TSA Medical Protocols

La Crosse Regional Pre-Hospital Guidelines
PRE-HOSPITAL
MEDICAL
Guidelines
Christopher M Eberlein, MD
Medical Director
Gundersen Health System
cmeberle@gundersenhealth.org
Darin Wendel, AD Paramedic, CCParamedic

Clinical Operations Supervisor
Tri-State Ambulance, Inc.
dwendel@tristateambulance.org
Tom Carpenter, NREMT-P, CCEMTP

Quality Assurance
tacarpen@gundersenhealth.org
Richard Barton, NREMT-P, CCEMTP

EMS Education
rkbarton@gundersenhealth.org
01-18-2016
CONTENTS
Contents ..................................................................................................................................................................................................2
FOREWARD .........................................................................................................................................................................................5
FORWARD CONTINUED .................................................................................................................................................................6
General Principles of Patient Care ............................................................................................................................................8
General Principles of Patient Care Continue .......................................................................................................................9
Abnormal Delivery .........................................................................................................................................................................10
Air Ambulance Use .........................................................................................................................................................................11
Airway Management .....................................................................................................................................................................12
Airway Obstruction........................................................................................................................................................................13
Altered Mental Status ...................................................................................................................................................................14
Amputation ........................................................................................................................................................................................15
Anaphylaxis/Allergic Reaction ................................................................................................................................................16
Automatic Implantable Cardiac Defibrillator (AICD) Deactivation ......................................................................17
Asthma / COPD ................................................................................................................................................................................18
Asystole ................................................................................................................................................................................................19
Bradycardia........................................................................................................................................................................................20
Blood Pressure Management ....................................................................................................................................................21
Burns .....................................................................................................................................................................................................22
Cancellation of Call .........................................................................................................................................................................23
Cerebrovascular Accident (Benchmark) ............................................................................................................................24
Stroke Benchmarks ........................................................................................................................................................................25
Coronary Insufficiency (Benchmark) ...................................................................................................................................26
STEMI Benchmark Check List ..................................................................................................................................................27
Continuous Positive Airway Pressure..................................................................................................................................28
Crush Syndrome ..............................................................................................................................................................................29
Decompression Sickness .............................................................................................................................................................30
Determination of Death ...............................................................................................................................................................31
Diabetic Emergency .......................................................................................................................................................................32
Emergency Childbirth...................................................................................................................................................................33
Envenomation ..................................................................................................................................................................................34
EZ-IO ......................................................................................................................................................................................................35
General Medical ...............................................................................................................................................................................36
General Trauma ...............................................................................................................................................................................37
Head Injury ........................................................................................................................................................................................38
Heat Related Illness .......................................................................................................................................................................39
Hemostatic Agent Use...................................................................................................................................................................40
Hyperkalemia....................................................................................................................................................................................41
Hypothermia .....................................................................................................................................................................................42
Inter-facility Pre-Transport Care............................................................................................................................................43
IFT of Insulin ....................................................................................................................................................................................44
IFT of Pantoprazole (Protonix) Or other PPI ...................................................................................................................45
IFT of tPA (tissue plasminogen activator) .........................................................................................................................46
01-18-2016

Intranasal Medications ................................................................................................................................................................47
King LTS-D Airway .........................................................................................................................................................................48
Medical Personnel on Scene ......................................................................................................................................................49
Multiple Patient Incident ............................................................................................................................................................50
Narrow Complex Tachycardia..................................................................................................................................................51
Nasogastric/Orogastric Tube ...................................................................................................................................................52
Nausea, Vomiting, Vertigo ..........................................................................................................................................................53
Needle Cricothyroidotomy.........................................................................................................................................................54
Needle Thoracentesis ...................................................................................................................................................................55
Neonatal Resuscitation ................................................................................................................................................................56
Pain Management ...........................................................................................................................................................................57
Postpartum Hemorrhage ............................................................................................................................................................58
Pre-Eclampsia / Eclampsia ........................................................................................................................................................59
Pediatric Asystole/PEA................................................................................................................................................................60
Pediatric Bradycardia ...................................................................................................................................................................61
Pediatric Tachycardia with Adequate Perfusion ............................................................................................................62
Pediatric Tachycardia with Poor Perfusion ......................................................................................................................63
Pediatric Ventricular Fibrillation / Pulseless Ventricular tachycardia ..............................................................64
Poisoning and Overdose..............................................................................................................................................................65
Post Arrest (ROSC) (Benchmark) ...........................................................................................................................................66
ROSC Benchmarks ..........................................................................................................................................................................67
Pulmonary Edema ..........................................................................................................................................................................68
Pulseless Electrical Activity .......................................................................................................................................................69
Radio Report Outline ....................................................................................................................................................................70
Rapid Sequence Intubation (Benchmark)..........................................................................................................................71
RSI Checklist ......................................................................................................................................................................................72
RSI Benchmark .................................................................................................................................................................................73
Refusal of Treatment or Transport........................................................................................................................................74
Respiratory Failure ........................................................................................................................................................................75
Restraint Use .....................................................................................................................................................................................76
Scene Rehabilitation ......................................................................................................................................................................77
Sedation ...............................................................................................................................................................................................78
Seizure ..................................................................................................................................................................................................79
Shock .....................................................................................................................................................................................................80
Selective Spinal Precautions; C-Spine Clearance ............................................................................................................81
Spinal Precautions For Transport Ambulance ................................................................................................................82
Spinal Examination ........................................................................................................................................................................83
Spinal Precautions For Non-Transport EMT/EMR .......................................................................................................84
Spit Hood .............................................................................................................................................................................................85
Surgical Cricothyroidotomy ......................................................................................................................................................86
Sustained Ventricular Tachycardia / Wide Complex Tachycardia .......................................................................87
Termination of Resuscitation ...................................................................................................................................................88
Thoracic/Abdominal Aortic Aneurysm ...............................................................................................................................89
01-18-2016

Trauma in Pregnancy....................................................................................................................................................................90
Treatment of the Terminally Ill Patient ..............................................................................................................................91
Vascular Access ................................................................................................................................................................................92
Ventricular Fibrillation / Pulseless Ventricular tachycardia ...................................................................................93
Appendix A-1: Nitroglycerine Drip ........................................................................................................................................93
Appendix A-2: Epinephrine Drip ............................................................................................................................................95
Appendix A-3: Dopamine Drip .................................................................................................................................................96
Appendix A-4: Post arrest anti-arrhythmic Drips..........................................................................................................97
Appendix B-1: Chest Tube Monitoring ................................................................................................................................98
Appendix B-2: Ventilator / BiPAP USE ................................................................................................................................99
Appendix B-2: Ventilator / BiPAP USE (continued) .................................................................................................. 100
Appendix B-2: Ventilator / BiPAP USE (continued) .................................................................................................. 101
Appendix B-3: Blood Transfusion & Continuation Monitoring............................................................................ 102
Appendix B-4: Arterial Line, Central Line, and CVP Monitoring ......................................................................... 103
Appendix B-4: Arterial Line, Central Line, and CVP Monitoring ......................................................................... 104
Appendix B-5: PICC Line usage............................................................................................................................................. 105
Appendix B-6: Transvenous Pacemaker .......................................................................................................................... 106
Appendix B-7: Foley Catheter insertion........................................................................................................................... 107
Appendix D-1: Trauma Activation Guidelines .............................................................................................................. 108
Appendix D-1: Trauma Activation Guidelines - continued .................................................................................... 109
Appendix D-2: Stroke Activation Guidelines ................................................................................................................. 110
Appendix B-8: Sedation Critical Care ................................................................................................................................ 111
Appendix B-9: Seizure Critical Care ................................................................................................................................... 112
Appendix E: Paramedic Medications ................................................................................................................................. 113
Medications..................................................................................................................................................................................... 114
0.45% SODIUM CHLORIDE
114
AZITHROMYCIN (ZITHROMAX) ........................................................................................................................................... 115
CALCIUM GLUCONATE (10%) .............................................................................................................................................. 116
CEFTRIAXONE (ROCEPHIN) .................................................................................................................................................. 117
CIPROFLOXACIN (CIPRO)........................................................................................................................................................ 118
CIPROFLOXACIN (CIPRO) Cont.
119
CLONIDINE HCL (CATAPRES, DIXARIL) .......................................................................................................................... 120
DEXAMETHASONE (DECADRON) ....................................................................................................................................... 121
DOBUTAMINE (DOBUTREX).................................................................................................................................................. 122
DROPERIDOL (INAPSINE)....................................................................................................................................................... 123
ENALAPRILAT (VASOTEC) ..................................................................................................................................................... 124
EPTIFIBATIDE (INTEGRILIN) ............................................................................................................................................... 125
ESMOLOL (BREVIBLOC)........................................................................................................................................................... 126
ESMOLOL (BREVIBLOC) Cont.
127
HEPARIN (Unfractionated) ..................................................................................................................................................... 129
HYDROMORPHONE (DILAUDID)......................................................................................................................................... 130
IMIPENEM (PRIMAXIN) ........................................................................................................................................................... 131
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KETAMINE (KETALAR) ............................................................................................................................................................ 133
TORADOL (KETOROLAC) ........................................................................................................................................................ 134
LEVOFLOXACIN (LEVAQUIN)................................................................................................................................................ 135
MANNITOL (OSMITROL) ......................................................................................................................................................... 136
MOXIFLOXACIN (AVELOX) ..................................................................................................................................................... 137
MOXIFLOXACIN (AVELOX) Cont.
138
NALBUPHINE (NUBAIN) Cont. ............................................................................................................................................ 140
NITROPRUSSIDE (NIPRIDE) .................................................................................................................................................. 141
NOREPINEPHRINE (LEVOPHED) ........................................................................................................................................ 142
Levophed Dose Chart 4mg/250CC D5W ......................................................................................................................... 143
PANCURONIUM (PAVULON).................................................................................................................................................. 144
PANTOPRAZOLE (PROTONIX).............................................................................................................................................. 145
PIPERACILLIN AND TAZOBACTAM (ZOSYN) ............................................................................................................... 146
POTASSIUM CHLORIDE ............................................................................................................................................................ 147
PROCHLORPERAZINE (COMPAZINE) ............................................................................................................................... 148
PROPOFOL (DIPRIVAN) ........................................................................................................................................................... 149
RACEMIC EPINEPHRINE .......................................................................................................................................................... 151
RETEPLASE RECOMBINANT (RETAVASE, rt-PA) ....................................................................................................... 152
TERBUTALINE SULFATE (BRETHINE) ............................................................................................................................ 153
VANCOMYCIN (VANCOCIN) ................................................................................................................................................... 154
VECURONIUM BROMIDE ......................................................................................................................................................... 155
FOREWARD
01-18-2016

Optimal pre-hospital care results from a combination of careful patient assessment, essential prehospital emergency medical services, and appropriate medical consultation. The purpose of this
manual is to provide guidance for ALL pre-hospital care providers and Emergency Department
Physicians within the Tri-State Ambulance, Inc. and the Tri-State Regional Ambulance, Inc. EMS
Systems.
The goal of these protocols is to standardize pre-hospital patient care. It is to be understood that
these protocols are guidelines. These protocols are not intended to be absolute treatment doctrines,
but rather guidelines which have sufficient flexibility to meet the complex challenges faced by the
EMS/ALS provider in the field. Nothing contained in these protocols shall be construed to expand
the Scope of Practice of any Emergency Medical Technician beyond that which is identified in
Wisconsin or National Emergency Medical Services Regulations and these protocols.
These protocols have been written in adherence with nationally recognized standards including but
not limited to: DOT guidelines, American Heart Associations Advanced Cardiac Life Support and
Pediatric Advanced Life Support, the Wisconsin standards and practices manual, and the
Wisconsin version of Basic Trauma Life Support. All providers will adhere to these protocols as
is appropriate for medical circumstance and provider agency level.
Nothing contained within these protocols is meant to delay rapid patient transport to a receiving
facility. Patient care should ideally be rendered while en-route to a definitive treatment facility.
The Spinal Immobilization protocol must be followed in the specific sequence noted. For all other
treatment protocols, the letter and numerical outline format is strictly for rapid and uniform
reference and does not imply or direct a mandatory sequence for patient care.
To maintain the life of a specific patient, it may be necessary, in rare instances, for the physician
providing on-line medical consultation, as part of the EMS consultation system, to direct a prehospital provider in rendering care that is not explicitly listed within these protocols. To proceed
with such an order both the telemetry physician and the provider must acknowledge and agree that
the patient's condition and extraordinary care are not addressed elsewhere within these medical
protocols, and that the order is in the best interest of patient care. Additionally, the provider must
feel capable, based on the instructions given by the telemetry physician, of correctly performing the
directed care. Whenever such care is provided, the telemetry physician and the provider must
immediately notify the Quality Assurance Office of the extraordinary care situation. All such
incidents will be entered into the Quality Improvement Review process.
Occasionally a situation may arise in which a physician's order cannot be carried out; e.g. the
provider feels the administration of an ordered medication would endanger the patient, a
medication is not available, or a physician's order is outside of protocol. If this occurs, the provider
must immediately notify the telemetry physician as to the reason the order cannot be carried out,
and indicate on the pre-hospital care record what was ordered, the time, and the reason the order
FORWARD CONTINUED
01-18-2016

could not be carried out. In addition, the provider must immediately notify the Quality Assurance
Office. All such incidents will be entered into the Quality Improvement Review process.
If On-line Medical Control cannot be obtained, the pre-hospital personnel may initiate appropriate
protocols/treatment as deemed necessary. However, every attempt must be made to contact
Medical Control as soon as possible.
Items in BOLD and UNDERLINED are hyperlinked to the corresponding protocol.
Items in BOLD designate a medication or treatment
Items in [brackets] and italicized designate treatments approved for a specific provider level. It is to
be understood all treatments listed for a specific level can be used by a provider trained to a more
advanced level, but only within the scope of practice to the level of care that the agency they
are responding for is licensed/certified by the respective state EMS licensing agency.
These protocols have been developed specifically for the Tri-State Ambulance, Inc. and the Tri-State
Regional Ambulance, Inc. EMS Systems and for all EMS and first response agencies for which
medical direction is provided by Gundersen Health System, and represent consensus amongst the
Medical Director, Quality Assurance Department, EMS Education Department, Clinical Services
Coordinator and Management Team for these EMS Systems. The protocols demonstrate a
commitment to a consistent approach to quality patient care.
From time to time, protocols may be added or revised upon recommendation by the parties
previously listed. Additional recommendations are welcome and appreciated at any time. They
may be submitted to the parties listed below for consideration.
Tri-State Ambulance, Inc.
235 Causeway Boulevard
La Crosse, WI 54603
Clinical Operations Supervisor Darin Wendel dwendel@tristateambulance.org
608-782-8827 ext. 1115
Gundersen Lutheran Emergency Medical Services
1900 South Ave
La Crosse, WI 54603
Medical Director: Christopher M. Eberlein, MD
cmeberle@gundersenhealth.org
Quality Assurance: Tom Carpenter, NREMT-P, CCEMTP
tacarpen@gundersenhealth.org
608-775-3218
EMS Education: Rick Barton, B.S., NREMT-P, CCEMTP
rkbarton@gundersenhealth.org
01-18-2016
GENERAL PRINCIPLES OF P ATIENT CARE

General Scope: A majority of the following protocols will begin with Perform routine medical
assessment. A thorough assessment is needed for treatment of complex medical conditions. It is
understood that at times the assessment will need to be interrupted to perform life saving treatment.
Providers shall resume assessment as soon as they are able, after performing life-saving interventions.
This shall serve as a general protocol for principles that apply to the assessment of all patients.
Applies to: All Medical Staff
Protocol:
Universal precautions and personal protective equipment shall be utilized at all times as is
appropriate for the situation.
o PPE can include but is not limited to:
Fluid barrier gloves
Safety eye protection
Infection control gown
Infection control shoe covers
Infection control bouffant cap
Surgical mask
N-95 mask
All patients shall receive a primary assessment to include, but not limited to the following:
o Airway patency
o Breathing (rate and quality)
o Circulation
Pulse
Skin color, temp, and condition
Assess for and treat life threatening bleeding
o Level of consciousness
All patients shall receive a secondary assessment to include, but not limited to the
following:
o Vital signs including but not limited to:
Pulse
Blood Pressure
SpO2
Respiratory rate and effort
o S.A.M.P.L.E. history as possible
o Rapid trauma and/or focused physical assessment
o Secondary head-to-toe physical assessment
01-18-2016
GENERAL PRINCIPLES OF P ATIENT CARE CONTINUE
All Primary and initial Secondary assessments shall be performed or supervised by the EMS
provider with the most advanced level of training nationally recognized.
All patients shall receive treatment as is appropriate per protocol and on-line medical
direction.
All patients shall be re-assessed after an intervention is performed. The success, secondary
effects, and possible side-effect of said intervention evaluated.
o i.e. if a protocol gives a medication dose such as Fentanyl 25-100 mcg Q 5 minutes;
the care provider shall give the initial appropriate dose of 25-100 mcg and perform
a re-assessment of the patient to include pain level, level of consciousness, and vital
signs prior to giving a second dose.
o The same principle applies to the titration of a medication. Titration is the
adjustment of medication dosing until the desired endpoint is reached. The
endpoint is the point at which the titration is complete as determined by an
indicator.
o i.e. titration of a Nitroglycerin drip to achieve a blood pressure of 185 systolic:
SBP of 185 mmHg is the endpoint
Starting dose if given per protocol
The care provider shall initiate the NTG drip per protocol.
The care provider shall assess vital signs.
The care provider shall adjust NTG drip per protocol.
The care provider shall assess vital signs.
This shall be repeated until the desired endpoint is reached or
patient care is transferred.
For pediatric patients:
o Equipment and medications must be appropriate for the size and weight of the
patient. Use of the Broselow Tape or equivalent is encouraged.
o The developmental age of the infant/child must be considered in the
communication and evaluation for treatment.
o Treatment priorities are similar to the adult patient.
o When appropriate, family members should remain with pediatric patients.
o Infants and children must be properly restrained prior to and during transport.
If a hospital declares an Internal Disaster or informs EMS agencies that they are on
diversion, that facility is to be bypassed for ALL patients except medical patients in cardiac
arrest or in whom the ability to adequately ventilate has not been established.
Patients will be transported to the closest appropriate facility per local, state, and federal
laws and guidelines.
o If two hospitals are of similar distance and have similar capabilities/resources for
the patients nature of illness, mechanism of injury, or clinical impression, the
patient will be transported to the hospital of their preference.
If the patient has no preference, the patient will be transported to the hospital
providing on-line medical direction at that time.
01-18-2016
ABNORMAL DELIVERY
General Scope: Protocol for delivering infants presenting with ominous signs.
Protocol:
1. Perform routine medical assessment
2. If Meconium staining is present:
a. Tracheal suctioning via ETT prior to stimulation and ventilation
b. See Neonatal Resuscitation Protocol
3. If prolapsed cord is present:
a. Do not push cord back in, cover with sterile towel moistened with warm NS
b. Place mother in Trendelenburg knee to chest position
c. With gloved hand, push presenting part off cervix to decompress cord and maintain
position en route to hospital
4. If infant is breech:
a. Deliver baby to waist
b. Rotate to face down position (The head should deliver on its own within 3 minutes)
c. Create breathing space around babys face with gloved hand (middle and index
finger along the baby's face and up to its nose)
d. Suprapubic pressure may help keep the head flexed and facilitate delivery
e. Try to assist delivery by placing finger in babys mouth and gently pulling
5. If other part is presenting (arm, foot, etc):
a. Do not pull on part
b. Cover exposed part with sterile towel moistened with warm NS
c. Place mother left side down
6. Multiple births:
a. After initial delivery, tie and cut cord
b. Proceed with subsequent deliveries
7. Rapid transport
8. Update Medical Control
APGAR SCORING:
Sign
Pulse
Respirations
Muscle Tone
Reflex irritability
Color
01-18-2016
0
Absent
Absent
Limp
None
Pale or Blue
1
<100
Slow or Irregular
Some flexion
Grimace
Pink body/blue
extremities
2
>100
Good Crying
Active motion
Cough or sneeze
Completely pink
AIR AMBULANCE USE

General Scope: Procedure and criteria for air ambulance request.
Protocol:
1. Routine medical and/or trauma assessment
2. Determine need for air transport
a. See criteria below
3. Assess appropriateness of air transport for distance/terrain
a. Air ambulance is inefficient if ground transport time is <30 minutes or 30 miles
4. Request air ambulance standby or launch through medical dispatch
5. Assure provision of a secure landing zone
6. Provide patient report to incoming air ambulance
a. ALS 400 for Med-Link Air unless otherwise instructed
b. BLS 340 for others unless otherwise instructed
7. Update dispatch and med control
2012 Tr aum a Fie ld Triag e Gu ide line s
Physi ol og i c C r i ter i a
1.
2.
3.
Glasgow Coma Scale 13

SBP of <90 mmHg
4. motorcycle crash >20 mph

Sp eci al C o nsi d er ati o ns
1.
in infant aged <1 year), or need for ventilatory support

Anat o mi c C r i ter i a
1.
chest wall instability or deformity (e.g. flail chest)
1.
falls
intrusion, including roof: >12 inches occupant

ejection (partial or complete) from automobile
death in same passenger compartment
vehicle telemetry data consistent
with a high risk for injury

automobile versus pedestrian/bicyclist thrown, run
over, or with significant (>20 mph) impact
01-18-2016
anticoagulants and bleeding disorders

a. patients with head injury are at high risk for rapid
burns
a. without other trauma mechanism: triage to burn
facility
site; >18 inches any site
b.
c.
d.
children
a. should be triaged preferentially to pediatric
deterioration
4.
adults: >20 feet (one story = 10 feet)
high-risk auto crash
a.
low impact mechanisms (e.g., ground-level falls)
capable trauma centers
3.
open or depressed skull fractures
children: >10 feet or two to three times the

height of the child
3.
2.
pelvic fractures
a.
b.
SBP <110 might represent shock after age 65
might result in severe injury
crushed, degloved, mangled, or pulseless extremity
paralysis
Me cha ni s m of I nj ur y
2.
c.
two or more proximal long-bone fractures

amputation proximal to wrist or ankle
risk for injury/death increases after age 55 years
years
all penetrating injuries to head, neck, torso, and

extremities proximal to elbow or knee
2.
3.
4.
5.
6.
7.
8.
older adults
a.
b.
respiratory rate of <10 or >29 breaths per minute (<20
b.
5.
6.
with trauma mechanism: triage to trauma center
pregnancy >20 weeks

EMS provider judgmen
AIRWAY MANAGEMENT
General Scope: Protocol for airway management
Protocol:
a. Consider EtCO2 monitoring if appropriate for scope of practice
2. If patient has a history of COPD
a. Titrate SpO2 to 90-92%
i. If respiratory rate<30 titrate SpO2 with nasal cannula
ii. If respiratory rate>30 apply partial rebreather mask, goal of 100% SpO2
b. Use the least amount of supplemental oxygen as necessary
3. If patient does not have history of COPD
a. Titrate SpO2 to >94%
i. If respiratory rate<30 titrate SpO2 with nasal cannula
ii. If respiratory rate>30 or SpO2<94% apply partial rebreather mask
b. Use the least amount of supplemental oxygen as necessary
4. If patient presents with bronchospasm
a. See Asthma / COPD Protocol
5. For respiratory failure despite above
a. Consider CPAP
b. See CPAP Protocol
6. For respiratory failure despite above
a. See Respiratory Failure Protocol
Note:
Signs of impending respiratory failure include:
RR <8 or >35 breaths per minute

SpO2<85% on 100% O2
Hemodynamic instability
Paradoxical respiratory efforts
Altered mental status
Acutely rising EtCO2 with respiratory acidosis
01-18-2016
AIRWAY OBSTRUCTION
General Scope: Protocol for airway obstruction.
Protocol:
2. If patient is unable to speak and is conscious
a. Perform Heimlich maneuver until the foreign body is expelled or the victim becomes
unconscious
3. If patient is unable to speak and is unconscious
a. Perform tongue-jaw lift
b. Use finger sweep if object is visible
c. Attempt ventilation
d. If obstruction persists, reposition and re-attempt ventilation
e. Give up to five chest thrusts
f. If obstruction persists perform CPR per ECC 2010 guidelines
i. Repeat steps a-f until obstruction is dislodged or 5 cycles
4. [EMT-B, EMT-I, AEMT, Paramedic] If unable to ventilate attempt direct laryngoscopy and
removal with Magill forceps
5. [Paramedic / Med Control] If unsuccessful in removing foreign body or relieving upper
airway obstruction see Surgical Cricothyroidotomy Protocol
01-18-2016
ALTERED MENTAL STATUS

General Scope: Protocol for treatment of patients who present with altered mental status
Protocol:
1. Perform routine medical assessment (with frequent rechecks every 5-10 minutes)
a. Consider hypoxia, hypovolemia, trauma, or ingestion
b. If suspected trauma see General Trauma Protocol
c. If suspected overdose see Poisoning and Overdose
d. If hypo/hypertensive see Blood Pressure Management Protocol
2. Airway support as needed, see Airway Management Protocol
3. [EMT-I, AEMT, Paramedic]Establish IV/IO per Vascular Access Protocol
4. If blood glucose <60 or >250 see Diabetic Emergency Protocol
5. [EMT/Firefighter] Give NARCAN 1-2mg IN (not to exceed 1ml per nares)
6. [EMT-I, AEMT, Paramedic] Consider NARCAN 2mg IV/1-2mg IN
7. [Paramedic] Consider THIAMINE 100mg IV/IM
8. [Paramedic] Consider intubation for GCS <8 see RSI Protocol
01-18-2016
AMPUTATION
General Scope: Protocol for treatment of patients who have experienced an amputation
Protocol:
1. Perform routine trauma assessment
2. Consider tourniquet for uncontrolled bleeding
3. Consider activation of air ambulance for transport to medical center specializing in reimplantation
4. [EMT-I/AEMT] Establish IV/IO per Vascular Access Protocol
5. See Trauma Care Protocol
6. See Pain Management Protocol
7. Irrigate amputated part with NS to remove gross contaminants (do not debride)
8. Place amputated part in sterile gauze moistened in NS
9. Place amputated part in sterile waterproof container
10. Place sealed container in iced NS or place activated cold packs around container
01-18-2016
ANAPHYLAXIS/ALLERGIC REACTION
General Scope: Protocol for treatment of patients who present severe allergic reaction
Applies to: All Medical Staff ** (optional use by EMR/ EMT/ AEMT service and then only with approval
of medical director, documentation of additional training, and prior approval of the Operational Plan by
the State EMS office)
Protocol:
a. Remove offending agent
3. If signs/symptoms of anaphylaxis:
a. EPINEPHERINE (use with caution in elderly/patients with coronary artery disease)
i. [**EMR/EMT] Epi-pen or Epi-pen Jr. if available
ii. [EMT/Paramedic] **0.3mg (1:1000) IM {child <8y/o 0.15mg}
iii. [Paramedic] 0.1-0.5mg (1:10,000) IV over 5 minutes {child 0.01mg/kg}
4. If localized reaction
a. Ice and elevate affected area as practical
b. [Paramedic]Consider BENADRYL 25-50mg IV or 50mg IM {child 1.25mg/kg}
5. [EMT-I, AEMT, Paramedic] Establish IV/IO per Vascular Access Protocol but do not delay
administration of EPINEPHRINE
a. [Paramedic] BENADRYL 25-50mg IV or 50mg IM {child 1.25mg/kg}
b. [Paramedic] SOLUMEDROL 125mg IV
6. If SBP<90 see Blood Pressure Management Protocol
7. If bronchospasm is present:
a. ALBUTEROL via nebulizer
i. [EMT] 2.5mg
ii. [EMT, EMT-I, AEMT,Paramedic] Consider 5.0mg
iii. [Paramedic] Consider continuous neb (10-20mg)
Note:
Anaphylaxis = syndrome of severe hypersensitivity reaction characterized by cardiovascular collapse and
respiratory compromise.
1. Presentation:
a. Symptoms may begin within seconds or may be delayed up to one hour from
exposure
b. Generalized angioedema
c. Tightening sensation in throat and chest progressing to laryngeal and bronchial
spasm manifested by hoarseness, stridor and wheezing
d. Frequently see nausea, abdominal cramps, vomiting and diarrhea
e. Impending cardiovascular collapse presents with tachycardia and hypotension
f. Localized redness, swelling, and/or itching alone is NOT anaphylaxis
01-18-2016
AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR (AICD)

DEACTIVATION
General Scope: Protocol for deactivating AICDs. This protocol should be activated only after consulting
with medical control.
Applies to: Paramedics
Protocol:
2. Patient must remain on cardiac monitor for duration transport.
3. If patient has an AICD that is inappropriately discharging. (for a non-shockable rhythm)
a. Place magnet directly over AICD.
b. Tape magnet in place
c. Document time of application, underlying rhythm, and if procedure is successful
4. If the patient develops a shockable rhythm, remove the magnet
a. If AICD does not begin working, See Cardiac Dysrhythmia Protocols
This magnet will not stop a pacemaker from functioning
Keep magnet away from computers, credit cards, electronics, etc
01-18-2016
ASTHMA / COPD
General Scope: Protocol for treatment of asthma and chronic obstructive pulmonary disease
**(Duo-Neb optional for EMT-Basic Service and then only with approval
of medical director, documentation of additional training, and prior approval of the Operational Plan by
the State EMS office)
Protocol:
1. Perform routing medical assessment
2. Begin initial treatment per Airway Management Protocol
3. If mild attack (Slight increase in respiratory rate, mild wheezes, and good skin color)
a. Consider ALBUTEROL via nebulizer
i. [EMT] 2.5mg
ii. [EMT, EMT-I, AEMT, Paramedic] Consider 2.5-5.0mg
b. [EMT-I, AEMT, Paramedic] Consider IV NS TKO
4. If moderate attack (Marked increase in respiratory rate, wheezes easily heard, and
accessory muscle use)
a. Consider ALBUTEROL via nebulizer
i. 2.5mg
ii. [EMT, EMT-I, AEMT, Paramedic] Consider 2.5-5.0mg
5. If severe attack (Respiratory rate more than twice normal, loud wheezes or silent chest,
patient anxious, and/or gray or ashen skin color)
a. ALBUTEROL via nebulizer
i. 2.5mg
ii. [EMT, EMT-I, AEMT, Paramedic] Consider 5.0mg
iii. [Paramedic] Continuous neb
c. [EMT-B**, EMT-I, AEMT, Paramedic] DUO-NEB nebulizer treatment
d. [Paramedic/Med Control] SOLUMEDROL 125mg IV
i. Pediatric dosing 1 mg/kg
e. [Paramedic/Med Control] MAGNESIUM 2 grams IV over 15 minutes
f. [EMT-I, AEMT, Paramedic] EPINEPHRINE (1:1000) 0.01mg/kg IM if possible
allergy-induced asthma
i. Up to 0.3mg
g. If failure of above
i. See Rapid Sequence Intubation Protocol
01-18-2016
ASYSTOLE
General Scope: Protocol for treatment of a patient in asystolic cardiac arrest
Applies to: EMT-I/ Paramedic
Protocol:
2. Initiate CPR and continue throughout resuscitation with minimal interruptions
3. Consider possible causes and treatments (Hs & Ts)
a. Hypoxia ventilation see Airway Management Protocol
b. Hypoglycemia check blood sugar
c. Hypothermia see Hypothermia Protocol
d. Hyperkalemia see Hyperkalemia Protocol
e. Hypovolemia consider 1000cc IV NS bolus see Vascular Access Protocol
f. (H+)Preexisting acidosis Ventilations, consider [Paramedic] SODIUM
BICARBONATE 1 amp IV
g. (Toxins)Drug overdose see Poisoning and Overdose Protocol
h. Tension pneumothorax consider [Paramedic] Needle Thoracentesis
i. Tamponade (Cardiac Tamponade)
j. Thrombosis PE/MI
4. Confirm asystole in two leads
a. If rhythm is unclear, see V-Fib/Pulseless V-Tach Protocol
5. Establish IV/IO per Vascular Access Protocol
6. Establish airway per Respiratory Failure Protocol
7. [Paramedic] Administer EPINEPHRINE (1:10,000) 1mg IV/IO Q 3-5 minutes
a. May request termination of efforts
01-18-2016
BRADYCARDIA
General Scope: Protocol for treatment of an adult patient with symptomatic bradycardia
Protocol:
2. Monitor SpO2
a. Airway support as needed per Airway Management Protocol
3. Identify patient as having serious signs or symptoms
a. [Basic EMT**]Obtain EKG. [EMT-I, Paramedic] review EKG if available
4. [EMT-I, AEMT, Paramedic] Establish IV/IO per Vascular Access Protocol
5. If patient is asymptomatic, observe closely
6. [Paramedic] If symptomatic 2nd or 3rd degree block or IV/IO not readily available
a. begin TRANSCUTANEOUS PACING
i. Consider Pain Management Protocol and/or Sedation Protocol as needed
b. [Paramedic] Administer ATROPINE 0.5mg IV/IO Q 3-5 minutes to a max of
0.04mg/kg (adult 3mg)
c. [Paramedic/Med Control] Consider DOPAMINE drip (200mg/250ml D5W
800mcg/ml) Initiate infusion at 5mcg/kg/min and titrate every 5 minutes by
increments of 1-5mcg/kg/min up to 20mcg/kg/min.
a.
[Paramedic/Med Control] Consider EPINEPHRINE drip (1mg/100ml D5W or
NS10mcg/ml) Initiate IV infusion at 0.01mcg/kg/min (2 mcg/min) and
titrate every 5 minutes by increments of 0.01mcg/kg/min (1 mcg/min) up to
0.1mcg/kg/min (10 mcg/min) maximum rate to achieve SBP>90
01-18-2016
BLOOD PRESSURE MANAGEMENT

General Scope: Protocol for treatment of patients who present with abnormally high or low blood
pressure
Protocol:
1.
2.
3.
4.
Perform routine medical assessment

Airway support as needed, see Airway Management Protocol
[EMT-I, AEMT, Paramedic ]Establish IV/IO per Vascular Access Protocol
If patient is hypertensive with cardiovascular or CNS compromise:
a. [Paramedic/Med Control] Labetalol 20mg Slow IV
i. May repeat at 40mg every 10 minutes to a max of 300mg
b. [Paramedic/Med Control] Consider NTG DRIP (20mg/100ml D5W/ or NS
200mcg/ml)
i. For patients <75kg, start at 10mcg/min
ii. For patients >75kg, start at 20mcg/min
iii. Titrate by 5-10mcg/min every 5-10 minutes to desired response
iv. Monitor BP every 3-5 minutes
5. If SBP<90 and patient is symptomatic with no signs of fluid overload
a. [EMT-I, AEMT] 250-500ml NS bolus up to 2-3 liters total
6. If SBP<90 and patient is symptomatic with signs of fluid overload or NS bolus unsuccessful
a. [Paramedic] DOPAMINE drip (200mg/250ml D5W800mcg/ml) Initiate infusion
at 5mcg/kg/min and titrate every 5 minutes by increments of 1-5mcg/kg/min up to
20mcg/kg/min to achieve SBP>90
7. If patient has inadequate response to fluid or dopamine infusion
a. [Paramedic/Med Control] Consider EPINEPHRINE drip (1mg/100ml D5W/NS
10mcg/ml) Initiate IV infusion at 0.01mcg/kg/min (2 mcg/min) and titrate every 5
minutes by increments of 0.01mcg/kg/min (1 mcg/min) up to 0.1mcg/kg/min (10
mcg/min) maximum rate to achieve SBP>90
Note:
1. NTG
a. Specifically indicated in patients with acute pulmonary edema or myocardial ischemia
b. Consider lower doses in the elderly
c. Avoid if any history of PDE 5 inhibitor (Viagra, Levitra, Cialis) use in the past 48 hours
2. Dopamine
a. Dosing at <5mcg/kg/min may worsen hypotension due to dilatation of renal and GI
vessels
b. Specifically indicated in bradycardic patients that are hypotensive
3. Epinephrine
a. May worsen underlying ischemia, tachycardia or acidosis
b. Increases peripheral vascular resistance
01-18-2016
BURNS
General Scope: Protocol for treatment of patients who have experienced a burn
Protocol:
2. Consider activation of air ambulance for transport to medical center with a specialized burn
center
4. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
6. See Blood Pressure Management Protocol
7. See Pain Management Protocol (IV ONLY)
8. If burn is thermal in nature:
a. Stop the burning process without causing hypothermia
b. Remove clothing and jewelry (Do not pull away clothing that is stuck to burn)
c. [EMT-I/AEMT/Paramedic] If burn is >10% BSA and ETA to hospital >15 minutes, IV
NS 150ml/hr
d. [Paramedic] Consider early intubation if signs of airway burns is present
9. If burn is chemical in nature:
a. Remove agent as appropriate
b. Irrigate for at least 15 minutes with NS
i. Use 1000ml for eye irrigation
ii. Use continuous irrigation for alkali burns
10. If burn is electrical in nature (severe high voltage injury):
a. Once scene is safe, remove the patient from the source
b. See Cardiac Dysrhythmia Protocols as needed
c. [EMT-I/AEMT/Paramedic] IV NS/LR x 2 lines
i. Run one line with 500-1000ml IV bolus
ii. [Paramedic/Med Control] Second line with SODIUM BICARBINATE 50mEq
per liter, run at 500-1000ml/hr
11. Dress burned area with dry sterile dressings (if burn BSA <10% may consider use of sterile
NS dressing)
12. Consider use of burn sheet with additional clean, dry sheet and blanket to conserve body heat
13. DO NOT BREAK BLISTERS. DO NOT APPLY CREAMS, OINTMENTS OR ANTIDOTES TO
BURNS
01-18-2016
CANCELLATION OF CALL
General Scope: Procedure for cancelling ambulance while en route to a call.
Protocol:
1. When EMS is activated but a request from first responders to cancel is made, dispatch will
ask responding crew to continue in a non-emergency fashion
a. Cancellation will be at the discretion of the TSA/TSAR shift supervisor with
consideration given to call circumstances, system status, and weather
2. TSA/TSAR Crew may cancel under the following conditions
a. No physical patient exists or patient has left the scene
b. The call or address has been determined to be false in nature
c. The patients personal physician is in attendance and determines the ambulance is
not needed
01-18-2016
CEREBROVASCULAR ACCIDENT (BENCHMARK)

General Scope: Protocol for treatment of patients who present with signs or symptoms of a stroke
Protocol:
1. Perform routine medical assessment with Cincinnati Stroke Scale and time of last known
well.
a. If stroke scale is positive TSA/TSRA to notify receiving hospital within 5 minutes of
being at patient side
a. [Paramedic] Consider intubation for GCS<8
3. Rule out hypoglycemia, hypoxia, hypovolemia, trauma, or ingestion
4. Consider special situations:
a. See General Trauma Protocol for suspected trauma
b. [Transport Crew] Consider contacting Medical Control for Stroke Team activation
ASAP(goal of 5 minutes of arriving at patient side).
5. [EMT-I, AEMT, Paramedic]Establish IV/IO per Vascular Access Protocol (Preferred site is AC)
6. If patient is hypertensive with SBP>180 or DBP>110 consider carefully lowering blood
pressure 10-15% only after discussion with Medical Control
a. See Blood Pressure Management Protocol
7. If blood glucose <60 or >250 see Diabetic Emergency Protocol
8. [EMR] consider NARCAN 1-2mg IN for decreased LOC
9. [EMT-I, AEMT, Paramedic] Consider NARCAN 2mg IV/IN for decreased LOC
10. [Paramedic] Consider THIAMINE 100mg IV/IM
Note:
1. Vitals and Cincinnati Pre-Hospital Stroke Scale every TEN minutes.
Patient Assessment - Cincinnati Pre-hospital Stroke Scale
1. Evaluates for facial palsy, arm weakness and speech abnormalities.
2. Items are scored as either normal or abnormal.
a. Facial droop (the patient shows teeth or smiles)
Normal: both sides of face move equally
Abnormal: One side of face does not move as well as the other
b. Arm drift (the patient closes their eyes and extends both arms straight out for 10 seconds)
Normal: both arms move the same, or both arms do not move at all
Abnormal: one arm either does not move, or one arm drifts down compared to the other
c. Speech (the patient repeats The sky is blue in La Crosse)
Normal: the patient says correct words with no slurring of words
Abnormal: the patient slurs words, says the wrong words, or is unable to speak
3. Signs of Herniation: Sudden decrease in level of consciousness, ipsilateral papillary dilation,
contralateral hemiparesis, and decerebrate or decorticate posturing
4. Preferred IV site is AC with 18g or larger
01-18-2016
STROKE BENCHMARKS
Rate of stroke scale assessment for patients diagnosed with a
stroke
Rate of BGL assessment for patients diagnosed with a stroke
Rate of BP assessment every 10 minutes for patients diagnose
with a stroke
Scene time < 15 minutes for stroke alert patients
Rate of hospital contact for a stroke alert < 10 minutes from
patient side with documentation of notification
Response time of < 10 minutes 90th% for patients diagnosed
with stroke
Maintenance of 02 Sat per protocol
% of patients with a diagnosis of stroke with a priority 2 EMD
and response
01-18-2016
CORONARY INSUFFICIENCY (BENCHMARK)

General Scope: Protocol for treatment of patients who present with signs or symptoms possible cardiac
events. Contact Medical Control to initiate this protocol if the patient < 35 years with no previous
history and a high clinical suspicion.
Protocol:
3. Obtain and transmit a 12-Lead ECG
a. [Paramedic] If 12-Lead is consistent with STEMI contact Medical Control to activate
Cardiac Alert
4. [EMT-I, AEMT, Paramedic ] Establish IV/IO per Vascular Access Protocol
5. [EMT, EMT-I, AEMT, Paramedic] Give ASPIRIN 324mg PO
6. [EMT, EMT-I, AEMT, Paramedic] Give NTG 0.4mg SL Q 3-5 minutes until pain free or NTG
drip established. (see below)
a. IF SBP <120 See Blood Pressure Management Protocol; Do not give SL NTG
b. [Paramedic] If SBP >100 consider NTG DRIP (20mg/100ml D5W200mcg/ml)
c. Discontinue NTG drip if SBP<100
7. [Paramedic] If SBP>100 consider FENTANYL 25-100mcg IV for refractory pain
Note:
1. NTG
a. Consider lower doses in the elderly
b. Avoid if any history of PDE 5 inhibitor (Viagra, Levitra, Cialis) use in the past 48 hours
2. Lopressor contraindications:
a. HR<60
b. Heart block over 1o
c. SBP<90
d. CHF
3. [Paramedic]Heparin infusions established by a medical facility prior to arrival may be
continued at current rate during transport
01-18-2016
STEMI BENCHMARK CHECK LIST

Aspirin administration rate for eligible patients
12 lead acquisition within 10 minutes of patient contact
Scene time of <15 minutes for STEMI patient
Field to ED 12 lead transmit to ED
Notification of STEMI >10 minutes prior to ED arrival
Chest pain management with reported relief rate
Chest pain patient with pre and post pain scores recorded
NTG administration rate for eligible patients
01-18-2016
CONTINUOUS POSITIVE AIRWAY PRESSURE

General Scope: Procedure for CPAP
Applies to: All Medical Staff ** (optional for EMT-Basic/EMT-I/AEMT Service and then only with
approval of medical director, documentation of additional training, and prior approval of the
Operational Plan by the State EMS office)
Protocol:
1. Determine need (Clinical Indications):
2. Moderate to severe respiratory distress with signs and symptoms of pulmonary edema,
CHF, or COPD, refractory to initial interventions, and all of the following apply:
a. Awake and able to follow commands
b. Over 12 years old and is able to fit the CPAP mask
c. Has the ability to maintain an open airway
i. And exhibits two or more of the following:
1. A respiratory rate > 26 breaths per minute
2. SPO2 < 92% on high flow oxygen
3. Use of intercostal or accessory muscles during respirations
4. Wet lung sounds
4. Talk patient through procedure and cautiously sedate as needed, see Sedation Protocol
5. Start CPAP at 5-10mmHg or pre-set level
Note:
1. Indications
a. Acute pulmonary edema as a bridge device
b. Patients already on CPAP
c. Mild respiratory failure due to muscle fatigue
d. COPD
2. Exclusion criteria
a. Recurrent aspiration
b. Large volumes of secretions
c. Inability to protect the airway
d. Vomiting
e. Obstructed bowel
f. Upper airway obstruction
g. Uncooperative, confused or combative patient
h. Inability to tolerate a tight mask
i. Orofacial abnormalities which interfere with mask/face interface
j. Untreated pneumothor
01-18-2016
CRUSH SYNDROME
General Scope: Protocol for treatment of patients experiencing crush syndrome. Protocol must be
initiated prior to patient extrication. This protocol is also appropriate for suspension trauma.
Protocol:
1. Perform routine medical and trauma assessment
3. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol (aggressive
volume replacement is essential prior to extrication if possible)
a. If SBP<90mmHg
i. [EMT-I/AEMT/Paramedic] IV NS 2-3L bolus
b. If SBP>90mmHg
i. [EMT-I/AEMT/Paramedic] IV NS 1500ml bolus
5. Evaluate for hypothermia, see Hypothermia Protocol
6. Apply direct pressure to control external bleeding
7. Consider using a tourniquet on affected limb before extrication if possible
a. Leave the tourniquet in place for the transport
b. If transport >20 minutes, slowly release the tourniquet
8. Early stabilization of all extremity fractures aids in controlling blood loss
9. [Paramedic/Med Control] Consider IV NS with SODIUM BICARBINATE 50mEq per liter at
500-1000ml/hr
01-18-2016
DECOMPRESSION SICKNESS
General Scope: Protocol for treatment of patients with potential decompression sickness.
Applies to: All Medical StaffProtocol:
2. Place patient on 100% O2 via tight fitting mask if spontaneously breathing, see Airway
Management Protocol
3. [EMT-I/AEMT/Parmedic] Establish IV/IO per Vascular Access Protocol
4. Evaluate for hypothermia, see Hypothermia Protocol
5. See Blood Pressure Management Protocol
7. Transport to the nearest hyperbaric chamber (consider air transport). Medical Control
must call to ensure chamber is available and working and establish an accepting physician
a. Contact:
i. Divers Alert Network 919-694-8111, ask for diving emergencies
ii. Hennepin County Medical Center
1. 800-424-4262 ED Physician
2. 612-873-3132 ED
3. 612-873-7420 Hyperbaric Department
iii. St. Lukes, Milwaukee 414-649-6577
iv. University of IA, Iowa City
1. 319-356-7706 (8-5)
2. 319-356-2233 (after hours)
3. 319-356-8220 HBO Physician
Note:
Definition
1. Decompression illness occurs when the gas
dissolved in the body fluids separates from
those fluids to form bubbles.
2. In a rapid ascent, the pressure differential
between the body tissues and blood and
alveoli becomes great enough to cause
separation of nitrogen from the liquid phase
resulting in the formation of bubbles in the
tissues or blood.
A. Predisposing factors that increase the incidence of
decompression illness
1. Dehydration
2. Cold temperatures
3. Obesity
4. Exercise during the dive
5. Older individuals
6. Previous joint injury
7. Previous recent dives
8. Flying after recent dive
01-18-2016
B.
C.
D.
Decompression illness can occur during ascent or

up to 72 hours after a dive (especially if multiple
dives/day)
Manifestations
1. Pain
a. Limb pain
b. Girdle pain
2. Cutaneous eg. itching, lymphedema
3. Neurological (including audio-vestibular, i.e.
loss of balance)
4. Pulmonary eg. CHF, cough, dyspnea
5. Constitutional (malaise, anorexia, fatigue)
6. Hypotension
7. Barotraumas (lung, sinus, ear, dental)
Important information
1. Time of onset
2. Gas burden (depth-time profile): Depth of
dive, dive time and number of div
DETERMINATION OF DEATH
General Scope: Protocol for not initiating or discontinuing CPR
Protocol:
1. CPR must be initiated unless the following conditions exist
a. DNR in the form of WI DNR wristband
b. Valid POLST form with DNR orders
c. Direct order from Medical Control Physician
d. Triple Zero (pulseless, apneic, and asystolic) with one of the following:
i. Decomposition
ii. Rigor mortis
iii. Dependent lividity
iv. Decapitation
v. MCI
vi. Traumatic death with prolonged extrication with no CPR
3. Ensure Coroner/Medical Examiner is notified
01-18-2016
DIABETIC EMERGENCY
General Scope: Protocol for treatment of patients who present with diabetic emergencies
**(Glucagon optional for EMR/EMT-Basic/AEMT/EMT-I Service
and then only with approval of medical director, documentation of additional training, and prior
approval of the Operational Plan by the State EMS office)
Protocol:
1.
2.
3.
4.
Perform routine medical assessment with blood glucose check

Establish IV/IO per Vascular Access Protocol
If blood glucose <60
a. Consider ORAL GLUCOSE if patient is conscious and airway is not compromised
b. [EMT**] GLUCAGON 1mg IM/SQ or [EMT-I**] 2mg IN {child 0.5mg IM/SQ or 1mg
IN}
i. First response agencies: Contact responding transport ambulance for ETA
to the scene prior to glucagon administration. Glucagon may be
administered only if transport ambulance ETA is > 10 minutes
c. [Paramedic] Consider THIAMINE 100mg IV/IM
d. [Paramedic] D50 12.5-25g IV {child D25 1-2cc/kg}
i. Repeat if blood glucose <60
5. If blood glucose >250
[EMT-I/ Paramedic] NS 500 ml bolus IV {child 20ml/kg/hr}
01-18-2016
EMERGENCY CHILDBIRTH
General Scope: Protocol for delivering infants.
Protocol:
2. If ominous signs see Abnormal Delivery Protocol
3. If imminent delivery:
a. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
b. Place mother in knee to chest position and prepare delivery equipment
c. Have mother pant through contraction and relax between
d. As head crowns at perineum, apply slight pressure to prevent explosive delivery
e. As head emerges, check for cord around neck
i. If cord is around neck and cannot be slipped overhead, clamp x 2 and cut
immediately
f. As soon as nose and mouth emerge, suction immediately before first breath
g. If HR<100 see Neonatal Resuscitation Protocol
h. Put baby on mothers abdomen and prevent heat loss
i. Take APGAR scores at 1 and 5 minutes
j. Deliver placenta (Place the cord and the placenta in a sack or container to be brought
to receiving facility)
k. Massage uterus if bleeding is brisk after delivery of the placenta
l. If heavy bleeding present see Post-Partum Hemorrhage Protocol
4. Transport if placenta has delivered or >15 minutes have elapsed
APGAR SCORING:
Sign
Pulse
Respirations
Muscle Tone
Reflex irritability
Color
01-18-2016
0
Absent
Absent
Limp
None
Pale or Blue
1
<100
Slow or Irregular
Some flexion
Grimace
Pink body/blue
extremities
2
>100
Good Crying
Active motion
Cough or sneeze
Completely pink
ENVENOMATION
General Scope: Protocol for treatment of patients with potential envenomation.
Protocol:
1.
2.
3.
4.
5.
Perform routine medical and trauma assessment

History of time and type of bite (bring offending agent if safe to do so)
[EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
See Blood Pressure Management Protocol
Consider tourniquet to impede venous/lymphatic flow if patient is showing serious
systemic symptoms. i.e. shock
01-18-2016
EZ-IO
General Scope: Procedure for EZ-IO placement. Applies to: EMT-Intermediate Tech / AEMT /
Paramedics (** EZ-IO is optional for AEMT/EMT-IV services and only with approval of the medical
director, documentation of training, and prior approval of the Operational Plan by the State EMS Office)
Protocol:
1. Determine need rule out contraindications
2. Locate insertion site and clean area with antiseptic wipe
a. Use EZ-IO AD (25 mm) if > 40 kg; EZ-IO LD (45 mm) for obese patients with excessive tissue
over the insertion site; EZ-IO PD (15 mm) for 3-39 kg
b. Tibia (pediatric and adult)
i. Two finger widths below the patella is the tibial tuberosity
ii. One finger width medial to the tibial tuberosity is the point of insertion
c. Humeral head (always use the LD needle for adults)
i. Keep arm adducted with patients palm on their umbilicus
ii. Place in the greater tubercle lateral to the intertubercle groove
d. Distal tibia
i. Two finger widths above medial malleolar prominence
3. Prepare EZ-IO driver and needle
4. Insert EZ-IO
a. Stabilize insertion site
b. Position driver 90 to bone surface
c. Push needle through the skin until it contacts bone
d. Evaluate needle for 5mm mark
e. Power the driver and insert needle until hub is flush or lack of resistance is felt
f. Remove driver and stylet from the catheter
5. Confirm position and patency
a. Flush with 10 ml NS (child<40 kg: use 5 ml NS)
b. Ensure catheter standing at 90 and firmly seated
c. No evidence of extravasation
d. Connect tubing utilizing the EZ-IO right angle extension piece and begin infusion
e. Pressure infusion may be needed
6. Secure hub utilizing EZ-IO transparent securement device
7. [Paramedic] If patient is conscious, administer LIDOCAINE 50mg IO for local analgesia
Note:
CONTRAINDICATIONS
1.
May be considered prior to peripheral IV

attempts in the following situations:
a. Cardiac arrest
b. Profound hypovolemia
c. IV access not readily available
a. Fracture of tibia or femur; consider
alternate side
01-18-2016
b.
c.
d.
Previous knee replacement; look for

vertical scars on knees
Infection at insertion site
Inability to locate landmar
GENERAL MEDICAL
General Scope: Protocol for treatment of patients with medical emergencies
Protocol:
1.
2.
3.
4.
5.

Check respirations, SpO2, and apply oxygen, see Airway Management Protocol
Check pulse and apply cardiac monitor, see appropriate Cardiac Dysrhythmia Protocol
Check blood pressure, see Blood Pressure Management Protocol
Consider checking blood sugar, see Diabetic Emergency Protocol
01-18-2016
GENERAL TRAUMA
General Scope: Protocol for treatment of all patients with potential traumatic injuries.
Protocol:
2. Consider Trauma Activation (Appendix D-1) with transport to nearest appropriate trauma
center as per state trauma guidelines
3. Spinal immobilization
5. Respiratory Failure Protocol as needed
6. See Needle Decompression Protocol as needed
7. Splint flail segments and apply occlusive dressing for sucking chest wound
a. Consider intubation
8. Direct pressure for external hemorrhage
a. Consider tourniquet for uncontrolled hemorrhage
b. Consider hemostatic agent per Hemostatic Agent Protocol
a. Avoid excessive fluid administration
b. Goal of maintaining SBP~100mmHg
c. See Blood Pressure Management Protocol
10. See Shock Protocol
11. Splint extremity fractures
12. Use a pelvic binder or wrap and secure a sheet around the pelvis for suspected pelvic
fractures and splint lower extremity fractures
01-18-2016
HEAD INJURY
General Scope: Protocol for treatment of all patients with potential head injuries.
Protocol:
1.
2.
3.
4.
Perform routine medical and trauma assessment

See General Trauma Protocol
Take C-Spine precautions if indicated
Aggressively manage the airway
a. See Airway Management Protocol
b. See Rapid Sequence Intubation Protocol
a. Goal to maintain SBP>90
b. Do not give excessive fluids
6. If no signs of herniation
a. Maintain normal EtCO2 of 35-45mmHg
b. See protocols as needed
i. Nausea, Vomiting, Vertigo Protocol
1. [Paramedic] ZOFRAN 4-8mg IV{child <40kg - 0.1mg/kg, >40kg 4mg}
ii. Seizure Protocol
7. If signs of herniation are present
a. Mildly hyperventilate patient (14-16 breaths/minute) to maintain EtCO2 3035mmHg
Note:
Elevate head of bed for transport if situation allows
01-18-2016
HEAT RELATED ILLNESS

General Scope: Protocol for treatment of all patients with potential heat related illnesses.
Protocol:
1.
2.
3.
4.

Remove from heat source
Maintain cool air flow over patient
If suspected Heat Exhaustion (patient alert)
a. Administer oral fluids as tolerated / available.
b. Place patient in Trendelenburg position if unable to take fluids
c. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
5. If suspected Heat Stroke (patient with altered LOC)
a. Airway support as needed, see Airway Management Protocol
b. Respiratory Failure Protocol as needed
c. See Altered Mental Status Protocol as needed (check blood sugar)
d. Cool patient immediately
i. Remove clothing as necessary
ii. Cool packs to lateral chest wall, groin, axilla, carotid arteries, temples, and
behind knees
iii. Sponge with cool water or cover with wet sheet and fan the body
e. Position patient in Fowlers position
f. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
i. Place cold packs around distal IV tubing
g. [EMT-I/AEMT/Paramedic] If SBP<100mmHg, give 250-500ml IV NS bolus, see
Blood Pressure Management Protocol
For seizures, see Seizure Protocol
01-18-2016
HEMOSTATIC AGENT USE

General Scope: Procedure for use of hemostatic gauze
Applies to: All Staff ( EMT-Basic /EMT-I/Paramedic )
Protocol:
1. Identify source of bleeding
a. Place proximal tourniquet if appropriate
b. Wipe pooled blood from wound if necessary
2. Apply hemostatic gauze, packing into wound as per manufacturers instructions
3. Pack entire length of gauze into wound
4. Apply direct pressure for 1-3 minutes with hemostatic gauze
a. If bleed-through occurs entire dressing must be removed before repacking
5. Apply standard dressing and bandage
Note: Specific brand of hemostatic gauze must not cause thermal reaction.
01-18-2016
HYPERKALEMIA
General Scope: Protocol for treatment of patients who are or suspected to be hyperkalemic
Protocol:
2. Identify as symptomatic: Patients with profound weakness or shock with peaked T-waves,
history of dialysis, renal failure, severe burns/trauma/crush injury, or laboratory confirmed
diagnosis of hyperkalemia
4. Obtain 12 lead EKG
6. [Paramedic/Med Control] Calcium Gluconate 1gram/10cc in 100ml D5W or NS over 10
minutes
a. This is the preferred treatment for pre-arrest or arrest situations
b. Do not mix this with sodium bicarbonate
7. [Paramedic/Med Control] ALBUTEROL 20mg via nebulizer
8. [Paramedic/Med Control] SODIUM BICARBONATE 50mEq IV over 10 minutes
a. May repeat up to 2 total doses
b. Avoid in dialysis and CHF patients
c. Do not mix with calcium gluconate.
9. [Paramedic/Med Control] LASIX 40-80mg IV
a. Avoid in dialysis patients
Note:
1. Cardiac effects (may or may not be present)
a. 5.6-6.0mEq/L - peaked T waves due to increased repolarization
b. 6.0-6.5mEq/L - prolonged PR & QT intervals
c. 6.5-7.0mEq/L - diminished P waves and depressed ST segments; may result in
an intracardiac block affecting in the following order: atria, AV node, ventricles
d. 7.5-8.0mEq/L - P waves disappear, QRS complex widens, S & T waves tend to
merge
e. 10-12mEq/L - classic sine wave occurs which represents loss of P wave and
wide QRS complexes.
2. Other effects
3. Skeletal muscle weakness to flaccid paralysis with preservation of diaphragm muscle
function
a. Paresthesias
b. Respiratory depression
01-18-2016
HYPOTHERMIA
General Scope: Protocol for treatment of all patients with potential hypothermia.
Protocol:
2. If patient is responsive
a. Remove wet clothing, cover with warm blankets, apply heat packs to axilla, groin,
neck, and thorax
b. If signs of frostbite:
i. Protect injured part (blisters) with light sterile dressings. Avoid pressure to
area
ii. Cover affected part with warm blankets and prevent re-exposure to cold or
refreezing of part
d. [EMT-I/AEMT/Paramedic] Give up to 2 liters of warmed NS IV
3. If patient is unresponsive
a. Airway support as needed, see Airway Management Protocol
b. Respiratory Failure Protocol as needed
d. [EMT-I/AEMT/Paramedic] Give up to 2 liters of warmed NS IV
e. If bradycardic do not start CPR
f. If patient is pulseless
i. Check for pulse, respirations, and/or viable rhythm for at least 1 minute
ii. If patient is pulseless:
1. start CPR
2. Follow appropriate cardiac arrest protocol
3. Consider transport as soon as possible for rewarming
***The field resuscitation may be withheld if the victim has obvious lethal injuries or if the body
is frozen so that nose and mouth are blocked by ice and chest compression is impossible.
01-18-2016
INTER-FACILITY PRE-TRANSPORT CARE

General Scope: Establishment of pre-transport standards of care for all intra/inter-facility transports.
Applies to: All Transport Medical Staff
Protocol:
1. Establish contact with referring facility and patient
2. Complete Primary Survey
a. Resuscitate if necessary
3. Complete Secondary Survey
a. To include Vital Signs, SpO2, Cardiac Monitor
4. Assess pre-arrival diagnostics and interventions
a. Paramedics can continue Heparin, IV antibiotics, electrolyte solutions, and
Insulin. They can also transport other medications not found in the protocol
with the use of Patient Side Training Report
5. Confirm correct placement and position of ETT, NGT, IVs, Foley catheter, etc
6. Review X-rays, lab results, and EKGs
7. Prepare to load patient, consider spinal immobilization for trauma patients
01-18-2016
IFT OF INSULIN
General Scope: Protocol for the IFT transport of Insulin drip initiated by sending hospital
Applies to: Paramedic/ Critical Care Paramedic
Protocol:
1. Obtain written order for rate and total volume of Insulin to be infused, confirm with
RN or physician.
2. Check blood sugar levels Q15 or per sending facilities written order
Indications:
1. Elevated blood glucose
2. Diabetic ketoacidosis
3. Hyperkalemia
Precautions:
1. Administration of excessive dose may induce hypoglycemia. Glucose should be available
01-18-2016
IFT OF PANTOPRAZOLE (PROTONIX) OR OTHER PPI

General Scope: Procedure for transporting patients with Protonixs or other PPIs running
Applies to: Paramedics;
Protocol: Pharmacology and Actions:

Pantoprazole, Nexium and similar proton pump inhibitors. It works by decreasing the amount of acid
produced by the stomach.
Indications:
1. Short term treatment of gastroesophageal reflux disease (GERD) with a history of erosive
esophagitis.
2. Zollinger-Ellison syndrome or cancer in which the stomach produces too much acid.
Precautions and Notes:
1. Can cause anaphylaxis.
2. Can cause Thrombophlebitis.
3. Can cause an increase in risk of having fractures.
4. Bleeding, blistering, burning, or discoloration of the skin, hives, infection, inflammation, itching,
numbness, pain, rash, swelling, fever, stomach pain, vision problems, GI problems, blood in urin,
dizziness, and tachycardia.
5. Changing the dose or stopping the infusion requires contact with medical control.
6. Dose according to the sending facilities orders.
Dosing and Administration:
Protonix:
1. Supplied as a powder containing 40 mg per vile. May be diluted in NS, D5W or LR
2. Reconstitute each vial with 10 mL of solution. For a standard infusion mix 1 vial with 80 mL for a
total solution of 100 mL or 0.4mg/mL. Infusion times vary between 2 minutes and one hour. Follow
the specific written orders for the patient.
Nexium:
1. 80 mg IV x1, then 8 mg/h IV x71.5h. . Follow the specific written orders for the patient.
01-18-2016
IFT OF TPA (TISSUE PLASMINOGEN ACTIVATOR)

General scope: Protocol for the IFT transport of TPA infusion
Applies to: Paramedic/CC Paramedic
Protocol:
1. Perform routine medical assessment with Cincinnati Stroke Scale, repeat stroke scale q15
2. [Sending Hospital RN] Bolus 0.09 mg/kg (10% of total), Max 9mg via pump over a
minute, USE DEDICATED LINE. NO IV fluids running with Alteplase during bolus or
infusion.
3. [Sending Hospital RN] Continuous Infusion: 0.81 mg/kg (90% of total), Max 81 mg via
pump over 60 minutes beginning immediately following the bolus.
4. Verify total dose given. Document total tPA dose to be administered, start and stop times;
Start tPA on IVAC pump. Half set may be needed to insure no medication loss.
5. BP goal during and after TPA SBP <180 and DBP <105
6. [CC Paramedic/Paramedic/ Med control] Start with 10mg LABETALOL IV push over 1-2
minutes if BP is not within range. Re-contact Med Control for further orders if needed
7. If excess medication remains in the bag after correct amount is given do not flush primary
tubing. Disconnect Alteplase tubing from the patient, then remove from the pump and
discard immediately.
8. If the complete bag needs to be given in order to receive the correct dose, follow tPA
administration with a NS infusion at the same rate. Make sure this is done before the pump
alarms air in line.
Stop Infusion if:
a.
b.
c.
d.
e.
1.
2.
3.
4.
5.
Neurologic deterioration and / or new headache

SBP >180 or DBP > 105 after treatment with medication. Contact Medical Control
Symptoms of internal bleeding. See Cerebrovascular Accident protocol
Nausea / Vomiting
Allerigic reaction including: rash, itching, anaphylaxis or angioedema
Notify Medical control:
If infusion was stopped
Change in patients condition (improved or deteriorating)
Temp > 38.5
Pulse <50 or >100
RR <10 or >24
Notes:
1. If receiving hospital does not have a half set ready you may need to wait or leave IVAC pump.
2. Never discard TPA if you are unsure if complete dose was given. TPA has a significant cost and
should never be discarded in error.
01-18-2016
INTRANASAL MEDICATIONS
General Scope: Procedure for administration of intranasal medications via the Mucosal Atomization
Device (MAD). Acceptable intranasal medications are: [Paramedic] Fentanyl, Versed, Narcan, and
Glucagon.
Applies to: EMT-I** / Paramedic (** Optional use by service and requires Prior Written Approval of
the Operational Plan by the State EMS Office and Medical Director Approval and Documentation of
Training.)
Protocol:
1. Determine MAD/Intranasal indications
2. Rule out contraindications
a. Epistaxis
b. Nasal trauma
c. Nasal septal abnormalities
d. Significant nasal congestion/discharge
3. Draw up medication not to exceed 2ml total volume
4. Attach MAD to syringe and place MAD in nostril
5. Briskly compress syringe to administer atomized medication
a. Point outwards and upwards
b. Do not to exceed 1ml total volume per nostril
Medications may be repeated in 5-10 minutes as needed and
indicated
01-18-2016
KING LTS-D A IRWAY

General Scope: Procedure for placement of King Airway
Applies to: All Medical Staff **(King LTS-D airway is optional for EMR services and is only allowed with
approval of the medical director, documentation of training, and prior approval of the Operational Plan
by the State EMS Office)
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Insert simple airway and ventilate via BVM

Consider spinal immobilization as needed
Select proper airway size (See table below)
Test cuff inflation (with volume as listed on table) and remove air prior to insertion
Apply water-based lubricant to beveled distal tip and posterior tube (avoid vent openings)
Position head as able
a. Sniffing position is ideal but neutral position is acceptable
Open mouth and apply chin lift (unless suspected c-spine injury)
Insert King rotated laterally 45-90
Introduce tip into mouth and advance behind base of tongue
As tube passes tongue rotate back to midline
Advance until proximal opening of gastric access lumen is aligned with teeth or gums
Inflate cuff with minimum volume to seal the airway
Confirm proper position with auscultation and capnography
If unable to ventilate patient, gently and slowly pull back on King airway until proper
position is confirmed.
Ventilate with 100% O2
Reassess as needed
Suction as required
a. Gastric access lumen allows insertion of up to a 18Fr gastric tube (lubricate prior to
insertion)
[Transport Crew] Update Medical Control
Size
3
4
5
01-18-2016
Description
4-5 feet height
5-6 feet height
6+ feet height
Color
Yellow
Red
Purple
Inflation
45-60 ml
50-70 ml
60-80 ml
MEDICAL PERSONNEL ON SCENE

General Scope: Protocol for dealing with extraneous medical professionals on the scene of a call
Protocol:
1. Bystander at scene identified as medical person
2. If bystander is non-physician they may assist as crew deems appropriate, but may not direct
care
3. If bystander is a physician involvement options include:
a. Assist and/or offer suggestions while EMS act under protocol and medical control
b. Request to talk to medical control and directly offer medical advice and assistance if
medical control deems it appropriate
c. Request to direct patient care (must meet the following criteria):
i. Show valid state medical license unless known to crew
ii. Contact medical control who must relinquish control to on scene physician
iii. Physically accompany patient to hospital
iv. Give orders which are reasonable, accurate, and within the scope of practice
for the EMS crew
If orders are given that the paramedics feel to be unreasonable, medically inaccurate, and/or not within
their capabilities, the paramedics DO NOT have to do that which they know by their training, skill, and
experience would be detrimental to the patient.
01-18-2016
MULTIPLE P ATIENT INCIDENT

General Scope: Procedure for MCI
Protocol:
1.
2.
3.
4.
5.
6.
Incident with 3 or more patients

Utilize START triage system
Implement ICS as appropriate
Notify possible receiving facilities as soon as possible
Identify patient by number
See Radio Report Outline
01-18-2016
NARROW COMPLEX TACHYCARDIA

General Scope: Protocol for treatment of an adult patient with symptomatic narrow complex
tachycardia
Applies to: EMT-I, Paramedic
Protocol:
2. Determine cardiac rhythm and assess for stability
a. [EMT-I, Paramedic ] Attempt IV/IO per Vascular Access Protocol (antecubital IV
preferred)
3. If ventricular rate is >150 beats/minute and patient is unstable:
a. Consider sedation per Sedation Protocol
b. [Paramedic/Med Control] Perform SYNCHRONIZED CARDIOVERSION
i. Narrow regular rhythm cardioversion dose is 50-100J
ii. Narrow irregular rhythm cardioversion dose is 120-200J
c. Consider pharmacological intervention (see #5b )
4. If ventricular rate is >150 beats/minute and patient is stable (SBP>110) and rhythm is
atrial fibrillation or atrial flutter
a. [Paramedic/Med Control] DILTIAZEM 0.25mg/kg (15-20mg) IV over 2 minutes
i. [Paramedic]After 15min, if inadequate response, consider repeat dose of
0.35mg/kg (20-25mg) IV over 2 minutes
b. [Paramedic/Med Control] Consider AMIODARONE 150mg IV over 10 minutes
5. If ventricular rate is >150 beats/minute and patient is stable and rhythm is SVT
a. Attempt Valsalva maneuver
b. [Paramedic/Med Control] ADENOSINE 6mg rapid IV push
i. [Paramedic/Med Control] Repeat at 12mg (May repeat twice)
[Paramedic/Med Control] Consider AMIODARONE 150mg IV over 10 minutes.
Notes:
2.
3.
4.
5.
Diltiazem in contraindicated: A. Sick-Sinus syndrome B. 2nd or 3rd degree heart block C. WPW or short PR
syndrome
Common side effects of diltiazem: A. Symptomatic hypotension. B. Flushing. C. Burning or itching at injection
site.
Lopressor should be used with caution if evidence of CHF/Pulmonary edema
Amiodarone precautions:
A. Hypotesion secondary to vasodilation
B. May prolong QT interval
C. Negative inotropic effects
D. Use with caution in renal failure; long T 1/2lige
01-18-2016
NASOGASTRIC/OROGASTRIC TUBE
General Scope: Procedure for NG Tube placement.
Protocol:
1. Assessment reveals the following:
a. Vomiting and/or abdominal pain with distended, tympanic abdomen and possible
frequent high-pitched bowel sounds
b. Distended abdomen after resuscitative efforts (air-filled stomach)
c. Avoid in patients with significant facial and head injuries
2. If conscious see Sedation Protocol and Pain Management Protocol
3. Determine NGT size
a. Adult: 12-18Fr
b. Child: 8-10Fr
4. Maintain patient with head in neutral or slightly flexed position
5. Determine length of insertion (tip of nose -> earlobe -> bottom of sternum)
6. Lubricate NGT with water-based lubricant
7. Insert NGT through nose to determined length
a. May use mouth as alternative route in intubated patients
8. Visualize mouth for coiled NGT
9. Inject air through NGT and auscultate over epigastrium
10. Tape NGT to nose and connect to low continuous suction
01-18-2016
NAUSEA, VOMITING, VERTIGO

General Scope: Protocol for treatment of patients who have complaints of nausea, vomiting, or vertigo
Protocol:
1.
2.
3.
4.
5.

Suction as needed
[Paramedic] ZOFRAN 4mg IV, repeat once if needed {child <40kg - 0.1mg/kg, >40kg - 4mg}
a. Preferred for patients with head injury
6. [Paramedic Medical Control] VERSED .5-1mg IV for extreme cases after failure of Zofran
01-18-2016
NEEDLE CRICOTHYROIDOTOMY
General Scope: Procedure for needle cricothyroidotomy. This is a last option for airway management
and requires approval from medical control. Needle cricothyroidotomy is the only allowable surgical
airway for children less than ten years of age.
Protocol:
1. Determine need and contact medical control
2. Palpate cricothyroid membrane and clean area with antiseptic wipe
3. Puncture membrane with large bore catheter, advance caudally drawing back on syringe
until air return
4. Withdraw needle and attach 3.0mm pediatric ETT adapter with BVM
5. Auscultate chest and secure device
01-18-2016
NEEDLE THORACENTESIS
General Scope: Procedure for needle chest decompression
Protocol:
1. Determine need
2. If conscious see Sedation Protocol
3. Cleanse site with antiseptic wipe
a. 5th intercostal space mid-axillary is preferred
b. 2nd intercostal space mid-clavicular is secondary
4. Insert 12g or 14g catheter
5. Listen for rush of air
6. Remove needle leaving catheter in place
01-18-2016
NEONATAL RESUSCITATION
General Scope: Protocol for resuscitation of a neonatal patient.
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.
9.

Dry and warm infant
Position and suction airway
Tactile stimulation
If cardiac arrest
a. Start CPR see appropriate Pediatric Dysrhythmia Protocol
i. Ventilate 40-60/minute
ii. Chest compressions 100/minute
iii. [Paramedic] INTUBATE
iv. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
v. [Paramedic] Give EPINEPHERINE (1:10,000) 0.01-0.03mg/kg IV/IO
vi. [Paramedic] Consider NS 10ml/kg IV/IO bolus
vii. [Paramedic] Consider NARCAN 0.5mg IV/IO
If heart rate < 100
a. 100% FiO2
b. Ventilate via BVM 40-60/min
If HR<60
a. Start CPR
i. Ventilate 40-60/minute
ii. Chest compression 100/minute
b. Recheck: If HR<80
i. [Paramedic] INTUBATE
ii. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol
iii. [Paramedic] Give EPINEPHERINE (1:10,000) 0.01-0.03mg/kg IV/IO
iv. [Paramedic] Consider NS 10ml/kg IV/IO bolus
v. [Paramedic] Consider NARCAN 0.5mg IV/IO
Consider blood glucose check, see Diabetic Emergency Protocol
Transport, keep warm, and maintain HR>80
01-18-2016
PAIN MANAGEMENT
General Scope: Protocol for treatment of patients who are or suspected to be experiencing pain
Protocol:
1.
2.
3.
4.
5.

Treat underlying cause of pain
[EMT-Intermediate99/Med Control] or [Paramedic] FENTANYL
a. 25-100mcg IV Q 5-10 minutes (100mcg IN Q 10 minutes) {child 1-2 mcg/kg or 23mcg/kg IN}Recheck vital signs between doses
b. If reversal is required, give NARCAN 1-2mg IV Q 5 minutes PRN {child 0.01mg/kg up
to 0.4-0.8 mg}
6. [Paramedic/CC Paramedic/] KETAMINE 0.25mg/kg
7. [Paramedic/Med Control] Consider VERSED 1-2mg IV for isolated injury with muscle spasm
8. For transports >15 minutes all patients receiving narcotic pain management should
have end tidal CO2 monitoring
Fentanyl Notes:
1. Use with caution in the elderly, small initial doses recommended
2. Hemodynamic instability: fentanyl may cause worsening of hypotension secondary to the direct
action on vascular smooth muscle resulting in peripheral pooling; avoid in patients with an
unstable cardiovascular status.
3. Allergies are uncommon; nausea and vomiting is less frequent than with other narcotics.
4. Skeletal and thoracic muscle rigidity occurs especially following rapid IV administration; if it occurs,
assist breathing with bag-valve mask breathing. Neuromuscular blockade may be required.
5. Histamine release rarely occurs. If evident treat with [Paramedic] DIPHENHYDRAMINE 25-50 mg
IV.
6. Avoid in patients with significant head injuries
a. May cause increase ICP due to CO2 retention from induced respiratory depression
b. May depress mental status
c. May affect pupillary reaction and obscure the neurological exam
Use of midazolam does not block pain receptors; patients often still require pain control.
01-18-2016
POSTPARTUM HEMORRHAGE
General Scope: Protocol for post-delivery hemorrhage.
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.

Maintain blood pressure, see Blood Pressure Management Protocol
Attempt to identify cause of post-partum hemorrhage
Apply direct pressure to any area of genital tract trauma
Manually explore uterus to remove any retained products
Use vigorous bimanual uterine massage to promote uterine tone
01-18-2016
PRE-ECLAMPSIA / ECLAMPSIA
General Scope: Protocol for pre-eclamptic or eclamptic patients.
Protocol:
1.
2.
3.
4.

If patient is seizing:
a. [Paramedic] Give MAGNESIUM 4 grams IV over 20 minutes
b. [Paramedic] Give VERSED 2 mg IV Q 2 minutes
i. See Seizure Protocol
c. [Paramedic] Consider more MAGNESIUM
5. If patient is not seizing:
a. Place patient is position of comfort
b. [Paramedic] Give MAGNESIUM 4 grams IV over 20 minutes
c. See Blood Pressure Management Protocol, Nitroglycerin should not be given
to a pregnant patient
Notes:
1. Preeclampsia: Toxic state which occurs in the last half of pregnancy or early postpartum
period in which mother exhibits the following:
a. Hypertension (SBP > 160, DBP > 90 or an increase in DBP of 15 mmHg from
previous baseline)
b. Hyperreflexia
c. Generalized peripheral edema
d. Proteinuria
2. Hyperreflexia and visual changes indicate imminent seizure
3. Magnesium
a. Stop or decrease if knee jerk absent, respiratory depression occurs, or cardiac
arrest
b. Antidote is [Paramedic] CALCIUM Gluconate 1g in 100ml IV over 10 minutes
c. Contraindicated if maternal renal disorder or history of Myasthenia Gravis
01-18-2016
PEDIATRIC ASYSTOLE/PEA
General Scope: Protocol for treatment of a pediatric patient in asystolic cardiac arrest
Protocol:
3. Consider possible causes and treatments
b. Preexisting acidosis Ventilations, consider [Paramedic] SODIUM BICARBONATE 1
Amp IV
c. Drug overdose see Poisoning and Overdose Protocol
d. Hypothermia see Hypothermia Protocol
e. Hyperkalemia see Hyperkalemia Protocol
4. [Paramedic] Confirm asystole in two leads
a. If rhythm is unclear, see Pediatric V-Fib/Pulseless V-Tach Protocol
7. [Paramedic] Administer EPINEPHRINE (1:10,000) 0.01mg/kg IV/IO Q 3-5 minutes
a. May request termination of efforts
01-18-2016
PEDIATRIC B RADYCARDIA
General Scope: Protocol for treatment of a pediatric patient with symptomatic bradycardia
Protocol:
2. Monitor SpO2
a. Airway support as needed per Airway Management Protocol
3. If HR<60 start CPR
4. Identify patient as having serious signs or symptoms
a. Obtain/review EKG if available
6. [Paramedic] Administer EPINEPHRINE 0.01mg/kg (1:10,000) IV/IO Q 3-5 minutes
7. [Paramedic] Administer ATROPINE 0.02mg/kg IV/IO Q 3-5 minutes
a. May repeat once
b. Min: 0.1mg single dose
c. Max: 0.5 mg single dose
[Paramedic] Consider Trancutaneous Pacing (rate at 100-120)
01-18-2016
PEDIATRIC TACHYCARDIA WITH ADEQUATE PERFUSION

General Scope: Protocol for treatment of a pediatric patient with tachycardia
Protocol:
2. [Paramedic] Determine cardiac rhythm and assess for stability/significant tachycardia
a. HR >180 for ages 1-8 years
b. HR>220 for ages newborn 1 year
3. [EMT-I/AEMT/Paramedic] Attempt IV/IO per Vascular Access Protocol
4. If QRS0.09 seconds:
a. [Paramedic] Evaluate rhythm
b. If likely ventricular tachycardia:
i. [Paramedic/Med Control] AMIODARONE 5mg/kg IV over 20 minutes
ii. [Paramedic] Perform SYNCHRONIZED CARDIOVERSION 0.5-1 J/kg
c. If likely SVT with aberrancy:
i. [Paramedic/Med Control] ADENOSINE 0.1mg/kg rapid IV push
1. [Paramedic/Med Control] Repeat at 0.2mg/kg (May repeat twice)
b. If likely SVT:
i. [Paramedic/Med Control] ADENOSINE 0.1mg/kg rapid IV push
c. If likely Sinus Tachycardia:
i. Search for and treat causes
01-18-2016
PEDIATRIC TACHYCARDIA WITH POOR PERFUSION

General Scope: Protocol for treatment of a pediatric patient with symptomatic tachycardia
Protocol:
2. [Paramedic] Determine cardiac rhythm and assess for stability/significant tachycardia
a. HR >180 for ages 1-8 years
b. HR>220 for ages newborn 1 year
3. [EMT-I/AEMT/Paramedic] Attempt IV/IO per Vascular Access Protocol
4. If QRS0.09 seconds and cardiopulmonary compromise:
a. Consider sedation per Sedation Protocol
b. [Paramedic] Perform SYNCHRONIZED CARDIOVERSION 0.5-1 J/kg
5. If QRS0.09 seconds and no cardiopulmonary compromise:
a. [Paramedic/Med Control] ADENOSINE 0.1mg/kg rapid IV push
i. [Paramedic/Med Control] Repeat at 0.2mg/kg (May repeat twice)
b. [Paramedic/Med Control] AMIODARONE 5mg/kg IV over 20 minutes
c. [Paramedic] Perform SYNCHRONIZED CARDIOVERSION 0.5-1 J/kg
b. If SVT:
i. Attempt Vagal maneuvers, do not delay further treatment
ii. [Paramedic/Med Control] ADENOSINE 0.1mg/kg rapid IV push
iii. [Paramedic/Med Control] AMIODARONE 5mg/kg IV over 20 minutes
iv. [Paramedic] Perform SYNCHRONIZED CARDIOVERSION 0.5-1 J/kg
c. If Sinus Tachycardia
i. Search for and treat cause
01-18-2016
PEDIATRIC VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR

TACHYCARDIA
General Scope: Protocol for treatment of a pediatric patient presenting with ventricular fibrillation or
pulseless ventricular tachycardia in cardiac arrest
Protocol:
3. Apply defibrillator or AED
a. Defibrillate at 2J/kg
6. [Paramedic] Administer EPINEPHRINE (1:10,000) 0.01mg/kg IV/IO Q 3-5 minutes
7. [Paramedic] Defibrillate at 4J/kg
a. Any time a shockable rhythm is present at pulse check
8. [Paramedic] Administer AMIODARONE 5mg/kg IV/IO
a. [Paramedic] May repeat 5mg/kg IV/IO up to two times
9. If pulse is returned see Post Arrest Protocol
01-18-2016
POISONING AND OVERDOSE

General Scope: Protocol for treatment of patients who have been exposed to a toxic substance or have
experienced an accidental or intentional overdose. While utilizing this protocol, safety of all personnel
is of primary concern. Law enforcement personnel should be requested for all overdose patients.
Protocol:
a. Special consideration given to time of exposure
3. Check blood pressure. See Blood Pressure Management Protocol
4. Aggressively assess of Level of Consciousness throughout patient care
5. Determine type of toxic agent
6. If agent is on skin and can possibly be dermally absorbed
a. Remove clothing
b. Brush any remaining toxic agent off skin
c. Flush affected areas with water for a minimum of 15 minutes prior to transport
7. If agent has been inhaled
a. Remove patient from environment
b. Remove clothing
c. Provide high concentration oxygen, see Airway Management Protocol
d. If bronchospasm present see Asthma / COPD Protocol
8. If ingested
b. If agent is potentially a narcotic and patient exhibiting toxicity (Respiratory
depression/compromise, SBP<90, decreased LOC)
i. [EMT/Firefighter] Give NARCAN 1-2mg IN (not to exceed 1ml per nares)
ii. [EMT-I/AEMT/Paramedic] Give NARCAN 1-2mg IV/1-2mgIN Q 5 minutes
PRN {child 0.01mg/kg up to 0.4-0.8mg}
c. If agent is a Tricyclic Antidepressant and patient exhibiting toxicity (HR>120,
SBP<90, decreased LOC, or widening of QRS)
[Paramedic] Give SODIUM BICARBINATE 50mEq followed by 50mEq in 1000 ml NS over 1 hour
01-18-2016
POST ARREST (ROSC) (BENCHMARK)

General Scope: Protocol for treatment of a patient who has regained a pulse following cardiac
resuscitation.
Protocol:
2. [EMT-I, AEMT, Paramedic ] Establish IV/IO per Vascular Access Protocol if not previously
initiated
4. [EMT-I, AEMT, Paramedic] Monitor EtCO2
a. Target range is 30-35mmHg with RR<12
b. DO NOT HYPERVENTILATE
5. [Paramedic] If patient received >2 minutes of CPR place NG per Nasogastric Tube Protocol
6. Continuous monitoring of vital signs
7. If patient remains hypotensive see Blood Pressure Management Protocol
8. If patient has significant cardiac dysrhythmia see appropriate protocol
9. If patient has bradycardia see Bradycardia Protocol
10. Obtain and transmit a 12-Lead ECG to the receiving facility
If arrest reoccurs revert to appropriate protocol and/or last successful treatment
01-18-2016
ROSC BENCHMARKS
Patients with EMS arrival within county contract minutes 90 th

Field ROSC with 12 lead acquired
compliance with medical protocols/ MD orders
field ROSC with transport to a STEMI center
01-18-2016
PULMONARY EDEMA
General Scope: Protocol for management of patients with suspected pulmonary edema
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.

Position patient in upright sitting position
See Airway Management Protocol
If respiratory arrest is imminent
a. see Respiratory Failure Protocol
b. Add PEEP 8-10mmHg
If moderate to severe respiratory distress
a. [EMT-B**, EMT-I**, AEMT**, Parmedic] Start CPAP at 5-10mmHg
b. [Paramedic/ Med Control] see Sedation Protocol as needed
[EMT-I, AEMT, Parmedic] IV NS TKO
If SBP<90 mmHg
a. See Blood Pressure Management Protocol
If SBP>120 mm Hg
a. [EMT-I, AEMT, Paramedic] NTG 0.4mg SL Q 3-5 minutes
b. [Paramedic] NTG DRIP If BP >100 (20mg/100ml D5W or NS200mcg/ml)
i. For patients <75kg, start at 10 mcg/min
ii. For patients >75kg, start at 20 mcg/min
c. [Paramedic] LASIX 40-80mg IV
Note:
Cardiogenic Pulmonary Edema (CPE)
2. Conditions associated with CPE
a. LV failure from acute MI, cardiomyopathies and valvular heart disease
b. Volume overload
2. Clinical features of CPE include:
a. Cough
b. Diaphoresis
c. Dyspnea
d. Fatigue
e. Wheezing
f. Pink tinged frothy sputum
Avoid use of NTG if any history of PDE 5 inhibitor (Viagra, Levitra, Cialis) use in the past 48 hours
01-18-2016
PULSELESS ELECTRICAL ACTIVITY

General Scope: Protocol for treatment of a patient presenting with PEA in cardiac arrest
Applies to: EMT-I and Paramedic
Protocol:
3. Consider possible causes and treatments (Hs & Ts)
b. Hypoglycemia check blood sugar
c. Hypothermia see Hypothermia Protocol
d. Hyperkalemia see Hyperkalemia Protocol
e. Hypovolemia consider 1000cc IV NS bolus see Vascular Access Protocol
f. (H+)Preexisting acidosis Ventilations, consider [Paramedic] SODIUM
BICARBONATE 1 amp IV
g. (Toxins)Drug overdose see Poisoning and Overdose Protocol
h. Tension pneumothorax consider [Paramedic] Needle Thoracentesis
i. Tamponade (Cardiac Tamponade)
j. Thrombosis PE/MI
4. [EMT-I, Paramedic ] Establish IV/IO per Vascular Access Protocol
01-18-2016
RADIO REPORT OUTLINE

General Scope: To Provide a general guideline for EMS to hospital patient report.
Applies to: All Transport Medical Staff
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Identify service, unit number, radio frequency, and personnel (if applicable)
Identify level of care being provided
Communicate patients age, sex, and level of consciousness
Communicate severity of condition
a. Include applicable activation of specialized services (trauma, cardiac, stroke)
Communicate patients chief complaint and/or primary impression
Communicate history of injury/illness and pertinent past medical history
Relate pertinent assessment and finding
Communicate any treatment initiated
a. EMS staff can request orders from on-line medical control at this time, but it is often
more expedient to initiate a request for orders prior to giving patient report
Give estimated time of arrival
01-18-2016
RAPID SEQUENCE INTUBATION (BENCHMARK)

General Scope: Procedure for rapid sequence intubation. This procedure may only be initiated when
two paramedics are at patient side.
Protocol:
1. Ventilate and oxygenate with BVM for >3 breaths
2. High flow O2 via nasal cannula for apneic oxygenation.
3. Have equipment ready and available
a. See RSI Equipment Check list
4. Pre-treat pediatric patients with ATROPINE 0.01-0.02mg/kg IV
i. Minimum 0.1mg
ii. Maximum 0.5mg
5. Induce with KETAMINE 1-2mg/kg IV
6. Neuromuscular blockade with ZEMURON 1mg /kg IV max of 100mg (~20 min duration)
7. Intubate patient with supple jaw
8. Confirm placement with auscultation and capnography
9. Monitor EtCO2, SpO2, and secure ETT
10. Re-sedate with VERSED 0.05mg/kg and treat patient for Pain management.
11. Only re-paralyze with ZEMURON 0.2mg/kg if sedation and pain management fails.
Note:
1.
2.
3.
LEMON law: assess indicators of a difficult airway

a. Look externally (obesity, retracted mandible, beard, abnormal dentition, etc.)
b. Evaluate the 3-2-2 rule (mouth opening, chin to hyoid and mandible to thyroid)
c. Mallampati classification (how much of the posterior pharynx is able to be seen)
d. Obstruction (epiglottitis, tumor, trauma, abscess, etc.)
e. Neck mobility (c-spine immobilization, arthritis, previous stabilization)
Pediatric airway differences:
a. The larynx is located more anteriorly and cephalad
b. The epiglottis is shorter and u-shaped (vs. flat in the adult)
c. The tongue is relatively large while obviously the larynx and trachea are much smaller in the pediatric
patient compared to the adult
d. Be careful not to hyperextend the neck, as the trachea is very pliable and can collapse during intubation
e. Straight laryngoscope blades are recommended in neonates and infants while either straight or curved can
be used in older children
Use of midazolam and rocuronium do not block pain receptors; patients often still require pain control.
01-18-2016
RSI CHECKLIST
Assesses airway for difficulty. (LEMON / Malampati)
Perform neurologic exam before paralytics are administered.
Pre-oxygenates w/ NRB or BVM.
Prepares intubation equipment. (Laryngoscope, ET Tube, syringe, securing device, intubating stylette)
Readies alternative airways. (King airway, surgical airway)
Monitor vital signs. (SaO2, EKG, ETCO2)
Prepare suction. (Yankauer within reach [under shoulder], turn on, check canister and lid)
Prepare bag-valve mask. (Attached to oxygen, mask is ALWAYS present, PEEP valve attached)
Ensure IV access. (Patent, appropriate size/location, fluid administration)
Ensures proper positioning. (Sniffing position: ear to sternal notch/face parallel to ceiling)
Performs rapid sequence induction.
Places basic airway adjunct. (Nasopharyngeal airway or oropharyngeal airway)
Performs apneic oxygenation.
Lubricate endotracheal tube, stylette, and blade.
Performs endotracheal intubation without significant change in clinical status.
Retains necessary equipment in case of problem. (Syringe, BVM mask, laryngoscope)
Confirms placement with epigastric sounds, lung sounds, and waveform capnography.
Secures device using commercial device or properly placed tape.
Provides sedation and pain management as needed. Re-paralyze if necessary.
Re-assesses through completion of patient contact. (Vital signs and interventions)
01-18-2016
RSI BENCHMARK
Scene time less than 30 minutes for RSI
Documentation of patients weight
Appropriate EMD (P1 response)
3 or less intubation attempts
ET outcome %
ET success rate %
Advanced airway outcome
ETCO2 confirmation
EKG strips attached to chart
Vitals q 10 minutes
Preoxygenation protocol prior to RSI
Sedation when not contraindicated
01-18-2016
REFUSAL OF TREATMENT OR TRANSPORT

General Scope: Procedure for releasing a patient from care on scene
Applies to: All Transport Staff
Protocol:
1. Determine mental status and extent of illness and/or injury
2. If patient is deemed to have altered LOC or impaired decision making capability
a. If possible treat/transport under implied consent
3. If patient has medical/legal decision making capability and the following criteria are met:
a. Patient is alert and oriented
b. No evidence of head injury
c. Patient is an adult, emancipated minor, or if patient is a minor and parent/guardian
has been contacted or is on scene and declines/refuses transport of patient when all
of the other criteria are met
d. Patient is not impaired by drugs or alcohol
e. Patient is not suffering from significant psychiatric illness
f. Patient refuses treatment/transport
4. Contact medical control if:
a. Declaration of death
b. Termination of resuscitation
c. The provider feels assistance is needed from medical control physician.
*Warn patient of risk of non-treatment/non-transport and document appropriately
** A patient that requested service should be offered transport.
01-18-2016
RESPIRATORY FAILURE
General Scope: Protocol for treatment of a patient in respiratory failure
Protocol:
2. See Airway Management Protocol as needed
3. Observe for signs/symptoms of respiratory failure
a. Failure to oxygenate and/or ventilate, severe respiratory fatigue, inability to
successfully use CPAP, or otherwise noted to be in clinical respiratory failure
4. [Paramedic] Assess expected success of intubation
5. Have rescue airway available
6. [Paramedic]If endotracheal intubation success likely
a. See Rapid Sequence Intubation Protocol
i. If less likely success, consider RSI without Zemuron
7. If failed intubation (3 unsuccessful attempts by skilled providers)
a. Consider BVM
b. Consider King Airway
c. [Paramedic/Med Control] Consider Surgical Cricothyroidotomy Protocol
Note:
Signs of impending respiratory failure include:
RR <8 or >35 breaths per minute

SpO2<85% on 100% O2
Hemodynamic instability
Paradoxical respiratory efforts
Altered mental status
Acutely rising EtCO2 with respiratory acidosis
01-18-2016
RESTRAINT USE
General Scope: Procedure for restraint of a combative patient
Protocol:
1.
2.
3.
4.
5.
6.
Routine medical and/or trauma assessment

Determine need (patient is danger to themselves or others)
Rule out hypoglycemia, hypoxia, hypovolemia, etc.
Choose appropriate restraint or combination of restraints
Physical
a. Secure patient to cot by use of four point soft Velcro/Neoprene restraints
b. Assess to ensure airway patency
c. Assure adequate distal circulation of all extremities
7. Chemical
a. [Paramedic] Consider VERSED IV/IM/IN
i. 1-5mg IV
ii. 0.3-0.5mg/kg IN to a max of 10 mg
iii. 5-10mg IM
iv. {child 0.05mg/kg IV or 0.2mg/kg IN}
b. [Paramedic/Med Control] Consider VERSED drip (5mg/100ml D5W or
NS=0.05mg/ml) 0.15mg/kg/hr IV
c. [Paramedic/Med Control] GEODON 10-20mg IM
i. Use with extreme caution in the elderly
ii. Postural hypotension can result, patients receiving GEODON should remain
supine
8. Document:
a. Reason for restraint
b. Method used
c. Frequent vital signs including SpO2 and LOC
FOR ANY PATIENT TRANSPORTED IN HANDCUFFS, LAW ENFORCEMENT SHOULD ACCOMPANY
PATIENT IN THE AMBULANCE WHEN POSSIBLE
01-18-2016
SCENE REHABILITATION
General Scope: Protocol for rehabilitation of rescue personnel when requested to a standby
Protocol:
1.
2.
3.
4.
Assign rehab area

Encourage removal of all PPE including bunker pants pushed down to boots
Rest, active cooling, and oral hydration
Immediate transport if any of the following criteria is met:
a. Chest pain
b. Shortness of breath
c. Arrhythmia other than sinus tachycardia
d. Syncope, confusion, or disorientation
e. Grossly abnormal vital signs
f. Vomiting or inability to maintain oral intake
g. Request for transport
5. If pulse is >85% max for age
a. Have person stand for 2 minutes and observe for symptoms
b. Perform orthostatic vital signs
c. If HR increase >20 or SBP drop >20
i. [EMT-I/AEMT/Paramedic] IV rehydration up to 2 L NS
ii. Release but not allowed to return to scene duties
6. If any of the following is met the patient must take mandatory rest, rehydration, and reevaluation. Will require transport if no improvement within 30 minutes
a. SBP 200 or DBP >100
b. RR<8 or >40
c. Temp>101F
d. SpO2 <91%
7. If none of the above is met the patient may return to full duty
Firefighters should report to rehab after 45 minutes or two (2) thirty
minute air bottles
01-18-2016
SEDATION
General Scope: Protocol for treatment of patients who require sedation in the prehospital setting. All
patients who receive sedation should have continuous monitoring of vital signs including cardiac
monitoring.
Protocol:
1.
2.
3.
4.

Consider hypoxia or hypovolemia
If patient is combative, maintain adequate restraints, see Restraint Protocol
a. Consider Tranzport Spit Hood if needed
5. [EMT-I/AEMT/Paramedic] Establish IV/IO per Vascular Access Protocol if possible
6. [Paramedic] VERSED
i. 1-5mg IV
ii. 5-10mg IM
iii. {child 0.05mg/kg IV or 0.2mg/kg IN}
b. [Paramedic/Med Control] GEODON 10-20mg IM
i. Use with extreme caution in the elderly
ii. Postural hypotension can result, patients receiving GEODON should remain
supine
c. [Paramedic/CCParamedic Med Control] KETAMINE 1-2mg/kg IV
Note: TSRA staff contact Medical Control for sedation of any patient
with respiratory distress.
01-18-2016
SEIZURE
General Scope: Protocol for treatment of patients who are or suspected to be experiencing seizures
Protocol:
1.
2.
3.
4.

Consider pregnancy, see Pre-Eclampsia / Eclanpsia Protocol
Rule out hypoglycemia, trauma, infection, hypoxia, withdrawal, or toxins
a. If glucometer < 60 or > 250 see Diabetic Emergency Protocol
b. See Altered Mental Status Protocol
c. [Paramedic] Consider THIAMINE 100 mg IV/IM for adults with history of
alcoholism, hyperemesis, cancer, gravidarum, or unknown seizure history
5. If actively seizing:
b. [Paramedic] VERSED
i. 2mg IV Q 2 minutes until seizure stops
ii. 0.2mg/kg IM
iii. {child 0.1mg/kg IV or 0.2mg/kg IM} 2mg max single dose
6. If seizure has resolved and patient is postictal
b. If patient is febrile, remove clothing and cool, but avoid shivering
01-18-2016
SHOCK
General Scope: Protocol for management of shock in all patients
Protocol:
1. Control obvious hemorrhage
2. Position patient supine when possible
a. 2 access points if evidence of Class II or greater shock
b. Initial fluid challenge with NS with a SBP goal of > 80 in trauma patients (permissive
hypotension except in patients with significant head injuries), 90 in medical patients
4. [Paramedic/Medical Control] For hemorrhagic shock: Tranexamic acid (TXA) 1g in 100ml D5W IV
over 10 minutes (faster may result in hypotension); use a filter needle to draw up
a. Follow by an infusion of 1g in 500ml NS over 8 hours (at receiving facility)
b. Indications: Evidence of acute blood lossClass II or greater
c. Administration as soon as possible but no later than 3 hours after initial injury
d. Exclusions:
i. Patients < 16
ii. Known time of injury greater than 3 hours or unknown time
iii. DIC
iv. Recent history of thrombosis or thromboembolism (DVT, PE, embolic stroke).
5. If evidence of anaphylaxis, see Anaphylaxis/Allergic Reaction Protocol
6. Shock Classifications
CLASS I
CLASS II
CLASS III
CLASS IV
Blood Loss (mL)
Up to 750
750-1500
1500-2000
>2000
Blood Loss (%BV)
Up to 15%
15-30%
30-40%
>40%
<100
>100
>120
>140
Normal
Normal
Decreased
Decreased
Normal or
Decreased
Decreased
Decreased
14-20
20-30
30-40
>35
>30
20-30
5-15
Negligible
Slightly
Mildly
Anxious and
Confused and
anxious
anxious
confused
lethargic
Pulse Rate
Blood Pressure
Pulse Pressure (mmHg)
increased
Respiratory Rate
Urine Output (mL/hr)
CNS/Mental Status
01-18-2016

Fluid Replacement (3:1)
Crystalloid
Crystalloid
Crystalloid
Crystalloid
and blood
and blood
SELECTIVE SPINAL PRECAUTIONS; C-SPINE CLEARANCE

General Scope: Criteria to exclude patients selectively from spinal precautions when a low index of
suspicion of injury and reassuring assessment is present.
Applies to: Paramedic/Transport Ambulance
Protocol:
1. Perform routine trauma assessment while cervical spine is manually immobilized
2. [Paramedic] Determine if patient meets any of the following Spinal Precautions criteria
a. Altered level of consciousness? If YES see spinal precautions protocol
b. Neuro Exam: Does the patient have any focal deficit? If YES see spinal precautions
protocol
c. Spinal Exam: Point tenderness over the spinous process(es) or pain during Range of
motion exam? If YES see spinal precautions protocol
d. >65 y/o or <5 y/o with significant mechanism of Injury? If YES see spinal
precautions protocol
e. Evidence of impairment by drugs/alcohol? If YES see spinal precautions protocol
f. Painful distracting injuries? If YES see spinal precautions protocol
3. [Paramedic]If the answer is NO to all the above, spinal precautions may be deferred
a. All deferred spinal precautionss shall have the criteria above documented on the
patient care report. When in doubt always refer to spinal precautions protocol
Pearls
You should not assume a walking patient has a clear C-Spine
Consider precautions in any patient with arthritis, cancer, dialysis or other underlying
spinal or bone disease.
The decision to NOT implement spinal precautions in a patient is the responsibility of the
paramedic solely.
In very old and very young, a normal exam may not be sufficient to rule out spinal injury.
Range of motion should NOT be assessed if patient has midline spinal tenderness. Patient's
range of motion should not be assisted. The patient should touch his chin to his chest, extend
his neck (look up), and turn his head from side to side (shoulder
to shoulder) without spinal pain.
01-18-2016
SPINAL PRECAUTIONS FOR TRANSPORT AMBULANCE

General Scope: Transport Ambulance Protocol for spinal precautions
Applies to: All Medical staff:
Protocol:
a. Explain the procedure to the patient
b. Asses CMS
c. Measure and place cervical collar while maintaining in-line stabilization of the Cspine by a second provider.
d. If cervical collar does not fit due to obesity or physical abnormality, attempt
stabilization with blanket roll
e. If patient is supine or prone place the patient on a long spine board/scoop by the
safest method available (i.e. log-roll, lift, etc.). For the patient in a vehicle or seated
position or otherwise unable to be placed prone or supine, and the patient condition
does not allow them to self-extricate to adjacent cot (i.e. other injury, pain, altered
level of consciousness), place him or her on a backboard/scoop by the safest method
available that allows maintenance of in-line spinal stability.
f. Secure the patient with straps.
g. Once extricated and moved, patients should be taken off the backboard or scoop
stretcher if possible, and be placed directly on the ambulance stretcher. It is
acceptable to leave a patient on a backboard for transport (transports < 5min, or life
threating patient condition), but every effort should be made to secure the patient to
the stretcher and not the backboard/scoop during transport.
h. When long spine board is not utilized, spinal precautions in at-risk patients is
paramount. These include cervical collar, securing to stretcher, minimal movement/
transfers and maintenance of in-line spine stabilization during necessary
movement/ transfers. This includes the elderly or those with body or spine habitus
preventing them from lying flat.
Note:
Spinal precautions may be achieved by many appropriate methods. In addition, some
patients, due to size or age, will not be able to be immobilized through in-line stabilization
with standard devices and C-collars. Never force a patient into a non-neutral position to
immobilize him or her. Manual stabilization may be required during transport. Special
situations such as athletes in full shoulder pads and helmet may remain immobilized with
helmet and pads in place.
Patients with penetrating traumatic injuries should only be immobilized if a focal
neurological deficit is noted on physical exam.
01-18-2016
Spinal Examination
General Scope: This procedure details the spinal examination process and must be used in conjunction
with the spinal precautions clearance protocol.
Applies to: Paramedic/Transport Ambulance
Protocol:
a. Explain to the patient the actions you are going to take. Ask the patient to
immediately report any pain, and to answer questions with a yes or no
rather than shaking the head
b. With the patients spine supported to limit movement, begin palpation at the
base of the scull at the midline of the spine
c. Palpate the vertebrae individually from the base of the skull to the bottom of the
sacrum
d. On palpation of each vertebral body, look for evidence of pain and ask the
patient if they are experiencing pain. If evidence of pain along the spinal column
is encountered, the patient should be immobilized
e. If the capable patient is found to be pain free, ask the patient to turn their head
first to one side (so that the chin is pointing toward the shoulder on the same
side as the head is rotating) then, if pain free, to the other. If there is evidence of
pain the patient should be immobilized
f.
01-18-2016
With the head rotated back to its normal position, ask the patient to flex and
extend their neck. If there is evidence of pain the patient use spinal precautions
protocol
SPINAL PRECAUTIONS FOR NON-TRANSPORT EMT/EMR

General Scope: Protocol for spinal precautions for agencies that have spinal precautions training but do
not transport.
Applies to: Non-Transport EMT/EMR
Protocol:
g. Explain the procedure to the patient
h. Asses CMS
i. Measure and place cervical collar while maintaining in-line stabilization of the Cspine by a second provider.
j. If cervical collar does not fit due to obesity or physical abnormality, attempt
stabilization with blanket roll
k. If patient does not need to be moved do not place patient on longboard/scoop
and await transport ambulance arrival.
l. If patient does require movement proceed to next step.
m. If indicated, place the patient on a long spine board with the log-roll technique if
the patient is supine or prone. For the patient in a vehicle or otherwise unable to
be placed prone or supine, place him or her on a backboard by the safest method
available that allows maintenance of in-line spinal stability.
n. Stabilize the patient with straps and head rolls/tape or other similar device.
Once the head is secured to the backboard, the second rescuer may release
manual in-line stabilization.
Note:
Spinal precautions may be achieved by many appropriate methods. In addition, some

patients, due to size or age, will not be able to be immobilized through in-line stabilization
with standard devices and C-collars. Never force a patient into a non-neutral position to
immobilize him or her. Manual stabilization may be required during transport. Special
situations such as athletes in full shoulder pads and helmet may remain immobilized with
helmet and pads in place.
Patients with penetrating traumatic injuries should only be immobilized if a focal
neurological deficit is noted on physical exam.
01-18-2016
SPIT HOOD
General Scope: Protocol for use of protective hoods. This protocol should be used for patients whom
are combative and/or aggressive, and purposely attempting to spit on providers or other public safety
personnel. Spitting carries potential risk of disease transmission. Use of a protective hood minimizes
said risk.
Protocol:
1. Use of one-piece surgical mask or oxygen mask is preferred for minimizing risk of disease
transmission by patients whom are purposely spitting.
2. CONDITIONS FOR USE
a. DO NOT USE unless patient is under control and restrained.
b. DO NOT USE on anyone that is vomiting, having difficulty breathing, or is bleeding
profusely from the area around the mouth or nose.
c. Patient must be under constant visual supervision and should never be left
unattended.
d. Remove patients jewelry and eyewear before application.
e. If there is difficulty applying due to large size head, discontinue use.
f. Conditions for use should be constantly monitored during patient encounter.
3. PROCEDURE FOR USE
a. Open and remove the Tranzport Hood
b. Place the Tranzport hood over the head of the person with the mesh fabric
positioned just below the eyes to allow the person to see.
c. For the best fit, place the center elastic under the nose and over the ears. For better
protection, the elastic may be placed above the nostrils.
d. Carefully push the plastic Secure-Lock Tab down toward the top of the head while
holding the top of the mesh fabric. This should take the slack out of the top and help
secure the Tranzport Hood in position.
i. ** DO NOT push so tightly as to be uncomfortable or impair the vision of the
wearer.
e. See manufacturer instructions included in packaging for visual representation of
procedure for use.
f. Patient should be transported in either left or right lateral position.
g. CONTINUOUSLY monitor patients airway, respiratory status, and pulse oximetry.
h. IMMEDIATELY remove surgical mask, oxygen mask, or Tranzport Hood if any
question of airway patency or potential compromise.
01-18-2016
SURGICAL CRICOTHYROIDOTOMY
General Scope: Procedure for surgical cricothyroidotomy. This is a last option for airway management
and requires approval from medical control. Surgical cricothyroidotomy is contraindicated in patients
< 10 years old.
Protocol:
1.
2.
3.
4.
5.
6.
7.
Determine need and contact medical control

Attempt to provide optimal O2 saturation prior to starting
Palpate cricothyroid membrane and clean area with antiseptic wipe
Make midline incision with #15 scalpel over cricothydoid membrane
Insert Sklar hook and provide upward and caudal traction
Use scalpel to open transversely into trachea keeping blade near or against Sklar hook
Introduce 6.0 mm ETT perpendicular to the trachea rotating as advanced
a. Inflate with 5-10ml air
01-18-2016
SUSTAINED VENTRICULAR TACHYCARDIA / WIDE COMPLEX

TACHYCARDIA
General Scope: Protocol for treatment of a patient in presenting in a wide or ventricular tachycardic
rhythm
Applies to: EMT-I and Paramedic
Protocol:
3. If patient is hemodynamically unstable
a. [Paramedic] Consider sedation per Sedation Protocol
b. [Paramedic] SYNCHRONIZED CARDIOVERSION starting at 100J
i. [Paramedic] If successful begin AMIODARONE drip (1 amp [150 mg] in 100
D5W or NS=1.5mg/ml) at 1mg/min IV (40cc/hr =1mg/min)
ii. If unsuccessful consult Medical Control
4. If patient is hemodynamically stable
a. [Paramedic/Med Control] If rhythm is regular and monomorphic consider
ADENOSINE 6 mg IV
i. [Paramedic/Med Control] Repeat at 12mg (may repeat twice)
b. [Paramedic] Administer AMIODARONE 150 mg IV over 10 minutes
i. [Paramedic] If successful begin AMIODARONE drip (1 amp [150 mg] in 100
D5W or NS=1.5mg/ml) at 1mg/min IV (40cc/hr =1mg/min)
ii. [Paramedic] If unsuccessful consider cardioversion (see #3)
5. [Paramedic/Med Control] Consider MAGNESIUM 2 grams (2g in 100ml D5W or NS) IV over
1-2 minutes for Torsades de pointes Update Medical Control
Note:
Amiodarone Precautions
Hypotension secondary to vasodilatation
May prolong QT interval
Negative inotropic effects
Use with caution in renal failure; long T1/2 life
01-18-2016
TERMINATION OF RESUSCITATION
General Scope: Procedure for terminating resuscitation efforts in cardiac arrest
Protocol:
1. Except in conditions in Determination of Death Protocol, CPR is to be initiated and
maintained until one of the following occurs
a. Resuscitation efforts have been transferred to other persons of at least equal skill
and training
b. Effective ROSC and ventilation have been restored
c. The rescuers are physically unable to continue efforts
d. Medical Control orders efforts to stop
i. If transport has been initiated, efforts must continue until patient care has
been turned over to the receiving hospital
01-18-2016
THORACIC/ABDOMINAL AORTIC ANEURYSM

General Scope: Protocol for treatment of patients who present with signs and symptoms consistent
with that of an aortic aneurysm
Protocol:
3. [EMT-I, AEMT, Paramedic] Establish IV/IO per Vascular Access Protocol (Two large bore
lines if possible)
4. Treat pain per Pain Management Protocol
5. If patient SBP>130:
a. [Paramedic/Med Control] Labetalol 20mg Slow IV
i. May repeat at 40mg every 10 minutes to a max of 300mg
b. [Paramedic/Med Control] NTG DRIP (20mg/100ml D5W or NS200mcg/ml)
iii. Titrate by 5-10mcg/min every 5-10 minutes to SBP~110
6. If patient SBP<90
a. [EMT-I, AEMT, Paramedic] 250-500ml NS bolus up to 2-3 liters total
b. [Paramedic] If failure response to fluid bolus, consider DOPAMINE drip
(200mg/250ml D5W800mcg/ml) Initiate infusion at 5mcg/kg/min and titrate
every 5 minutes by increments of 1-5mcg/kg/min up to 20mcg/kg/min.
Note:
Patient assessment
1. History:
a. Thoracic:
i. Relatively sudden onset
ii. severe "tearing" chest pain with possible radiation to back
b. Abdominal:
i. Intermittent or constant abdominal pain commonly localized to left middle
or lower quadrant
ii. Back pain and flank pain are the next most common symptoms
2. Physical exam:
a. Possible hypotension
b. Pulse discrepancy side-to-side or upper versus lower extremities
c. Pulsatile abdominal or groin mass with or without a bruit
01-18-2016
TRAUMA IN P REGNANCY
General Scope: Protocol for treatment of all potentially pregnant patients with potential trauma.
Protocol:
2. See General Trauma Protocol
3. Position patient on left side unless a spinal injury is suspected (minimize uterine
compression on the inferior vena cava)
4. If patient is immobilized on a long back board:
a. Tilt backboard to left side
b. Elevate right buttock and push uterus to the left
6. Maintain blood pressure, see Blood Pressure Management Protocol
a. SBP & DBP is 5-15mmHg less starting in second trimester
b. HR is 15-20 BPM more during third trimester
c. Shock is not always obvious in the pregnant patient (Because of an increase in
circulating blood volume during pregnancy, the pregnant female will show signs of
hypovolemia later in their course)
01-18-2016
TREATMENT OF THE TERMINALLY ILL P ATIENT

General Scope: Procedure for dealing with terminally ill patients
Protocol:
1.
2.
3.
4.
5.
6.
7.
If called to the scene of a terminally ill patient before death:

Follow POLST form
Initiate low-flow O2
[Paramedic] Apply cardiac monitor
Make patient comfortable, see Pain Management Protocol
Reassure family members that are present
When patient becomes pulseless, apneic, and asystolic proceed as with Triple Zero, see
Determination of Death Protocol
01-18-2016
VASCULAR ACCESS
General Scope: Procedure for vascular access.
Applies to: Intermediate Technicians, AEMT**, Paramedics
** Optional use by service and requires Prior Written Approval of the Operational Plan
by the State EMS Office and Medical Director Approval and Documentation of Training.
Protocol:
1. [EMT-I/AEMT/Paramedic] Establish peripheral IV
a. 2 IVs if indicated and possible
b. 16g or larger if indicated and possible
i. Trauma activations
ii. Cardiac arrest
iii. GI bleed
iv. Hypovolemia
2. [EMT-I/AEMT**/Paramedic] If unsuccessful, consider EZ-IO or [Paramedic]external jugular
IV
a. [Paramedic] Consider external jugular IV (patient age>6)
i. Place patient supine or head down
ii. Locate vein
iii. Cleanse area with antiseptic wipe
iv. Make venipuncture midway between angle of jaw and mid-clavicular line
v. Confirm placement
vi. Attach IV tubing and secure to patients neck
b. Consider EZ-IO, see EZ-IO Protocol
3. [Paramedic] If EZ-IO failure, attempt manual IO
a. Support leg with knee slightly raised
b. Cleanse area with antiseptic wipe
c. Inset needle through skin at 90 angle on tibial plateau
d. Insert needle into bone marrow cavity with twisting motion
e. Upon loss of resistance remove stylet, aspirate, then attach IV
f. Secure needle
01-18-2016
VENTRICULAR FIBRILLATION / PULSELESS VENTRICULAR

TACHYCARDIA
General Scope: Protocol for treatment of a patient presenting with ventricular fibrillation or Pulseless
ventricular tachycardia in cardiac arrest
Protocol:
a. [Paramedic] May administer precordial thump if witnessed arrest
3. Apply defibrillator or AED
a. Defibrillate at 150J
b. Repeat defibrillation (consider escalating energy) every 2 minutes with medications
administered as listed below
7. [Paramedic] Administer AMIODARONE 300mg IV/IO
a. [Paramedic] May repeat with 150mg IV/IO
8. [Paramedic/Med Control] Consider MAGNESIUM 2 grams (2g in 100ml D5W or NS) IV over
1-2 minutes for Torsades de pointes
9. [Paramedic/Med Control] Consider SODIUM BICARBINATE 50mEq IV/IO if patient is
severely acidotic
10. If pulse is returned see Post Arrest Protocol
APPENDIX A-1: NITROGLYCERINE DRIP

01-18-2016

General Scope: Drip rate and pump set-up charts
Nitroglycerine Drip
Pre-mixed Drip
01-18-2016
*Pump Set
*Drug Rate
2 ml/hr
5 mcg/min
3 ml/hr
10 mcg/min
4 ml/hr
15 mcg/min
6 ml/hr
20 mcg/min
8 ml/hr
25 mcg/min
9 ml/hr
30 mcg/min
11 ml/hr
35 mcg/min
12 ml/hr
40 mcg/min
14 ml/hr
45 mcg/min
15 ml/hr
50 mcg/min
18 ml/hr
60 mcg/min
21 ml/hr
70 mcg/min
24 ml/hr
80 mcg/min
30 ml/hr
100 mcg/min
36 ml/hr
120 mcg/min
42 ml/hr
140 mcg/min
48 ml/hr
160 mcg/min
54 ml/hr
180 mcg/min
60 ml/hr
200 mcg/min
APPENDIX A-2: EPINEPHRINE DRIP

General Scope: Drip rate and pump set-up charts.
Initial Epinephrine Drip

1mg Epinephrine / 100ml D5W or NS (10mcg/ml)
Weight
Pump
(KG)
Dose mcg/min rate
ml/hr
40
0.4 mcg/min
2.4 ml/hr
50
0.5 mcg/min
3 ml/hr
60
0.6 mcg/min
3.6 ml/hr
70
0.7 mcg/min
4.2 ml/hr
80
0.8 mcg/min
4.8 ml/hr
90
0.9 mcg/min
5.4 ml/hr
100
1 mcg/min
6 ml/hr
110
1.1 mcg/min
6.6 ml/hr
120
1.2 mcg/min
7.2 ml/hr
130
1.3 mcg/min
7.8 ml/hr
140
1.4 mcg/min
8.4 ml/hr
150
1.5 mcg/min
9 ml/hr
160
1.6 mcg/min
9.6 ml/hr
170
1.7 mcg/min
10.2 ml/hr
180
1.8 mcg/min
10.8 ml/hr
200
2 mcg/min
12 ml/hr
01-18-2016
APPENDIX A-3: DOPAMINE DRIP

Recommended Dopamine infusion Rate
(for 800mcg/ml concentration)
Patient weight (kg)
mcg/kg/min
5
7
10
15
20
Pump Setting
Dose
01-18-2016
40
15
21
30
45
60
50
18.75
26.25
37.5
56.25
75
60
22.5
31.5
45
67.5
90
70
26.25
36.75
52.5
78.75
105
80
30
42
60
90
120
90
33.75
47.25
67.5
101.25
135
100
37.5
52.5
75
112.5
150
110
41.25
57.75
82.5
123.75
165
120
45
63
90
135
180
130
48.75
68.25
97.5
146.25
195
140
52.5
73.5
105
157.5
210
150
56.25
78.75
112.5
168.75
225
160
60
84
120
180
240
170
63.75
89.25
127.5
191.25
255
APPENDIX A-4: POST ARREST ANTI -ARRHYTHMIC D RIPS

Post-conversion Lidocaine Drip
Premixed 4mg/ml
Pump Set
Rate
15 ml/hr
1 mg/min
30 ml/hr
2 mg/min
45 ml/hr
3 mg/mi
60 ml/hr
4 mg/mn
Post-conversion Amiodarone Drip

150mg Amiodarone in 100ml D5W or NS
Pump Set
Rate
40 ml/hr
1 mg/min
01-18-2016
APPENDIX B-1: CHEST TUBE MONITORING

General Scope: Chest tube monitoring. ** Paramedics may monitor and troubleshoot chest tubes.
**(Optional use by Paramedic service and requires Prior Written Approval of the
Operational Plan by the State EMS office and Medical Director Approval and
Documentation of additional training)
Applies to: Paramedics and Critical Care Paramedics
Indications: Chest tubes are indicated for pneumothorax, hemothorax and pleural empyema.
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Routine Trauma and/or Medical Assessment.

Assure that the chest tube(s) is securely fastened to the patient.
Check chest tube(s) for patency and proper function prior to transport.
Assure that the long flexible tubing is securely fastened to the container that acts as a
drainage device, water seal and suction control device. Assure that the tubing is free of
kinks.
Make note of the fluid and blood levels in the drainage and water seal compartments.
Obtain orders as to the water seal level.
When suction is used, assure that there is bubbling in the suction control chamber. (if not,
check the suction unit).
If the water seal fails to stop bubbling after the lung is reinflated or later begins to bubble:
a. Momentarily clamp the flexible tubing near the chest. If the bubbles quit emanating
from the tube while it is clamped, then the problem is either a persistent air leak in
the patients lung or the chest tube is not sealed at the chest wall.
b. Never leave the clamp on for more than a few seconds.
c. Evaluate the insertion site.
d. Apply occlusive dressings to the site.
e. Evaluate the patient for distress.
f. Consult physician immediately if needed.
g. If the bubbling does not cease during the clamping of the proximal end, then suspect
a leak at a connection site in the tubing or the tubing itself.
i. Check all connections and secure with tape.
ii. Seal the leak with occlusive dressing and tape or replace the tubing. When
replacing the tubing, remember to clamp the distal end of the chest tube to
avoid the formation of a pneumothorax.
If water seal device becomes damaged, a temporary water seal can be accomplished by
putting flexible tubing into a bottle of sterile saline. Keep this device and tubing below chest
level.
To clear clots from the tubing, squeeze the proximal end of the tubing with one hand and
with the other below, squeeze the tube, stripping the material down the tube toward the
drainage container.
Consult with the physician/staff for the best patient positioning.
If the chest tube is not functioning and a tension pneumothorax is suspected, perform a
needle decompression of the affected side.
01-18-2016
APPENDIX B-2: VENTILATOR / BIPAP USE

General Scope: Protocol and criteria for transport ventilator and BiPAP use.
Applies to: All Critical Care Staff
Protocol:
1. VENTILATOR SETTINGS
a. If time allows during response, turn on ventilator connected to test lung.

b. Mode: Set at Assist Control or SIMV(SIMV V is the most common setting)
c. Go to Powerup setting. Change to Powerup with user 1. Go to Save Setting and save user
1 settings. This should allow the vent to turn on with your recent settings. Note: This
will only save the most basic settings, such as Mode, Vt and I:E ratio. This will not save
high and low pressure alarm setting or Trigger level settings.
d. Turn Vent off until patient side.
e. Turn vent on
f. Set High and Low pressure alarms to desired setting.
g. Press menu button.
h. Adjust trigger level to desired setting
i. Adjust Contrast to desired setting
j. Initial tidal volume: 7-10 cc/kg IDEAL BODY weight with a maximum of 800cc;
consider decreasing to 6-8 cc/kg in patients with reactive airways disease and
increasing PEEP requirements.
k. FiO2 100% or adjust FiO2 to maintain SaO2 at >95%
l. PEEP: 5 cm. Titrate in increments of 2 cm (max of 10 cm) every 15 minutes to increase
oxygenation saturations where other measures (sedation, paralysis) have failed and
SBP is > 90mmHg.
m. RR: 8-10
i. If attempting to decrease intracranial pressure [ICP] hyperventilate keeping p
EtCO2 between 30-35. Start at a rate of 10 and increase or decrease rate in
increments of 2 to obtain desired EtCO2
ii. If RR 16-20, use no PEEP
n. Be aware of pneumothorax risk (especially with traumatic chest injuries)
o. Maintain EtCO2 between 35-40 for most patients; 30-35 if evidence of lateralizing signs
p. Pressure alarm: monitor patients inspiratory pressure and set at 10 cm above Peak
Inspiratory Pressure
q. Increase sensitivity slowly if ventilator doesnt capture inspiratory effort
r. Monitor I:E ratio and maintain at a minimum of 1:2 if patient is prone to air-trapping
2. VENTILATION OPTIONS WITH PERMANENT TRACHEOSTOMY
a. Metal cannula, fenestrated (cuffless) or button device: replace with 6-7F ETT,
whichever can be placed with the least effort/trauma
b. Non-fenestrated cuffed trach: insert inner cannula and inflate balloon; if no inner
cannula available, go to 2A.
01-18-2016
APPENDIX B-2: VENTILATOR / BIPAP USE (CONTINUED)

3. NPPV (BiPAP)
a. NPPV delivers CPAP but also senses when an inspiratory effort is being made and
delivers a higher pressure during inspiration. This positive pressure wave during
inspirations unloads the diaphragm decreasing the work of breathing.
b. There is an increased number of MIs in patients on NPPV compared to CPAP;
recommended that CPAP be attempted first. If NPPV is used, watch for evidence of
hypotension.
c. Indications
i. Recent and rapid worsening of dyspnea
ii. Respiratory rate > 30
iii. pH < 7.28
iv. PaCO2 > 50mmHg
v. Hypoxemia
1. Pneumonia
2. Fluid overload
vi. CHF
vii. Moderate to severe respiratory failure
viii. Post-op patients with rising EtCO2 levels
ix. COPD patients with acute-on-chronic ventilatory failure
d. Exclusion criteria
i. Recurrent aspiration
ii. Large volumes of secretions
iii. Inability to protect the airway
iv. Vomiting
v. Obstructed bowel
vi. Upper airway obstruction
vii. Uncooperative, confused or combative patient
viii. ARDS
ix. Inability to tolerate a tight mask
x. Orofacial abnormalities which interfere with mask/face interface
xi. Hemodynamic instability
xii. Untreated pneumothorax
4. Settings for Impact Ventilator BiPAP.
a. Preset alarms and settings by turning the unit on: let the vent start in default mode.
b. Select CPAP under the mode menu. Then change PPV to NPPV in the upper right hand
corner of the mode menu. Always make sure to use the green check mark when
changing a setting.
c. If the BiPAP setting are unknown start with 10 over 5. This is done by setting the PEEP
at 5 and the pressure support to 5. Remember pressure support is found in the
secondary PIP menu. This is achieved by pressing and holding the PIP menu button for
greater than 5 seconds.
d. Pressure support of 5 and PEEP of 5 is equal to BiPAP of 10/5
e. Use a standard resuscitation mask with blue elbow and the head strap when providing
BiPAP with the Impact ventilator.
f. If improvement in ventilation and oxygenation is not achieved, discontinue NPPV and
consider tracheal intubation
01-18-2016
APPENDIX B-2: VENTILATOR / BIPAP USE (CONTINUED)

5. Pediatric recommendations
a. Less than 1 year of age
i. Assist control pressure ventilation mode
ii. PIP 15 (increase pressure only if needed to get normal chest rise)
iii. Inspiratory time 0.7 seconds
iv. Rate of 15 (increase by increments of 5 to maintain EtCO2 between 40-50
v. PEEP of 4.
vi. FiO2 to maintain sats > 95%
vii. Monitor TV
b. Greater than 1 year of age
i. Assist control volume mode
ii. Start with default Pediatric settings
iii. Change to Volume Mode; calculate 10 ml/kg TV
iv. Inspiratory time 0.7 seconds
v. Rate of 15 (increase by increments of 5 to maintain EtCO2 between 40-50
vi. PEEP of 4
vii. FiO2 to maintain sats > 95%
viii. Monitor TV
6. Initial settings for specific scenarios
a. Severely brain injured i.e. localizing signs such as dilated pupil and posturing
i. Assist control
ii. RR 8-12
iii. TV 6-10cc/kg ideal body weight with a maximum of 1000cc
iv. PEEP 5 cm
v. FiO2 100% or adjust FiO2 to maintain SaO2 at >95%
b. Depressed respiratory drive, eg, intoxicated or overdose patient
i. Assist control or SIMV
ii. RR 6-15
iii. TV 6-10 cc/kg ideal body weight with a maximum of 1000cc
iv. PEEP 5 cm
c. Acute bronchospasm
i. Assist control
ii. RR 8-10
iv. PEEP 5 cm
vi. May need to increase peak flow setting to 50-80 lpm
d. Multilobar disease, eg., pneumonia, pulmonary edema/ARDS, extensive disease patterns
i. Assist control
ii. RR 10-20
iv. PEEP 5 cm with titration to maintain oxygen saturations
vi. Set inspiratory flow rate above patient demand, usually greater than 80 lpm
01-18-2016
APPENDIX B-3: BLOOD TRANSFUSION & CONTINUATION

MONITORING
General Scope: Protocol and criteria for transport infusion of blood product. All blood products to be
infused must be initiated by the transferring facility. This protocol does not allow CCEMT-paramedics or
Paramedics to initiate infusion of blood products. Critical Care Paramedics may infuse a second bag of
blood product so long as the infusion was begun at the transferring facility. Paramedics may monitor a
transfusion of blood product during transport, but may not initiate transfusion or hang a second bag of
blood product.
Protocol:
1. Obtain written order for rate and total volume of blood product to be infused, confirm with
RN or physician
2. Confirm with RN or physician that name on patients wristband matches the name on the
infusing blood. The patient must have a wristband, no exceptions.
3. Vital signs (including body temperature) must be recorded pre-transport and q10 minutes
during transport
4. If the patient develops any sign of allergy/sensitivity reaction, including; chills, fever, chest
pain, flank pain, hives, wheezing, uticaria, or the patient shows signs of shock; the following
actions should be taken immediately:
a. Infusion of blood product must be immediately stopped, disconnected, and all
tubing and product saved for delivery to the receiving facility.
b. IV NS initiated
c. See Blood Pressure Management Protocol
d. See Anaphylaxis Protocol
e. Hemolytic reactions (fever, chills, chest pain, flank pain, and/or shock) may require
administration of diuretics in addition to fluid administration. Contact Medical
Control if a hemolytic reaction is suspected.
5. Written orders must accompany patient and be included in the patient care report.
01-18-2016
APPENDIX B-4: ARTERIAL LINE, CENTRAL LINE, AND CVP MONITORING

General Scope: Protocol and criteria for accessing central lines, and monitoring arterial lines and central
venous pressure.
Protocol:
Arterial Line Monitoring
1. Ensure the pressure bag is pressurized to 300 mm Hg
2. Use steps 3-6 if using arterial line to measure arterial blood pressure
3. With the transducer connected to the monitor, select arterial monitor, and perform a
transducer check by fast flushing the line. As you do this, you should see a change in the
waveform. This is called a square wave test.
4. Zero the transducer and monitor
a. Place the transducer at the phlebostatic axis of the patient.
b. Close the line off to patient and open to air.
c. Press zero on the monitor.
d. To monitor pressure, close the port off to an air and open to patient.
5. Connect the catheter and fast flush to clear the catheter of blood.
6. Check for good waveform.
Central Line Access
1. To access the line first clamp off the hub line you intend to use.
a. Its important to clamp off the line to prevent air from being sucked in to the line and
blood stream.
b. Any of the hub lines can be used, they all go to the same place and work the same way.
2. Once you have the line clamped off, expose the end of the hub (it may have a cap or be taped
over) clean it well with an alcohol prep and put an INT hub on it.
3. With the INT hub in place, unclamp the tubing and let the INT hub seal out air.
4. Clean the INT hub and attach an empty 10 cc syringe to the INT hub
a. Aspirate about 5ml of blood and heparin to confirm the line is in place,
i. There should be no resistance to aspiration.
b. discard the syringe and contents as biohazard waste.
5. Attach a saline flush syringe to INT hub and flush it gently.
6. Attach a flushed 60 drop set (or blood set if you think you need volume replacement) and saline
bag and run it into the line at a TKO rate.
7. Use the y-sites on the IV tubing to give meds as needed; make sure to clean the y-site correctly
and flush with the saline IV line after each med.
01-18-2016
APPENDIX B-4: ARTERIAL LINE, CENTRAL LINE, AND CVP MONITORING

(Continued)
Continuous Venous Pressure Monitoring:

1. Assemble A-line set up as per arterial line monitoring system or Swan-Ganz multi-lumen
monitoring system instructions.
2. Make sure there are no air bubbles in the system.
3. Connect pressurized tubing to central venous catheter.
4. Zero and calibrate transducer system.
5. Validate waveform on monitor. Obtain 'mean' pressure reading.
01-18-2016
APPENDIX B-5: PICC LINE USAGE

General Scope: Protocol and criteria for accessing and using PICC lines
Protocol:
1. May administer medications through previously placed PICC lines when no other option is
available, under direct on-line medical control or standing orders.
a. Maintenance of sterility is of significant importance.
b. Sterile technique must be maintained if new medications are being initiated through
PICC line.
c. Flush medication with 10ml NS using at least a 10cc syringe.
i. Syringes smaller than 10cc can exert excessive pressure on PICC lines.
d. Maintain dressing at PICC site.
01-18-2016
APPENDIX B-6: TRANSVENOUS PACEMAKER

General Scope: Protocol and criteria for transporting a patient with a transvenous pacemaker
Protocol:
1. Locate pacemaker generator
2. Ensure battery is fresh
3. Identify each wire set as atrial or ventricular
a. Epicedial ventricular wires exit from the left side of the chest
b. Atrial wires exit from the right side of the chest generally
4. Attach wires to the appropriate sites
5. Power on the pulse generator
6. Set rate based on need and physician orders
a. Surgical: 90-110 BPM
b. Medical: 70-90 BPM
c. Cardiac Arrest: 80 BPM
7. Set amperage
a. Nonurgent: 10mA
b. Emergent: 15-20mA
8. Set the sensitivity
a. Start at 2-5mV
b. If failure occurs turn sensitivity DOWN
c. If pacer is sensing beats not present turn sensitivity UP
9. Observe patient for response
10. Secure all wires, connections, and pacemaker in a safe location
01-18-2016
APPENDIX B-7: FOLEY CATHETER INSERTION

General Scope: Protocol and criteria for foley catheter insertion
Protocol:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Gather equipment.
Explain procedure to the patient
Assist patient into supine position with legs spread and feet together
Open catheterization kit and catheter
Prepare sterile field, apply sterile gloves
Check balloon for patency.
Generously coat the distal portion (2-5 cm) of the catheter with lubricant
Apply sterile drape
If female, separate labia using non-dominant hand. If male, hold the penis with the nondominant hand. Maintain hand position until preparing to inflate balloon.
Using dominant hand to handle forceps, cleanse peri-urethral mucosa with cleansing solution.
Cleanse anterior to posterior, inner to outer, one swipe per swab, discard swab away from
sterile field.
Pick up catheter with gloved (and still sterile) dominant hand. Hold end of catheter loosely
coiled in palm of dominant hand.
In the male, lift the penis to a position perpendicular to patient's body and apply light upward
traction (with non-dominant hand)
Identify the urinary meatus and gently insert until 1 to 2 inches beyond where urine is noted
Inflate balloon, using correct amount of sterile liquid (usually 10 cc but check actual balloon size)
Gently pull catheter until inflation balloon is snug against bladder neck
Connect catheter to drainage system
Secure catheter to abdomen or thigh, without tension on tubing
Place drainage bag below level of bladder
Evaluate catheter function and amount, color, odor, and quality of urine
Remove gloves, dispose of equipment appropriately, wash hands
Document size of catheter inserted, amount of water in balloon, patient's response to
procedure, and assessment of urine
01-18-2016
APPENDIX D-1: TRAUMA ACTIVATION GUIDELINES

General Scope: Guidelines/Criteria for activation of trauma teams
GLMC Activation:
Level 1
Traumatic arrest: active or history of
Intubated and/or Respiratory compromise/Obstruction
o
Stridor or grunting in children
Systolic blood pressure at any time:
o
Adult
<90mmHg
o
Pediatric
<60mmHg (0-6 months)
o
<70mmHg (6 months-5 yrs)
o
<80mmHg (over 5 yrs)
Penetrating injury to torso, neck, or head
Penetrating injury to extremity with pulsatile bleeding
Amputation above wrist or ankle
Evisceration
GCS 8 with mechanism attributed to trauma
Blood transfer in ED or PTA
Flail chest or multiple rib fractures (>3 ribs unilaterally)
Pelvic Fracture: unstable or open/displaced/comminuted
Level 2
Extrication > 20 minutes
GCS < 14
Revised trauma score less than < 11
Combination of trauma with burns
New onset paralysis
Burns
o
Adult
>20% TBSA or involving face or airway
o
Pediatric
>15% TBSA
IFT of trauma patient this is multiply injured or has multiple long bone fractures
Ejection from vehicle
Falls greater than 20 feet
Auto-pedestrian / auto-cycle injury with significant (>5mph) impact
Pedestrian thrown or run over
Electrocution
Hypothermia/cold water immersion
Traumatic drowning or diving incident
Trauma Consult
Death in same vehicle
Rollover
High speed accident (>40mph)
o
Intrusion > 12 inches into passenger compartment
o
Major auto deformity > 20 inches
Motorcycle, ATV, bicycle crash > 20 mph or ejection from bike
Co-morbidity: COPD, DM, CAD, CRF, etc
Pregnancy
Age < 5 or > 60
Three or more patients on long board
Bleeding disorder or anticoagulants
Suspect alcohol or drug intoxication
EMT High index of suspicion
Immunosuppressed/compromised
01-18-2016
APPENDIX D-1: TRAUMA ACTIVATION GUIDELINES - CONTINUED
Trauma Destination Determination Guidelines

In an effort to clarify any confusion as to where Tri-State Ambulance should transport trauma patients,
please consider the following recommendations:
Trauma patients who meet the following criteria should be transported to a Level II or
higher trauma center (Gundersen Health System in the La Crosse area):
o Hemodynamically unstable patients as a direct result of traumatic injury.
o Pediatric neurotrauma with deficits.
o Penetrating injury to head, neck, torso, or proximal extremity.
o Flail chest.
o Unstable pelvic fracture.
MCHS medical control physician should be consulted on all major trauma patients who do
not meet the above criteria and who may be transported to MCHS by choice or medical
control
rotation. The MCHS physician (or nurse in consultation with physician) may divert an
ambulance to the closest Level II trauma center (Gundersen Health System).
All Diversions must be charted in the ePCR explaining the reason for diversion and the
reason that transport to MCHS was initially chosen.
01-18-2016
APPENDIX D-2: STROKE ACTIVATION GUIDELINES

General Scope: Guidelines/Criteria for activation of stroke teams
Applies to: All Staff
Find out the patients last known well time from most reliable source
Get and report a blood sugar reading
Get and report blood pressure status
Are they taking an oral anticoagulant/blood thinner [Coumadin,
Dabigatran (Pradaxa), Rivaroxaban, (Xarelto)]?
(Stroke) Alert the hospital that you are bringing a potential stroke in
progress
Identify & report any Yes answers regarding IV tPA
Report Yes answers regarding IV tPA Exclusion
01-18-2016
Do they have history of previous intracranial hemorrhage?

Have they Received Heparin in past 48 hrs?
Do they have a history of myocardial infarction within past 3 months?
Do they have a history of major surgery in past 14 days?
Do they have a history of head trauma or stroke in past 3 months?
Do they have a history of GI or urinary hemorrhage in past 21 days?
APPENDIX B-8: SEDATION CRITICAL CARE

General Scope: Protocol for treatment of patients who require sedation during critical care transports.
All patients who receive sedation should have continuous monitoring of vital signs including cardiac
monitoring.
Applies to: Critical Care Paramedics
Protocol:
1.
2.
3.
4.
5.
6.
7.

Consider hypoxia or hypovolemia
If patient is combative, maintain adequate restraints, see Restraint Protocol
Establish IV/IO per Vascular Access Protocol if possible
For routine sedation see Sedation Protocol
If patient is intubated:
a. PROPOFOL
i. 5-50mcg/kg/min. If greater than 50mcg is required contact medical control.
Absolute maximum dose is 80mcg/kg/min
ii. May increase 5mcg/kg/min every 5 minutes based on required sedation
iii. Bolus dosing 10-20 mg IVP slowly to quickly increase depth of sedation for
patients not at risk for hypotension
8. If patient is not intubated:

a. ATIVAN
i. IV 1-2mg
ii. IM 1-4mg
iii. {Child: 0.05mg/kg IV}
b. DIAZEPAM:
i. IV 2-10mg may repeat q 15 minutes as needed
c. HALOPERIDOL:
i. IV 2.5-5mg, may repeat in 30 minutes
ii. IM 5mg q 1-8 hours as needed
01-18-2016
APPENDIX B-9: SEIZURE CRITICAL CARE

General Scope: Protocol for treatment of patients who require seizure care during critical care
transports. All patients who receive sedation should have continuous monitoring of vital signs including
cardiac monitoring.
Applies to: Critical Care Paramedics
Protocol:
3. Rule out hypoglycemia, trauma, infection, hypoxia, withdrawal, or toxins
a. If glucometer < 60 or > 250 see Diabetic Emergency Protocol
b. See Altered Mental Status Protocol
c. Consider THIAMINE 100 mg IV/IM for adults with history of alcoholism,
hyperemesis, cancer, gravidarum, or unknown seizure history
4. If actively seizing:
a. Establish IV/IO per Vascular Access Protocol
b. VERSED
i. 2mg IV Q 2 minutes until seizure stops
ii. 0.2mg/kg IN
iii. 0.2mg/kg IM
iv. {child 0.1mg/kg IV or 0.2mg/kg IM} 2mg max single dose
c. ATIVAN
i. IV 1-2 mg q 5-10 minutes up to 4mg
ii. IM 1-2mg q 10 minutes up to 4mg
iii. {Child: 0.1mg/kg IV over 2 minutes, may repeat at 0.05mg/kg}
5. If seizure has resolved and patient is post-ictal
a. Establish IV/IO per Vascular Access Protocol
b. If patient is febrile, remove clothing and cool, but avoid shivering
c. Following seizure cessation FOSPHENYTOIN 15-18 PE(phenytoin equivalent)
mg/kg IV
Notes:
Dilute ATIVAN with equal amount NaCl prior to IV administration

FOSPHENYTOIN is contraindicated in patients with bradycardia or 2nd or 3rd degree heart
block.
01-18-2016
APPENDIX E: P ARAMEDIC MEDICATIONS

General Scope: The following medications are the medications that have been state approved to be
transported by Tri-State ambulance at the Paramedic level. Medications may be transported (added)
using the Patient Side Training Report
0.45% sodium chloride
10% dextrose
5% dextrose in 0.45% sodium chloride
5% dextrose in LR
5% dextrose in water (d5w)
Lactated Ringers
Dextrose (50%, 25%, 10%)
Normal saline (0.9% sodium chloride)
Activated charcoal
Adenosine (adenocard)
Atropine
Albuterol
Amiodarone (cordarone)
Antibiotics (if hung by facility)
Aspirin
Atropine
Blood Products
Diazepam (valium)
Calcium chloride
Clopidogogrel (plavix) - oral only
Cyanide antidote package (cyanokit)
Amyl nitrate
Sodium nitrate
Sodium thiosulfate
Dexamethasone (decadron)
Diazepam (valium)
Diltiazem (cardizem)
Diphenhydramine (benadryl)
Dopamine
Droperidal (inapsine)
Enalaprilat
Epinephrine
Etomidate (amidate)
Famotidine (pepcid)
Fentanyl (sublimaze)
Flumazenil (romazicon)
Furosemide (lasix)
Glucagon
Glucose
Haloperidol (haldol)
01-18-2016
Heparin
Hydromorphone (dilaudid)
Insulin
Ipratropium (atrovent)
Ketamine (ketalar)
Ketorolac (toradol)
Labatelol
Levalbuterol (xopenex)
Lidocaine (xylocaine)
Lorazepam (ativan)
Magnesium sulfate
Mannitol
Methylprednisolone (solu-medrol)
Metoclopramide (reglan)
Metoprolol (lopressor)
Midazolam (versed)
Nalbuphine (nubain)
Naloxone (narcan)
Morphine
Nitroglycerin
Nitrous oxide
Ondansetron (zofran)
Oxygen
Oxytocin (pitocin)
Pancuronium (pavulon)
Pralidoxime (2-pam chloride)
Procainamide
Prochlorperazine (compazine)
Pantoprazole (protonix)
Rocuronium (zemuron)
Sodium bicarbonate
Succinylcholine (anectine)
Terbutaline
Thiamine
tPA(tissue plasminogen activator)
Vasopressin (pitressin)
Vecuronium (norcuron)
Ziprasidone (geod
MEDICATIONS .
0.45% SODIUM CHLORIDE
ACTION: Replaces free water and electrolytes
INDICATIONS:
Patients with diminished renal or cardiovascular function for whom rapid rehydration is not indicated
CONTRAINDICATIONS:
Cases in which rapid rehydration is indicated
PRECAUTION:
1. Clinical evaluation and periodic laboratory determinations are necessary to monitor changes in fluid
balance, electrolyte concentrations and acid-base balance during prolonged parenteral therapy or
whenever the condition of the patient warrants such evaluation.
2. Caution must be exercised in the administration of parenteral fluids, especially those containing sodium
ions to patients receiving corticosteroids or corticotropin.
3. Do not administer unless solution is clear and container is undamaged. Discard unused portion
ADVERSE REACTIONS AND SIDE EFFECTS:
1. Increased urination
2. Pain
3. Redness
4. Swelling at the injection site
5. Swelling of hands or ankles
6. Muscle twitching
ADULT ADMINISTRATION:
Dependent on patients condition and situation being treated.
PEDIATRIC ADMINISTRATION:
The safety and effectiveness in the pediatric population are based on the similarity of the clinical conditions of
the pediatric and adult populations. In neonates or very small infants the volume of fluid may affect fluid and
electrolyte balance.
SPECIAL CONSIDERATIONS:
1. May only be used by Critical Care Paramedics.
2. Solutions containing sodium ions should be used with great care, if at all, in patients with congestive heart
failure, severe renal insufficiency and in clinical states in which there exists edema with sodium retention.
3. Excessive administration of potassium-free solutions may result in significant hypokalemia.
4. In patients with diminished renal function, administration of solutions containing sodium ions may result
in sodium retention.
5. The intravenous administration of these solutions can cause fluid and/or solute overloading resulting in
dilution of serum electrolyte concentrations, overhydration, congested states or pulmonary edema.
6. The risk of dilutional states is inversely proportional to the electrolyte concentrations of administered
parenteral solutions. The risk of solute overload causing congested states with peripheral and pulmonary
edema is directly proportional to the electrolyte concentrations of such solutions.
3-19-15
AZITHROMYCIN (ZITHROMAX)
ACTION:
Bactericidal and bacteriostatic to select organisms including anaerobic and facultative gram positive and gram
negative organisms, Chalmydophila and Mycoplasma
INDICATIONS:
1. Treatment of community acquired pneumonia and pelvic inflammatory disease caused by specific
organisms.
2. Non-gonococcal urethritis and cervicitis due to Chlamydia trachomatis
3. Mycobacterial Infections
CONTRAINDICATIONS:
1. Known Hypersensitivity
2. Erythromycin allergy
3. Any macrolide antibiotic allergy
4. Ketolide antibiotic allergy
PRECAUTIONS:
1. Monitor vitals closely
2. May aggravate CHF
3. Renal insufficiency
1. Abdominal pain
2. Arrhythmias
3. Dizziness
4. Hypotension
5. Facial edema
6. Jaundice
7. Nausea
8. Vomiting
9. Diarrhea
1. Physician ordered dose.
2. 500 mg daily for minimum of prescribed days
Not for Pediatric patients
1. May only be administered by Critical Care Paramedics.
2. Do not use anti-diarrhea products or narcotic pain medications if you have any of the side effects because
these products may make them worse
3. Do not take antacids that contain aluminum or magnesium within 2 hours before or after you take
azithromycin they will make azithromycin less effective
3-19-15
CALCIUM GLUCONATE (10%)

ACTION: Maintains cell membrane and capillary permeability, assists in transmission of nerve impulses and
contraction of cardiac, skeletal, and smooth muscle.
INDICATIONS:
1. Hypocalcemia
2. Hyperkalemia
3. Treatment of black widow spider bites
4. Adjunct to magnesium sulfate overdose
CONTRAINDICATIONS:
1. Hypersensitivity
2. Patients in ventricular fibrillation
3. Hypercalcemia
4. Digitalis toxicity
PRECAUTIONS:
1. For IV use only, do not use SQ or IM
2. May cause decreased blood pressure, vasodilation, bradycardia, cardiac arrhythmias and syncope
3. Administer slowly into large vein. Rapid infusion may cause cardiac arrest.
4. Do not administer without physician order.
1. Arrhythmias, bradycardia and cardiac arrest
2. Tissue necrosis at injection site
3. Syncope
1. Physician ordered dose
2. Hypocalcemia: 500mg to 2 grams (5-20ml) IV/IO
3. Magnesium Sulfate Overdose: 500mg to 2 grams (5-20ml) IV/IO (titrate to effect)
1. Contact medical control prior to administration.
2. Initial dose is 200 to 500 mg (2-5ml)
SPECIAL NOTES:
1. May only be administered by Paramedic or Critical Care Paramedics.
2. If infiltration occurs, notify physician at receiving hospital immediately upon arrival so that antidotal
therapy can begin immediately.
3-19-15
CEFTRIAXONE (ROCEPHIN)
ACTION:
Preferentially binds to one or more of the penicillin binding proteins located on cell walls of susceptible
organisms. This inhibits third and final stage of bacterial cell wall synthesis, thus killing the bacterium. Similar
to other third-generation cephalosporins, it is effective against serious gram-negative organisms, and also
penetrates the CSF in concentrations useful in treatment of meningitis.
INDICATIONS:
Infections caused by susceptible organisms in lower respiratory tract, skin structures, urinary tract, bones, and
joints; also intra-abdominal infections, pelvic inflammatory disease, uncomplicated gonorrhea, meningitis, and
surgical prophylaxis.
CONTRAINDICATIONS:
1. Hypersensitivity to ceftriaxone or other cephalosporin antibiotics
2. Viral infection
3. S & S of gallbladder disease
4. Neonates with hyperbilirubinemia
5. Neonates receiving calcium-containing infusions or TPN
6. Premature neonates
PRECAUTIONS:
1. Hypersensitivity to penicillin and beta-lactam antibiotics
2. Coagulopathy
3. Impaired vitamin K synthesis
4. Chronic hepatic disease
5. History of GI disease
6. Colitis
7. Renal disease or impairment
8. Pregnancy
1. GI (nausea, vomiting, diarrhea)
2. Leukopenia (Lower WBC count)
3. Pain at injection site
2. Moderate to Severe Infections: 1-2 g every 12-24 hrs, max 4 g/day
3. Meningitis: 2 g every 12 hrs
2. Moderate to Severe Infections: 50-75 mg/kg/day in 2 divided doses (max 2 g/day)
3. Meningitis: 100 mg/kg/day in 2 divided doses (max 4 g/day)
2. Infuse over 30 minutes, use smaller needles, larger veins.
3-19-15
CIPROFLOXACIN (CIPRO)
ACTION:
Antibiotic: Inhibits DNA-gyrase, an enzyme required for DNA replication, transcription, repair, and
recombination of bacterial DNA. Effective against many gram-positive and gram-negative organisms
INDICATIONS:
1. UTI
2. Lower respiratory tract infections
3. Skin and skin structure infections
4. Bone and joint infections
5. GI infections or infectious diarrhea
6. Chronic bacterial prostatitis
7. Nosocomial pneumonia
8. Inhalation anthrax
CONTRAINDICATIONS:
1. Known hypersensitivity to ciprofloxacin or other quinolones
2. Syphilis
3. Viral infection
4. Tendon inflammation or tendon pain
5. Lactation
PRECAUTIONS:
1. Known or suspected CNS disorders (i.e., severe cerebral arteriosclerosis or seizure disorders)
2. Myasthenia gravis
3. Myocardial ischemia, a-fib, QT prolongation, CHF
4. GI disease, colitis
5. CVA
6. Uncorrected hypokalemia
7. Patients receiving theophylline derivatives or caffeine
8. Severe renal impairment and crystalluria during ciprofloxacin therapy
9. Patients on coumadin therapy
10. Pregnancy
11. Children
1. GI
a. Nausea and vomiting
b. Diarrhea
c. Cramps
d. Gas
e. Pseudomembranous colitis
2. Musculoskeletal
a. Tendon rupture
b. Cartilage erosion
3. CNS
a. Headache
b. Vertigo
3-19-15

CIPROFLOXACIN (CIPRO) CONT.
c. Malaise
d. Peripheral neuropathy
e. Seizures (especially with rapid IV infusion)
4. Skin
a. Rash, phlebitis, pain, burning, pruritus, and erythema at infusion site
5. Special Senses
a. Local burning and discomfort, crystalline precipitate on superficial portion of cornea
b. Lid margin crusting, scales, foreign body sensation, itching and conjunctival hyperemia
2. Moderate to Severe Systemic Infections:
a. 200-400 mg every 8-12 hrs
b. Infuse over 60minutes. Avoid rapid infusion and use of small veins.
c. Discontinue other IV infusions while infusing or infuse through another site.
NOT FOR PEDIATRIC PATIENTS
May only be administered Critical Care Paramedics.
3-19-15
CLONIDINE HCL (CATAPRES, DIXARIL)

ACTION:
1. Inhibits sympathetic vasomotor centers
2. Decreases nerve impulses
3. Reduces systolic and diastolic blood pressure
4. Produces bradycardia
5. Inhibits renin release from kidneys
INDICATIONS:
1. Hypertension
2. Especially useful if no IV access
3. Ethanol and opiate withdrawal syndrome
CONTRAINDICATIONS:
1. Altered mental status
2. Hypotension
3. Known hypersensitivity
PRECAUTIONS:
Catapres (clonidine) tablets should be used with caution in patients with severe coronary insufficiency,
conduction disturbances, recent myocardial infarction, cerebrovascular disease or chronic renal failure.
1. Hypotension
2. Bradycardia/ tachycardia
3. Angioedema
4. Somnolence
5. Weakness
2. 0.1 0.2 mg oral/ sublingual
2. 5 10 mcg/ kg per day, divided over 8 12 hours
2. Monitor blood pressure and cardiac rhythm closely.
3-19-15
DEXAMETHASONE (DECADRON)
ACTION:
1. Inhibits many of the substances that cause inflammation and inhibits the synthesis of pro-inflammatory
enzymes
2. Potent Anti-inflammatory and immunosuppressant
INDICATIONS:
1. Severe anaphylaxis
2. Asthma
3. COPD
4. Dermatologic diseases
5. Endocrine disorders
6. Gastrointestinal diseases
7. Hematologic disorders
8. Respiratory diseases
9. Rheumatic disorders
CONTRAINDICATIONS:
None in the acute management of anaphylaxis
PRECAUTIONS:
1. Kidney disease
2. Liver disease
3. Low blood minerals
ADVERSE REACTIONS:
1. Hypertension
2. Vertigo
4. Congestive heart failure
5. Hyperglycemia
6. Headache
7. Nausea
8. Hiccups
9. Glaucoma
1. 4-10mg IV/IO, can be administered IM when IV/IO not available
2. Contact medical control for further orders.
1. 0.2-0.5 mg/kg IV/IO
2. Only a single dose should be given in the pre-hospital setting.
3. Should be protected from heat.
3-19-15
DOBUTAMINE (DOBUTREX)
ACTION:
1. A sympathomimetic drug used in the treatment of heart failure and cardiogenic shock
2. Increases the force of systolic contraction with little chronotropic activity
INDICATIONS:
1. Inotropic support for short-term treatment of cardiac decompensation due to depressed myocardial
contractility (cardiogenic shock)
2. Used to support BP, CO and renal perfusion in shock.
3. Inotropic support for short-term treatment of CHF when and increased cardiac output, without and
increased cardiac rate, is desired
CONTRAINDICATIONS:
1. Hypersensitivity
2. V-tach
3. Idiopathic hypertrophic subaortic stenosis
4. Hypovolemia
5. Children < 2 yrs
PRECAUTIONS:
1. Preexisting hypertension
2. A-fib
3. Acute MI, unstable angina
4. Severe coronary artery disease
5. Pregnancy
1. CNS : Headache, tremors, paresthesias, mild leg cramps, nervousness
2. Cardiovascular: Increased heart rate and BP, premature ventricular beats, palpitation, anginal pain,
arrhythmias
3. GI: Nausea and vomiting
1. Renal
a. 1-5 mcg/kg/min.
2. Severely ill patients
a. Initially 5 mcg/kg/min, increase by 5-10 mcg/kg/min (q10 to 30 min) up to max of 50mcg/kg/min.
3. Cardiac life support
a. Initially 2-5 mcg/kg/min - titrated to effect. Infusion may be increased by 1-4 mcg/kg/minute at 10
to 30 minute intervals until optimal response is obtained.
4. Refractory CHF: administer 0.5 2 mcg/kg/min.
NOT RECOMMENDED FOR PEDS.
2. Administer into large vein to prevent the possibility of extravasation (central line administration).
3-19-15
DROPERIDOL (INAPSINE)
ACTION:
Alters the action of dopamine in the central nervous system causing sedation and the suppression of nausea
and vomiting
INDICATIONS:
1. Nausea and/or vomiting with vertigo.
2. Sedation
CONTRAINDICATIONS:
1. Known hypersensitivity
2. Narrow-angle glaucoma
3. Known or suspected QT prolongation
PRECAUTIONS:
1. Use with caution on patients with:
a. CNS depression
b. Impaired renal function
c. Diabetes
d. Seizures
e. Severe liver disease
2. Use with extreme caution in patients with risk factor for prolonged QT syndrome
a. CHF
b. Bradycardia
c. Diuretic use
d. Hypokalemia
e. Hypomagnesema
1. Seizures
2. Extrapyramidal reaction
3. Excessive sedation
4. Arrhythmias
5. Hypotension
6. Tachycardia
1. 0.625-1.25 mg IV over 5 minutes
Physician ordered dose.
1. May only be administered by Paramedics under the Nausea, Vomiting, Vertigo protocol
2. May be administered by Critical Care Paramedics
3-19-15
ENALAPRILAT (VASOTEC)
ACTION:
Enalaprilat, is an angiotensin converting enzyme (ACE) inhibitor. ACE is a peptidyl dipeptidase that
catalyzes the conversion of angiotensin I to the vasoconstrictor substance, angiotensin II. Angiotensin II also
stimulates aldosterone secretion by the adrenal cortex. Inhibition of ACE results in decreased plasma
angiotensin II, which leads to decreased vasopressor activity and also decreased aldosterone secretion.
While the mechanism through which enalaprilat lowers blood pressure is believed to be primarily
suppression of the renin-angiotensin-aldosterone system, enalaprilat has antihypertensive activity even in
patients with low-renin hypertension.
INDICATIONS:
1. Pulmonary edema
2. Congestive heart failure
CONTRAINDICATIONS:
1. Hypersensitivity
2. ACE inhibitor cross sensitivity
3. Angioedema
PRECAUTIONS:
1. Renal impairment
2. Hypovolemia
3. Hyponatremia
4. Aortic stenosis
5. Cerebrovascular or Coronary insufficiency
1. CNS: dizziness, fatigue, headache, weakness
2. Respiratory: cough
3. Cardiovascular: hypotension, angina, tachycardia
4. GI: taste disturbances, anorexia, diarrhea
1.25 mg IV or physician ordered dose
Paramedics may only administer Enalaprilat under the Pulmonary Edema protocol and with medical control
orders.
3-19-15
EPTIFIBATIDE (INTEGRILIN)
ACTION:
1. Inhibits platelet aggregation by blocking the glycoprotein IIb/IIIa receptor on activated platelets.
2. Treating unstable angina (chest pain) or certain types of heart attacks.
INDICATIONS:
1. Treatment of acute coronary syndromes (unstable angina, non-Q-wave MI)
2. Patients undergoing percutaneous coronary interventions (PCIs)
CONTRAINDICATIONS:
1. Hypersensitivity
2. Active internal bleeding
3. GI or GU bleeding within 6 weeks
4. Recent major surgery
5. Thrombocytopenia
6. Intracranial neoplasm
7. Intracranial bleeding within 6 months
8. Renal dialysis
9. Severe hypertension (systolic BP> 200 or diastolic BP > 110)
10. Aneurysm
11. Hemorrhagic stroke or other stroke within 30 days
PRECAUTIONS:
1. Hypersensitivity to related compounds (abciximab, tirofiban, lamifiban)
2. Patients that have an increased risk of bleeding
3. Pregnancy and lactation
4. Maintaining Target aPTT and ACT
5. Arterial and venous punctures, IM injections, urinary catheters, NG tubes, and nasotracheal intubation
should be minimized
ADVERSE REACTIONS AND SIDE EFFETCS:
1. Increased risk of bleeding
2. Hypotension
3. Allergic reaction
1. 180 mcg/kg initial bolus, give over 1-2 minutes
2. 2 mcg/kg/min up to 72 hours, begin immediately after bolus dose
Not recommended for PEDS.
2. Safety and effectiveness in children are not established
3. Use vented tubing
4. Use caution in patients taking oral anticoagulants or NSAID medications
3-19-15
ESMOLOL (BREVIBLOC)
ACTION:
1. Antiarrhythmic properties occur at the AV node. Decreases heart rate, decreases AV conduction
2. Beta1-selective (cardioselective) adrenergic receptor blocking (Beta Blocker) agent with a very short
duration of action (elimination half-life is approximately 9 minutes)
INDICATIONS:
1. Short term treatment in the control of heart rate for patients with MI.
2. Control ventricular rate in a-fib and a-flutter
3. Stable, narrow complex tachycardias if rhythm remains uncontrolled or unconverted by adenosine or vagal
maneuvers or if SVT is recurrent
CONTRAINDICATIONS:
1. Hypersensitivity to Esmolol
2. Heart block greater than first degree
3. Sinus bradycardia
4. Cardiogenic shock
5. Decompensated CHF
6. Acute bronchospasm (asthma and COPD)
PRECAUTIONS:
1. History of allergy
2. History of CHF
3. History of pulmonary disease such as bronchial asthma; COPD; pulmonary edema
4. History of diabetes mellitus
5. History of kidney function impairment
6. Elderly
7. Pregnancy, lactation
1. CNS
a. Headache
b. Dizziness
c. Confusion
d. Agitation
2. CV
a. Hypotension (dose related)
b. Bradyarrhythmias
c. Flushing
d. Myocardial depression
3. GI
4. Respiratory
a. Dyspnea
b. Wheezing
c. Rhonchi
d. Bronchospasm
3-19-15
ESMOLOL (BREVIBLOC) CONT.

1. Patient must be on EKG monitor and VS should be monitored frequently.
2. 500 mcg/kg loading dose, give over 1 minute. Followed by 50 mcg/kg/min x 4minutes
3. If response inadequate, may repeat loading dose followed by100 mcg/kg/min x 4 minutes
4. Dose can be titrated at 4-minute intervals by repeating the loading dose for 1 minute and increasing the
maintenance dose by 50mcg/kg/min at 4-minute intervals until the desired effect is obtained.
5. Max dose 300 mcg/kg/min
3-19-15
GENTAMICIN SULFATE
ACTION:
Medicine used to treat severe or serious bacterial infection
INDICATIONS:
1. Sulfite sensitivity
2. Kidney disease
3. Hearing loss or loss of balance due to ear problems
4. Parkinson's disease
5. Neuromuscular disorder such as myasthenia gravis.
CONTRAINDICATIONS:
Hypersensitivity to gentamicin
PRECAUTIONS:
1. Pregnancy
2. The frequency of administration of gentamicin should be reduced in patients with impaired renal function
2. Little or no urine
3. Decreased hearing or ringing in ears
4. Dizziness
5. Numbness
6. Seizures
7. Severe diarrhea
8. Abdominal cramps
9. Neurotoxicity
10. Nephrotoxicity
2. 1.5 to 2 mg/kg loading dose over 1-1.5 hours, followed by 1 to 1.7 mg/kg IV or IM every 8 hours or 5 to 7 mg/kg
IV every 24 hours
2. 0 to 4 weeks, birth weight <1200 g: 2.5 mg/kg IV or IM every 18 to 24 hours
3. 0 to 1 week, birth weight >=1200 g: 2.5 mg/kg IV or IM every 12 hours
4. 1 to 4 weeks, birth weight 1200 to 2000 g: 2.5 mg/kg IV or IM every 8 to 12 hours
5. 1 to 4 weeks, birth weight >=2000 g: 2.5 mg/kg IV or IM every 8 hours
6. >1 month: 1 to 2.5 mg/kg IV or IM every 8 hours
2. Dosage should be adjusted for patients with renal impairment.
3. Monitor IV site for irritation or infiltration
3-19-15
HEPARIN (UNFRACTIONATED)
ACTION:
Anticoagulant
INDICATIONS:
1. Management of Acute Myocardial Infarction (AMI) presenting with STEMI
2. Anticoagulant therapy
3. Thrombosis
CONTRAINDICATIONS:
1. Active bleeding, uncontrollable; except when due to disseminated intravascular coagulation.
2. Severe hypertension (Systolic BP > 200)
3. Bleeding disorders/ known GI bleeding
4. Known Heparin induced thrombocytopenia = (persistent decrease in the number of platelets in the blood
that is often associated with hemorrhagic conditions).
1. Allergic reaction/Anaphylaxis.
2. Hemorrhage.
3. Osteoporosis (only with long term, high-dose administration).
4. Thrombocytopenia
1. STEMI: Initial loading dose is 60 units/kg (max 4000 units)
2. STEMI: May continue with infusion at 12 units/kg/hr, round to nearest 50 units (maximum of 1000
units/hr for patients > 70 kg.
3. Further orders must come from medical control.
Contact medical control prior to administration.
2. Paramedics may continue an infusion initiated at a sending facility
3. Protamine sulfate may be administered for heparin overdose/toxicity.
3-19-15
HYDROMORPHONE (DILAUDID)
ACTION:
1. Binds with opiate receptors in the CNS, altering both perception and emotional response to pain.
2. Dilaudid is 7-10 times more analgesic than morphine.
INDICATIONS:
1. Musculoskeletal trauma
2. Severe pain
CONTRAINDICATIONS:
1. Do not use in pediatric patients
2. Patients in labor
3. Respiratory depression in asthmatics, COPD.
4. Known allergies to Dilaudid (hydromorphone)
5. Patients with increased intracranial pressure.
6. Systolic BP < 90
PRECAUTION:
1. IV/IO administration should be done over 2-5 minutes
2. May be considered in patients with head or abdominal pain.
3. Use with caution in asthmatic or COPD patients presenting with respiratory difficulty.
1. Sedation, dizziness
2. Hypotension and bradycardia
3. Nausea or vomiting
4. Respiratory depression and bronchospasm.
1. Management of pain:
a. Administer 0.5 2mg IV/IO/IM titrated to pain relief, to a max initial dose of 2mg.
b. May repeat to total dose of 4mg.
2. Monitor vital signs after each dose.
1. For management of pain, may administer 0.5 1.0 mg IV/IO/IM or per Broselow tape to max initial dose of
1.0 mg.
SPECIAL NOTES:
2. Have equipment ready to assist ventilations as necessary.
3. Naloxone (narcan) may be administered for respiratory depression.
4. Dilaudid is a controlled substance, and its use must be documented according to the Controlled Substance
Policy.
3-19-15
IMIPENEM (PRIMAXIN)
ACTION:
A potent broad spectrum antibacterial agent. Bactericidal for gram negative, gram positive and anaerobic
organisms.
INDICATIONS:
Treatment of serious lower respiratory tract, urinary tract, skin and skin structure, bone and joint,
gynecological, intrabdominal, and polymicrobic infections, bacterial septicemia and endocarditis.
CONTRAINDICATIONS:
Known hypersensitivity
PRECAUTIONS:
1. Seizure potential
2. Use with caution on patients with impaired renal function
1. Anaphylaxis
2. Pruritus
3. Rash and urticaria
4. Abdominal pain
5. Abnormal clotting time
6. Burning at injection site
2. Range from 250mg 500mg over 1 hour every 6 to 8 hours. Dose based on severity of disease,
susceptibility to pathogens, condition of patient age and weight.
3. Do not exceed 4 Gm/24hrs.
2. Not recommended for pediatric patients with CNS infections because the risk of seizures.
3. Do not exceed 50mg/kg or 4 Gm/24hrs
4. Infants 15-25mg/kg dose every 6 hours
2. Dilute in 10 ml of compatible solution for infusion.
3. Doses greater than 500mgs should be infused over 40-60 min.
3-19-15
INSULIN
ACTION:
1. Causes uptake of glucose by the cells
2. Decreases blood glucose level
3. Promotes glucose storage
INDICATIONS:
1. Elevated blood glucose
2. Diabetic ketoacidosis
CONTRAINDCATIONS:
Avoid overcompensation of blood glucose level
PRECAUTIONS:
1. Administration of excessive dose may induce hypoglycemia. Glucose should be available
2. Conditions like puberty, pregnancy, menstruation, severe pyrexia, Infection, Psychological stress may
increase blood sugar and may increase the amount of insulin needed
1. Few in emergency situations
2. Redness, swelling, or itching at injection sites
1. 0.1 units/kg regular insulin IV followed by an infusion at 0.1 units/kg/hr.
Dosage is based on blood glucose level contact medical control for orders.
3-19-15
KETAMINE (KETALAR)
ACTION:
1. Causes a dissociation between the cortical and limbic system, resulting in a seemingly awake patient who is
dissociated from the environment
2. Used as a general anesthetic to prevent pain and discomfort during certain medical tests or procedures, or
minor surgery
INDICATIONS:
1. Sedation
2. RSI
CONTRAINDICATIONS:
1. Hypersensitivity
2. Significant elevation in BP
PRECAUTIONS:
Not recommended during pregnancy
1. Hallucinations
2. Dream like feeling
3. Nausea and vomiting
4. Excessive bronchial secretions
5. Increased skeletal muscle tone
6. Hypotension
7. Bradycardia
8. Apnea
1. See Pain Management, RSI, and Sedation protocol
1. 0.5 1.0 mg/kg IV/IO/IN
2. Supplemental maintenance doses are the initial dose to total dose of 4mg/kg.
1. Resuscitation equipment must be readily available
2. ECG, SPO2, ETCO2 must be in place prior to administration
3. Ketamine may be harmful to an unborn baby. Use with extreme prejudice in pregnant patients
4. Cardiac function should be continually monitored during the procedure in patients found to have
hypertension or cardiac decompensation
3-19-15
TORADOL (KETOROLAC)
ACTION:
Nonsteroidal anti-inflammatory drug (NSAID) that is indicated for the management of moderately severe,
acute pain that requires analgesia.
INDICATIONS:
1. Musculoskeletal pain
2. Abdominal pain / kidney stones
CONTRAINDICATIONS:
1. Allergy or known hypersensitivity or allergic manifestations to aspirin or other NSAIDs
2. Active peptic ulcer disease, recent GI bleeding or perforation
3. Suspected or confirmed cerebrovascular bleeding
4. Hemophilia or other bleeding problems
5. Hypotension (systolic BP < 90 systolic in adults)
6. Do not use in the second and third trimesters of pregnancy.
PRECAUTIONS:
1. Use with caution in hepatic or renal disease, CHF and asthma.
2. Use caution if the patient may need to go to surgery, Ketorolac inhibits platelet aggregation and can prolong
bleeding time for up to 48 hours.
3. Contact Medical Control Physician before giving to patients > 65 years old.
4. Carefully observe patients with defects in the blood clotting mechanism and those taking anticoagulants.
5. Use caution if patient is taking ASA or other NSAIDs on a regular basis.
6. Ketorolac lacks the sedative and anti-anxiety activity of Fentanyl, Morphine, or Versed.
1. Nausea and/or vomiting, gastrointestinal pain, diarrhea
2. Pain at the injection site
3. Prolonged bleeding time
4. Edema (face, fingers, lower legs, ankles and/or feet)
1. Patients less than 65 years of age, administer 30 mg slow (> 15 sec.) IV/IO or, administer 60 mg IN/IM
slowly. If IM administration, vigorously massage site for 15-30 sec. to decrease local effects. Initial onset
with IV/IN use is 1-5 minutes with peak action in 1-2 hours and duration of 4-6 hours. Initial onset with IM use
is 30-60 minutes with peak action 1-2 hours and duration of 4-6 hours.
2. For adults with renal insufficiency or adults weighing <110 lbs., administer 15 mg IV or 30 mg IM.
1. Administer initial dose of 15 mg IV/IO/IM.
2. Further orders must come from medical control.
SPECIAL NOTES:
2. Do not mix ketorolac tromethamine with morphine sulfate or promethazine in a syringe as this will result
in precipitation of ketorolac from solution.
3-19-15
LEVOFLOXACIN (LEVAQUIN)
ACTION:
Levofloxacin is an antibiotic that stops multiplication of bacteria by preventing the reproduction and repair of
their genetic material, DNA. It is in a class of antibiotics called fluoroquinolones.
INDICATIONS:
1. Nosocomial Pneumonia
2. Community-Acquired Pneumonia
3. Acute Bacterial Sinusitis
4. Acute Bacterial Exacerbation of Chronic Bronchitis
5. Complicated Skin and Skin Structure Infections
6. Chronic Bacterial Prostatitis
7. Complicated Urinary Tract Infections
CONTRAINDICATIONS:
Persons with known hypersensitivity to levofloxacin, or other quinolone antibacterials
PRECAUTIONS:
Renal Disease
1.
2.
3.
4.
5.
6.
Nausea
Headache
Diarrhea
Insomnia
Constipation
Dizziness
1. 250 or 500 milligrams over 60 minutes

2. 750 milligrams over 90 minute
Physician ordered dose

May only be administered by Critical Care Paramedics
3-19-15
MANNITOL (OSMITROL)
ACTION:
Mannitol increases the osmotic pressure of the glomerular filtare, thereby inhibiting reabsorption of water and
electrolytes. Causes excretion of: water, sodium, potassium, chloride, calcium, phosphorus, magnesium, urea,
and uric acid.
INDICATIONS:
1. Increased intracranial pressure
2. Toxic overdose
3. Edema
4. Crush syndrome
5. Electrical burns
CONTRAINDICATIONS:
1. Hypersensitivity
2. Anuria
3. Dehydration
4. Active intracranial bleeding
Confusion
Headache
Blurred vision
Chest pain
CHF
Pulmonary edema
Tachycardia
Nausea
Thirst
Vomiting
1. 0.5-1.0 g/kg IV

1. Paramedics may administer with Physician order per protocol
3-19-15
Renal failure
Urinary retention
Dehydration
MOXIFLOXACIN (AVELOX)
ACTION:
It inhibits DNA gyrase, an enzyme required for DNA replication, transcription, repair, and recombination of
bacterial DNA. Broad spectrum bactericidal agent against both gram-positive and gram-negative organisms
INDICATIONS:
Treatment of acute bacterial sinusitis, acute bacterial exacerbation of chronic bronchitis, community acquired
pneumonia, skin and skin structure infections, bacterial conjunctivitis, and complicated skin infection
CONTRAINDICATIONS:
1. Hypersensitivity to moxifloxacin or other quinolones
2. Moderate to severe hepatic insufficiency
3. Syphilis
4. History of prolonged QT interval on EKG
5. History of acute MI, acute myocardial ischemia, ventricular arrhythmias, a-fib, bradycardia,
6. History of hypokalemia
7. Patients receiving Class IA or Class III antiarrhythmic drugs
8. Tendon pain
9. Viral infection
10. Lactation
11. Torsades de pointes
PRECAUTIONS:
1. CNS disorders
2. Cerebrovascular disease
3. Colitis, diarrhea, GI disease
4. Diabetes Mellitus
5. Seizure disorder
6. Mild or moderate heart insufficiency
8. Sunlight exposure
9. Pregnancy
ADVERSE REACTIONS:
1. CNS
a. Dizziness
b. Headache
c. Peripheral neuropathy
2. GI
b. Abdominal pain and diarrhea
c. Taste perversion
d. Abnormal liver function tests
e. Dyspepsia
3. Musculoskeletal
a. Tendon rupture.
b. Cartilage erosion
3-19-15
MOXIFLOXACIN (AVELOX) CONT.

2. 400 mg daily
3. Infuse over 60 minutes. AVOID RAPID OR BOLUS DOSE.
Contact medical control, not recommended for peds.
1. May only be administered by Critical Care Paramedic
2. Inspect IV injection site frequently for signs of phlebitis.
3-19-15
NALBUPHINE (NUBAIN)
ACTION:
1. CNS depressant
2. Decreases sensitivity to pain
3. Can also be used as a supplement to balanced anesthesia, for preoperative and postoperative analgesia, and
for obstetrical analgesia during labor and delivery.
INDICATIONS:
Moderate to severe pain
CONTRAINDICATIONS:
1. Hypersensitivity
2. Head injury
3. Undiagnosed abdominal pain
PRECAUTIONS:
1. Impaired respiratory function
2. Impaired Renal or Hepatic Function
3. Myocardial Infarction
4. Patients dependent on narcotics
5. Older patients
6. Pregnancy
ADVERSE REACTIONS:
1. Respiratory depression
2. Headache
3. Altered mental status
4. Hypertension, hypotension
5. Bradycardia
6. Tachycardia
7. Blurred vision
8. Confusion, hallucinations
9. Nausea and vomiting
1. 10 mg IV/IO, may be repeated every 3 to 6 hours as necessary
2. The recommended single maximum dose is 20 mg, with a maximum total daily dose of 160 mg.
3. Nubain as a supplement to balance anesthesia
a. 0.3 mg/kg to 3 mg/kg intravenously to be administered over a 10 to 15 minute period with
maintenance doses of 0.25 to 0.5 mg/kg in single intravenous administrations
Contact medical control prior to administration.
3-19-15
NALBUPHINE (NUBAIN) CONT .

1. May only be administered by Critical Care Paramedics
2. Nubain is a controlled substance, and its use must be documented according to the Controlled
3. Substance Policy
4. May cause significant respiratory depression, narcan should be readily available
5. May potentiate the effects of narcotics, sedatives, hypnotics, and alcohol
6. Nalbuphine may be habit forming
7. 6. Because of antagonistic properties, can cause withdrawal symptoms in patients addicted to narcoti
3-19-15
NITROPRUSSIDE (NIPRIDE)
ACTION:
Dilates both peripheral arteries and veins. This reduction in peripheral vascular resistance
results in an immediate reduction in blood pressure, usually accompanied by an increase in
heart rate.
INDICATIONS:
1. Short term, rapid reduction of BP in hypertensive crises
CONTRAINDICATIONS:
1. None when used in the management of life-threatening emergencies
2. Compensatory hypertension, as in atriovenous shunt or coarctation of aorta
3. Control of hypotension in patients with inadequate cerebral circulation
4. Lactation
PRECAUTIONS:
1. Hepatic insufficiency
2. Hypothyroidism
3. Severe renal impairment
4. Hyponatremia
5. Pregnancy
1. Body as a Whole: diaphoresis, apprehension, restlessness, muscle twitching, retrosternal
discomfort, thiocyanate toxicity (profound hypotension, tinnitus, blurred vision, fatigue,
metabolic acidosis, pink skin color, absence of reflexes, faint heart sounds, loss of
consciousness)
2. CV: Profound hypotension, palpitation, increase or transient lowering of pulse rate,
bradycardia, tachycardia, EKG changes
3. CNS: headache, dizziness
4. GI: Nausea and vomiting, retching, abdominal pain
1. Initial 0.5mcg/kg/min via pump (usual dose: 3 mcg/kg/min-rarely need > 4 mcg/kg/min).
2. Increase rate 0.5 mcg/kg/min every 3-5 minutes
3. Blood pressure checks q 1-2 minutes
4. Max 10 mcg/kg/min (should not be maintained for more than 10 minutes)
Contact medical direction, not recommended for peds.
2. Following reconstitution, solutions usually have faint brownish tint. If solution is highly
colored, do not use
3. Promptly wrap container with aluminum foil or other opaque material to protect from light.
4. Monitor BP constantly to titrate IV infusion rate to BP response
5. Minimize adverse effects by keeping patient supine
3-19-15
NOREPINEPHRINE (LEVOPHED)
ACTION:
Causes peripheral vasoconstriction
INDICATIONS:
1. Hypotension (systolic BP <70) not due to hypervolemia
2. Neurogenic shock
CONTRAINDICATIONS:
1. Hypotensive states due to hypervolemia
2. Avoid use in patients with peripheral or mesenteric thrombosis or in patients with severe
occlusive vascular disease
PRECAUTIONS:
1. Can be deactivated by alkaline solutions
2. Constant monitoring of blood pressure is essential
3. Extravasation can cause tissue necrosis.
ADVERSE REACTIONS:
1. Anxiety
2. Headache
3. Palpitations
4. Tachyarrhythmias
5. Reflex bradycardia
6. Myocardial ischemia
7. Pulmonary edema
8. Confusion
9. Anxiety
10. Hypertension
1. Initiate at 0.05 mcg/kg/min via IV pump.
a. Increase rate 0.01-0.05 mcg/kg/min every 3-5 minutes as needed Max rate of 0.3
mcg/kg/min
2. Contact medical control for further orders or questions.
0.01-0.5 mcg/kg/minute (rarely used)
2. Must monitor BP every 5 minutes
3. May increase myocardial oxygen demand
4. In general, hypovolemia should be corrected prior to use of pressors.
5. Effects of norepinephrine are enhanced by tricyclic antidepressants, MAO inhibitors,
antihistamines, guanethidine, egot alkaloids, and methypdopa.
6. Do not mix norepinephrine with alkaline solutions (e.g., sodium bicarbonate).
3-19-15
LEVOPHED DOSE CHART 4MG/250CC D5W

Dose in
mcg/kg/mi
n
4
5
5
0
5
5
6
0
6
5
7
0
.01
.02
.03
2
3
5
2
4
6
2
4
6
2
5
7
2
5
7
3
5
8
.04
.05
.06
1
0
1
2
1
4
1
5
1
7
1
9
2
0
2
2
2
4
2
5
1
1
1
3
1
5
1
7
1
9
2
1
2
3
2
4
2
6
2
8
1
0
1
2
1
4
1
7
1
9
2
1
2
3
2
5
2
7
2
9
3
1
1
1
1
4
1
6
1
8
2
0
2
3
2
5
2
7
2
9
3
2
3
4
1
0
1
2
1
5
1
7
2
0
2
2
2
4
2
7
2
9
3
2
3
4
3
7
1
1
1
3
1
6
1
8
2
1
2
4
2
6
2
9
3
2
3
4
3
7
3
9
.07
.08
.09
.10
.11
.12
.13
.14
.15
3-19-15
Weight in Kilograms
7 8 8 9 9
5 0 5 0 5
Milliliters per hour
3 3 3 3 4
6 6 6 7 7
8 9 1 1 1
0 0 1
1 1 1 1 1
1 2 3 4 4
1 1 1 1 1
4 5 6 7 8
1 1 1 2 2
7 8 9 0 1
2 2 2 2 2
0 1 2 4 5
2 2 2 2 2
3 4 6 7 9
2 2 2 3 3
5 7 9 0 2
2 3 3 3 3
8 0 2 4 6
3 3 3 3 3
1 3 5 7 9
3 3 3 4 4
4 6 8 1 3
3 3 4 4 4
7 9 1 4 6
3 4 4 4 5
9 2 5 7 0
4 4 4 5 5
2 5 8 1 3
10
0
10
5
11
0
11
5
12
0
4
8
11
4
8
12
4
8
12
4
9
13
5
9
14
15
16
17
17
18
19
20
21
22
23
23
24
25
26
27
26
28
29
30
32
30
32
33
35
36
34
35
37
39
41
38
39
41
43
45
41
43
45
47
50
45
47
50
52
54
49
51
54
56
59
53
55
58
60
63
56
59
62
65
68
PANCURONIUM (PAVULON)
ACTION:
Skeletal muscle relaxant, paralyzes skeletal muscles including respiratory muscles
INDICATIONS:
1. Long term paralyzation post RSI
2. An adjunct to general anesthesia, to facilitate tracheal intubation and to provide skeletal
muscle relaxation during surgery or mechanical ventilation
CONTRAINDICATIONS:
Hypersensitivity
PRECAUTIONS:
1. Renal failure
2. Anaphylaxis
3. Hepatic and/or biliary tract disease
4. Long term use in ICU
5. Severe obesity
6. Pregnancy
1. Respiratory depression
2. Increased intracranial pressure
3. Wheezing
4. Arrhythmias, bradycardia, sinus arrest
5. Hypertension, hypotension
6. Increased intraocular pressure
1. Initial dose 0.04 0.1 mg/kg
2. Repeat doses of 0.01 0.02 mg/kg
1. Initial dose 0.04 0.1 mg/kg
2. Repeat doses of 0.01 0.02 mg/kg
2. Onset of action 30-45 seconds, peak 3-5 minutes. Effect may persist up to 60 minutes
3. Have equipment ready to assist ventilations as necessary
3-19-15
PANTOPRAZOLE (PROTONIX)
ACTION:
A proton pump inhibitor that suppresses the final step in gastric acid production.
INDICATIONS:
1. Short term treatment (7-10 days) of gastroesophageal reflux disease (GERD) with a history
of erosive esophagitis.
2. Maintenance of Healing of Erosive Esophagitis
3. Pathological Hypersecretory Conditions Including Zollinger-Ellison Syndrome
CONTRAINDICATIONS:
Known hypersensitivity
PRECAUTIONS:
1. Gastric malignancy may be present even though patients symptoms have subsided
2. Watch for hypersensitive reaction
3. Atrophic Gastritis
4. Bone Fracture (Pts with long term use of Medication)
5. Tumorigenicity
1. Headache
2. Abdominal pain
3. Chest pain
4. Dyspnea
5. Hemorrhage
6. Diarrhea
7. Nausea
8. Vomiting
9. Dizziness
10. Rash
40mg IV/IO once
1. Children 5 years and older (short term treatment of erosive esophagitis associated with
GERD)
a. 33 lbs. 88 lbs. 20 mg IV/IO once
b. Greater than 88 lbs. 40 mg IV/IO once
2. Pt should not receive Protonix if allergic to pantoprazole or to any other benzimidazole
medication such as albendazole (Albenza), or mebendazole (Vermox)
3. Protonix is not for immediate relief of heartburn syptoms
3-19-15
PIPERACILLIN AND TAZOBACTAM (ZOSYN)

ACTION:
1. Piperacillin and tazobactum combination is an antibiotic that belongs to the group of
medicines known as penicillins and beta-lactamase inhibitors. It works by killing the
bacteria and preventing growth.
2. Antibotic
INDICATIONS:
Piperacillian and tazobactum combination is used to treat bacterial infections in many different
parts of the body.
CONTRAINDICATIONS:
1. Allergy to Piperacillin or Tazobactam
2. Allergy or hypersensitivity to other penicillin antibiotics.
As with other semisynthetic penicillins, piperacillin therapy has been associated with an
increased incidence of fever and rash in cystic fibrosis patients.
PEDIATRIC ADMINISTATION:
2. Studies of ZOSYN in pediatric patients suggest a similar safety profile to that seen in adults.
May only be administered by Critical Care Paramedics.
3-19-15
POTASSIUM CHLORIDE
ACTION:
1. Important for maintenance of body fluid composition and electrolyte balance.
2. Prevent or to treat low blood levels of potassium (hypokalemia)
INDICATIONS:
Prophylaxis or treatment of potassium deficiency. (Hypokalemia due to diuretic therapy,
adjunct to treatment of digoxin toxicity, low dietary potassium intake, vomiting diarrhea,
diabetic acidosis, metabolic alkalosis, corticosteroid therapy, increased renal excretion
resulting from acidosis, hemodialysis.)
CONTRAINDICATIONS:
1. Any disease or condition in which potassium levels increase may occur through potassium
retention or other processes.
2. Hyperkalemia
3. Renal failure
4. Complete heart block
PRECAUTIONS:
Impaired renal function or adrenal insufficiency can cause potassium intoxication, which can
develop rapidly and without symptoms.
1. Abdominal Pain
2. Diarrhea, Nausea Vomiting
3. Potassium Intoxication: cardiac arrest, cardiac arrhythmias, increased amplitude of T wave,
decreased amplitude of R wave, disappearing P wave, PR elongation, hypotension, altered
LOC.
4. Fever
5. Hyperkalemia
6. Hypervolemia
7. Muscle weakness
8. Venous thrombosis
9. Phlebitis
2. Infusion rates should not exceed 10 mEq per hour or 120 mEq per day.
3. A liter of fluid containing 40 mEq of potassium should be administered over an 8-hour
period
2. Concentrated potassium solutions must be diluted before administration; direct injection
can be fatal.
3. 40mEq/L is preferred dilution amount but check labels
4. Can be mixed with Sodium Chloride
3-19-15
PROCHLORPERAZINE (COMPAZINE)
ACTION:
1. Blocks dopaminergic receptors in the brain
2. Anti-psychotic medication
3. Anti-emetic
INDICATIONS:
1. Severe nausea and vomiting
2. Acute psychosis
3. Migraine headache
4. Treatment of schizophrenia
CONTRAINDICATIONS:
1. Hypersensitivity
2. Comatose patients
3. Patients that have received large amounts of CNS depressants
4. Pediatric surgery
5. Do not use in pediatric patients under 2 years of age or under 20 lbs. Do not use in children
for conditions for which dosage has not been established
PRECAUTIONS:
The antiemetic action of Compazine (prochlorperazine) may mask the signs and symptoms of
overdosage of other drugs and may obscure the diagnosis and treatment of other conditions .
1. Drowsiness
2. Sedation
3. Blurred vision
4. Tachycardia or bradycardia
5. Dizziness
6. Hypotension
7. Neuromuscular (Extrapyramidal) Reactions
8. Dystonias
9. Pseudo-parkinsonism
10. Tardive Dyskinesia
11. Neuroleptic Malignant Syndrome (NMS)
1. 5-10mg IM or slow IV.
Not recommended.
2. May potentiate the effects of narcotics, sedatives, hypnotics, and alcohol
3-19-15
PROPOFOL (DIPRIVAN)
ACTION:
1. Short-acting, intravenously administered hypnotic agent
2. Used to help you relax before and during general anesthesia for surgery or other medical
procedure
INDICATIONS:
Provide sedation to patients with controlled ventilation
CONTRAINDICATIONS:
Patients should not receive this medication if allergic to Propofol, eggs, soy products, or soy
beans
PRECAUTIONS:
1. Patients should be continuously monitored for early signs of hypotension and/or
bradycardia
2. Apnea requiring ventilatory support often occurs during induction and may persist for
more than 60 seconds
3. Medical use requires caution when administered to patients with disorders of lipid
metabolism such as primary hyperlipoproteinemia, diabetic hyperlipemia, and pancreatitis
4. When injected to a patient who is epileptic, there is a risk of seizure during the recovery
phase
1. Allergic reactions:
a. Hives
b. Difficulty breathing
c. Swelling of face, lips, tongue, or throat
2. Seizure
3. Respiratory
4. Fast or slow HR
5. Nausea
6. Green urine
1. 5-50mcg/kg/min. If greater than 50mcg is required contact medical control. Absolute
maximum dose is 80mcg/kg/min
2. May increase 5mcg/kg/min every 5 minutes based on required sedation
3. Bolus dosing 10-20 mg IVP slowly to quickly increase depth of sedation for patients
not at risk for hypotension

a. Administration of fentanyl simultaneously with Propofol may result in serious
bradycardia
2. Not recommended for use in nursing mothers because Propofol has been reported to be
excreted in human milk and the effects of oral absorption of small amounts of propofol are
not known
3-19-15
PROTAMINE SULFATE (FOR HEPARIN OVERDOSE)

ACTION:
1. It acts as a heparin antagonist
2. Protamine sulfate injection, USP is a sterile, non-pyrogenic, isotonic solution of protamine
sulfate
3. It is also a weak anticoagulant
INDICATIONS:
Treatment of Heparin overdose
CONTRAINDICATIONS:
1. Intolerance to drug
2. Hypersensitivity to fish
PRECAUTIONS:
1. Pregnancy
2. Patients who have received previous protamine containing insulin
3. Vasectomized men
1. Decreased blood pressure
2. Bradycardia
3. Pulmonary hypertension
4. Dyspnea
5. Transitory flushing
6. Nausea
1. 1 mg / 100 IU of active heparin may have to be titrated depending on the time at which the
heparin was given.
2. Protamine Sulfate Injection, USP should be given by very slow intravenous injection in
doses not to exceed 50 mg of protamine sulfate in any 10-minute period
1mg /100 IU of heparin (0.5mg/100 IU of heparin if > 1 hour since heparin dose); subsequent
doses of protamine 1mg/kg (max 50mg)
2. Hyperheparinemia or bleeding has been reported in experimental animals and in some
patients 30 minutes to 18 hours after cardiac surgery (under cardiopulmonary bypass)
even though complete neutralization of heparin by adequate doses of protamine sulfate at
the end of the operation
3. Therefore, it is important to keep the patient under close observation after cardiac surgery.
Additional doses of protamine sulfate should be administered if indicated by coagulation
studies, such as the heparin titration test with protamine and the determination of plasma
thrombin time.
4. Too-rapid administration of protamine sulfate can cause severe hypotensive and
anaphylactoid-like reactions
3-19-15
RACEMIC EPINEPHRINE
ACTION:
Sympathomimetic bronchodilator. Racemic epinephrine works by stimulation of the adrenergic receptors in the airway with resultant tightening of the mucosa (mucosal
vasoconstriction) and decreased fluid in the airway (subglottic edema) and by stimulation of
the -adrenergic receptors causing relaxation of the bronchial smooth muscle.
INDICATIONS:
1. Stridor
2. Croup
3. Bronchiolitis
CONTRAINDICATIONS:
1. Hypersensitivity to drug or sulfates
2. Epiglottitis
PRECAUTIONS:
1. Use cautiously in patients with hypertension, diabetes, elderly patients and patients with
cardiac disease (angina, MI, or tachycardia)
2. Syncope may develop in asthmatic children.
1. Increased heart rate
2. Nausea
3. Anxiety
4. Heart palpations
5. Headache
1. 0.5 0.75 ml of a 2.25% solution in 2.0 ml normal saline via nebulizer.
2. Contact medical control for additional orders.
1. >4 years: 0.25 0.50 ml of a 2.25% solution in 2.0 ml normal saline via nebulizer. Contact
medical control for additional orders.
2. <4 years: Contact medical control for orders.
SPECIAL NOTES:
3-19-15
RETEPLASE RECOMBINANT (RETAVASE, RT-PA)

ACTION: DISSOLVES CLOTS
1. Converts plaminogen to plasmin
2. Breaks down fibrin mesh that binds clot
INDICATIONS:
1. AMI
2. Ischemic stroke
CONTRAINDICATIONS:
1. Active internal bleeding
2. History of CVA
3. CNS surgery within past 2 months
4. Neoplasm
5. Severe, uncontrolled hypertension
PRECAUTIONS:
1. Standard management of myocardial infarction should be implemented
2. Pregnancy
1. Bleeding
2. Reperfusion dysrhythmias
3. Anemia
1. Physician ordered dose OR
2. 10 units IV over 2 minutes
a. Repeat after 30 minutes (total of 20 U)
2. Should an arterial puncture be necessary during the administration of Retavase, it is
preferable to use an upper extremity vessel that is accessible to manual compression.
3. Intramuscular injections and nonessential handling of the patient should be avoided.
4. Stop concomitant Heparin if bleeding develops.
3-19-15
TERBUTALINE SULFATE (BRETHINE)

ACTION:
1. Is selective for beta2 adrenergic receptors, resulting in relaxation of smooth muscle in the
bronchial tree and in the peripheral vasculature.
2. Inhibition of uterine smooth muscle contractility
INDICATIONS:
1. Bronchial asthma, spasm associated with exercise and/or COPD.
2. Control premature labor
CONTRAINDICATIONS:
1. Hypersensitivity
2. Tachydysrhythmias
3. Digitalis-induced tachycardia
PRECAUTIONS:
1. Hypertension
2. Seizure disorders
3. Known ACS patients
4. Older than 60 years of age
5. Changes in systolic and diastolic blood pressure.
6. Not recommended in patients less than 12 years of age.
1. Restlessness, apprehension, palpitations.
2. Nausea, vomiting, headache.
3. Tachycardias
1. Respiratory distress
a. Administer 0.25 mg SQ
b. Monitor vitals
c. Contact medical control for additional orders
2. Uncontrolled premature labor
a. Contact medical control to administer 0.25 mg SQ
Contact medical control to administer 0.01 mg/kg SQ-max dose of 0.25 mg for respiratory
distress.
2. Protect ampule from light and do not use if discolored.
3. Closely monitor maternal heart rate and blood pressure if given for pre-term labor.
3-19-15
VANCOMYCIN (VANCOCIN)
ACTION:
A very potent tryicylic glycopeptide antibiotic, it is bactericidal against gram positive
organisms.
INDICATIONS:
1. Serious gram positive infections.
2. Penicillin allergic patients
3. Endocarditis
CONTRAINDICATIONS:
1. Known Hypersensitivity
2. Corn Products
PRECAUTIONS:
1. Prolonged use can cause super infections that are not susceptible to antibiotic treatment.
2. Kidney problems
3. Hearing problems
4. Stomach and intestinal problems
1. Chills
2. Dizziness
3. Fever
4. Fatigue
5. Rash/urticaria
6. Anaphylaxis
7. Flushing of the upper body
8. Easy bleeding or bruising
9. Diarrhea
10. Ringing in the ears
11. Change in the amount of urine
2. 7.5mg/kg every 6 hours or 15mg/kg (1gm) every 12 hours for 7-10 days
3. Max dose: 3 4 gm/24 hrs
2. 40mg/kg/24 hrs
3. Do not exceed 2 Gm in 24 hours
2. Drug may cause dizziness, do not drive or use machinery
3-19-15
VECURONIUM BROMIDE
ACTION:
1. Non-depolarizing neuromuscular blocking agent; onset 2-3 minutes; duration: 30-90
minutes.
2. Paralysis onset decreases and duration of maximal effect increases with increasing doses.
INDICATIONS:
1. When further muscle paralysis is necessary following RSI.
2. Intubated patients that are experiencing tube stress agitation.
3. Patients that have uncontrolled motor activity that may threaten the airway or spine.
4. For further paralysis of an interfacility patient who has already been through RSI by
hospital staff.
CONTRAINDICATIONS:
1. Hypersensitivity
2. Newborns (< 28 days)
PRECAUTION:
1. Known pregnancy
2. Must use measures to control pain and anxiety after the paralytic has been administered.
3. Sedation should be used when vecuronium has been administered unless contraindicated.
1. Prolonged apnea/respiratory paralysis.
2. Inability to perform adequate neurological exam.
3. Quinidine, magnesium and certain antibiotics may intensify paralysis
1. Must be diluted with sterile water.
2. For paralysis:
a. Adult administration is 0.1 mg/kg IV/IO
b. May repeat dose, as indicated and necessary
3. Must provide total ventilatory support after administration
1. Administer 0.1 mg/kg IV/IO (Refer to Broselow pediatric tape.) May repeat dose as
necessary.
2. Must provide total ventilatory support after administration
2. Not to be used for initial paralysis to obtain an airway.
3. Have equipment ready to assist ventilations as necessary.
4. Watch for hypersensitivity or allergic reaction.
5. May be useful in status asthmaticus or epilepticus.
3-19-15
3-19-15

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La Crosse Regional Pre-Hospital Guidelines

Darin Wendel, AD Paramedic, CCParamedic

Tom Carpenter, NREMT-P, CCEMTP

Richard Barton, NREMT-P, CCEMTP

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

GENERAL PRINCIPLES OF P ATIENT CARE

La Crosse Regional Pre-Hospital Guidelines

GENERAL PRINCIPLES OF P ATIENT CARE CONTINUE

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

AIR AMBULANCE USE

Glasgow Coma Scale 13

4. motorcycle crash >20 mph

in infant aged <1 year), or need for ventilatory support

chest wall instability or deformity (e.g. flail chest)

intrusion, including roof: >12 inches occupant

with a high risk for injury

anticoagulants and bleeding disorders

site; >18 inches any site

adults: >20 feet (one story = 10 feet)

high-risk auto crash

low impact mechanisms (e.g., ground-level falls)

capable trauma centers

open or depressed skull fractures

children: >10 feet or two to three times the

SBP <110 might represent shock after age 65

might result in severe injury

crushed, degloved, mangled, or pulseless extremity

two or more proximal long-bone fractures

risk for injury/death increases after age 55 years

all penetrating injuries to head, neck, torso, and

respiratory rate of <10 or >29 breaths per minute (<20

with trauma mechanism: triage to trauma center

pregnancy >20 weeks

La Crosse Regional Pre-Hospital Guidelines

RR <8 or >35 breaths per minute

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

ALTERED MENTAL STATUS

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

AUTOMATIC IMPLANTABLE CARDIAC DEFIBRILLATOR (AICD)

This magnet will not stop a pacemaker from functioning

Keep magnet away from computers, credit cards, electronics, etc

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

BLOOD PRESSURE MANAGEMENT

Perform routine medical assessment

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

CEREBROVASCULAR ACCIDENT (BENCHMARK)

La Crosse Regional Pre-Hospital Guidelines

La Crosse Regional Pre-Hospital Guidelines

CORONARY INSUFFICIENCY (BENCHMARK)