunct and 100% oxygen.
IV 0.9% NaCl KVO, if signs of severe cardiopulmonary compromise; proceed with E/Z IO access.
Using the most readily available route, administer
Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg IV or IO, repeat every 3-5 min.
Potential Asystole cause Treatment
Hypovolemia (most common cause) Normal Saline 20 cc / kg may repeat times 2
(to a maximum total of 60ml/kg)
Hypoxia / Hydrogen ion – acidosis Open/secure airway and ventilate
Hypothermia Active core rewarming
Hypoglycemia (Blood glucose < 60 mg/dL) - Dextrose 50% 25 gm Slow IVP
Tablets (drugs) Calcium channel blocker OD - Glucagon 0.5 mg < 20 kg or 1 mg > 20 kg
If no response: Atropine 0.02 mg/kg
If no response: Calcium Chloride 30 mg/kg Narcotic OD - Naloxone (Narcan) 0.1 mg/kg
Tamponade, cardiac Normal Saline 20 m1/ kg (In hospital pericardiocentesis)
Tension pneumothorax Plural Decompression (20 gauge needle)
Trauma (In hospital surgery)
Maintain the child’s body temperature throughout the examination
Medical Control
Contact Medical Control for any further orders, questions, or assistance.
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Pulseless Electrical Activity (PEA)
Pediatric
Advanced Life Support
Establish patient responsiveness / If trauma suspected, stabilize spine
Confirm apnea and pulselessness and administer CPR
o (Two minute cycles of 30:2 or 15:2 with two rescuers)
Apply heart monitor soon as available.
Maintain adequate ventilation via BVM with airway adjunct (OPA) and 100% oxygen
Endotracheal Intubation (Max 2 attempts)
Assess effective ventilations with exam, EtCo2 and capnography.
If unable to intubate, maintain adequate ventilations via BVM with airway adjunct and 100% oxygen
Follow Nontraumatic Cardiac Arrest Protocol
Treat suspected cause of PEA if known:
Potential PEA cause Treatment
Hypovolemia (most common cause) Normal Saline 20 cc / kg may repeat times 2
(to a maximum total of 60ml/kg)
Hypoxia / Hydrogen ion – acidosis Open/secure airway and ventilate
Hypothermia Active core rewarming
Hypoglycemia (Blood glucose < 60 mg/dL) - Dextrose 50% 25 gm Slow IVP
Tablets (drugs) Calcium channel blocker OD - Glucagon 0.5 mg < 20 kg or 1 mg > 20 kg
If no response: Atropine 0.02 mg/kg
If no response: Calcium Chloride 30 mg/kg Narcotic OD - Naloxone (Narcan) 0.1 mg/kg
Tamponade, cardiac Normal Saline 20 m1/ kg (In hospital pericardiocentesis)
Tension pneumothorax Plural Decompression (20 gauge needle)
Trauma (In hospital surgery)
If PEA persists, using the most readily available route
Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg IV or IO, repeat every 3-5 min.
Flush medication port with 10-20 ml of normal saline after each dose
Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature
throughout the examination
Perform focused history and detailed physical examination en route to the hospital if patient status and
management of resources permit.
Reassess frequently
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EMS Protocols
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V-Fib / Pulseless V-Tachycardia
Pediatric
Advanced Life Support
Establish patient responsiveness / if spinal trauma suspected, stabilize / Apply heart monitor soon as available
Confirm apnea and pulselessness and administer CPR (Two minute cycles of 30:2 or 15:2 with two
rescuers)
Defibrillate at 2.0 j/kg (maximum of 200 joules) or equivalent biphasic followed by immediate CPR for
two minutes.
Continue ventilations via BVM/ETT with 100% oxygen throughout resuscitation/post resuscitation
efforts as indicated.
Endotracheal Intubation (Max 2 attempts)
Assess effective ventilations with exam, EtCo2 and capnography.
Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia using the most readily available route
administer:
Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg (1cc/kg) IV or IO, repeat every 3-5 min.
Flush medication port with 10-20 ml of normal saline after each dose
Defibrillate at 4.0 j/kg (maximum of 360 joules) or equivalent biphasic followed by immediate CPR for
two minutes. May repeat this step as indicated at end of two minute CPR cycles.
Amiodarone (Cordarone) 5 mg/kg IV/IO (1cc/kg) bolus. Repeat at 2.5 mg/kg one time if needed.
o Magnesium 50 mg/kg IV/IO for torsades de pointes or hypomagnesaemia
Defibrillate at 4.0 J/kg within 30-60 seconds after each medication at end of two minute CPR cycles.
IF VF or pulseless VT reoccurs after successful defibrillation, repeat defibrillation using the last energy level that
restored perfusing rhythm
Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the
examination
Perform focused history and detailed physical examination en route to the hospital if patient status and management of
resources.
Polk State College
EMS Protocols
37
Pain Management
Pediatric
Basic Life Support
Establish responsiveness / Mental Status
If trauma suspected, stabilize spine
Airway/Breathing/Oxygenation
Assess perfusion and circulation
Advanced Life Support
Assist airway, ventilation if needed
If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with
non-rebreather mask or blow-by as tolerated
Obtain baseline blood pressure
Initiate cardiac monitoring and determine rhythm
IV 0.9% NaCl KVO
Analgesic agents may be administered if patient has severe pain and one of following
Extremity injury including long bone fracture in the presence of multi-system trauma.
o (Patient must be alert, normotensive)
Burn without airway, breathing, or circulatory compromise
Typical sickle cell crisis for patient
Agents for pain control
Phenergan (Promethazine) 6.25 mg diluted in 5ml 0.9% NaCl slow IVP
Morphine Sulfate 1 mg slow IVP every 5 minutes until pain relief achieved (Maximum 10 mg)
Reassess the patient every 5 minutes
After drug administration note adequacy of ventilation and perfusion
Medical Control
Contact Medical Control for questions concerning pain control in children not meeting above criteria
Polk State College
EMS Protocols
38
Pediatric Trauma Triage Criteria
COMPONENT
BLUE
RED
SIZE (1) 11 KG ( 24 LBS) OR LESS
OR (2) The body length is equivalent to this
weight on a PEDIATRIC LENGTH AND
WEIGHT EMERGENCY TAPE
AIRWAY
(1) Intubated
OR (2) Breathing is Assisted Through Manual Jaw
Thrust, Suctioning, Adjuncts
CONSCIOUSNESS
(1) Symptoms of Amnesia
OR (2) Loss of Consciousness
(1) Altered Mental Status OR
(2) COMA OR
(3) Presence of Paralysis OR
(4) Suspicion of Spinal Cord Injury OR
(5) Loss of Sensation
CIRCULATION (1) Only Carotid or Femoral Pulses
Palpable, But Radial and Pedal Pulses are
not Palpable
OR (2) SBP < 90 MM / HG
(1) Faint or Nonpalpable Carotid or Femoral
Pulses
OR (2) SBP < 50 MM / HG
FRACTURE Signs / Symptoms of a Single Closed Long
Bone Fracture
(EXCLUDING ISOLATED WRIST OR
ANKLE FRACTURE)
(1) Any Open Long Bone Fracture
OR (2) Multiple Fracture / Dislocation Sites
(EXCLUDING WRIST / ANKLE FRACTURE
AND DISLOCATIONS)
CUTANEOUS
(1) Amputation Proximal to Wrist or Ankle
OR
(2) Major Tissue Disruptions
(Flap, Avulsions, Degloving Injuries)
OR (3) 2nd or 3rd Degree Burns to > 10 % TBSA
OR
(4) Any Penetrating Injury to Head, Neck or
Torso (Excluding Superficial Injuries Where
The Depth of The Wound Can Be Determined)
Altered Mental Status:
Drowsiness
Lethargy
Inability to follow commands
Unresponsiveness to voice, or totally unresponsive.