Anchorage (AK) Protocols (2008)

ANCHORAGE FIRE DEPARTMENT
Medical Operations Manual

MOM 3.0
Michael Levy, M.D., FACEP, FACP

Medical Director
Erich Scheunemann, MICP

Assistant Chief, Operations
Anne Sigsworth, MICP

Battalion Chief, Operations
MOM 3.0
August 1, 2008
Anchorage Fire Department Medical Operations Manual
Introduction to MOM 3.0

The Medical Operations Manual (MOM) remains the basic document that describes the
Anchorage Fire Department’s protocols and standing medication orders as directed by the
Medical Director for pre-hospital care by AFD personnel. Version 3.0 introduces new and revised
protocols and drug orders. In most cases, off-line medical control using this document’s content
will allow for the care of the vast majority of our patients. On-line control, i.e. contact with medical
control, is strongly encouraged in situations that are outside the scope of these protocols. The
protocols in this document are based upon best available evidence for efficacy and safety. As
new information becomes available, protocols may change and the electronic version of the MOM
will be updated accordingly. AFD administration will make all personnel aware of the current
standard version of MOM. Please contact me or Chief Scheunemann with any questions
regarding the MOM.
Michael Levy, MD
Medical Director AFD
Procedure and Instruction (Extracted from P&I 905-9, 7/08)
Purpose
The Medical Operations Manual (MOM) is the Anchorage Fire Department's core reference for
medical protocols and medication standing orders. The MOM therefore defines the basic medical
standard and boundaries for EMS practice within the department.
Policy
The policy of the Anchorage Fire Department is to provide personnel with a Medical Operations
Manual.
Maintenance
1.1 The Medical Operations Manual will be developed and maintained under the
direction of the Medical Director.
1.2 Any member who recognizes a situation for which an addendum to the MOM would
be appropriate may request through their EMS Battalion Chief an update to the
Medical Operations Manual.
1.3 The Medical Operations Manual will be reviewed and updated as necessary.
1.4 The Medical Operations Manual will be maintained at each fire station and operations
work site.
2 MOM 3.0
Contact Telephone Numbers
Alaska Division of Family and Youth Services 269-4000

(Child Abuse/Neglect Reporting) (fax) 269-3939
Alaska Native Medical Center Emergency 729-1729
Department (fax) 729-1759
Alaska Regional Hospital Emergency Department 264-1222
(fax) 264-2004
Elmendorf AFB Hospital Emergency Department 580-5555
(fax) 580-2230
Providence Alaska Medical Center Emergency 212-3111
Department (fax) 212-3647
Mat-Su Regional Medical Center 861-6620
Emergency Department (fax) 861-6776
Oregon Poison Control Center (24 hour 1-800-222-1222
toxicology)
Anchorage Emergency Operations Center 343-1414
Medical Operations Branch 343-1413
Fire/Rescue Operations Branch (fax) 343-1441
AFD Dispatch 267-4950
(fax) 267-4989
AFD EMS 1 (shift EMS Battalion Chief) 267-4912
(cell) 317-3353
AFD Medical Director (pager) 762-2452
(cell) 632-0309
(fax) 696-7385
AFD Assistant Chief (EMS), Operations 267-5090
(pager) 792-0237
(cell) 223-4204
(fax) 267-4977
AFD Battalion Chief (EMS), Editor 267-4912
APD Non-Emergency Number 786-8500
3 MOM 3.0
Table of Contents
Introduction to MOM 3.0 ......................................................................................................................................2

Medical Operations Manual ............................................................................................................ 2
Contact Telephone Numbers ..............................................................................................................................3
Table of Contents.................................................................................................................................................4
Section 1: Standing Medication Orders .............................................................................................................7
adenosine ....................................................................................................................................... 7
albuterol .......................................................................................................................................... 8
amiodarone ..................................................................................................................................... 9
aspirin ............................................................................................................................................10
atropine sulfate...............................................................................................................................11
calcium chloride .............................................................................................................................12
captopril .........................................................................................................................................13
(Capoten®) ....................................................................................................................................13
dextrose 50% .................................................................................................................................14
diphenhydramine............................................................................................................................15
dopamine .......................................................................................................................................16
Dopamine Drip Chart for Adults .....................................................................................................17
droperidol .......................................................................................................................................18
epinephrine 1:1000 ........................................................................................................................19
epinephrine 1:10,000 .....................................................................................................................20
epinephrine 1:100,000 ...................................................................................................................21
etomidate .......................................................................................................................................22
fentanyl ..........................................................................................................................................23
furosemide .....................................................................................................................................24
glucagon ........................................................................................................................................25
glucose, oral...................................................................................................................................26
HemCon® Bandage .......................................................................................................................27
lidocaine.........................................................................................................................................28
lorazepam ......................................................................................................................................29
magnesium sulfate .........................................................................................................................30
morphine sulfate.............................................................................................................................31
naloxone ........................................................................................................................................32
nitroglycerin....................................................................................................................................33
nitrous oxide...................................................................................................................................34
oxytocin..........................................................................................................................................35
phenylephrine HCL ........................................................................................................................36
sodium bicarbonate........................................................................................................................37
succinylcholine ...............................................................................................................................38
tetracaine .......................................................................................................................................39
vasopressin ....................................................................................................................................40
vecuronium bromide.......................................................................................................................41
(Norcuron®) ...................................................................................................................................41
Section 2: Treatment Protocols ........................................................................................................................42
Introduction ........................................................................................................................................42
General Guidelines for the Treatment and Transport of Patients...................................................42
General Guidelines for All EMS Providers .....................................................................................42
EMT-I/ETT Patient Care Protocol...................................................................................................43
EMT-II Patient Care Protocol .........................................................................................................43
EMT-III Patient Care Protocol ........................................................................................................44
Scope of Practice for EMT-II and EMT-III ......................................................................................44
Airway and Ventilation........................................................................................................................44
Administration of Oxygen ...............................................................................................................44
Airway Protocol ..............................................................................................................................45
Bag-Valve-Mask Ventilation (BVM) ................................................................................................45
Endotracheal Intubation .................................................................................................................45
Combitube or King LT-DTM Airway................................................................................................46
Cricothyrotomy ...............................................................................................................................47
Eschmann Endotracheal Tube Introducer......................................................................................48
4 MOM 3.0
Gastric Intubation ...........................................................................................................................49

Inspiratory Impedance Device........................................................................................................49
Rapid Sequence Intubation with Neuromuscular Blockade............................................................50
Cardiac...............................................................................................................................................51
CPR ...............................................................................................................................................51
Chest Pain .....................................................................................................................................52
Congestive Heart Failure and Acute Pulmonary Edema ................................................................53
Cardiac Monitoring .........................................................................................................................54
12-Lead ECG .................................................................................................................................54
Revivant AutoPulse Device............................................................................................................55
Transcutaneous Pacing .................................................................................................................55
ACLS Algorithms and BLS Charts......................................................................................................56
Post Resuscitation Care.................................................................................................................56
Post Cardiac Arrest Cooling ...........................................................................................................56
Post Resuscitation Care Algorithm.................................................................................................58
Pulseless Arrest Algorithm .............................................................................................................59
Bradycardia Algorithm....................................................................................................................60
NCT (Narrow Complex Tachycardia) Algorithm .............................................................................61
Perfusing WCT (Wide Complex Tachycardia) Algorithm................................................................62
Automatic External Defibrillator (AED) Algorithm ...........................................................................63
Basic Life Support Summary Sheet ...............................................................................................64
Foreign Body Airway Obstruction (FBAO) Summary Sheet ...........................................................65
Intravascular Access and Medication Administration .........................................................................66
Intravenous (IV) Therapy ...............................................................................................................66
Adult Intraosseous (IO) Therapy ....................................................................................................66
Medication Administration ..............................................................................................................67
General Medical .................................................................................................................................68
Asthma, Wheezing, COPD.............................................................................................................70
Carbon Monoxide (CO) Poisoning .................................................................................................71
Combative Patient..........................................................................................................................71
Diabetic Emergencies ....................................................................................................................72
Blood Glucose Determination ........................................................................................................73
Epistaxis.........................................................................................................................................73
Hyperkalemia .................................................................................................................................73
Hypertension ..................................................................................................................................74
Hypotension ...................................................................................................................................74
Pain Management ..........................................................................................................................75
Seizures, Status Epilepticus and Postictal States ..........................................................................76
Seizure Algorithm...........................................................................................................................77
Stroke (CVA) ..................................................................................................................................78
Tricyclic Antidepressant Overdose.................................................................................................78
Unconscious Patient Unknown Etiology.........................................................................................79
Trauma and Environmental Injuries ...................................................................................................80
General Trauma Guidelines ...........................................................................................................80
Amputations ...................................................................................................................................81
Burn Management..........................................................................................................................81
C-Spine Guidelines (Axial Spine Immobilization) ...........................................................................81
Clinical Criteria for Assessment of Spine Injury .............................................................................83
External Hemorrhage .....................................................................................................................85
Eye Injuries ....................................................................................................................................86
Hypothermia...................................................................................................................................86
Inflatable Lower-Body Splint (MAST/PASG) ..................................................................................87
Near Drowning ...............................................................................................................................87
Pelvic Fracture ...............................................................................................................................87
Traumatic Brain Injury (TBI) ...........................................................................................................91
Airway Management in TBI Patients ..............................................................................................91
TurkelTM Safety Thoracentesis Catheter ........................................................................................92
Appendix ............................................................................................................................................93
Triage (START Algorithm)..............................................................................................................93
Glasgow Coma Scale.....................................................................................................................94
FACES© Pain Rating Scale...........................................................................................................94
Adult Burn Chart.............................................................................................................................95
5 MOM 3.0
Precordial Lead Placement ............................................................................................................96

12 Lead Waveforms .......................................................................................................................97
Capnography Waveform Elements ................................................................................................98
Capnography Waveform Analysis ..................................................................................................99
VentiSure™ ET CO2 Reference ...................................................................................................100
Section 3: Pediatric Treatment Protocols and Weight Pages ......................................................................101
Transporting the Pediatric Patient ................................................................................................101
Spinal Immobilization ...................................................................................................................101
Safeguard Transport Seat............................................................................................................101
Pediatric Intraosseous (IO) Therapy ............................................................................................102
Neonate/Small Infant Intraosseous (IO) Therapy .........................................................................103
Obstetrics and Neonatal Treatment Protocols .................................................................................104
Newborn Care ..............................................................................................................................104
Obstetrics.....................................................................................................................................105
Third Trimester Hemorrhage ........................................................................................................105
Pre-eclampsia and Eclampsia......................................................................................................106
Childbirth......................................................................................................................................106
Postpartum Hemorrhage..............................................................................................................107
Pediatric Weight Pages....................................................................................................................107
Appendix ..........................................................................................................................................125
APGAR Scores ............................................................................................................................125
Infant Burn Chart..........................................................................................................................125
Child Burn Chart...........................................................................................................................126
Section 4: Medical Operations........................................................................................................................127
EMS P&Is, SOGs, and Manuals ..................................................................................................127
EMS Incident Disposition .............................................................................................................128
Definition of Patient ......................................................................................................................128
Destinations for Hemodialysis (HD) and Peritoneal Dialysis (PD) Patients..................................128
Destination of Patients with Psychiatric Problems........................................................................129
Direct Admit Patients....................................................................................................................129
Dispatch Alerting to First Defibrillation .........................................................................................129
ePCR Completion ........................................................................................................................130
Hospital Alerts ..............................................................................................................................130
STEMI Alert..................................................................................................................................130
Trauma Alert ................................................................................................................................131
Stroke Alert ..................................................................................................................................131
Arrival Times at Hospital ..............................................................................................................131
Hospital Disposition of Code 99, Status 1 and Status 2 Pediatric Patients and Pre-term Labor ..131
Hospital Radio Report Format/Patient Status ..............................................................................132
Medical Consumables Expiration Dates.......................................................................................132
Medication Use and Patient Safety ..............................................................................................133
Patient Safety and EMS Medical Supplies ...................................................................................134
Utilizing ICS for Code 99 Resource Management........................................................................134
Perimortal Policy ..........................................................................................................................134
SUID (Sudden Unexpected Infant Deaths) ..................................................................................135
Obvious Death/Decision Not to Resuscitate ................................................................................135
Patients Unresponsive to CPR.....................................................................................................136
Traumatic Cardiac Arrests ...........................................................................................................136
Comfort One/Do Not Resuscitate.................................................................................................136
Public Inebriate Incident Disposition ............................................................................................137
Requesting APD Assistance ........................................................................................................137
Safety Modification to Mixed EMS Responses.............................................................................138
Transfer of Care/Return to Service Policy....................................................................................138
Transport Policy for the Mat-Su Regional Medical Center ...........................................................139
Appendix A: Approved Medical Abbreviations ............................................................................................140
Appendix B: MOM 3.0 ......................................................................................................................................148
6 MOM 3.0
Section 1: Standing Medication Orders
adenosine
(Adenocard®)
Actions
A nucleoside found in all cells of the body. It slows conduction time through the AV junction, can
interrupt reentry pathways through the AV junction, and can restore normal sinus rhythm in
patients with paroxysmal supraventricular tachycardia (PSVT).
Indications
Conversion of PSVT. (Will not convert AFib, Aflutter or most VT).
Contraindications
• Known hypersensitivity.
• Second or third degree block (except if functioning pacemaker).
• Sick sinus syndrome (except if functioning pacemaker).
Side Effects and Adverse Reactions

• CV: Facial flushing, chest pain, occasional prolonged asystole.
• RESP: Shortness of breath, chest pressure. May exacerbate active asthma (contact
physician if active wheezing).
• CNS: Nausea.
Warnings
• Obtain 12-lead ECG prior to administration. Run continuous lead I, II, V2 printout during
adenosine administration.
• Effect potentiated by dipyridamole (Persantine) and carbamezapine (Tegretol).
• Effect antagonized by theophyllines.
Adult Dose
• IV/IO: 6.0 mg RAPID IVP at site as close to needle hub as possible followed immediately by
rapid flush. If after 2 minutes second dose is required, increase to 12.0 mg RIVP. May repeat
once at 12.0 mg RIVP to a total of 30.0 mg.
o Option: NCT: If adenosine antagonists are present (Theophyllines), contact
Physician for 3rd dose of 18 mg (total 36 mg).
• IM: NOT given IM.
Protocol Reference
• Narrow Complex Tachycardia Algorithm.
• Perfusing Wide Complex Tachycardia Algorithm.
Pediatric Dose
IV/IO: 0.1 mg/kg, dilute 2 ml Adenosine with 4 ml NS to 6 mg/6 ml if patient < 6 kg. May repeat
twice at 0.2 mg/kg. See specific pediatric weight page.
How supplied
60 mg in 20 ml vial.
7 MOM 3.0
albuterol
(Ventolin®, Proventil®)
Actions
Primarily a beta-2 sympathomimetic, it produces bronchodilation. Because it is more specific for
beta-2 adrenergic receptors than isuprel, it produces fewer cardiovascular side effects and more
prolonged bronchodilation. Onset is within 15 minutes, and it peaks in 60-90 minutes. Therapeutic
effects may last up to 5 hours.
Indications
Relief of bronchospasm in patients with reversible obstructive airway disease, including asthma.
Contraindications
History of hypersensitivity.

• CNS: Nervousness, tremor, headache, dizziness, insomnia.
• CV: Tachycardia, hypertension, angina.
• GI: Drying of oropharynx, nausea, vomiting, and unusual taste.
Warnings
• Use cautiously in patients with coronary artery disease, hypertension, hyperthyroidism, and
diabetes.
• Should not be used at the same time as epinephrine. However, either may be used after
failure of the other.
• Administer cautiously to patients on MAO inhibitors or tricyclic antidepressants.
o Common MAO inhibitors include Nardil® (phenilizine) and Parnate®
(tranylcypromine).
• Beta-blockers and albuterol will inhibit each other.
Adult Dose
2.5-5 mg via nebulizer, as indicated by specific protocol. Add sodium chloride to medication to a
total of 3ml volume of medication and dilutent in nebulizer.
Protocol Reference
• Asthma, Wheezing, COPD.
• Congestive Heart Failure and Acute Pulmonary Edema.
• Allergy/Anaphylaxis.
Pediatric Dose
2.5-5 mg via nebulizer, blow by into face, PRN, transport.
How Supplied
3 ml unit dose (2.5 mg albuterol sulfate in 3 ml), and/or 20 ml multi-use 0.5% (5 mg/ml).
8 MOM 3.0
amiodarone
(Cordarone®)
Actions
Amiodarone is a very complex drug with actions upon sodium, potassium and calcium channels
as well as alpha and beta-adrenergic blocking properties.
Indications
• Recurrent/Persistent Pulseless VT/VF after defibrillation and epinephrine.
• Perfusing WCT (second-line to Lidocaine if chest pain or ischemia.)
Contraindications
• History of hypersensitivity.
• Cardiogenic shock.
nd rd
• 2 or 3 degree AV block in absence of functioning pacemaker.
• Sinus Bradycardia

• CV: Hypotension / bradycardia.
• Vessels: Can cause sclerosis / phlebitis.
Warnings
• Safety in pregnancy not established. May only be given in pregnancy if potential benefit
outweighs risk to fetus.
• Torsade des pointes is an uncommon pro-arrhythmic effect usually associated with QTc>450
ms.
Adult Dose
• IV/IO: Pulseless VT/VF: 300 mg IVP. May repeat 150 mg after five minutes if necessary for
recurrent Pulseless VT/VF.
• Perfusing WCT, Torsades with perfusion: 150 mg in 50 ml bag NS administered over
approximately 10 minutes (50 gtts/min using 10 gtts/ml dripset).
• IM: NOT given IM
Protocol Reference
• Pulseless Arrest Algorithm.
• Perfusing WCT.
• Post Resuscitation Care Algorithm.
Pediatric Dose
• Physician contact required.
• Pulseless VT/VF: 5 mg/kg IV, IO, SIVP.
• Perfusing WCT, Torsades with perfusion: 5 mg/kg IV/IO over 10 min. Dilute 150 mg with 50
ml NS. and infuse with a volumetric infusion device.
How Supplied
150mg in 3ml vial. The drug must be drawn slowly from the vial directly into the syringe without a
needle to avoid foaming.
9 MOM 3.0
aspirin
(ASA, acetylsalicylic acid)
Actions
Inhibits platelet aggregation.
Indications
Chest pain with suspicion of myocardial infarction or unstable angina.
Contraindications
• Active peptic ulcer disease.
• Sensitivity to aspirin or other nonsteroidal anti-inflammatory.
• Patient who has already taken aspirin within last 12 hours.

• GI:Upper GI bleeding, upset stomach.
• RESP:Acute bronchospasm in susceptible individuals.
Warnings
None.
Adult Dose
162mg PO, chewed well.
Protocol Reference
• Chest pain.
• Post Resuscitation Algorithm.
Pediatric Dose
Not indicated.
How Supplied
81 mg chewable tablets.
10 MOM 3.0
atropine sulfate
(Atropine)
Actions
Potent parasympatholytic (anticholinergic). By reducing vagal tone it increases automaticity in the
SA node and increases A-V conduction.
Indications
• Sinus bradycardia accompanied by hemodynamic compromise: hypotension (SBP < 90);
confusion; frequent PVCs; pale, cold, clammy skin.
• Second- and third-degree AV blocks (unless accompanied by wide QRS).
• Asystole.
• Pre-medication for pediatric succinylcholine administration.
• Pesticide exposure and organophosphate exposure (physician contact required).
Contraindications
None in emergency situations.

• CNS:Restlessness, agitation, confusion, psychotic reaction, pupil dilation, blurred vision,
headache.
• CV: Increases heart rates; may worsen ischemia or increase area of infarction; ventricular
fibrillation.
• GI:Dry mouth, difficulty swallowing.
• GU:Urinary retention.
• Other:Can worsen pre-existing glaucoma.
Warnings
• Too small a dose (< 0.02 mg/kg), or normal dose pushed too slowly, may initially cause the
heart rate to decrease.
• Potentiated by antihistamines and antidepressants.
• Do not use in tricyclic antidepressant overdose.
• May worsen cardiac ischemia.
• Do not exceed maximum dose of 3 mg IV.
Adult Dose (IV/IO)

• Perfusing bradycardias and blocks, 0.5 mg IV q 3-5 min. to max. 3 mg.
• Asystole/PEA: 1 mg IV q 3-5 min, to max 3 mg.
• Organophosphate poisoning may require large doses of atropine: contact medical control.
• IM: This route may be used in organophosphate exposure: contact medical control.
Protocol Reference
• Pulseless Arrest Alogorithm.
• Bradycardia Algorithm.
• Pediatric pre-medication for paralytic agent, field use.
Pediatric Dose
0.02 mg/kg IV or I0. Minimum dose: 0.1 mg. Maximum single dose 0.5 mg for child, 1.0 mg for
adolescent.
How Supplied
1 mg in 10 ml pre-filled syringe.
11 MOM 3.0
calcium chloride
(CaCl)
Actions
Has multiple membrane actions in conducting and muscular tissue. Stabilizes irritable
myocardium in the setting of hyperkalemia.
Indications
• Unstable arrhythmia in a patient who may be hyperkalemic.
• Calcium channel blocker overdose with hypotension.
Contraindications
None in the setting of confirmed hyperkalemia with a sinusoidal cardiac rhythm.

Integument: Pain at injection site.
Warnings
• Rapid injection may cause bradycardia.
• May worsen digoxin toxicity.
• Co-administration with sodium bicarbonate will cause precipitation.
Adult Dose
• IV/IO: 1 gm SIVP.
Protocol Reference
Hyperkalemia.
Pediatric Dose
Not indicated.
How Supplied
1 gm in 10 ml vial.
12 MOM 3.0
captopril
(Capoten®)
Actions
Angiotensin-coverting enzyme (ACE) inhibitor. The ACE converts inactive angiotensin I to
biologically active angiotensin II. The blocking effect of captopril causes a decrease of the plasma
levels of angiotensin II and aldosterone. ACE inhibitors decrease the peripheral resistance
without causing a compensatory tachycardia. Captopril also has well documented efficiency for
heart failure: it reduces the ventricular preload and afterload.
Indications
• Pulmonary edema. Second-line to Nitroglycerine. Use only if SBP remains > 110.
• Hypertension (at physician request only).
Contraindications:
• Pregnancy: can cause renal failure in neonate
• Relative contraindications:
o Breast feeding.
o Dehydration (high renin state) may cause exaggerated lowering of BP.

Single dose therapy is not expected to cause any of the side effects typically associated with ACE
inhibitors except for possible hypotension.
Adult Dose
• SL: 25 mg SL is usual dose (may give 12.5 in small individuals or if concern about possible
excessive effect).
Protocol Reference
• Congestive Heart Failure and Acute Pulmonary Edema
• Hypertension
Pediatric Dose
By direct medical control order only.
How Supplied
25 mg tablets
13 MOM 3.0
dextrose 50%
(D50W, D50, D25, D10)
Actions
A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss
of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution.
Indications
Hypoglycemia or suspected hypoglycemia.
Contraindications
None.

• CV: Thrombosis, sclerosis if given in small peripheral vein.
• Integ: Tissue irritation if IV infiltrates. May cause skin necrosis.
• Other: Acidosis, alkalosis, hyperglycemia, and hypokalemia.
Warnings
• May theoretically cause Wernicke-Korsakoff syndrome in acute alcohol intoxication.
• Theoretically may worsen cerebral edema if present.
Adult Dose
• IV/IO: 25 gm (50 ml). Obtain a Glucometer reading (if possible) before administering.
Administer with running IV fluid. May repeat once if required.
Protocol Reference
• Unconscious patient unknown etiology.
• Diabetic Emergencies.
• Seizures.
• Blood Glucose Determination.
Pediatric Dose
• 0.5 gm/kg SIVP/IO to max of 25 gm.
• Give as D25 (1 ml/kg diluted with 1 ml/kg NS or sterile water) if weight less than 25 kg.
• Give as D10 (1 ml/kg diluted with 4 ml/kg NS or sterile water) for neonate.
Notes
• Doses are the endpoint. If patient responds to smaller dose during a slow push, stop at that
level and reassess.
• May dilute to D25 if needed for adult with fragile veins or small-bore IV catheter.
How Supplied
25 gm in 50 ml pre-filled syringe.
14 MOM 3.0
diphenhydramine
(Benadryl®)
Actions
An antihistamine with anticholinergic (drying) and sedative side effects. Antihistamines appear to
compete with histamine for cell receptor sites on effector cells. Prevents, but does not reverse,
histamine mediated responses, particularly its effects on smooth muscle in the bronchial airways,
GI tract, uterus, and blood vessels.
Indications
• Allergy symptoms.
• Anaphylaxis, as an adjunct to epinephrine.
• Dystonic (extrapyramidal) and dysphoric reactions associated with use or overdose of
phenothiazines and related drugs: droperidol, haloperidol, Thorazine, Compazine, Stelazine,
metoclopromide (Reglan).
• Adjunct to use of morphine in potentially hypotensive patient (give 12.5-25 mg SIVP prior to
morphine).
Contraindications
• Newborn or premature infants.
• Nursing mothers.
• Lower respiratory tract symptoms, including asthma.

• CNS: Drowsiness, confusion, insomnia, headache, vertigo, hyperactivity in children.
• CV: Palpitations, tachycardia, PVCs, hypotension.
• GI: Nausea, vomiting, diarrhea, dry mouth, constipation.
• GU: Dysuria, urinary retention.
• RESP: Thickening of bronchial secretions, chest tightness, wheezing, nasal stuffiness.
Warnings
• In infants and children especially, OD may cause hallucinations, convulsions, or death.
• May diminish mental alertness in adults and children. In young children, may produce
excitation.
• Have additive effects with alcohol and other CNS depressants (hypnotics, sedatives,
tranquilizers, etc).
• More likely to cause dizziness, sedation, and hypotension in the elderly (>60 y/o).
Adult Dose
• IV/IO: 25–50 mg IV.
• IM: 25–50 mg IM.
Protocol Reference
• Anaphylaxis.
• Pain management.
• Combative Patient
Pediatric Dose
• IV/IO: 1 mg/kg IV. Maximum: 50 mg per dose.
• IM: 1 mg/kg deep IM. Maximum: 50 mg per dose.
How Supplied
50 mg in 1 ml vial.
15 MOM 3.0
dopamine
(Intropin®)
Actions
Stimulates dopaminergic, alpha-adrenergic and beta-adrenergic receptors. Inotropic effect
increases cardiac output. Dilates renal and mesenteric vessels at low doses that may not
increase heart rate or blood pressure. Therapeutic doses have predominantly beta adrenergic
effects that increase cardiac output and vital organ perfusion without marked increases in
pulmonary occlusive pressure. At high doses, alpha-receptor stimulation causes peripheral
vasoconstriction and marked increases in pulmonary occlusive pressure.
Indications
Cardiogenic or vasogenic shock.
Contraindications
• Hypovolemia.
• Pheochromocytoma.
• Uncorrected tachyarrhythmias or ventricular fibrillation.

• CNS:Headache.
• CV: Ectopic beats, tachycardia, anginal pain, palpitations, hypotension.
• GI: Nausea, vomiting.
• Local:Necrosis and tissue sloughing with extravasation.
• Other:Piloerection, dyspnea.
Warnings
• Inactivated in alkaline solutions.
• Patients taking monoamine oxidase MAO inhibitors will require substantially reduced dosage.
(tranylcypromine).
Adult Dose
• IV/IO: Mix 400mg of dopamine in 250 ml of NS to yield a concentration of 1600 mcg/ml.
Begin infusion at 5 mcg/kg/min and titrate to effect. Dosages of over 20 mcg/kg/min have
occasionally been required. Refer to Dopamine Drip Chart.
Protocol Reference
• Bradycardia Algorithm
• Hypotension.
Pediatric Dose
• IV/IO: Mix 150 mg (3.75ml) of dopamine in 250 ml NS to yield a concentration of 600
mcg/ml. Start at 10 mcg/kg/min.If not effective in 3-5 minutes, consider physician contact for
permission to increase to 20 mcg/kg/min.
• IM: NOT given IM
How Supplied
16 MOM 3.0
Dopamine Drip Chart for Adults
FOR A CONCENTRATION OF 1600 μg of DOPAMINE PER MILLILITER SOLUTION:

400 mg dopamine in 250ml NS.
Body Wt. lbs. 110 121 132 143 154 165 176 187 198 209 230 231 242
Wt. kgs. 50 55 60 65 70 75 80 85 90 95 100 105 110
μg/min. 5μg 10 11 11 12 13 14 15 16 17 18 19 20 21
6μg 11 13 14 15 16 17 18 19 21 22 23 24 25
7μg 13 15 16 17 19 20 21 23 24 25 27 28 29
8μg 15 17 18 20 21 23 24 26 28 29 31 32 34
9μg 17 19 21 22 24 26 28 29 31 33 34 36 38
10μg 19 21 23 25 27 29 31 32 34 36 38 40 42
11μg 21 23 25 27 29 32 34 36 38 40 42 44 46
12μg 23 25 28 30 32 34 37 39 41 44 46 48 50
13μg 25 27 30 32 35 37 40 42 45 47 50 52 55
14μg 27 29 32 35 37 40 43 45 48 51 53 56 59
15μg 29 32 34 37 40 43 46 49 52 54 57 60 63
16μg 31 34 37 40 43 46 49 52 55 58 61 64 67
17μg 32 36 39 42 45 49 52 55 58 62 65 68 71
18μg 34 38 41 45 48 52 55 58 62 65 69 72 76
19μg 36 40 44 47 51 54 58 62 65 69 73 76 80
20μg 38 42 46 50 53 57 61 65 69 73 76 80 84
FLOW RATE IN DROPS PER MINUTE BASED ON A MICRODRIP CALIBRATION OF 60 DROPS EQUAL
1.O MILLILITER.
Note: Refer to the Pediatric Weight Pages for pediatric drip rates.
17 MOM 3.0
droperidol
(Inapsine®)
Actions
Droperidol produces tranquilization and sedation with reduced motor activity and reduced anxiety.
Additionally, droperidol produces alpha adrenergic blockade, which can lead to hypotension.
Indications
Combative patient without any other obvious, reversible reason for the behavior who threatens
the safety of the crew or who may him/herself be injured in our physical attempts to contain the
behavior.
Contraindications
History of hypersensitivity to droperidol or haloperidol.

• CNS:Extrapyramidal reactions, Dysphoric reactions. These may be treated with
Diphenhydramine.
• CV:Hypotension; tachycardia.
• Resp:Increased respiratory depression if baseline status is decreased (particularly by other
drugs).
Warnings
• Hypotensive effect potentiated by hypovolemia.
• Hypotensive effect due to alpha blockade more likely to occur at IV doses > 2 mg.
• This drug will generally be given IM! Be sure to reduce dose for IV.
• Reduce dose for small body size, elderly, infirmity.
• Prolonged effect may occur with renal or hepatic failure.
Adult Dose
Droperidol 1.25-5.0 mg IM or 1-2mg IV for combativeness. IM May repeat in 10 minutes if not
effective. IV may repeat in 5 minutes if not effective.
Protocol Reference
Combative Patient.
Pediatric Dose
Not indicated; call medical control.
How Supplied
5 mg in 2 ml vial.
18 MOM 3.0
epinephrine 1:1000
(Epi 1:1000)
Actions
A sympathomimetic that stimulates both alpha and beta-adrenergic receptors. Causes immediate
bronchodilation, increase in heart rate, and increase in the force of cardiac contraction.
Subcutaneous dose lasts 5-15 minutes.
Indications
• Asthma.
• Allergy/Anaphylaxis
• Angioneurotic edema.
• Pediatric cardiac resuscitation second-line to IV/IO 1:10,000 only if IV/IO unobtainable.
Contraindications
• Hyperthyroidism.
• Hypertension.
• Elderly or debilitated patients with underlying cardiovascular disease.
• Note: in anaphylaxis, there are no Contraindications.

• CNS:Anxiety, headache, cerebral hemorrhage.
• CV: Tachycardia, ventricular dysrhythmias, hypertension, angina, palpitations.
• GI: Nausea and vomiting.
Warnings
• Asthmatic patients >55 years of age require Physician contact.
• Inactivated by alkaline solutions; never mix with sodium bicarbonate.
• Catecholamine action is depressed by acidosis; attention to ventilation and circulation is
essential.
• Antidepressants potentiate the effects of epinephrine.
• Causes hyperglycemia.
• Cannot be given intravenously at this strength.
Adult Dose
• SC: 0.3-0.5 mg (0.3-0.5ml) SC. May be repeated every 15 minutes x 3 for asthma. May be
repeated every 10 mins as needed for anaphylaxis, but if multiple does are required consider
moving to IV Epi 1:100,000. Can also be given SL.
• IV/IO: NOT given IV/IO.
Protocol Reference
• Anaphylaxis.
• Asthma.
• Newborn Care.
Pediatric Dose
• SC: 0.01 mg/kg SC if patient > 4 kg. Maximum dose: 0.3 mg. Repeats same as adult
• IV/IO: NOT given IV/IO.
• ET In cardiac resuscitation, 0.1 mg/kg flushed with 3-5 ml NS.
How Supplied
1mg in 1 ml ampule.
19 MOM 3.0
epinephrine 1:10,000
(Epi 1:10,000)
Actions
A sympathomimetic that stimulates both alpha and beta-receptors. Increases myocardial and
cerebral blood flow during ventilation and chest compression. Increases systemic vascular
resistance and thus may enhance defibrillation.
Indications
• Asystole.
• Ventricular fibrillation unresponsive to defibrillation.
• Pulseless ventricular tachycardia (including pulseless WCT) unresponsive to defibrillation
• PEA.
• Additional pediatric Indications
o Hypotension with circulatory instability.
o Bradycardia unresponsive to atropine.
o Initial treatment of bradycardia in neonates.
Contraindications
None in these situations.

• CNS:Anxiety, headache, cerebral hemorrhage.
Warnings
• Inactivated by alkaline solutions; never mix with sodium bicarbonate.
essential.
Adult Dose
• IV/IO: 1mg IV. May repeat every 5 minutes.
Protocol Reference
• Pulseless Arrest Algorithm
• Bradycardia Algorithm
• Newborn Care.
Pediatric Dose
• IV/IO: 0.01 mg/kg (0.1 ml/kg) IV. Repeat every 5 minutes as necessary.
How Supplied
1mg in 10 ml prefilled syringe.
20 MOM 3.0
epinephrine 1:100,000
(Epi 1:100,000)
Actions
Provides vascular tone, inotropic support, and bronchodilation in the setting of an acute
hypersensitivity reaction with anaphylactic shock.
Indications
Anaphylactic shock.
Contraindications
None in this setting.

• CNS: Anxiety, headache, cerebral hemorrhage.
• Integ: Skin sloughing if IV extravasates.
Warnings
• Epinephrine is inactivated by alkaline solutions; never mix with sodium bicarbonate.
essential.
Adult Dose
• Remove 9 ml from an epi 1:10,000 preload and draw up 9 ml of NS from a vial or IV bag.
• Administer as slow, continuous IV/IO push, titrating against symptoms.
• May repeat dose as needed.
Protocol Reference
Anaphylaxis.
Pediatric Dose
Same as for adults.
How Supplied
See Adult Dose instructions.
21 MOM 3.0
etomidate
(Amidate®)
Actions
Ultrashort acting non-barbiturate hypnotic.
Indications
• Sedation prior to paralytic assisted intubation.
• Sedation prior to emergency synchronized cardioversion.
Contraindications
• Known allergy to etomidate.

• CV: Usually no effect.
• RESP:Usually no effect.
• Neuro:Involuntary muscle movements.
• Other: Pain on injection.
• GI:May cause GI discomfort; hiccoughs.
Warnings
None.
Adult Dose
• IV/IO: 0.3 mg/kg SIVP over 15-60 sec. For procedures other than RSI, start with ½ dose and
titrate to desired effect up to full dose.
• IM: not recommended.
Protocol Reference
• Rapid Sequence Intubation.
• Narrow Complex Tachycardia Algorithm.
• Perfusing Wide Complex Tachycardia Algorithm.
Pediatric Dose
• IV/IO: 0.3 mg/kg for age >7 weeks. For procedures other than RSI, start with ½ dose and
titrate to desired effect up to full dose.
How Supplied
22 MOM 3.0
fentanyl
(Sublimaze®)
Actions
Potent opiate analgesic with same mechanism of action as other narcotic analgesics. Onset of
action is almost immediate, duration of action is 30-60 minutes.
Indications
Patients suffering from severe pain in whom a shorter duration of narcotic effect is desired:
• Multiple Trauma.
• Head Injury.
• Abdominal Pain.
Contraindications
• History of hypersensitivity to opiates.
• Not to be used in patients taking MAO inhibitors.
(tranylcypromine).

• CNS: Sedation.
• CV: Hypotension; bradycardia.
• Resp: Respiratory depression, apnea.
Warnings
• Rapid infusion can lead to chest wall spasm, muscle rigidity.
• Dosage units are MICROGRAMS.
Adult Dose
1.0 microgram/kg SIVP. May repeat x 1 if ineffective after 5 minutes or effect wanes during
transport.
Protocol Reference
Pain Management.
Pediatric Dose
IV/IO: 1.0 microgram/kg SIVP (titrate to 1.0 microgram/kg total dose).
IN: 1.5 microgram/kg Intranasal via MAD (titrate to 1.5 microgram/kg total dose)
How Supplied
100 microgram in 2 ml.
23 MOM 3.0
furosemide
(Lasix®)
Actions
A sulfonamide derivative and potent diuretic that inhibits the re-absorption of sodium and chloride
in the proximal and distal renal tubules, and in the Loop of Henle. With IV administration, onset of
diuresis is within 5 minutes, peak is in 30 minutes; and duration is 2 hours.
Indications
• Pulmonary edema.
• Hypertension (at physician request only).
Contraindications
• Anuria.
• Relative Contraindications:
o Allergy to sulfa. If previous reaction was minor, consider the risks versus benefit to
the patient.
o Pregnancy. Use only when benefits clearly outweigh risks.

• CNS:Dizziness, tinnitus, hearing loss, headache, blurred vision, weakness.
• GI:Anorexia, vomiting, nausea.
• CV: Hypotension.
• Other:Pruritus, urticaria, muscle cramping.
Warnings
• Rapid infusion and high doses (>100 mg) can cause tinnitus and inner ear damage.
• Should be stored to protect it from light.
• Dehydration and electrolyte imbalance can result from excessive dosages.
• Rapid diuresis can lead to hypotension.
Adult Dose
• IV/IO: 0.5 mg/kg SIVP if not currently on furosemide; give 1.0 mg/kg SIVP if currently taking.
For repeat doses, physician contact required.
Protocol Reference
• Hypertension.
Pediatric Dose
• Not permitted without physician contact.

• IV/IO: 0.5-1 mg/kg IV slowly over 1-2 minutes.
How Supplied
40 mg in 4 ml vial
24 MOM 3.0
glucagon
(Glucagon)
Actions
Produced naturally in the pancreas by alpha cells in the islets of Langerhans. Acts only on liver
glycogen, converting it to glucose. Increases blood glucose concentrations. Effective in small
doses. No toxicity problems have been reported.
Indications
• Hypoglycemia when IV access is not available.
• Symptomatic β-blocker overdose.*
• Symptomatic Calcium-channel blocker overdose.*
Contraindications
Hypersensitivity to glucagon.

GI: Occasionally causes nausea and vomiting.
Warnings
• Use caution in patients with a history of insulinoma or pheochromocytoma.
• Response for hypoglycemia may take up to 20 minutes.
• Depletes liver glycogen stores. Increased carbohydrate intake is important, as is transport
after administration.
Adult Dose
IV, IO, IM, SC: 1.0 unit of glucagon. Can be repeated once. *
Protocol Reference
• Asystole.
.
Pediatric Dose
IV, IO, IM, SC: 0.05 mg/kg. Maximum:1 mg.*
*Doses required for treatment of calcium channel blocker or β-blocker OD may be much higher
than listed here. Start with above listed doses and if OD is strongly suspected, contact medical
control.
How Supplied
1 unit (1 mg) glucagon in dry powder form and 1ml diluting solution.
25 MOM 3.0
glucose, oral
(Insta-glucose ®)
Actions
A monosaccharide that provides calories for metabolic needs, and spares body proteins and loss
of electrolytes. Readily excreted by kidneys producing diuresis. Hypertonic solution.
Indications
Hypoglycemia or suspected hypoglycemia in alert patient.
Contraindications
None.

None.
Warnings
None.
Dose
Swallow one tube. If no improvement in 10 minutes, repeat.
Protocol Reference
• Blood Glucose Determination.
How Supplied
Insta-Glucose contains 24 grams of carbohydrate.
26 MOM 3.0
HemCon® Bandage
(HemCon®)
Actions
The HemCon® Bandage is a hemostatic dressing made of chitosan, a natural substance that
adheres when in contact with blood. The HemCon® Bandage is a freeze-dried chitosan-based
dressing designed to optimize the mucoadhesive surface density and structural integrity of
chitosan at the site of injury. There is evidence suggesting the HemCon® Bandage may also
enhance platelet function and possibly incorporate red blood cells into the clot formed at the site
of the wound.
Indications
• For uncontrolled external hemorrhage when conventional methods are unsuccessful or not
possible, for example, due to the anatomical area incompatible with a tourniquet or direct
compression.
Contraindications
• Known allergy to chitosan.
Precautions
• Once applied, do not attempt to reposition the bandage. A new bandage should be applied
to other exposed bleeding sites.
• Care must be taken to avoid contact with the patient’s eyes.
• If bandage is not effective in stopping bleeding, remove original and apply a new bandage.
Additional bandages cannot be applied over ineffective bandages.
Use
• The HemCon® Bandage works by adhering aggressively to tissue surfaces when in contact
with blood or moisture. This adhesive-like action forms a strong, flexible barrier that seals
and stabilizes the wound.
• Initial approach to most external bleeding sources (lacerations, abrasions, puncture wounds)
should be to apply pressure using a gauze bandage and elevated the bleeding area if
possible. If the gauze bandage soaks through with blood, remove it and apply the HemCon®
Bandage as directed
• For suspected arterial bleeding (large spurts of blood following deep lacerations), attempt
direct pressure on a “pressure point”, i.e. pulsatile vessel proximal to the bleeding area if one
can be found. If this is not effective proceed with the use of the HemCon® Bandage
immediately. If the wound is causing potentially life threatening bleeding and the area is
accessible a tourniquet may be used in concert with the HemCon® Bandage.
• Apply cream colored side towards the wound.
• Apply directly to the lacerated vessel not to the surface of the wound. The bandage can be
cut into smaller pieces to fit into small wounds, or multiple bandages can be overlapped for
large injuries.
• Apply pressure for 2-5 minutes or until the bandage adheres
and bleeding stops. Use Kerlix or gauze to apply even pressure against wound.
• The bandage can be wrapped with gauze or a pressure dressing for transport.
• Do not let moisture from your hand come in contact with the bandage. The moisture could
cause the bandage to become sticky.
Removal
• To remove, simply irrigate the area with saline. There is no need for wound debridement.
Protocol Reference and How Supplied

• General Trauma Guidelines.
• 2” x 4” Bandage in a sterile foil sealed package.
27 MOM 3.0
lidocaine
(Xylocaine®)
Actions
Decreases ventricular automaticity and raises the ventricular fibrillation threshold.
Indications
• PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more.
• Perfusing ventricular tachycardia in setting of possible myocardial ischemia.
• Ventricular fibrillation and pulseless WCT (second line to amiodarone).
• Reduction of infusion discomfort in the conscious adult patient with whom IO vascular access
has been made in.
Contraindications
• Heart blocks:
o Second-degree, Mobitz II.
o Complete AV block.
o Stokes-Adams syndrome.
• Allergy to amide-type local anesthetics (not Novacaine [procaine]).

• CV: Rarely with toxic levels, causes hypotension, QRS widening, bradycardia, cardiac arrest.
• RESP:At toxic levels, respiratory depression or arrest.
Warnings
• If PVCs occur in conjunction with symptomatic sinus bradycardia, treat the bradycardia first.
• Metabolized in the liver. Note dosage for liver failure, low cardiac output, and patients >70
years of age.
Adult Dose
• PVCs >6/min.,R-on T phenomenon, multifocal, or in bursts of 2 or more or ventricular
tachycardia in setting of possible myocardial ischemia, 1.0 mg/kg IV/IO, repeat with 0.5
mg/kg every 5-10 minutes if necessary to a total of 3.0 mg/kg.
• Liver failure, low cardiac output, patient >70 y/o: give normal 1mg/kg IV/IO bolus dose, but
repeats are at 0.25 mg/kg.
• IO Infusion Preparation: 20 mg to 50 mg slowly administered prior to fluid bolus and/or
medication administration.
Protocol Reference
• Perfusing WCT Algorithm.
Pediatric Dose
1 mg/kg IV/IO bolus. Not allowed below 3 kg. Can be repeated twice.
How Supplied
100mg in 5ml (2%) prefilled syringe.
28 MOM 3.0
lorazepam
(Ativan®)
Actions
A benzodiazepine that depresses the limbic system, thalamus, and hypothalamus, resulting in
calming effects. Produces an amnesic effect, suppresses seizures, is an antiemetic, and is also a
muscle relaxant.
Indications
• Status epilepticus.
• Adjunct to cardiac pacing to alleviate anxiety in conscious patient.
• Post-intubation sedation.
• Sedation of TBI patient.
Contraindications
(Relative): Alcohol or other sedatives may exaggerate and prolong sedative effect.

• CNS: Confusion, muscular weakness, blurred vision, slurred speech, drowsiness.
• CV: Respiratory depression can occur (1%). Hypotension is very rare (0.1%).
Adult Dose
• IV/IO: 1-2 mg diluted with 1 ml sodium chloride, SIVP.
• Repeat up to additional 2 mg if seizure persists after 5 minutes.
• Additional dose of 2 mg can be given in the intubated patient if required due to agitation
(must be first verified that agitation is not due to correctable hypoxemia or complication of
tube placement). Total for the intubated patient not to exceed 4mg without physician contact.
• IM: 2 mg, may repeat x1 as above.
Protocol Reference
• Seizures.
• Traumatic Brain Injury.
Pediatric Dose
• IV/IO: 0.05-0.1 mg/kg diluted 50% with NS, SIVP, titrated to effect (max 2 mg).
o Repeat dose if seizure persists after 5 minutes.
• IM: 0.1 mg/kg, may repeat x1 as above.
How Supplied
2 mg in 1 ml preload.
29 MOM 3.0
magnesium sulfate
(MgS04)
Actions
The mechanisms of action in arrhythmias and eclampsia are not fully understood. They are
thought to be caused in part by magnesium’s effect on chronotropy and smooth muscle tone.
Indications
• Refractory VFib or pulseless WCT: last line.
• Torsade de pointes: first line if known hypomagnesemia or preexistent prolonged QT.
• Perfusing WCT.
• Eclampsia.
Contraindications
• Heart block.
• Hypermagnesemia.

CV: Heart block, flushing, bradycardia, hypotension.
Warnings
• May cause respiratory depression.
• MgS04 is hyperosmolar and must be diluted to prevent red blood cell damage.
Adult Dose
• IV/IO:
o Torsades, refractory VF/WCT: 1gm of MgS04 in 100 ml of NS (Pre-mix). Run drip at
full flow. May repeat x1 in 2 min.
o Eclampsia: 3 gms added to pre-mix (above) titrated to cessation or maximum of 4
gm.
• IM: painful; absorption may not be fast enough to effect arrhythmia. Contact medical control if
this route is necessary.
Protocol Reference
• Obstetrics: Pre-eclampsia and eclampsia.
• Perfusing WCT Algorithm.
Pediatric Dose
Not indicated.
How Supplied
• 1 gm in 100 ml pre-mix bag.
• 5 gm in 10 ml vial.
30 MOM 3.0
morphine sulfate
(MS)
Actions
A narcotic analgesic that depresses the central nervous system and suppresses pain by binding
at opioid receptors in the brain. Increases venous capacitance, decreases venous return, and
produces mild peripheral vasodilation. Also decreases myocardial oxygen demand.
Indications
• Pain from acute MI.
• Pain from other sources.
Contraindications
• Acute abdomen.
• Volume depletion or hypotension.
• Head trauma (GCS<13).
• Acute substance abuse.
• Acute asthma.
• History of hypersensitivity to opiates.
• Multiple trauma: excluding isolated extremity fractures.

• CNS:Euphoria, drowsiness, pupillary constriction, respiratory arrest.
• CV:Bradycardia, hypotension.
• GI:Decreases gastric motility; may cause nausea and vomiting.
• GU:Urinary retention.
• RESP:Bronchoconstriction, decreased cough reflex.
Warnings
• Detoxified by the liver.
• Potentiated by alcohol, antihistamines, barbiturates, phenothiazines, and other sedatives.
Adult Dose
• IV/IO: 2-5 mg IV, slowly. Repeat with small increments every 5 minutes until desired
response is achieved. Adult maximum 15 mg. Physician contact required for larger doses.
• IM: 5 mg-15 mg IM. Adult maximum 15 mg. Physician contact required for larger doses.
Protocol Reference
• Chest Pain.
• Pain Management.
• Transcutaneous pacing.
Pediatric Dose
0.1 mg/kg SIVP/IO. Can also be given IM or SC. Can be repeated once. Not given to patient
under 4 kg in weight.
How Supplied
10 mg in 1 ml preload.
31 MOM 3.0
naloxone
(Narcan®)
Actions
The mechanism of action is not fully understood. It does appear that Narcan antagonizes the
effects of opiates by competing at the same receptor sites. When given IV, the action is apparent
within two minutes. IM or SC administration is slightly less rapid.
Indications
• Respiratory depression secondary to narcotics or related drugs.
• Suspected acute opiate overdose.
Contraindications
• Hypersensitivity.
Warnings
• Caution in newborns of mothers who are known or suspected to be physically dependent on
opiates; may precipitate an acute abstinence syndrome.
• May precipitate acute narcotic withdrawal in opiate addicted patient. Symptoms could
include:
o CNS: Tremor, agitation, belligerence, pupillary dilation, seizures, increased tear
production, sweating.
o CV: Hypertension, hypotension, ventricular tachycardia, pulmonary edema,
ventricular fibrillation.
o GI: Nausea, vomiting.
• Duration of action of some narcotics may exceed that of Narcan; may need to be repeated.
• Not effective for respiratory depression caused by non-opioid drugs.
• Patient may become violent as level of consciousness increases.
• Large doses may be required in propoxyphene overdose (Darvon ®, Darvocet ®).
Adult Dose
IV, IO, IN, IM, SC, SL: 2 mg injection. May repeat in 2-3 minutes. If no response after 10 mg, then
condition probably not due to narcotic.
Note
If patient has a high likelihood a narcotic addiction (based upon physical stigmata, other
informants at scene, etc) and the situation is stable, consider using smaller doses of naloxone
(e.g., 0.4-0.8 mg) to stimulate respirations yet avoid abrupt withdrawal.
Protocol Reference
Unconscious patient unknown etiology.
Pediatric Dose
IV, IO, IM, SC: 0.1 mg/kg, max dose 2 mg. Can be repeated as needed if no improvement is
noted.
How Supplied
• 2 mg in 2 ml preload (1 mg/ml).
32 MOM 3.0
nitroglycerin
(Nitrolingual® spray)
Actions
A direct vasodilator that acts primarily on the venous system, although it also produces direct
coronary artery vasodilation. Causes a decrease in venous return that also decreases workload
on the heart and thus myocardial oxygen demand. Sublingual spray is preferred over tablets
because it is more reliably absorbed and bio-available.
Indications
• Ischemic chest pain.
• Pulmonary edema.
• Severe hypertension (not generally recommended; physician contact required).
Contraindications
• Increased intracranial pressure.
• SBP <90.
• Children under 12.
• Viagra® (sildenafil), Levitra® (vardenafil), or Cialis® (tadalafil) use in past 24 hours.

• CNS: Headache, dizziness, flushing, nausea, and vomiting.
• CV: Hypotension, reflex tachycardia.
Warnings
• Because of an easily developed tolerance, patients on chronic nitrate therapy may require
larger doses of nitroglycerin during acute anginal episodes.
• Light, air and moisture inactivate Nitro tablets. Must be kept in amber glass containers with
tight-fitting lids. Do not leave cotton in container. Once opened, nitroglycerine has a shelf life
of 3 months.
• Nitrospray has a shelf- life of 1 to 2 years.
• Alcohol will accentuate vasodilating and hypotensive effects.
Adult Dose
1 metered dose sublingually (0.4mg). May repeat PRN at 3-5 minutes intervals. Hold canister
upright. Do not shake. At the onset of attack, 1 or 2 metered doses to be sprayed into mouth.
Blood pressure and relief of pain limit dosing, otherwise no upper limit to number of doses.
Notes:
• Position the canister as close as possible, press button firmly to release spray onto or under
tongue. Advise patient not to inhale spray.
• Establish IV access before or concurrent with NTG administration.
Protocol Reference
• Chest pain.
• Hypertension.
Pediatric Dose
Not indicated.
How Supplied
0.4 mg (400 ug) per metered dose spray.
33 MOM 3.0
nitrous oxide
(Nitronox®, NO2)
Actions
A colorless gas that acts on the central nervous system. When mixed with 50% oxygen and
inhaled, it produces an effect similar to a mild intoxicant. The patient laughs and talks but does
not go to sleep. When inhaled, nitrous has a potent analgesic effect that dissipates within 2-5
minutes after stopping administration.
Indications
Moderate to severe pain, such as that caused by trauma, acute MI, burns, acute abdomen.
Contraindications
• Any altered state of consciousness, such as alcohol ingestion, drug OD.
• Trapped gas conditions: COPD patients, acute pulmonary pneumothorax, or suspected
intestinal blockage.
• Pregnancy.

CNS: Light-headedness, confusion, drowsiness, nausea, vomiting.
Warnings
Since nitrous is heavier than air, it may accumulate on floor of ambulance. During transports of
more than 15 minutes, it may affect ambulance personnel.
Adult Dose
Self-administered through inhalation. Also apply 02 cannula at 4 -6 LPM to maintain oxygen
therapy when Nitrous is not being administered.
Protocol Reference
• Chest Pain.
• Transcutaneous Pacing.
Pediatric Dose
Same as adult.
How Supplied
Blended mixture of 50% nitrous oxide and 50% oxygen. One oxygen and one nitrous oxide
cylinder fed into a regulator that maintains the appropriate concentration.
34 MOM 3.0
oxytocin
(Pitocin®)
Actions
Selectively affects uterine smooth muscle. Stimulates rhythmic contractions of the uterus,
increases the frequency of existing contractions, and raises the tone of uterine muscle.
Indications
• Uncontrolled postpartum hemorrhage.
Contraindications
• Not to be administered before delivery of both baby and placenta.
• Cardiovascular disease.

• CNS:Cerebral hemorrhage.
• CV: Hypertensive crises.
• OB:Uterine rupture.
• Neon:Fetal death.
Warnings
None other than those above.
Adult Dose
• IV/IO:
o Hemorrhage: add 40 units to 1 liter NS and titrate to a firm uterus. Use second IV line
for volume replacement.
• IM: 10 units.
Protocol Reference
• OB: Postpartum Hemorrhage.
Pediatric Dose
Not indicated.
How Supplied
10 units in 1 ml vial.
35 MOM 3.0
phenylephrine HCL
(Neo-synephrine nasal spray)
Actions
Topical vasoconstrictor.
Indications
• Epistaxis.
• Pretreatment for nasal endotracheal intubation.
Contraindications
• Known sensitivity to the product.
• Systolic BP>220 and/or Diastolic BP>110.
• Severe coronary artery disease.
• Use of MAOI medications within 14 days.
(tranylcypromine).

CV: Possible increase in blood pressure.
Warnings
None.
Adult Dose
• Sprays to nostril(s).
Protocol Reference
• Epistaxis.
• Nasal endotracheal intubation.
Pediatric Dose
• Not indicated below age 12. Adult dose for age>12.
How Supplied
• 15 ml spray bottle.
36 MOM 3.0
sodium bicarbonate
(NaHCO3)
Actions
An alkalizing agent used to buffer acids. Bicarbonate combines with excess acid (usually lactic
acid) present in the body to form a weak, volatile acid. This acid is broken down into C02 and
H20.
Indications
• Cardiac arrest, prolonged resuscitation.
• Hyperkalemia (second line to CaCl2 if cardiac arrest or bizarre/sinusoidal rhythm).
• Tricyclic overdose with cardiac manifestations.
Contraindications
None in these settings.

Metabolic alkalosis, hypernatremia, cerebral acidosis, sodium and H20 retention that can lead to
CHF.
Warnings
• May inactivate catecholamines given at the same time.
• Will precipitate if mixed with calcium chloride.
Adult dose (IV/IO)

• Cardiac arrest:
o 1 mEq/kg IVP. Repeat at 0.5 mEq/kg every 10 minutes, to a maximum of 250 mEq.
• Hyperkalemia:
o 50 mEq IVP. Limit to single dose in hyperkalemia.
• TCA OD:
o 50 mEq IVP. Limit to single dose in TCA OD.
Protocol Reference
• Hyperkalemia.
• Tricyclic OD.
Pediatric Dose
1 mEq/kg IV/IO. Can repeat twice at 0.5 mEq/kg q 10 minutes. (Dilute to half strength in neonatal
resuscitation).
How Supplied
50 mEq in 50 ml prefilled syringe.
37 MOM 3.0
succinylcholine
(Organon®, Anectine®)
Actions
A short acting neuromuscular blocking agent that acts at the motor endplate.
Indications
To establish an airway in a patient in imminent danger because of an uncontrolled airway or
ventilatory insufficiency, in whom other methods for securing the airway have been unsuccessful
or are obviously impractical or impossible.
Contraindications
• Upper airway obstruction.
• Probable inability to intubate afterward because of very unfavorable anatomical
characteristics, or face or neck trauma.
• History of malignant hyperthermia.
• Patient who is 24 hours post-spinal cord injury, severe burn or crush injury.
• Known hyperkalemia.
• Known myopathy (personal or family history of disease of muscles).

• CV: Bradycardia; may be severe in pediatrics.
• Neuro:Prolonged paralysis will occur in persons lacking pseudocholinesterase.
Warnings
• A second dose of succinylcholine is more likely to cause bradycardia.
• Succinylcholine must be administered per the Rapid Sequence Intubation Protocol.
Adult Dose
• IV/IO: 1.5 mg/kg IVP.
Protocol Reference
Rapid Sequence Intubation with Neuromuscular Blockade.
Pediatric Dose
IV/IO: 2 mg/kg (to 35 kg as per Peds SO), after pre-medication with atropine (.02 mg/kg IV).
How Supplied
200 mg in 10 ml.
38 MOM 3.0
tetracaine
(Alcaine®)
Actions
A local anesthetic for topical ophthalmologic use.
Indications
Short-term relief of pain caused by corneal injuries such as flash burns, corneal abrasions, and
chemical exposures.
Contraindications
• Penetrating eye injuries.
• Allergy to local anesthetics.

None.
Warnings
• Administer ONLY to patients who are being transported by AFD.
• Use only on patients who can open the eye spontaneously.
• Advise patient to avoid touching the eye while anesthetized.
• Do NOT give unused portion to patient.
Adult Dose
2 drops in affected eye. May repeat once.
Protocol Reference
• Eye injury.
Pediatric Dose
2 drops in affected eye. May repeat once.
How Supplied
15 ml squeeze bottle of 0.5% solution.
39 MOM 3.0
vasopressin
(Vasopressin®)
Actions
Vasopressin (arginine vasopressin, AVP; antidiuretic hormone, ADH) is a hormone released
from the posterior pituitary. AVP has two principle sites of action: kidney and blood vessels.
AVP increases water reabsorption by the kidneys. This is the antidiuretic effect of AVP. This
hormone also constricts arterial blood vessels, contributing to an increase in systemic
vascular resistance during heart failure, thus increasing coronary perfusion without the beta
adrenergic effects of epinephrine.
Indications
Pulseless cardiac arrests including Asystole, PEA, Ventricular Fibrillation, and Pulseless
Ventricular Tachycardia.
Contraindications
None in the above setting.

None in the above setting.
Warnings
None in the above settings.
Adult Dose
40 units IVP/IO. Not repeated.
Protocol Reference
Pulseless Arrest Algorithm.
Pediatric Dose
Not recommended.
How Supplied
20 units in 1 ml vial.
40 MOM 3.0
vecuronium bromide
(Norcuron®)
Actions
Non-depolarizing neuro-muscular blocking agent of intermediate duration. Competes with
cholinergic receptors at the motor endplate. Reversed by acetylcholinesterase inhibitors. Its onset
to effective paralysis is on the order of 2-3 minutes but decreases with increased dose. Its clinical
duration in normal doses is 25-40 to show signs of muscle activity and 45-65 minutes to recover
90% function.
Indications
Post cardiac arrest cooling.
Contraindications
• Known sensitivity to the agent.
• History of Myasthenia Gravis.

None in the above situation.
Warnings
• May have prolonged effect in patients with hepatic and renal disease.
• Malignant hyperthermia: insufficient data, considered possible.
• Not to be used for primary RSI.
Adult Dose
• IV/IO: Induction of paralysis (post-resuscitation cooling): 0.1mg/kg IVP.
• Contact Medical Control if maintenance dose required.
Protocol Reference
• Endotracheal intubation.
• Rapid sequence induction.
• Post cardiac arrest cooling.
How Supplied
10 ml vial with reconstitution fluid.
41 MOM 3.0
Section 2: Treatment Protocols
Introduction
General Guidelines for the Treatment and Transport of Patients
Critical Trauma
The goal in critical trauma is the shortest possible scene time. To the extent possible, after initial
scene assessment and necessary immobilization is performed, all other interventions are
performed in the MICU enroute to the hospital. Early notification or Trauma Alert to the receiving
facility is crucial.
Cardiac Arrest
The goal is to obtain a perfusing rhythm and then to transport.
All Patients
• The offer of transport will be extended to every patient.
• Transport offers will be extended in a neutral manner and without qualification.
• Any refusal of medical assistance, and/or transport, must be informed and competent.
• Informed and competent refusals of medical assistance, and/or AFD transport, must be
thoroughly documented in the PCR. Patient or guardian signatures must be obtained. In
cases where this is not possible, then the reason(s) for the absence of a signature must
be explained in the PCR.
• Patients will only be transported to a hospital.
• The safest method of transporting the adult patient is using the gurney with restraint
belts. The practice of transporting a patient on the bench seat or a jump seat is strongly
discouraged and acceptable only when multiple patients are being transported in one
ambulance (and the additional patients can be secured properly with existing safety
restraints).
• All patients transported on the gurney are to have the torso-to-waist restraints applied. If
the patient condition allows, the headrest is to be elevated. There are situations that
might require different techniques to restrain the patient safely to the gurney (e.g., a
patient who is morbidly obese or lying left lateral recumbent), and every means should be
utilized.
General Guidelines for All EMS Providers

Initial Size-up
1. Observe Body Substance Isolation precautions.
2. Ensure scene safety.
3. Determine number of patients.
4. Determine mechanism of injury/nature of illness.
5. Call for additional help or specialty resources as needed.
6. Consider need to provide spinal immobilization.
7. Form a general impression of the condition of the patient(s)
General Approach to the Patient

1. Establish patient responsiveness. If cervical spine trauma is suspected, manually
stabilize the spine.
2. Assess the patient’s airway for patency, protective reflexes and the possible need for
advance airway management. Look for signs of airway obstruction.
42 MOM 3.0
3. Open the airway as necessary using head tilt/chin lift if no spinal trauma is suspected, or
modified jaw thrust if spinal trauma is suspected.
4. Suction as necessary.
5. Consider placing an oropharyngeal or nasopharyngeal airway adjunct if the airway
cannot be maintained with positioning. EMTs may use Combitube or King Airway in a
patient with no gag reflex and immediate need for airway control.
6. Assess for signs of respiratory distress, failure, inadequate tidal volume or arrest. If
present, refer to the appropriate protocol for treatment options.
7. If breathing is adequate, place the patient in a position of comfort and administer high-
flow, 100%concentration oxygen as necessary. Use a partial nonrebreather mask.
8. Assess pulse/perfusion status.
9. Look for external hemorrhage if indicated and control using direct pressure or a pressure
dressing.
10. Immediately treat imminent life threatening problems as they are found during the initial
assessment.
11. Reassess the patient frequently.
EMT-I/ETT Patient Care Protocol

General
• Follow General Patient Care as listed above.
• Determine chief complaint and level of distress.
• Measure and record vital signs.
• Perform physical exam specific to chief complaint.
Medical Emergencies
• Code 99: Follow AED Protocol.
• Diabetic Emergencies: Suspected hypoglycemia: check blood sugar with Glucometer, if
blood sugar <80 and patient has symptoms of hypoglycemia but is alert, administer oral
glucose.
• Assist with patient’s nitroglycerin, metered dose inhaler, or epinephrine auto-injector per
State of Alaska regulations.
• Chest Pain: ASA per Standing Medication Order and Chest Pain Protocol.
• All other: Follow General Patient Care and Oxygen Therapy guidelines in this document.
Approved advanced airway is Combitube® or King Airway.
Trauma Emergencies
• Stabilize spine when indicated by mechanism of injury or signs and symptoms (See C-
Spine guidelines).
• Control external hemorrhage.
• Perform rapid head-to-toe exam.
• Follow General and Oxygen Therapy guidelines in this document.
• Approved advanced airway is Combitube® or King Airway.
Multi-victim/Mass Casualty Incident

Follow Start Protocol.
EMT-II Patient Care Protocol

General
Follow all guidelines per EMT-I/ETT Patient Care Protocol.
Additional Authorized Activities
43 MOM 3.0
An AFD EMT-II who has been authorized by the Medical Director may:
• Initiate peripheral IV therapy per IV Therapy Protocol.
• Initiate IO therapy in unconscious adult patients per EZ-IO protocol under the direct
supervision of a MICP.
• Administer D50W per Diabetic Emergencies Protocol and D50W Standing Medication
Order.
• Administer naloxone HCL (Narcan ®) per Standing Medication Order.
• Administer nebulized albuterol for bronchospasm per albuterol medication order when so
directed by an incoming MICP.
EMT-III Patient Care Protocol

General
Follow all guidelines per EMT-II Patient Care Protocol.
Additional Authorized Activities

An AFD EMT-III who has been authorized by the Medical Director may:
• Apply electrodes and monitor cardiac activity.
• Manually defibrillate ventricular fibrillation and pulseless ventricular tachycardia.
• Administer specific medications according to Treatment Protocols and Standing
Medication Orders when trained to those specific medications and under the direct
supervision of a state licensed and municipally certified MICP.
• Administer lidocaine per Pulseless Arrest Algorithm and lidocaine Standing Medication
Order.
• Administer atropine per Pulseless Arrest and Bradycardia Algorithms and atropine
Standing Medication Order.
• Administer epinephrine 1:10,000 per the Pulseless Arrest Algorithm and epinephrine
1:10,000 Standing Medication Order.
• Administer epinephrine 1:1000 per Anaphylaxis and Asthma Protocols and epinephrine
1:1000 Standing Medication Order.
• Administer morphine sulfate per Pain Management and Chest Pain Protocols and
morphine sulfate Standing Medication Order.
• Administer NTG for chest pain per Chest Pain Protocol and NTG Standing Medication
Order.
Scope of Practice for EMT-II and EMT-III

EMT-II and EMT-III providers are limited to the scopes of practice defined in the MOM and only
when supervised by an MICP or in direct communication with an incoming MICP.
Airway and Ventilation
Administration of Oxygen
Oxygen therapy
Oxygen will be administered as the paramedic and/or EMT/ETT deems appropriate according to
clinical signs and clinical situation. If pulse oximeter is used in addition to the clinical assessment,
the Sa02 should be >95%.
• COPD: a relatively small number of patients with this condition will react to supplemental
oxygen by slowing their respiratory rate and eventually becoming obtunded. These
patients have at baseline a compensated hypoxemia. This must be considered in all
COPD patients and 02 should not be used routinely in such patients unless they are
44 MOM 3.0
being treated for symptomatic hypoxemia. If a COPD patient is being treated for
hypoxemia, carefully titrate oxygen to improve the patient’s clinical status. Carefully
monitor these patients and if ventilatory drive is suppressed and the need for oxygen
persists, then augment with BVM or other measures as required.
Airway Protocol
General Airway and Oxygenation
1. Head tilt/chin lift maneuver if unconscious; jaw thrust if suspected cervical spine injury or
trauma.
2. Oropharyngeal or nasopharyngeal airway as indicated.
3. Suction as needed to maintain clear airway but limit each event to 15 seconds with re-
oxygenation between attempts.
4. Oxygen will be delivered as deemed necessary. Use appropriate 02 delivery device and
flow rate to achieve Sp02 of> 95%. If Sa02 not available, use clinical judgment for delivery
method and concentration.
• 2-6 liters by nasal cannula.
• 10-15 liters by non-rebreather mask.
• 15-25 liters by bag-valve mask (depends on oxygen resources).
Bag-Valve-Mask Ventilation (BVM)

Deliver breaths slowly over 1 second with a volume adequate to cause chest rise when ventilating
the apneic patient.
• Limit ventilations to 10 per minute in the adult cardiac arrest patient.
Endotracheal Intubation
Endotracheal intubation (oral or nasal) is recognized as the most direct and effective means of
securing and maintaining the airway. Orotracheal intubation is generally preferable, but the nasal
route allows for a definitive airway in persons who have a gag reflex (yet require an airway) or in
whom an oral approach is not possible.
Indications
• Unprotected airway with danger of aspiration.
• Need to support ventilation due to patient's inability to generate adequate tidal volumes.
• Apnea (relative indication).
• Inability to ventilate by other means.
• Occasionally as the only means of drug delivery.
Contraindications
• Orotracheal intubation: none if the proper indications are present.
• Nasotracheal intubation:
o Possible mid-face fracture.
o Nasal deformity or obstruction.
o Possibility of nasopharyngeal foreign body that could be blindly pushed into
airway.
o When there is any consideration of increased intracranial pressure.
Method - Orotracheal Intubation

1. One team member should oxygenate the patient with 100% 02.
2. If the patient is breathing spontaneously, DO NOT HYPERVENTILATE OR BVM
AUGMENT. If patient is apneic or ventilating inadequately, bag at appropriate rate.
45 MOM 3.0
3. Assemble intubation equipment: check tube cuff, have suction ready, have Endostat® or
other securing method ready.
4. Consider Eschmann Stylet for difficult airways.
5. Intubate.
6. Confirm placement in apneic patient with TubeChek®.
7. Apply capnography (if available).
8. Confirm placement in perfusing patient with VentiSure™ colormetric device (if no
capnography available).
9. Check breath sounds in both axillae and in the epigastrium, and check the tube’s
distance at the teeth.
10. ETT tube should be inflated until no air is heard to escape around the tube, or, to a
maximum of 10 ml of air in cuff.
11. Secure tube.
12. Intubation should be completed in no more than 2 attempts each by 2 providers
MAXIMUM in non-arrest patients. Move to alternative airway if unable to intubate.
Method - Nasotracheal Intubation

1. Check patient for the larger or more patent nare.
2. Instill Neo-synephrine: administer 3 squirts of 0.5% Neo-synephrine spray prior to
nasotracheal intubation when time and conditions permit.
3. Lubricate tube and/or nare and nasal passage well and insert the tube, advancing along the
slightly downward path of the nasal cavity.
4. Listen for the approach of the tube to the glottis. Advance tube on inhalation. Success is often
confirmed by a cough.
5. Check breath sounds, inflate cuff and secure tube.
Notes
• While CPR is being performed, it is expected personnel will set up for or try ETT
placement without interrupting compressions.
• In cardiac arrest, one attempt by one provider for ETT placement; if unsuccessful, move
on to Combitube.
• Do not delay initial defibrillations for intubation.
• Apply cricoid pressure when patient is being BVM ventilated (if personnel are available)
and release pressure only after cuff of endotracheal tube is inflated with position
confirmed!
• The patient should be oxygenated prior to placement attempts.
• ETT placement will be re-evaluated after each time patient is moved and
periodically throughout transport. This must be documented in the PCR.
• Secure the neck of intubated unresponsive patients with c-collar or other method to help
avoid displacement of the tube by unintended head movement.
• Measure pulse oximetry continuously. Pulse oximetry is a routine diagnostic tool used to
measure oxygen saturation and response to oxygen therapy. It is generally reliable but,
as always, clinical impression is the final determinant in whether to believe a given
reading.
• NGT may be placed in the intubated patient with distended abdomen as per Gastric
Intubation Protocol.
Combitube or King LT-DTM Airway

The Combitube®, Combitube®SA or King Airway will be used by MICPs or EMTs when
endotracheal intubation is not possible, technically difficult or when the Combitube® or King
Airway is considered the best method to safely expedite airway management in a critical patient’s
care.
46 MOM 3.0
Indications
• Unprotected airway with danger of aspiration.
• Need to support ventilation due to patient's inability to generate adequate tidal volumes.
• Apnea (relative indication).
• Inability to ventilate by other means.
• In trauma: may be used initially as the most expedient method. Must be used if
unsuccessful endotracheal intubation after two attempts maximum.
• General patient in need of airway intervention in which endotracheal intubation is
unsuccessful.
Contraindications
• Gag reflex present.
• Height less than 4 feet.
• Known or suspected esophageal disease.
• Caustic ingestion.
• Suspected foreign body in airway.
King Airway
The King Airway is a single lumen supraglottic airway device that occludes the esophagus and
oropharynx providing isolation of laryngopharynx for ventilation of the trachea. Intubation of the
trachea is nearly impossible and shouldn’t be considered an possibility as in the combitube. The
King Airway accepts the Eschmann stylet to aid in endotracheal intubation.
Placement and sizing:
Size Height Connector Color Inflation Volume

3 4-5 feet Yellow 45-60 ml
4 5 – 6 feet Red 60-80 ml
5 ≥ 6 feet Purple 70-90 ml
Method
Refer to training document for the Combitube® and Combitube®SA, and King LT-D.
Cricothyrotomy
Cricothyrotomy is a last resort intervention available to MICPs for unrelieved airway obstruction or
a patient emergently requiring an airway who cannot be intubated.
Indications
Absolute need for an airway with no other practical option.
Contraindications
None in this setting.
Method
Refer to document: Melker™ Cuffed Emergency Cricothyrotomy Catheter Set.
47 MOM 3.0
Eschmann Endotracheal Tube Introducer

(Portex Endotracheal Tube Introducer; Eschmann Stylet; Gum Bougie)
The introducer is a 15 French, 60 cm long semi-rigid, resin coated, braided polyester instrument
used as an adjunct to assist with oral endotracheal intubation. The first (distal) 2.5 cm is angled
35 degrees to facilitate placement within the trachea.
Indications
• Any oral endotracheal intubation attempt involving poor vocal cord visualization.
• Anatomic, traumatic, or pathologic conditions limiting laryngeal access.
Contraindications
Patients requiring endotracheal tubes smaller than 6.0 mm.
Precautions
When passed blindly, the introducer should not be forced.
Method
1. While this procedure can be performed by a single paramedic, preferably it requires two
personnel: the intubating paramedic and an assistant.
2. Lubricate introducer with water-soluble lubricant.
• Option: slide appropriately selected endotracheal tube over the introducer.
3. Perform laryngoscopy.
4. With the angled tip directed anteriorly, guide the introducer towards the epiglottis.
5. Advance the introducer posterior to the epiglottis and into the glottic opening.
• Cricoid pressure may facilitate correct placement and the introducer may be palpable
when the angled tip passes the cricoid cartilage.
6. Tracheal placement of the introducer is indicated by palpable “clicking” of the introducer
as the angled tip passes over tracheal rings.
• If the angled tip stops advancing, it has reached the carina.
• Failure to palpate “clicking” or to meet resistance after inserting nearly the full length
of the introducer indicates esophageal placement.
7. When the introducer is confirmed to be in the trachea, the intubating paramedic maintains
laryngoscopy and holds the introducer in position.
• If the angled tip has been placed at the carina, withdraw the tip approximately 2 cm
and hold in position.
8. The assistant advances the endotracheal tube along the stationary introducer, holding
the proximal tip as it is exposed.
9. With the intubating paramedic continuing laryngoscopy, the paramedic (or assistant) then
advances the endotracheal tube along the stationary introducer past the larynx.
10. If any difficulty in passing the endotracheal tube is encountered, rotate the tube 90
degrees counter-clockwise to orient the bevel of the tube posteriorly.
• The introducer may be allowed to rotate with the endotracheal tube but should not be
moved up or down the trachea.
11. Secure the endotracheal tube manually, remove the introducer, and verify tube
placement in the usual manner.
• Placement depth is approximately 20-21 cm at the teeth for adult females and 22-23
cm at the teeth for adult males.
12. Fully secure endotracheal tube with commercial restraint device.
Notes
• The Eschmann Endotracheal Tube Introducer is not a disposable, single-use device. If
undamaged, the introducer may be disinfected following standard procedures and reused
to a maximum of five times (manufacturer’s recommendation).
48 MOM 3.0
• If the introducer is stored in a curled or shaped condition at less than body temperature it
can develop cracks. The manufacturer recommends storage in its hard plastic sheath.
Gastric Intubation
Indications
Gastric decompression
Contraindications
• Ingestion of caustic substances.
• Nasogastric: not used if there is facial trauma or significant head trauma.
Method - Nasogastric Insertion

1. Select tube size appropriate to patient size and age.
2. Examine for the more patent nare.
3. Measure the tube against the patient to get a rough idea of the length of tube that will be
necessary to intubate the stomach.
4. Lubricate the tube with water-soluble lubricant.
5. Place the tube following the natural downward slope of the nose, trying to keep the tube
on the floor of the nasal cavity.
6. The tube should move easily, do not use excessive force.
7. When the tube appears to be in position, place a stethoscope over the stomach,
insufflate 20 ml of air with a syringe and auscultate for air in the stomach.
8. Place the tube to suction.
Method - Orogastric Insertion

1. Select tube size appropriate to patient size and age.
2. Measure the tube against the patient to get a rough idea of the length of tube that will be
necessary to intubate the stomach.
3. Lubricate the tube with water-soluble lubricant.
4. Insert the tube into the mouth.
5. The tube should move easily, do not use excessive force.
6. When the tube appears to be in position, place a stethoscope over the stomach,
insufflate 20 ml of air with a syringe and auscultate for air in the stomach.
7. Place the tube to suction.
Inspiratory Impedance Device

(ResQPOD® Circulatory Enhancer)
This device causes as brief impedance to inspiration and can lead to improved cardiac output in
low flow states.
Indications:
• For temporary increase in blood circulation in perfusing patients with persistent
hypotension and spontaneous ventilations supported by ETT/Combitube or BVM.
• PEA cardiac arrest or cardiac arrest with a mixture of “promising” rhythms (organized
rhythms intermixed with VF/VT/asystole) in which CPR is being performed.
Contraindications
• Known decompensated heart failure or CHF.
• Pulmonary hypertension or aortic stenosis.
• Flail chest.
• Chest pain.
• Patient with primary complaint of shortness of breath.
49 MOM 3.0
• It is currently not indicated for pediatric use (<12 yo, <80lb).
Method
1. Refer to appendix for graphics on use of device.
2. With facemask and BVM: apply ResQPOD between facemask and BVM. Provide
ventilations in customary manner
3. With ETT or Combitube: apply ResQPOD between airway device and BVM and ventilate
as per protocol.
4. Be sure that all pieces fit tightly
5. The device has a timing light that is activated by a switch on the upper face rim. This
light directs the timing for delivering 10 breaths per minute with each breath lasting 1.0
seconds, and will be used with cardiac arrest indications.
Note
This is a relatively new technology with which our experience is not yet mature. This device may
help improve blood pressure in the spontaneously ventilating patient. It also increases the work of
breathing by causing a brief inspiratory increase in effort. Careful monitoring may be required to
balance these two effects in any given patient. As an example, a patient who is mildly
hypotensive and with respiratory difficulties may WORSEN with this intervention. Careful
monitoring of the clinical effect will be necessary. As another example, a resuscitated cardiac
arrest patient with a good pulse who begins to have spontaneous ventilation should have the
device removed.
Rapid Sequence Intubation with Neuromuscular Blockade

Indications
To establish an airway in a patient in imminent danger because of an uncontrolled airway or
ventilatory insufficiency, in whom other methods for securing the airway have been unsuccessful
or are obviously impractical or impossible.
Contraindications
• Upper airway obstruction.
• Probable inability to intubate afterward because of very unfavorable anatomical
characteristics, or face or neck trauma.
• History of malignant hyperthermia.
• Patient who is 24 hours post-spinal cord injury, severe burn, or crush injury.
• Known hyperkalemia.
• Known myopathy (personal or family history of disease of muscles).
Note
If unable to intubate or use Combitube® or King Airway and succinylcholine is contraindicated,
proceed to cricothyrotomy.
Guidelines
• Prior to initiating RSI, reevaluate the patient for any obvious contraindications for
paralysis
• One paramedic and at least one other provider with advanced airway skills (approved by
the medical director for field intubations) will directly attend the airway during and
immediately after administration of the paralytic, until the following have been
successfully completed:
o Intubation.
o Confirmation of tube placement as per Airway Protocol.
o Re-confirmation of tube placement with a C02 monitor or other recommended
adjunct (mandatory).
o Tube is secured.
50 MOM 3.0
Procedure
1. Assemble personnel and equipment:
• 2 providers with airway skills.
• Intubation tools, check ETT cuff, suction.
• IV access with running IV.
• Check label and draw up succinylcholine 1.5 mg/kg and etomidate 0.3 mg/kg (if
indicated)
2. Preoxygenate patient with 100% oxygen from BVM. If patient is spontaneously ventilating
with adequate volume, DO NOT VENTILATE. If patient requires BVM ventilation, apply
cricoid pressure.
3. Give succinylcholine. If neuromuscular blockade is required in the conscious patient, use
etomidate 0.3 mg/kg SIVP for sedation prior to succinylcholine.
4. Proceed with intubation as per Airway Protocol.
5. Maintain cricoid pressure from time of paralysis until tube is inflated. Must be fully
prepared to ventilate and suction prior to administration, and to establish a surgical
airway if necessary.
6. For sedation of combativeness after successful intubation and end of paralytic action,
lorazepam 2 mg (may give up to 4 mg) SIVP.
Pediatric Guidelines
• Pre-medicate with atropine (0.02 mg/kg) before giving succinylcholine (see atropine
standing order).
Note
Consider restraints during paralysis, after securing the airway and initiating ventilation, especially
in restless head injury patients.
Cardiac
CPR
Available evidence shows that high quality, uninterrupted cardiac compressions are of great
importance to victims of cardiopulmonary arrest. Compressions using an external device
(Revivant® Autopulse) show promise as an adjunct in this setting. AFD personnel are directed to
institute CPR at the earliest possible moment and to limit all interruptions to continuous CPR.
Early, high-quality CPR in unwitnessed cardiac arrests is the most important early activity that
influences survival from a cardiac arrest.
• Compressions must be deep enough and fast enough to provide perfusion but also must
be minimally interrupted for the positive benefit to be realized.
• CPR now is to occur BEFORE any other activity except to confirm the presence of
cardiac arrest and the absence of airway obstruction.
• CPR will be done for 5 cycles of 30:2 compressions to ventilations ratio (about 2 minutes)
before the first pause for any procedure.
o PUSH HARD and PUSH FAST at a rate of 100 compressions/minute and release
completely.
o Ventilations are delivered over 1 second only; do not hyperventilate.
• While CPR is being performed it is expected that personnel will apply monitor pads, BVM
mask, attempt IV and a MICP will set up for or try intubation without interrupting
compressions.
• After an endotracheal tube or combitube has been successfully placed, continue CPR
compressions without pauses at a rate of 100/minute with synchronized ventilations.
51 MOM 3.0
• After this first complete CPR cycle, there will be a brief pulse check and a monitor rhythm
check.
o If the rhythm is VF/VT without pulse, one defibrillation will be done at maximum
output and compressions will be resumed WITHOUT pulse check and without
rhythm check for another 5 cycles of CPR.
• Medications may be administered during this period.
Chest Pain
The new era of fibrinolytics and emergency angioplasty requires that patients with signs and
symptoms consistent with acute myocardial infarction be transported as quickly as possible.
Indications
All patients with chest pain of possible cardiac origin. These orders may also be applied to
patients with symptoms that may represent an acute coronary syndrome including:
• Unexplained diaphoresis.
• Pain in a typical cardiac referral pattern.
• Indigestion in a suspicious clinical setting.
Guidelines
• ABC’s, Airway Protocol, Hypotension Protocol, ACLS Protocols as required.
• Oxygen, cardiac monitor, IV or IO.
• 12-Lead ECG Protocol with 12-Lead ECG performed within 5 minutes of first EMS
contact.
• “OPQRST” and history of current events.
• Be sure to ask about aspirin and Viagra, Levitra, Cialis usage.
• Physical exam focusing on LOC, signs of pulmonary edema.
Medications
• Nitroglycerin, per standing orders.
• Aspirin, 162 mg PO, per standing orders (do not re-administer if given within last 12h).
• Morphine, per standing orders.
• Nitrous oxide, per standing orders (may be helpful if morphine allergy or hypotension).
Management and Transport Considerations

• Patients that require an IV/IO or 12-Lead ECG should have those therapies initiated
ASAP after arrival and at the initial contact point whenever practical.
• Short scene times for patients with potential myocardial infarction are a priority, and
consideration shall be given to completing interventions on scene so as to comply with
provider transport safety guidelines while maintaining the shortest practical scene times.
• Transport code appropriate to the patient’s need.
• If patient is a potential acute MI, notify the hospital that you have a patient with chest pain
consistent with myocardial ischemia.
• If the patient presents with contiguous lead ST segment elevations, initiate STEMI Alert
(See Medical Operations section).
Note
• Treat chest pain aggressively.
• Pain will increase the patient’s ischemia.
52 MOM 3.0
Congestive Heart Failure and Acute Pulmonary Edema

The diagnosis of Congestive Heart Failure (CHF)/Acute Pulmonary Edema (APE) can be difficult
and is easily confused with COPD exacerbation as well as infectious causes of respiratory
distress. It is best made by considering medical history, risk factors, medications and physical
exam with particular attention paid to blood pressure.
Factors most associated with a dyspneic patient having CHF include:

• History of CHF.
• Exam showing Jugular Venous Distention (JVD).
• Atrial fibrillation on monitor.
• History of cardiac disease: coronary disease, valvular or MI.
• Hypertension.
• Orthopnea, Dypnea on Exertion (DOE) and Paroxysmal Nocturnal Dyspnea (PND).
• Blood pressure is typically quite high in APE.
• Peripheral edema may be present.
• Symmetric “moist” rales and pink frothy sputum.
Applies To
All non-pediatric patients with respiratory symptoms consistent with CHF/APE, including those
from various sources such as iatrogenic fluid overload or renal failure, as well as other more
typical causes.
Severity
• Asymptomatic: Dyspnea on exertion but no symptoms at rest.
• Mild: Mild dyspnea at rest despite 02 treatment. Able to speak in full sentences.
• Moderate: Moderate dyspnea. Sp02 < 93% on supplemental 02. Normal mental status.
• Severe: Severe dyspnea, ventilatory failure, hypoxia (Sp02 < 90% on 02). Typically with
high systolic BP. Altered consciousness. Difficulty speaking due to dyspnea.
Guidelines
• ABC’s, airway protocol, hypotension protocol, ACLS protocols as required.
• Refer to ACLS monograph for treatment pathways for ACS
• Oxygen, cardiac monitor, 12-lead-protocol, IV. EtC02 monitoring.
• ”OPQRST” and history of current events. Be sure to ask about aspirin usage. Physical
exam focusing on LOC, signs of pulmonary edema.
• Position the patient in high fowlers. Legs dependent off of the stretcher is often required.
• Nitroglycerin is the most effective, fasting acting agent and should be used first and with
a frequency based upon the patient’s severity and response.
• Captopril given sublingually is the second line drug following initial nitroglycerin therapy. It
effectively treats the afterload and makes the heart’s output more effective.
Drug Treatment
• Severe with cardiogenic shock (patient with evidence of “Severe APE” and with
hypotension MAP <75 and/or SBP<100)
o Dopamine 5 mcg/kg/min and titrate.
o Alternative: consider 250 cc normal saline bolus prior to or concurrent with
initiation of dopamine.
• Severe symptoms
o NTG 0.4 mg SL and repeat every 3 minutes with ultimate dosing determined by
clinical response and SBP.
o Captopril 25 mg SL after initial NTG if SBP maintained at >110.
o Albuterol 2.5 mg via nebulizer for wheezing.
o Furosemide 0.5 mg/kg SIVP if not currently on furosemide; give 1.0 mg/kg SIVP
if currently taking.
53 MOM 3.0
• Moderate symptoms
o Treatment modalities are the same as with severe but the intensity of dosing will
be less frequent. NTG is first line, captopril 25mg SL as above unless symptoms
completely resolve with nitroglycerin therapy.
• Mild symptoms
o Nitroglycerin SL.
o Captopril should be considered depending on symptoms and blood pressure.
Medications
1. Nitroglycerin SL, per standing orders.
2. Captopril SL, per standing orders.
3. Furosemide SIVP, per standing orders.
4. Aspirin PO, per standing orders.
• Note: When an MI is suspected.
Cardiac Monitoring
Initiate continuous monitoring in all of the following:
• First time seizures and patients over 30 y/o with seizures.
• Chest pain of all causes (including symptoms suggestive of Acute Coronary Syndrome).
• Unconscious patients of any etiology.
• Patients with a neurological deficiency of unknown etiology.
• Any blunt or penetrating chest trauma.
• Irregular or abnormal peripheral pulses.
• Syncope.
• Suspected overdoses*.
• Patients who are hemodynamically unstable.
• Asthmatic patients over 35 y/o receiving epinephrine.
*Measure QRS and QT intervals.
12-Lead ECG
Purpose
EMS-generated 12-lead ECG may hasten the restoration of vessel patency by speeding the
acquisition of that vital piece of data. In rhythm disturbances, the 12-lead gives additional
information as to the type of rhythm.
Method
EMS will obtain the 12-lead ECG for the indications listed below. In general, the leads will be
applied by EMT while the paramedic takes history, obtains IV access etc. The goal is to add no
more than one minute to scene time for ECG.
Indications
• Narrow Complex Tachycardia - Obtain pre-adenosine 12-lead. Try to get continuous strip
during conversion with adenosine (leads I, II and V2).
• Suspected AMI or acute coronary syndrome (symptoms may include indigestion, nausea,
arm or jaw pain).
• CHF, pulmonary edema, acute respiratory distress that might be due to cardiac etiology.
• Unexplained diaphoresis (age appropriate).
• Unexplained tachycardia or hypoxemia in a patient with known coronary artery disease.
• Unexplained syncope or near-syncope in non-pregnant patient greater than age 40.
54 MOM 3.0
Contraindications
Unstable patient.
Reporting
Paramedic will make a verbal report at earliest appropriate time alerting the receiving hospital of
the patient’s history, physical exam, response to therapy and ECG findings (rate, rhythm and
evidence of injury, ischemia or infarction). The paramedic shall report the findings by describing
ST elevation or depression, q-waves and other abnormalities in each lead in which the
abnormality is seen.
Notes
Try to get the 12-lead before giving nitroglycerin to patients with cardiac chest pain. If this will
result in significant delay (>60sec), treat symptoms prior to 12-lead acquisition.
Revivant AutoPulse Device

The Zoll AutoPulse is a battery operated, non-invasive mechanical CPR pump. The AutoPulse
device is currently in limited use in the Municipality of Anchorage EMS system.
Indications
• Non-traumatic cardiac arrest, to include PEA requiring CPR
• >age 18
• >90 lbs body weight
• <300 lbs body weight
Contraindications
• Cardiac arrest due to traumatic injury
• Confirmed Comfort One or DNR order
• Abdominal or chest surgery in previous 6 weeks
Usage guidelines
• The AutoPulse device automatically sizes to fit a 32 to 54 inch chest diameter.
• The AutoPulse shall be used in accordance with the manufacturer’s recommendations.
• At the current time, the AutoPulse device is to be incorporated as soon as feasible into
the treatment flow of a cardiac arrest without changing current Anchorage Fire
Department protocols.
• The Autopulse is equipped with rate settings of:
° 30:2
° Continuous
Transcutaneous Pacing
Indications
• Witnessed asystole.
• Consider as first approach to patient with anginal chest pain and symptomatic
bradycardia.
• Any of the following rhythms when they are symptomatic and either not responsive to
atropine or are causing major instability requiring use before atropine.
o Sinus or junctional bradycardia.
o Sinus pause.
o 2nd or 3rd degree AV block.
Current Settings
• Cardiac arrest or mentation that makes pain problems unlikely: 20mA increments.
55 MOM 3.0
• Mentation suggesting potential pain problems: 5mA increments with brief pauses for the
patient to adjust.
Procedure
• Pace @70/min. Increase current to electrical capture (consistent T waves) and check
perfusion signs carefully for mechanical response.
• Discontinue and retry later if perfusion clearly does not improve.
Pain control
• In conscious person pain control will most likely be paramount.
• Morphine and Lorazepam preferred if neither is contraindicated; use Nitronox if neither is
practical.
• Pain will increase the patient’s ischemia.
ACLS Algorithms and BLS Charts

Post Resuscitation Care
Indications
Care of patients who have the return of spontaneous circulation after a no-flow cardiac arrest.
Guidelines
• Work to optimize oxygenation and ventilation by reassessing these parameters frequently
by clinical exam and monitoring of physiologic parameters such as oxygen saturation and
capnography.
• Careful attention to the airway device regarding maintenance of its position and
suctioning as necessary. Remove Airway Impedance Device (ResQPod).
• Work to optimize blood pressure while paying careful attention to the possibility of
adversely increasing cardiac work. If there are no contraindications and rate is adequate,
try bolus of 250 ml saline and reevaluate. If evidence of “pump failure” then begin with
dopamine.
• Consider precipitating cause of arrest: Obtain 12 lead ECG if possible.
• Treat bradycardia-associated hypotension with atropine, fluids, dopamine, or
transcutaneous pacing as per the algorithm.
• Consider nasogastric tube.
• Consider aspirin therapy.
• If blood pressure adequate and ECG shows ST elevations, try to use NTG.
• Lorazepam titrate to a maximum of 4 mg SIVP for agitation or post-arrest seizure.
Contact Medical Control for repeat doses if needed for long transport.
• Maintain normothermic body temperature in trauma.
• For ROSC after medical cardiac arrest refer to Post Cardiac Arrest Cooling protocol.
Note
See Algorithm on page 59.
Post Cardiac Arrest Cooling

Adult patients who suffer a cardiac arrest of presumed cardiac etiology and who experience a
sustained return of spontaneous circulation (ROSC) have been shown to have improved
outcomes when the body temperature is cooled to approximately 32° Celsius (90° Fahrenheit).
56 MOM 3.0
Applies to:
1. All patients with cardiac arrest with sustained ROSC >5 minutes and who are:
a. Unable to follow verbal commands if intubated.
b. Unable to open eyes and verbalize if not intubated.
2. The patient must be intubated or have a competent rescue airway (Combitube® or King
Airway) in place prior to cooling.
Exclusions:
1. Age <18 years old.
2. Traumatic cardiac arrest.
3. “Significant” head trauma.
4. Actual or suspected significant hemorrhage (GI bleeding, AAA, for example).
5. Suspected hypothermia already present.
6. Frank pulmonary edema present.
Procedure:
1. If pulses are lost, stop cooling and treat underlying problem as per appropriate protocol.
2. Expose patient and apply ice packs to axilla and groin.
3. IV/IO: Pressure infuse 2.0 liters of chilled normal saline at maximum possible rate. The
goal is to achieve either prehospital or in ED a total of 30.0 ml/kg of cooled fluid.
4. Label saline bags with “Hypothermia Protocol” with date and time initiated.
5. Suppress shivering: Give vecuronium 0.1 mg/kg to maximum of 10.0 mg IVP/IO. If
SBP>100, give lorazepam 2.0 mg SIVP/IO.
6. Dopamine 10-20 mcg/kg/min IVPB/IO to MAP of 90-100 (see note below).
7. Monitor EtCO2 and maintain at 40 mmHg. Cooling and paralytic may decrease CO2
output.
Note:
Methods of Obtaining Mean Arterial Pressures (MAP)
• MAP = [(2 x diastolic)+systolic] / 3
• Check the MAP on the LP 12
o WARNING: The importance of confirming the BP with manual checks should be
emphasized. Studies have shown that NIBP readings are inaccurate in
hypotensive patients. Since the patients that need this MAP calculation to be
accurate are unstable, it will be that much more important. The MAP reading is
on the screen in lower left corner BP box as well as on the printout of vitals on
the code summary.
• Use this table:
Systolic Diastolic MAP

110 80 90
120 75-90 90-100
130 70-85 90-100
140 65-80 90-100
57 MOM 3.0
Post Resuscitation Care Algorithm
58 MOM 3.0
Pulseless Arrest Algorithm
59 MOM 3.0
Bradycardia Algorithm
Routine Medical Care
Monitor, IV, O2
Patient symptomatic?
Definition of symptomatic bradycardia:

HR<60 bpm with at least one of the following:
1. Chest pain.
2. Altered LOC.
3. Hypotension
4. Difficulty breathing.
YES NO
Atropine Monitor and transport.

0.5 mg IV q 3-5 min. to max. 3 mg.
OR
Transcutaneous pacing
Dopamine Fluid challenge if

5-20 μgm/kg/min. no signs of CHF.
60 MOM 3.0
NCT (Narrow Complex Tachycardia) Algorithm
Monitor, IV, O2
YES Patient stable? NO
Valsalva; 12-Lead ECG Etomidate 0.3 mg/kg SIVP

(Continual I, II, V2 If situation allows.
printout during adenosine
administration.)
Rhythm unchanged
Adenosine 6 mg Synchronized
RIVP cardioversion
100j
Rhythm unchanged
RIVP cardioversion
200j
Rhythm unchanged
RIVP cardioversion
300j
Option: If adenosine Rhythm unchanged
antagonists are present
(theophyllines), contact Synchronized
Physician for 3rd dose of cardioversion
18 mg (total 36 mg). 360j
Definition of unstable:
1. Chest pain
2. Altered LOC
3. Hypotension
4. Difficulty breathing
61 MOM 3.0
Perfusing WCT (Wide Complex Tachycardia) Algorithm

If Pt. becomes unstable,
move to appropriate point Monitor, IV, O2
on “unstable” arm of
algorithm.
Patient Stable?
YES NO
SVT WCT: WCT:

Uncertain Monomorphic Etomidate 0.3 mg/kg SIVP
Type VT If situation allows.
Rhythm unchanged
Ischemia: Lidocaine per protocol

Otherwise: Amiodarone, 150 mg in NS Sensing Adequate?
50 ml bag. YES NO
50 gtts/min. using 10 gtts/ml dripset.
Rhythm unchanged
Cardioversion Defibrillation
Adenosine WCT: 100j 200j
6 mg RIVP Polymorphic VT
Rhythm unchanged
Adenosine Cardioversion Defibrillation

12 mg RIVP Suspected or known 200j 300j
hypomagnesemia or
prolonged QT (Torsades)
Adenosine Cardioversion Defibrillation

12 mg RIVP* 300j 360j
Magnesium
1 gm IVPB
Cardioversion
360j
Definition of unstable: Chest Pain, altered LOC, hypotension, or difficulty breathing.

*If adenosine antagonists are present (Theophyllines), contact Physician for 3rd dose of 18 mg
(total 36 mg).
62 MOM 3.0
Automatic External Defibrillator (AED) Algorithm
63 MOM 3.0
Basic Life Support Summary Sheet
Procedure Adult Child (1-8 years) Infant (1 year or less)1

Head tilt/chin-lift Head-tilt/chin lift Head-tilt/chin-lift
Airway maneuver
Jaw thrust Jaw thrust Jaw thrust
Anchorage Fire Department
10-12 breaths/minute 12-20 breaths/minute 12-20 breaths/minute

Rescue breathing rate
Each breath 1 second Each breath 1 second Each breath 1 second
Pulse location Carotid Carotid Brachial
Lower half of the Lower half of the 1 fingerbreadth below

Hand position
sternum sternum intermammary line
64
2 hands stacked or 2 fingers, or both thumbs
Compression method 2 hands stacked
Heel of 1 Hand with hands around chest
About 1/3 to 1/2 the About 1/3 to 1/2 the depth
Compression depth 1½ to 2 inches
depth of the chest of the chest
Compression rate 100 per minute 100 per minute 100 per minute
30:2, single rescuer 30:2, single rescuer 30:2, single rescuer

CPR ratio
30:2, two rescuers2 15:2, two rescuers2 15:2, two rescuers2
Pause for ventilation?3 Yes Yes Yes

________________________________________
This summary sheet may be freely copied and distributed for educational purposes but not reprinted for sale.
2
Neonatal resuscitation should be performed at a rate of 120 compressions per minute and a ratio of 3:1.
3
If endotracheal tube or Combitube in place, continuous compressions at 100/min with ventilations synchronized.
4
A pause is not indicated in the intubated or combitubed patient.
MOM 3.0
Foreign Body Airway Obstruction (FBAO) Summary Sheet
Abdominal Chest Blind Visualize

Condition Backblows
Thrust Compressions1 Fingersweep Mouth
Conscious Repeated
No No No N/A
Anchorage Fire Department
Adult Thrusts
Unconscious
No CPR No No Yes
Adult
Conscious
65
Repeated
Child No No No N/A
Thrusts
(poor air exchange)
Unconscious
No CPR No No Yes
Child
Conscious Yes, 5 Yes, 5

Infant No No N/A
Alternate Alternate
(poor air exchange)
Unconscious
No CPR No No Yes
Infant
________________________________________
This summary sheet may be freely copied and distributed for educational purposes but not reprinted for sale.
1
Pregnancy obesity
MOM 3.0
Intravascular Access and Medication Administration
Intravenous (IV) Therapy

Indications
• Patients in shock or impending shock requiring volume replacement.
• Patients requiring IV drug therapy.
• Pediatric IV placement at paramedic discretion.
• Cardiac arrest.
o One attempt or one minute, then move to EZ-IO
Method
• Apply venous tourniquet.
• Prep site with alcohol.
• Perform venous catheterization with appropriate gauge IV.
• Appropriate disposal of sharps
• Chart site, gauge and number of attempts.
Guidelines
• Volume replacement: Start 1-2 large-bore IVs and infuse NS to maintain systolic blood
pressure above 90 (adult) or to maintain perfusion (improved mentation, color, or
capillary refill) in pediatric patients. * Monitor vital signs and lung sounds frequently.
• Medications: Infuse medications through a running IV.
• Saline lock: For stable patient with the potential to need IV access medication or fluid.
• Cardiac arrest: large-bore IV.
*Vigorous fluid therapy in patients with internal bleeding may lead to further hemorrhage. Aim for
SBP of 90 and signs of improved tissue perfusion (as above), then decrease rate. Refer to
Traumatic Brain Injury Protocol for additional pressures.
Adult Intraosseous (IO) Therapy

(EZ-IO)
Indications
• Adults > 40 kilograms in weight.
• An alternate to peripheral IV access in any seriously ill or injured patient in which IV
access cannot be established in timely manner.
• Cardiac arrest.
Contraindications
• Patients under 40 kilograms (with Adult needle).
• Fracture of tibia or femur.
• Previous orthopedic procedures (ie. knee replacement).
• Infection at insertion site.
• Inability to locate landmarks.
• Excessive tissue at insertion site.
• Previous attempts at IO insertion in same bone.
Considerations
• Any medication, fluid, or blood products that can be given intravenously can be given via
IO.
• Due to anatomy of IO space flow rates may be slower than those achieved with IV
catheters. Use of initial 10.0 ml NS bolus and continued use of a pressure bag may help.
66 MOM 3.0
• Insertion of EZ-IO in conscious patients causes mild to moderate discomfort and is

usually no more painful than a large bore IV.
• IO infusion may cause severe discomfort for conscious patients.
o Adults: Consider slow administration of 20mg to 50mg of 2% Lidocaine prior to
IO bolus or infusion.
o Note: This is the same Lidocaine preparation as used in cardiac patients.
• The needle can remain in place for up to 24 hours.
Method
1. Place patient into supine position.
2. Identify and locate bony landmarks:
a. The site of choice is the proximal tibia, just medial to the tibial tuberosity, on the
flat portion of the proximal tibia (2 finger widths below the patella and 1 finger
width medial).
b. Alternative site:
i. Distal tibia. Locate the insertion site 2 fingerbreadths proximal to the
medial maleous.
c. Alternative site:
i. Humeral head: Place patient’s hand on abdomen. The humeral head
insertion site is found slightly anterior to the arms lateral midline on the
greater tubercule of the humeral head.
3. Prep site with betadine or alcohol or chlorhexidine 4% (preferred).
4. Load the Adult needle onto driver.
5. Stabilize leg near (not under) the insertion site.
6. Press needle against the site at a 90 degree angle and operate the driver using firm,
gentle pressure.
7. Stop when the needle flange touches the skin or a sudden decrease in resistance is felt.
The black horizontal line on the shaft of the needle should be visible above the level of
the skin surface prior to activation of the IO driver to assure adequate needle length to
reach the marrow space.
8. Remove stylet and dispose in sharps container.
9. Do not aspirate bone marrow (may cause obstruction in needle).
10. Connect primed IV extension.
11. Consider use of Lidocaine for conscious patients unless contraindicated.
12. Flush or bolus EZ-IO catheter rapidly with 10.0 ml of normal saline.
13. Place a pressure bag on solution being infused when applicable.
14. Dress site, secure tubing and apply wristband.
15. Monitor EZ-IO site.
Medication Administration
Route
In cardiac arrest or other critical resuscitation, IV is the preferred route when available. Give a 20
ml flush after each IV injection. Use IO when IV is not available. IO doses are equivalent to IV.
Parental administration definitions
Route Method
IN Intra-nasal using mucosal administration device
IM Intra-muscular using approved technique.
IO Intraosseous.
IVD IV drip.
IVP IV push (bolus).
IVPB IV piggy-back
PO Per Os, Orally.
67 MOM 3.0
Rapid IV bolus Specific attention to rapid push and immediate follow up flush.
RIVP Rapid IV push.
SC Subcutaneous.
SIVP Slow IV push, over 1-2 minutes unless specified otherwise.
SL Sublingual.
Endotracheal administration of medications has been shown to be ineffective and should no

longer be used. The only exception is 1:1000 Epinephrine in pediatric resuscitation, and then
only if an IV/IO is unobtainable.
Definitions – Restricted Situations

• Contraindication - the drug cannot be given without physician contact. Deviation without
contact requires immediate Special Medical Report (FD-1). Note: all medications are
understood to be contraindicated when the patient has a known sensitivity or allergy.
• Relative contraindication - the drug is not normally recommended; physician contact
preferred.
Note
Deviation in a restricted situation requires:
• Thorough charting of circumstances that support the decision.
• Notification and explanation to the receiving physician upon hospital arrival.
• FD-1 to be completed and submitted to EMS Battalion Chief and to Medical Director for
review.
General Medical
Anaphylaxis
Anaphylaxis is a severe, generalized allergic reaction. By its nature, anaphylaxis is potentially
life-threatening and involves more than one of the body’s systems. Anaphylaxis is triggered by
the immune system which produces IgE (Immunoglobulin E- an anti body class produced in
excess during allergic reaction) as a response to an allergen. IgE then attaches itself to the
surface of Mast cells. Anaphylaxis occurs when a person is exposed to a trigger substance, to
which they have already become sensitized. Minute amounts of allergens may cause a life-
threatening anaphylactic reaction. Anaphylaxis may occur after ingestion, skin contact, injection
of an allergen or, in rare cases, inhalation.
Anaphylactic shock, the most severe type of anaphylaxis, occurs when an allergic response
triggers a quick release from mast cells of large quantities of immunological mediators
(histamines, prostaglandens, leukotrienes ) leading to systemic vasodilation (associated with a
sudden drop in blood pressure) and edema of bronchial mucosa (resulting in bronchoconstriction
and difficulty breathing). Anaphylactic shock requires agents to support vascular tone
(epinephrine, IV fluids and in severe cases dopamine), bronchodilation (epi, albuterol) and
membrane stabilizers (steroids) as well as antihistamines (diphenhydramine.) Anaphylactic
shock can lead to death in a matter of minutes if left untreated.
Reactions usually begin within minutes of exposure, but may be delayed. Sometimes symptoms
will improve initially, only to recur or progress a few hours later – this is known as biphasic
anaphylaxis. Symptoms of anaphylaxis commonly include those in the skin such as itch, hives or
urticaria, swelling or angioedema and flushing. Respiratory symptoms might include wheeze,
cough, shortness of breath and chest tightness, throat tightness, swelling in the throat, or change
in voice. At times eyes itch and the nose will become congested. Rapid heart rate may occur and
low blood pressure may cause dizziness. Nausea, vomiting and abdominal cramping indicate
68 MOM 3.0
involvement of the gastrointestinal tract. Symptoms may start mildly and rapidly progress to
severe. Consider what may be causing the reaction and remove it from the patient or the patient
from exposure, if possible.
SC/IM Epinephrine is the medication of choice for first line treatment of anaphylaxis regardless of
severity. Early and aggressive use of Epi in this setting leads to improved patient outcomes and
reduces the chance for the patient to progress to anaphylactic shock.
Note; EMT I can assist with the patient’s EpiPen or EpiPen Jr Autoinjector.
Early Onset/Stable Reaction

1. Airway Protocol. *
2. Cardiac Monitoring Protocol.
3. Epinephrine: 1:1000 SC/IM (unless contraindicated)
• Adult: 0.3-0.5 mg SC/IM may repeat q10 as needed.
• Ped: 0.01 mg/kg SC may repeat q10 as needed.
4. IV Protocol.
5. Diphenhydramine (Benadryl):
• Adult: 25 mg IV.
• Ped: 1 mg/kg to a maximum 25 mg/dose.
Moderate to severe anaphylaxis- includes wheezing

3. Epinephrine**: 1:1000 SC/IM (unless contraindicated)
• Adult: 0.3-0.5 mg SC/IM may repeat q10 as needed.
• Ped: 0.01 mg/kg SC may repeat q10 as needed.
4. IV Protocol.
• Adult: 25- 50 mg IV/IO.
• Ped: 1 mg/kg (give IM if no IV available) to a maximum 50 mg/dose.
6. Albuterol: Nebulize per albuterol standing order if wheezing persists post epinephrine
administration.
**Be prepared to move quickly to IV/IO epinephrine as per anaphylactic shock protocol if
patient’s symptoms progress .
Anaphylactic shock
2. IV Protocol
4. Epinephrine: 1:100,000 IV/IO.
• Give as a slow push from a 10ml syringe and titrate to symptoms. No dose limits in
this setting if heart rate remains stable with no ectopy.
• Ped administration same as adult.
• Adult: 50 mg IV/IO.
• Ped: 1 mg/kg to a maximum 50 mg/dose.
6. Albuterol: Nebulize per albuterol standing order if wheezing persists post epinephrine
administration.
* Be prepared to proceed directly to cricothyrotomy due to the potential for massive

laryngeal edema in the setting of anaphylaxis / anaphylactic shock.
69 MOM 3.0
Asthma, Wheezing, COPD

Asthma, also referred to as reactive airway disease, and Chronic Obstructive Pulmonary Disease,
are conditions of obstructed outward airflow. These patients require substantial expiratory time in
their ventilatory cycle. If these patients require BVM or intubation with assisted breathing, it is
crucial to give sufficient time for the expiratory phase. They also require small tidal volumes,
delivered slowly. Neglecting this technique will result in a patient that is tight and “can’t be
bagged.”
Indications
All patient being treated for known or presumed asthma (reactive airway disease), wheezing,or
chronic obstructive pulmonary disease.
Guidelines
1. Airway Protocol.
2. Supplemental oxygen by the method yielding the highest usable 02 delivery tolerated by
the patient.
3. Cardiac Monitoring Protocol if patient:
• Is in moderate to severe respiratory distress.
• Has prior cardiac history.
• Is >50 years old.
• Patients >35 years old receiving epinephrine.
Mild Distress
1. Albuterol inhaler, 3 breaths; Note: EMT-I may assist with patient’s own inhaler/nebulizer.
2. Nebulized albuterol, 2.5 mg at 6-8 lpm.
Moderate Distress:
Nebulized albuterol, 5 mg at 6-8 lpm, may repeat once.
Severe Distress:
1. Nebulized albuterol, 5 mg at 6-8 lpm.
• Note: Continuous administration.
2. Epi 1:1000: 0.3-0.5mg SC.
• Note: May repeat q15 min. x3.
• Physician contact required for age >55.
3. Pediatric: Epi 1:1000: 0.01 mg/kg SC; max.0.3 mg/dose.
• Note: May repeat q15 min. x3.
• Nebulized albuterol, 5 mg at 6-8 lpm, blow by into face, PRN, in transport.
Note
Epinephrine is not indicated in the patient with COPD.
Oxygen administration is indicated for all symptomatic, hypoxemic patients. Those with severe
COPD and CO2 retention may be very sensitive to 02; high concentrations may cause further C02
retention. Nevertheless, if these patients are having severe respiratory distress, they should be
treated with 02 and monitored carefully for changes in mental status. As they improve, the 02
should be titrated down to the lowest comfortable level. Assist ventilations if respiratory distress
does not improve and level of consciousness deteriorates.
If a COPD patient is being treated for hypoxemia, carefully titrate oxygen to improve the patient¹s
clinical status. If available, apply capnography and monitor C02 level. If it begins to increase,
70 MOM 3.0
consider decreasing oxygen concentration. If ventilatory drive is suppressed and the need for
oxygen persists, then augment with BVM or other measures as required.
All patients treated for asthma or COPD by AFD must be transported to a receiving facility.
Carbon Monoxide (CO) Poisoning

Carbon Monoxide is an odorless, colorless, tasteless toxic gas resulting from incomplete
combustion. Common sources of carbon monoxide include motor vehicles, structure and wild-
land fires, gas powered machines operating in closed spaces, improperly functioning heaters or
furnaces and industrial sites. Certain solvents can also cause CO poisoning.
Carbon monoxide poisoning is often misdiagnosed as the flu, gastroenteritis, or psychiatric or

other disorders and is the single leading cause of poisoning mortality in the United States.
Headache is the most common symptom of CO poisoning. Other common symptoms include
fatigue, dizziness, nausea and vomiting. More severe exposures can cause confusion, shortness
of breath, and fainting. In severe cases, cardiac arrhythmias, hypotension, seizures, coma, and
death may occur. Untreated carbon monoxide poisoning may result in short and long-term health
consequences.
Assessment
• Based on clinical presentation, environmental factors, clusters of patients, and/or a high
index of suspicion.
• Do not rely on any machine reading over clinical suspicion. Transport to an emergency
department if clinical suspicion of symptomatic CO exposure exists.
• Oximetry does not help in pure CO cases since the hemoglobin is typically fully
saturated. CO-oximetry will non-invasively measure SpCO percentage ±3%.
Treatment
• Airway, Oxygen, IV, and ECG Protocols as appropriate.
• All potential victims of CO poisoning should be placed on NRB 02 with tight fitting mask.
Measure SpCO.
• SpCO 0-3%-no further evaluation of SpCO needed if low index of suspicion for CO
exposure.
• SpCO > 3% and nonsmoker: provide O2 and any supportive measures and transfer to
emergency department for further evaluation.
o If the patient is a smoker some judgement issues come into play. If the patient is
completely asymptomatic and the index of suspicion for significant exposure is
low (based upon e.g. duration of exposure, status of others in the structure, etc)
no further evaluation may be required up to a SpCO of 10% in a 2 pack/day
smoker (rough rule : up to 5% CO /pack of cigarettes/day).
o Always transport if there is any uncertainty.
Combative Patient
Indications
All violent and combative patients thought to be a risk to themselves or AFD personnel during
transport. The usual etiology of this behavior would be secondary to cocaine or
methamphetamine use, but may be secondary to neuro-psychiatric disorders or other ingestions.
It is important to exclude hypoglycemia, hypovolemia, hypoxia, or head injury as the cause of the
behavior.
Guidelines
• Protect yourself first, and then protect the patient from injury.
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• Be sure that you have the right kind (e.g. law enforcement) and number of personnel to
handle the problem.
• Always leave yourself, and the patient, escape routes.
• Obtain vital signs, if possible.
Medical Support
• Maintain ABC’s.
• Monitor vital signs, take history, and do physical assessment if possible.
Optional treatment modalities

• IV at a TKO rate.
• Obtain glucometer reading if possible. If behavior is likely due to hypoglycemia (history or
clinical) treat as per Diabetic Emergencies Protocol.
• Restraints may be needed for patient and/or medical staff protection.
• Consider Droperidol 1.25-5.0 mg IM or 1-2mg IV. Extrapyramidal reactions may be
treated withDiphenhydramine.
• For the intubated combative patient, refer to and utilize the Rapid Sequence Intubation
Protocol.
Transport
• Maintain ABC’s (this may include physical restraints in intubated and combative patients).
• Monitor vital signs.
• Bring samples of drugs, plants or other causative agents.
• Patient management may interrupt radio communication.
• PROTECT PATIENT AND PERSONNEL FROM INJURY.
Diabetic Emergencies
Adult Guidelines
1. Provide general supportive care as required by patient’s status.
2. Check blood glucose with Glucometer.
3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral
glucose and monitor for improvement.
4. If patient has a significantly altered level of consciousness and blood glucose is <60,
administer D50W: 25 gm IV. A running IV line is required.
5. If unable to establish IV, give glucagon: 1 mg (1 unit) SC/IM.
6. If patient does not improve, repeat glucometer and may repeat D50 x1. Re-evaluate and
consider other etiologies.
7. All hypoglycemic patients taking an oral hypoglycemic must be transported and all others
should be strongly encouraged to allow transport.
Pediatric Guidelines
1. Provide general supportive care as required by patient status. Septic neonates and
young infants may become hypoglycemic with serious infections.
2. Check blood glucose with Glucometer.
3. If glucose <80 and patient has symptoms of hypoglycemia but is alert, administer oral
glucose and monitor for improvement.
4. If patient has a significantly altered level of consciousness and glucose is <60:
a. Wt < 25kg: administer D25 IV or IO per Pediatric Weight Pages.
b. Wt ≥ 25kg give as D50W per Pediatric Weight Pages.
5. If unable to establish IV, give glucagon 1 mg (1 unit) SC/IM if >20 kg; if less than 20 kg
then use .05 mg/kg.*
6. If patient does not improve, repeat Glucometer and may repeat D50W x1.
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*In neonates and infants, hypoglycemia may result from depletion of available liver glycogen due
to physiological stress. Since glucagon uses glycogen as the energy source, it is less likely to be
effective in this setting.
Blood Glucose Determination

Indications
• Before and after D50 administration, when possible, to evaluate response to therapy.
• Suspected abnormal blood sugar values: diabetes, possible hypoglycemia.
• Unconsciousness of unknown etiology.
• Status seizures.
• Symptoms/signs suggestive of CVA.
Method
Glucometer.
Epistaxis
Epistaxis is a common problem and may arise spontaneously or from trauma. Although the lay
public strongly correlates elevated blood pressure with epistaxis, scientific evidence is lacking.
There are two basic types of epistaxis: those that arise from the anterior nasal cavity and those
that arise from the posterior. Anterior bleeding is usually controlled with direct pressure or
pharmacological agents. Posterior bleeding is generally incompressible in the prehospital setting
and is often the result of significant arterial bleeding. Bleeding which does not respond to therapy
for anterior epistaxis should be assumed to be of posterior origin. Significant nasal arterial
bleeding in the elderly should be considered to likely be of posterior origin unless an anterior
bleed is visualized.
Procedure - Known or Presumed Posterior Bleeding

1. IV access.
2. Trial of compression of nares.
3. Trial of rolled 2x2 gauze firmly placed beneath upper lip(should resemble the size and
shape of cigarette filter) in the midline between lip and gum, with pressure then applied in
a direction toward the nasal spine(either with pressure applied from the skin surface of
the upper lip or directly on the gauze).
4. 3 squirts of neosynephrine to each nare.
5. Positioning to allow blood to be expectorated by patient or suctioned by EMS.
6. Airway control if necessary.
Procedure - Anterior Bleeding

1. If no current active bleeding, transport without further intervention.
2. Compression of nasal alae. This should include the entire cartilaginous area distal to
nasal bone.
3. If bleeding persists: see 3 above.
4. If bleeding persists: have patient gently blow nose to try to evacuate all clot and use 3
squirts of neosynephrine to affected side.
Hyperkalemia
Severe elevations of potassium cause progressive derangement of cardiac conduction. This
eventually leads to VTach or VFib, often preceded by a sinusoidal ECG pattern.
The prehospital provider will rarely have sufficient information to make this diagnosis since it
generally requires lab confirmation. It should be strongly suspected in a dialysis-dependent renal
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failure patient who demonstrates a sinusoidal cardiac rhythm, suffers cardiac arrest after missing
a dialysis session, or is otherwise known to be hyperkalemic. Tall, peaked T waves in multiple
leads are also suggestive, and often diagnostic in a patient who is known to be at risk for
hyperkalemia.
Indications
Unstable patient who is at risk for hyperkalemia.
Guidelines
1. Airway Protocol.
2. IV Protocol.
4. Administer calcium chloride, 1 gm (10 ml) SIVP.
5. Administer sodium bicarbonate, 50 mEq IVP.
Note
Do not co-administer these agents because precipitation will occur.
Hypertension
Severe hypertension requiring pre-hospital treatment is quite rare. Treatment is necessary only if
the hypertension clearly is causing a clinical condition to evolve or if there is documented end-
organ damage due to the hypertension (difficult to establish pre-hospital). The main examples of
this are intracranial hemorrhage, myocardial ischemia, or renal failure associated with severe
elevations of blood pressure (systolic >240,diastolic >140). This is a largely unstudied area. The
danger in pre-hospital treatment is that an agent may cause a precipitous change in blood
pressure that creates a new, and potentially worse, problem.
Guidelines
1. Treat the underlying condition if it may be causing the elevated BP.
2. Pain: Pain Protocol.
3. Anxiety: Verbal calming techniques and reassurance.
4. Pulmonary edema: CHF and APE Protocol.
5. NTG: not generally recommended; physician contact required.
6. Captopril: at physician request only.
7. Furosemide: at physician request only.
Hypotension
Patients who present with symptomatic hypotension should be categorized as to their probable
intravascular volume status as well as the presumed mechanism for the hypotension (if known or
presumed). Therapy should then be directed accordingly.
Indications
Symptomatic hypotension unrelated to trauma.
Guidelines
• Consider volume status: Is patient “dry” (hypovolemic), normally hydrated(euvolemic), or
“wet” (hypervolemic).
a. If the patient is hypovolemic: use repeat boluses of normal saline titrated
against clinical exam.Potential situations: gastrointestinal illness, dehydration
of other causes.
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b. Is the patient euvolemic? May need volume and dopamine.Potential causes:

septic shock, neurogenic shock, anaphylactic shock.
c. Is the patient hypervolemic? Use dopamine. This situation is generally
cardiogenic shock.
Pain Management
Many of our patients experience acutely painful conditions. We can help many of them with
medications or other techniques. In general, we must balance our wish to ease their pain with the
possibility of complicating their care.
Pediatric patients experience pain that is as real as in older persons and should be offered pain
control when appropriate.
General Guidelines
• A calm and supportive provider will help the injured person deal with the anxiety
associated with an injury. Conversation used to distract from the situation is helpful.
• Fractures and sprains are generally more comfortable if splinted and iced. This is
especially true for femur fractures that can be traction splinted.
Documentation
• Document by means of the FACES© Pain Rating Scale the patient’s pain level at the
onset of EMS care.
o The Pain Rating Scale is found within the Appendix of Section 2: Treatment
Protocols.
• Document any change in that level after EMS intervention or at termination of EMS care.
Medical Therapy
Patients with no contraindications who are experiencing moderate to severe pain should be
offered pain relief.
Absolute contraindications
• Allergy to proposed pain agent.
• Hypotension.
• Acute multi-system trauma with unstable vital signs.
• Penetrating eye injury (tetracaine).
• Significant impairment due to alcohol or other intoxicants.
Relative contraindications
• Pregnancy (N02).
• Pneumothorax (N02).
• Bowel obstruction (N02).
Therapies
• Morphine sulfate, per standing orders. Note: See diphenhydramine regarding
hypotension.
• Fentanyl, preferred for situations where short action desired e.g. abdominal pain, head
injury, multiple trauma or if patient has morphine allergy.
• Nitrous oxide (NO2), per standing orders.
• Tetracaine, per standing orders.
Note
• All patients given analgesics by AFD shall be transported to a receiving facility.
• The patient must be aware of and agree to this before receiving therapy.
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Seizures, Status Epilepticus and Postictal States

Seizures are generally of short duration and, if self-limited, require no drug therapy in the field.
Seizures that are not self-limited, or that last longer than a few minutes, do require drug therapy.
Always consider possible etiologies, including hypoglycemia, hypoxemia, toxic ingestion, trauma,
CNS infections, and subarachnoid hemorrhage.
Observe the type of seizure that is occurring. If it is a motor seizure, observe whether it is general
or focal. If focal, communicate this to the receiving physician and record it on the PCR.
Adult Guideline
• Control all further seizure activity with lorazepam 1-2 mg repeated in 5 minutes if
necessary.
• Apply supplemental oxygen by NRB.
• Oxygen may be discontinued if patient returns to normal mentation and has no more
indication for oxygen.
• If further doses are required, physician contact required.
Pediatric Guideline
• Attention to ABCs and general supportive care.
• Lorazepam 0.1 mg/kg SIVP. May give lorazepam IM 0.1 mg/kg.
• Begin cooling if febrile.
Note
Transport at the level appropriate to patient’s status.
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Seizure Algorithm
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Stroke (CVA)
A stroke is a focal neurological change that occurs as a result of lack of blood flow to the brain.
This is typically the result of a clot in a blood vessel in or near the brain or from a bleeding blood
vessel. EMS treatment is supportive emphasizing protection against secondary insults such as
hypoxemia. Although blood pressure may be elevated in these patients, there is rarely (if ever) an
indication for rapid blood pressure lowering in the field. Recent advances have lead to an
opportunity to use clot-busting drugs in a select group of patients who are suffering an acute
stroke. Interventions must be initiated within 3 hours of onset of symptoms so EMS time can be
very critical.
Guidelines
1. Airway Protocol. Attention to need for suctioning.
2. Apply O2.
3. Cardiac monitor.
4. IV saline lock.
5. If evidence of increased intracranial pressure, elevate head 15 degrees.
6. Perform 30 Second Stroke Exam. A positive on any of the three measures suggests
stroke:
• Test upper extremity strength: have the patient close his/her eyes and extend both
arms. Ask him/her to maintain this for 10 seconds. Downward drift with one (but not
both) indicates unilateral weakness.
• Test facial strength: have the patient smile. If this is equivocal, have the patient blow
up both cheeks with air and then gently tap on either cheek to see if air is released. A
facial droop with smiling or inability to keep air in only one side of the face indicates
facial weakness.
• Test speech: have the patient repeat a saying such as “the sun shines on the
fearless in Fairbanks”. Inability to repeat this due to lack of articulation or due to not
being able to form the words is a positive finding.
7. If a Stroke Exam is positive and onset is within 3 hours, notify ED ASAP that patient may
be a candidate for stroke intervention (Stroke Alert). See “Stroke Alert” in Operations
Section for further criterea.
8. Continually reassess for, and document, any neurological changes during transport.
Tricyclic Antidepressant Overdose

Tricyclic antidepressants (TCAs) are widely prescribed for a variety of conditions and are
responsible for more intentional drug overdose deaths than any other group of prescribed
medications. These agents act upon a number of physiologic systems and therefore have effects
that are the net result of those actions. Pupillary findings, for example, may range from dilated to
constricted depending upon whether the anticholinergic effects (dilation), or the adrenergic
blockade (constriction) predominate.
Dose Range
Therapeutic ranges for most TCAs are 2-4 mg/kg. Life-threatening symptoms usually occur with
ingestions greater than 10 mg/kg. Fatalities often occur within 2hours and rarely >24 hours post-
ingestion. Serious toxicity is almost always seen within 6hours.
Clinical Presentation
• CNS: Mild to moderate TCA toxicity may present as drowsiness, confusion, slurred
speech, and ataxia with increasing TCA toxicity, CNS depression progresses to coma
and respiratory depression. Seizures may occur and are usually brief and single (the
tetracyclics, amoxapine and maprotiline may cause status epilepticus).
• Cardiovascular: cardiac conduction delays, supraventricular tachycardia, premature
ventricular beats, ventricular tachycardia, hypotension, and respiratory depression.
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• Electrocardiographic abnormalities are common, especially prolongation of the PR, QRS,

and QT intervals. Other ECG abnormalities include conduction blocks. The natural
progression of ECG and cardiac abnormalities occurs in the following order: sinus
tachycardia, widening of the QRS complex, decreased cardiac inotropy, increased PR
interval, and finally, decreased heart rate.
Pre-Hospital Focus Points

• Consider TCA OD in all unconscious unknowns.
• If the patient has decreased LOC, ECG findings of prolongation of QRS, or QT intervals,
and OD are conceivable, initiate therapy for TCA OD as listed below.
• Death in TCA OD will be due to a lethal cardiac arrhythmia, poor peripheral perfusion due
to decreased cardiac output or respiratory embarrassment due to aspiration or decreased
ventilatory effort.
• Progression of neurological deterioration can occur remarkably quickly: anticipate that the
patient may require intubation.
Treatment
• Decreased LOC, poor gag reflex: intubate.
• QRS abnormalities: QRS>.10 sec, QT>.35 sec at 100 bpm; or QT>.44 sec at 60 bpm: 50
mEq NaHCO3, hyperventilate.
• Ventricular arrhythmias: bursts of VT or frequent PVCs: 50 mEq NaHCO3,
hyperventilate.
• Hypotension: 50 mEq NaHCO3, hyperventilate, fluid bolus with careful attention to fluid
overload.
Note
Overaggressive use of NaHCO3 may result in severe base excess, which is very difficult to
correct. LIMIT TO: 50 mEq.
Tricyclic Antidepressants
Generic Names Trade Names Comments

Amitriptyline Elavil, Endep, Etrafon, Limbritol, Triavil
Amoxapine Asendin
Clomipramine Anafranil
Desipramine Norpramin
Doxepin Adapin, Sinequan, Zonalon
Imipramine Tofranil
Maprotiline Ludiomil
Nortriptyline Pamelor
Protriptyline Vivactil
Trimipramine Surmontil
Cyclobenzaprine Flexeril Treat as TCA OD
Carbamazepine Tegretol Treat as TCA OD.
Unconscious Patient Unknown Etiology

Guidelines
• Assess ABC’s.
• Assess for signs of trauma.
• Look for medic alert bracelet, pill bottles or other evidence for underlying medical
condition.
• Look for signs of drug abuse.
• Look for treatable causes.
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• Consider metabolic etiology:

o Check glucose and treat if significantly low: see Diabetic Emergencies Protocol.
o If evidence of opiate narcotic overdose (including propoxyphene): treat with
naloxone.
o Observe for smells of alcohol, ketones, or other unusual odors.
Vital Signs
• Hypotension: see Hypotension Protocol.
• Bradycardia: see Bradycardia Algorithm.
• Tachycardia: see tachycardia algorithms in ACLS Algorithms.
Physical Exam
Focus on potential causes including infection (fever, lung exam, skin etc), toxins (drugs, carbon
monoxide, others).
Neuro Exam
Seizure, other? If evidence of focal findings on exam (and blood sugar within normal range): treat
as TBI.
Trauma and Environmental Injuries

General Trauma Guidelines
Victims of severe trauma benefit most from very rapid transport to a facility capable of caring for
their injuries. Pre-hospital interventions that extend scene time, with the possible exception of
those related to airway and spine management, are detrimental to patient well-being. Minimal
scene times are more difficult to achieve in blunt trauma, which may require extrication and
immobilization, and this is understood when applying the following standards. It is vital to give
early notification to the receiving hospital so that they can assemble their trauma team.
Applies To
All victims of serious trauma resulting in an unstable or potentially unstable patient.
Standards
• Airway at the scene if emergently required.
• Control severe external hemorrhaging.
• IV/IOs en route.
• Scene time <8 minutes.
• Early notification of the receiving hospital.
Guidelines
1. High-flow 02.
2. C-Spine and Spinal injury Protocol.
3. External Hemorrhage Protocol.
4. Cardiac monitor.
5. Two Large-bore IVs if possible (14 or 16 G) or IOs.
6. For shock, IV NS at rapid flow rates with initial goal reversal of symptoms of shock.
• Bleeding into body cavities may worsen with overly aggressive IV fluid
therapy. In cases of suspected internal bleeding, limit fluids to the amount
required to bring SBP to 90 and/or alleviate the shock state as demonstrated
by mental status, skin signs, and vital signs.
7. Keep patient warm.
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Amputations
Guidelines
1. Amputated part shall be wrapped in sterile dressing, slightly moistened with NS (dressing
should be damp, not wet).
2. Place the part in a plastic bag and seal.
3. Place bag in a cool solution.
4. Never immerse the part or put it directly on ice.
5. Transport amputated part with patient to hospital.
6. Stump care:
• Apply bulky dressing.
• Control extremity hemorrhage by direct pressure and elevation of the limb.
• If these meausres are inadequate, consider HemCon® bandages.
• Follow the Tourniquet Protocol if ongoing bleeding is uncontrolled by other
measures.
7. If tourniquet was applied in the field prior to EMS arrival, it is usually best to leave it in
place. Note in writing as accurately as possible the time of application.
Burn Management
Thermal trauma presents significant diagnostic challenges. The possibility of multi-system injury
is very high in patients rescued from burning structures, explosions, electrical burns or dermal
chemical exposures. Initially subtle airway compromise may become acutely life threatening. An
explosion or electrical injury may have thrown the victim some distance resulting in internal
injuries, initially masked by painful burns. The EMS provider should try to get a rapid size-up of all
potentially injuring mechanisms involved in the injury.
Guidelines
1. Extinguish the fire.
2. Remember: Molten plastics/tar should be rapidly cooled to stop further burning. NEVER
try to pull such substances off of the skin. This can result in the loss of vital skin
structures and convert the burn to one requiring a graft!
3. Airway Protocol.
4. Remove clothing and jewelry as needed.
5. Cover with burn sheet or dry dressings.
6. Estimate percentage of total body surface involvement.
7. Estimate thickness of burn.
8. For second and third degree burns over 20% total body surface area, start IV with NS
using large-bore catheter.
• Refer to burn charts for estimation of BSA.
• Use variation of Parkland formula: Fluids in 24h=TBSA burn x 4 ml x wt (kg)
with 1st half in first 8 hours.
9. Treat for shock.
10. Pain Management Protocol.
PREHOSPITAL REMEMBER: TBSA burned x 2 x Wt (kg) = mls NS in first 8hrs.
C-Spine Guidelines (Axial Spine Immobilization)

The proper and timely application of axial immobilization to a patient with an unstable injury of the
spine is unquestionably one of the most important pre-hospital skills. It clearly reduces or
eliminates the potentially devastating effects of a spinal injury if it is applied prior to compression
or laceration of nervous structures by either active or passive movement.
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These guidelines are provided to set a uniform standard for all AFD personnel. They may be
independently applied by ETT through MICP.
Situations in which cervical and full spinal immobilization are indicated:
Categories
• Patient complaint /clinical signs and symptoms.
° All patients c/o pain or tenderness on palpation of the neck or midline back, following
physical injury of sufficient magnitude that damage to ligaments or bone of the spinal
column could have occurred.
° All patients with a cervical, thoracic or lumbar deformity or any form of neurological
deficit following physical injury.
° All patients with altered or decreased level of consciousness and a major mechanism
of injury, regardless of presence or absence of pain.
° Unconscious patients with significant penetrating trauma to the head, neck or trunk in
which trajectory could include spinal column (T or L-spine).
° Any neurological deficit after penetrating trauma to the head, neck or trunk (T or L-
spine)
° Any unconscious patient following significant trauma.
• Suspicious mechanism of injury: spinal immobilization indicated.

° Ejection from a vehicle.
° Fall >15 feet.
° Pedestrian struck by a moving vehicle with evidence of significant impact with vehicle
or upon impact with ground.
° Any seriously injured multiple trauma patient.
Notes
• Use these as guidelines. If there is any doubt, immobilize the patient.
• In certain circumstances spinal immobilization may be omitted even though a potential
mechanism for spinal injury exists. The following algorithm, Clinical Criteria for
Assessment of Spine Injury, explains the decision-making process for omitting spinal
precautions in this setting.
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Clinical Criteria for Assessment of Spine Injury
Mechanism
Negative Positive / Uncertain
Spine Pain/
YES
Tenderness
Negative Spine
Injury NO
Motor / Sensory Exam Possible Spine

ABNORMAL
Injury
NORMAL
YES Reliable Patient /Exam NO
• Calm • Acute Stress Reaction

• Cooperative (ASR)
• Sober • Brain Injury
• Alert • Intoxication
• Abnormal Mental
Status
• Distracting Injuries
• Communications
• Age<12
• Advanced age?
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Spinal Immobilization Method
Notes
• The cervical collar should contact the shoulders and securely support the chin.
• Head movement should be restricted by: the cervical collar, blanket-roll, and 2” tape.
• The occipital padding should position the head in a neutral or very slightly flexed position.
• The popliteal padding should provide some flexion to the knees.
• The Spyder™ strap should be snug enough to prevent lateral displacement of the patient
if the board is tilted.
• The chest strap should be high on the thorax so diaphragmatic movement is unrestricted.
• Strap from the shoulders and chest working toward the feet. Secure the head last.
• Use additional padding between legs or between legs and straps or flanks and straps as
needed to prevent lateral movement when board is tipped.
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External Hemorrhage
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Eye Injuries
Chemical Exposures
Copiously irrigate the eye(s)right away. Use available fluid. Examples: a kitchen sink with the
depth to allow the patient to put the eye under running water; an eye wash station at an industrial
site; irrigation with IV fluid through an 18g catheter held at the nasal or temporal canthus, or
through a nasal cannula placed on the bridge of the nose. Tetracaine may be used to facilitate
this process.
Note
Bring the MSDS, chemical agent, or name of the agent to receiving facility with the patient.
UV Exposure
Manage pain with tetracaine and transport.
Blunt Trauma
• Obtain basic visual acuity if possible (light/dark vision or ability to read newsprint or count
fingers). Do this in children as well as adults.
• Protect eye from pressure or further injury, and transport. May apply eye shield if
available but DO NOT patch.
• Elevate head and have patient avoid valsalva.
Penetrating
• As with blunt trauma.
• Leave any penetrating object in place.
Hypothermia
Assessment
• Severe hypothermia is present in a cold patient with any of the following signs: depressed
vital signs, altered level of consciousness, core temperature of 90°F. (32°C) or lower,
absence of shivering (less reliable in the presence of ETOH), or who has significant
illness or injury.
o Mild to moderate hypothermia is assumed in the cold patient without any of these
signs.
Basic Treatment
• Focus on preventing further heat loss.
• Add heat to the core surface areas (head, neck, chest, and groin), or re-warm internally
with warm, moist air.
• Caution: warm packs must be wrapped and monitored, especially in the perfusion-
impaired patient.
• Treat and transport in very warm air (80°F. or warmer) if possible.
Specific Therapy
• Indications for O2 are as usual for mild or moderate hypothermia.
o If severe, administer at 2-4 lpm via nasal cannula.
• Indications for oral airways and ETT tubes are the same as in warm patients.
• In severe patients attempt IV line of NS after other stabilization and give a 10 ml/kg bolus
followed by 5 ml/kg/hr infusion. (Example: 70 kg pt and 10 gtt/ml dripset =1 gtt/sec).
• In mild to moderate hypothermia, indications for IVs and medications are as usual.
• In severe hypothermia, pacing is not indicated, nor are medications unless specifically
ordered.
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• Intubation may be more difficult than usual and should be performed gently to reduce the
risk of VF.
CPR Setting
• Do not resuscitate if:
o Core temp is <60°F.
o Patient has ice in airway.
o Generalized or total-body frozen skin/tissue is present (such that it is obviously
more than localized frostbite).
• Provide basic treatment and specific therapy as above.
• Carefully assess absence of pulse and respirations for up to 45 seconds before
beginning CPR.
• For patients with a core temperature >86°F, follow standing orders.
• For patients with a core temperature <86° F, VF, one defibrillation only should be
performed as indicated.
o If unsuccessful, transport with CPR.
• Asystole or other pulseless rhythms: transport with CPR.
Inflatable Lower-Body Splint (MAST/PASG)

Indications
• To splint pelvic and/or multiple leg fractures.
• Can be considered as an option to treat traumatic shock, particularly in the setting "1"
above or with suspected intra-abdominal bleeding but do not delay transport time to
apply.
• Suspected ruptured abdominal aortic aneurysm.
Contraindications
Pulmonary edema.
Relative Contraindications
• Chest injury.
• Evisceration.
• Impaled object.
• Pregnancy.
Near Drowning
Treatment
No Heimlich unless evidence of foreign body airway obstruction. The “up to” 45 second pulse
check before CPR also applies here. Other therapy follows the hypothermia guidelines.
Pelvic Fracture
Stabilize an unstable pelvis by the application of moderate circumferential pressure around the
pelvic girdle. This may be accomplished by the application of the abdominal section only of the
MAST®, using the trunk portion of an inverted KED®, binding the pelvic girdle with a folded sheet,
or using the long elastic straps packaged with the Sager® traction splint.
Tourniquet
Indications:
• Amputation of an extremity with uncontrolled bleeding.
• Failure to stop extremity bleeding with pressure dressing.
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• Failure to stop extremity bleeding with hemostatic agent.

• Significant extremity hemorrhage in the face of any or all of the following requiring scene
resources being re-directed:
o Need for airway management.
o Need for breathing support.
o Circulatory shock.
o Need for other emergent interventions or assessment.
o Bleeding from multiple sources.
o Inability to specifically localize the source of severe hemorrhage.
• Impaled foreign body with ongoing extremity bleeding.
• Danger presented to responding crew(s).
• Total darkness or other adverse environmental factors.
• Mass casualty events.
Contraindications:
• None if indication is present.
Method:
• Application site will be the most prominent muscle mass on the extremity proximal to the
injury. (EXAMPLE: forearm for injury at or about the wrist, biceps area for any other injury
of the upper extremity, calf for ankle or lower, and thigh for all other lower extremity
injury).
• Expose skin or ensure that article of clothing is absolutely flat to avoid pressure points.
• Tighten the tourniquet ONLY to the point that bleeding stops.
• Mark patient’s forehead with tourniquet time in military time (24hour clock). Marking will
be in large letters “TT ___”
• The tourniquet should NEVER be placed out of site such as beneath a blanket.
• The transferring medic will give verbal report to receiving physician that a tourniquet is in
place and will receive verbal confirmation of this information.
• Tourniquet removal may be considered by provider. Follow “Tourniquet Reassessment
Algorithm” and “Tourniquet Removal Algorithm.”
88 MOM 3.0
89 MOM 3.0
90 MOM 3.0
Traumatic Brain Injury (TBI)

TBI is a significant cause of morbidity and mortality in trauma. Scientific evidence exists showing
how pre-hospital care can improve outcome in TBI. Pre-hospital therapy should focus on limiting
secondary brain injury that can result from hypoxemia, hypoventilation, and hypo-perfusion. EMS
must also try to limit physical factors that can increase intracranial pressure.
Guidelines
1. Assess ABC’s. Stabilize spine.
2. Oxygenate with 100% 02, or highest concentration available. Monitor 02 saturation.
3. Secure airway. If intubation is required, it should be done with minimal gag stimulation.
Consider RSI if gag is present and patient requires airway.
4. Capnography if available. Maintain pC02 35-40 unless patient shows signs of herniation
(see below)
5. Establish IV with NS. Treat hypotension with fluid infusion. If normotensive, TKO.
AGE SBP
12-Adult <90
5-12 <80
1-5 <75
0-1 <65
Treatment
• Elevate head of stretcher or backboard 15 degrees if possible while maintaining spinal
precautions.
• Evaluate and record mental status; the patient’s level of consciousness is the best
indicator of brain function. Use the Glasgow Coma Scale to assess patient’s status on
EMS arrival and document. Frequently reevaluate vital signs and GCS (q5 min.).
• Hyperventilation is indicated in an unconscious trauma patient who is deteriorating
neurologically with:
o Decerebrate or decorticate posturing.
o Significantly different pupil size (>2 mm difference) in a comatose, head injury
patient.
o Cushing’s reflex (bradycardia and hypertension associated with acute head
injury).
o Lateralizing signs (one-sided neurological changes elsewhere on the body, i.e.,
other than just pupil differences).
o Decrease in GCS by 2 or more points.
Definition of Hyperventilation
• Capnography reading of 32-35.
o Adult: 20 breaths per minute.
o Child: 25 breaths per minute.
o Infant: 30 breaths per minute.
Combative patients with TBI may suffer an increase in ICP if forcibly restrained. Such patients
may require chemical sedation if verbal calming methods are not effective. EMS providers must
have some certainty that the combativeness is not due to correctable causes such as
hypoglycemia or hypoxemia before initiating sedation. Lorazepam is the preferred agent (doses
titrated to 4 mg SIVP).
Airway Management in TBI Patients

• Patients with TBI who are unable to be oxygenated or ventilated by other measures will
have an airway established by EMS in compliance with protocols previously established
in the MOM.
91 MOM 3.0
• Patients whose airway can be adequately managed with basic measures will
preferentially be managed in this fashion even if it is apparent that intubation will
ultimately be required. Intubation in this case will be deferred to the emergency
department.
• End-tidal C02 will be monitored whenever possible with a goal of 35-40 mmHg. Low
EtC02 is associated with a worse outcome.
• Regardless of the airway method chosen, goals are:
o Short scene time
o No episodes of hypoxemia
o Avoiding hypotension
o Early notification of the receiving hospital
Destination Issues
The receiving facility must have a functioning CT scanner available as well as neurosurgeon on
staff; (as of this writing EAFB is the only receiving facility without a neurosurgeon).
Note
• Evaluation of a patient with mental status changes is often complicated.
• The EMS provider must consider TBI in cases without apparent mechanism and must
also consider toxic/metabolic causes in cases in which there is a trauma mechanism that
does not seem sufficient to explain the patient’s exam.
• Blood glucose determination should be used liberally when the cause of the change in
mental status is not obvious.
TurkelTM Safety Thoracentesis Catheter

Pleural decompression will be performed on patients with life threatening, progressive respiratory
distress due to suspected tension pneumothorax by inserting a TurkelTM Thoracentesis Catheter
into the second intercostal space on the mid-clavicular line on the affected side.
Method
See the training document TurkelTM Safety Thoracentesis Catheter.
92 MOM 3.0
Appendix
Triage (START Algorithm)
93 MOM 3.0
Glasgow Coma Scale

Components Value Score
Best eye opening Spontaneous 4

To voice 3
To pain 2
None 1
Best verbal Oriented 5

Confused 4
Inappropriate 3
Moans / unintelligible 2
None 1
Best motor Obeys commands 6

Purposeful movement (pain) 5
Withdraw (pain) 4
Decorticate 3
Decerebrate 2
None 1
FACES© Pain Rating Scale
From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's
Essentials of Pediatric Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc.
Reprinted by permission.
94 MOM 3.0
Adult Burn Chart
95 MOM 3.0
Precordial Lead Placement
96 MOM 3.0
12 Lead Waveforms
97 MOM 3.0
Capnography Waveform Elements
98 MOM 3.0
Capnography Waveform Analysis
99 MOM 3.0
VentiSure™ ET CO2 Reference
100 MOM 3.0

Section 3: Pediatric Treatment Protocols and Weight

Pages
Transporting the Pediatric Patient

Spinal Immobilization
The pediatric patient that requires spinal immobilization must be packaged with as much care as
adult patients. Due to their decreased size, and the limitations of equipment designed and tested
for adults, additional care must be made to properly ensure correct fit and stabilization of the
pediatric patient.
Long Backboard / KED – Used in accordance to the standard of care for spinal immobilization.
Additional padding will be need to be used to ensure patient’s stabilization.
Child Passenger Restraint Seats (CPRS) – “Car Seats” can be used with pediatric patients who
have a potential for neck or back trauma. The patient’s head and torso is to be padded. The use
of a properly sized and placed c-collar is recommended in addition to padding stabilization.
The CPRS is then secured to the gurney using both the knee and waist straps. This is done by
placing the CPRS in a rear facing position, elevating the back of the gurney to full upright
position, then running the gurney straps through both belt positions on the CPRS.
Exceptions: Belt-positioning boosters and infant only (rear facing) seats cannot be utilized.
Non-Spinal Immobilized (Medical or Isolated Trauma)
Acceptable Adjuncts
¾ Patient-fitted Child Passenger Restraint Seat (CPRS) – “Car Seat;” fitted as
above
¾ AFD Ferno Pedi-Mate: Patients from 10-40 lbs
¾ AFD Safeguard Transport Seat: Patients from 22-100 lbs
Ferno Pedi-Mate
a. The Ferno Pedi-Mate must be attached securely to the stretcher utilizing the
upper black strap behind the stretcher and the lower black straps around the
frame of the stretcher.
b. The head portion of the stretcher may be adjusted to any angle for the comfort of
the patient.
c. The fully adjusting 5-point harness must be used when transporting patients and
must rest snugly against the patient. The retainer clip must be used on the
patient at armpit level.
d. Weight limits will be strictly adhered to using the Ferno Pedi-Mate, which are 10
– 40 lbs.
e. If in doubt of proper fitting and installation when using the Ferno Pedi-Mate,
consult an AFD-certified Child Passenger Safety Technician.
Safeguard Transport Seat
a. The Safeguard Transport seat must be attached securely to the stretcher utilizing the
upper brown strap behind the stretcher and the lower black straps around the frame
of the stretcher.
101 MOM 3.0

b. The head portion of the stretcher may be adjusted to any angle for the comfort of the
patient.
c. The fully adjusting 5-point harness must be used when transporting patients and
must rest snugly against the patient. The retainer clip must be used on the patient at
armpit level.
d. Weight limits will be strictly adhered to using the SafeGuard, which are 22 – 100 lbs.
e. If in doubt of proper fitting and installation when using SafeGuard, consult an AFD-
certified Child Passenger Safety Technician.
f. Additional installation instruction can be found at SafeGuard EMS Seating
g. The SafeGuard Transport seat is not to be used with patients who have potential
spinal compromise.
Pediatric Intraosseous (IO) Therapy

(EZ-IO)
Indications
• Pediatric patients in the 3 - 39 kilogram weight range.
• An alternate to peripheral IV access in any seriously ill or injured patient in which IV
access cannot be established in timely manner.
• Cardiac arrest.
Contraindications
• Patients under 3 kilograms or over 39 kilograms (with Pediatric needle).
• Fracture of tibia or femur.
• Previous orthopedic procedures (ie. knee replacement).
• Infection at insertion site.
• Inability to locate landmarks.
• Excessive tissue at insertion site.
• Previous attempts at IO insertion in same bone.
Considerations
• Any medication, fluid, or blood products that can be given intravenously can be given via
IO.
• Due to anatomy of IO space flow rates may be slower than those achieved with IV
catheters. Use of initial 5.0 ml NS bolus and continued use of a pressure bag may help.
• Insertion of EZ-IO in conscious patients causes mild to moderate discomfort and is
usually no more painful than a large bore IV.
• IO infusion may cause severe discomfort for conscious patients.
o Pediatric: 0.5 mg/kg of 2% Lidocaine prior to IO bolus or infusion
o Note: This is the same Lidocaine preparation as used in cardiac patients.
• The needle can remain in place for up to 24 hours.
Method
1. Place patient into supine position.
2. Identify and locate bony landmarks:
3. The site of choice is the proximal tibia, just medial to the tibial tuberosity, on the flat
portion of the proximal tibia (2 finger widths below the patella and 1 finger width medial).
4. Alternative site:
• Distal tibia. Locate the insertion site 1 fingerbreath proximal in the midline of the tibial
shaft.
5. Alternative site:
102 MOM 3.0

• Humeral head: Place patient’s hand on abdomen. The humeral head insertion site is
found slightly anterior to the arms lateral midline on the greater tubercule of the
humeral head.
6. Prep site with betadine or alcohol or chlorhexidine 4% (preferred).
7. Load the Pediatric needle onto driver.
8. Stabilize leg near (not under) the insertion site.
9. Press needle against the site at a 90 degree angle and operate the driver using firm,
gentle pressure.
10. Stop when the needle flange touches the skin or a sudden decrease in resistance is felt.
The black horizontal line on the shaft of the needle should be visible above the level of
the skin surface prior to activation of the IO driver to assure adequate needle length to
reach the marrow space.
11. Remove stylet and dispose in sharps container.
12. Do not aspirate bone marrow (may cause obstruction in needle).
13. Connect primed IV extension.
14. Consider use of Lidocaine for conscious patients unless contraindicated.
15. Flush or bolus EZ-IO catheter rapidly with 5.0 ml of NS.
16. Place a pressure bag on solution being infused when applicable.
17. Dress site, secure tubing and apply wristband.
18. Monitor EZ-IO site.
Neonate/Small Infant Intraosseous (IO) Therapy

(Jamshidi Needles)
Indications
• An alternative to venipuncture in infants <3 kilograms when peripheral IV access cannot
be quickly achieved within 2 attempts or 90 seconds.
• Drug and fluid resuscitation in the infant who is unconscious and unresponsive, and in
need of immediate life saving intervention.
• Cardiac arrest.
Contraindications
• Insertion of an IO into a fractured bone.
• Insertion of an IO distal to a fractured bone (i.e., tibial placement with a femur fracture).
• Previous attempts at IO insertion in the same bone.
Relative Contraindications
Infection or burns at the intended site (physician contact required)
Precautions
• The infusion rate may not be adequate for resuscitation of ongoing hemorrhage or severe
shock. It is a good alternative route when venous access is difficult.
• Extravasation of fluid is the most common problem secondary to improper initial
placement or dislodgement of needle.
• Other complications reported in the literature are rare, including fat embolism and
osteomyelitis.
Method
1. Infant is placed in the supine position.
2. Identify and locate the bony landmarks:
• The site of choice is in the proximal tibia 1-2 finger breadths below the tibial
tuberosity on the anteromedial surface.
• Alternate sites are:
o The distal femur 2 finger breadths above the external condyles in the midline;
103 MOM 3.0

o The distal tibia 1-2 finger breadths above the medial malleolus at the ankle.
3. Prep the site with betadine.
4. Direct and insert the needle with the stylet in place perpendicular to the bone or angled
away from the joint, avoiding the epiphyseal plate.
5. Insert with pressure and a boring or screwing motion until penetration into the marrow,
which is marked by a sudden lack of resistance.
6. Remove the stylet.
a) Appropriate disposal of sharps.
7. Attach a 5 ml syringe filled with saline. The IO is appropriately placed if the following are
present:
• Aspiration with syringe yields blood with marrow particulate matter.
• Attempt at infusion of saline in syringe is not met with resistance or infiltration at the
site.
• Needle stands without support.
8. Attach stopcock to IO; attach IV tubing or use syringes directly to the stopcock for
medication flushes/fluid replacement.
• IV flow rates to gravity may be unacceptably slow.
• Use 60 ml syringes for fluid boluses.
• Medications administered by IO must be followed by a flush of at least 5 ml to ensure
that the drug is infused into the marrow.
9. Stabilize needle on both sides with sterile gauze and secure with tape.
• Avoid tension on the needle.
10. Chart site, gauge and number of attempts.
Obstetrics and Neonatal Treatment Protocols

Newborn Care
1. Suction the infant’s airway using a bulb syringe as soon as the infant’s head is delivered
and before delivery of the body. Suction the mouth first, then the nasopharynx.
2. Once the body is fully delivered, dry the baby, replace wet towels with dry ones, and wrap
the baby in a thermal blanket or dry towel. Cover the infant’s scalp to preserve warmth.
3. Open and position the airway. Re-suction the infant’s airway. Suction the mouth first, then
the nasopharynx.
4. If thick meconium is present, initiate endotracheal intubation before the infant takes a first
breath.
5. Suction the airway using an appropriate suction adapter while withdrawing the
endotracheal tube. Repeat this procedure until the endotracheal tube is clear of
meconium. If the infant’s heart rate slows, discontinue suctioning immediately and
provide ventilation until the infant recovers. Note: If the infant is already breathing or
crying, this step may be omitted.
6. Assess breathing and adequacy of ventilation.
7. If ventilation is inadequate, stimulate the infant by gently rubbing the back and flicking
the soles of the feet.
8. If ventilation is still inadequate, after brief stimulation, begin assisted ventilations at
40 to 60 breaths per minute using a bag-valve-mask device with high-flow, 100%
concentration oxygen.
9. If ventilation is adequate and the infant displays central cyanosis, administer high-
flow, 100% concentration oxygen via blow-by. Hold the tubing 1 to 1-1/2 inches from the
infant’s mouth and nose and cup a hand around the end of the tubing to help direct the
oxygen flow toward the infant’s face.
10. Assess heart rate by auscultation or by palpation of the umbilical cord stump.
11. If the heart rate is slower than 60 beats per minute after 30 seconds of assisted
ventilation with high-flow, 100% concentration oxygen, initiate the following actions:
104 MOM 3.0

• Continue assisted ventilation.

• Begin chest compressions at a combined rate of 120/minute (three compressions
to each ventilation).
• If there is no improvement in heart rate after 30 seconds, perform endotracheal
intubation.
• If there is no improvement in heart rate after intubation and ventilation, administer
Epi. 1:1000 solution at 0.1 mg/kg (maximum individual dose 1 mg) via
endotracheal tube, or establish vascular access and administer 0.01mg/kg Epi
1:10,000 IVP (maximum individual dose 1 mg). Repeat epinephrine at the same
dose every 3 to 5 minutes PRN.
• Initiate transport. Reassess heart rate and respirations en route.
12. If the heart rate is between 60 and 80 beats per minute, initiate the following actions:
• Continue assisted ventilation with high-flow, 100% concentration oxygen.
• If there is no improvement in heart rate after 30 seconds, initiate management
sequence described in step 11b.
13. If the heart rate is between 80 and 100 beats per minute, initiate the following actions:
• Continue assisted ventilation with high-flow, 100% concentration oxygen.
• Stimulate as previously described.
• Initiate transport. Reassess heart rate after 15 to 30 seconds.
14. If the heart rate is faster than 100 beats per minute, initiate the following actions:
• Assess skin color. If central cyanosis is still present, continue blow-by oxygen.
• Clamp umbilical cord securely 8-10 inches from the infant.
• Do APGAR scores at one and five minutes, if possible. This can be done later.
Do not delay resuscitative or warming measures to obtain APGAR.
• Reassess the patient frequently.
NOTE
Assess and support temperature (warm and dry), breathing (stimulate to cry), circulation (heart
rate and color).
Obstetrics
All EMS encounters with pregnant patients will proceed with the care directed toward the
maternal-fetal unit; all interventions are to be performed with an understanding of their potential
effect on both the mother and fetus. Provide supplemental O2 in all cases of trauma or
hypoxemia. Position the mother to maximize blood flow (15 degree left lateral tilt or manually
displace the uterus).
Third Trimester Hemorrhage

Indications
All patients known or believed to be in the third trimester of pregnancy that is experiencing
vaginal bleeding. Possible causes of third trimester bleeding include placenta previa, abruptio
placentae*, and uterine rupture.
*In the presence of abruptio placentae, shock is likely to be out of proportion to the apparent
volume of blood loss.
Guidelines
1. O2.
2. Position left lateral recumbent.
3. Begin emergency transport, code red.
105 MOM 3.0

4. Notify receiving facility immediately.

5. Establish at least one, preferably two, large-bore IVs. Titrate fluid rate to patient’s status.
IV should be deferred until transport is underway.
6. Under no circumstances attempt to examine the patient internally
Pre-eclampsia and Eclampsia

Pre-eclampsia, characterized by hypertension, edema, and proteinuria develops after the
twentieth week of gestation, and may occur up to 3 weeks postpartum. Eclampsia is pre-
eclampsia with seizures.
Indications
All patients with eclampsia, or one with symptoms of pre-eclampsia who appears likely to have a
seizure. These patients are expected to meet the minimum criteria of systolic BP >140 and
peripheral edema.
Guidelines
1. ABC’s: Airway Protocol as required, supplemental 02, large bore IV, TKO.
2. Monitor.
3. Minimize lights, noise or other stressors.
4. Position left lateral recumbent.
5. Magnesium sulfate 1-4 gm IVPB.* Carefully monitor for respiratory depression.
6. Unstable pre-eclamptic: handle and transport gently.
* Add 3 gm magnesium sulfate (50% solution) to a 1 gm/100ml bag (total 4 gm/100ml).
Magnesium sulfate is hyperosmolar and will cause damage to red blood cells if not diluted, or if
injected too quickly even when properly diluted.
Childbirth
Indications
Women in active labor who desire transport to a hospital.
Policy
1. Complications of delivery that require immediate emergency transport are prolapsed
cord, breech, limb breech, shoulder, or face presentation.
2. Specific history should include prenatal care, expected complications, para, gravida, due
date, personal MD, high risk factors, whether water has broken, color of amniotic fluid,
previous c-section, medical history, medications and allergies.
Guidelines – Imminent Delivery
1. Prepare for delivery.
2. Establish one large-bore IV.
3. Deliver at home.
4. Assess baby and mother.
5. Attend to neonatal needs: ABCs, warmth, APGARs. (See Newborn Care Protocol).
6. If uncomplicated and neonate is OK, place at mother’s breast.
7. If delivery is uncomplicated and mother and baby are stable, transport code yellow.
Normal blood loss during delivery is 250-500 cc. If on-going, severe hemorrhage occurs, follow
Postpartum Hemorrhage protocol below.
Guidelines - Active Labor, Delivery NOT Imminent

1. Exam and history.
2. Saline lock.
3. Transport left lateral recumbent to hospital of choice, code yellow.
106 MOM 3.0

Postpartum Hemorrhage
Indications
Postpartum patient with more than 500 ml of blood loss.
Guidelines:
1. Establish large bore IV with 40u Pitocin in 1000 cc NS.
2. Check perineum for any obvious source of bleeding from birth trauma. Apply direct
pressure if site found.
3. Perform vigorous external uterine massage.
4. Give Pitocin solution by rapid infusion (titrate to firm uterus) or 10u by IM injection.
5. Establish second unmedicated large bore IV of NS for volume replacement.
6. Treat for shock.
7. Rapid transport with frequent vital signs.
Pediatric Weight Pages
2.2 pounds 1kg

Adenocard Dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.1 mg = 0.1 ml of dilute mix.
rpt q 3 min x 2 @ 0.2 mg = 0.2 ml
Albuterol-neb not allowed
Amiodarone 5 mg = 0.1 ml. Physician contact required.
Atropine not allowed
Benadryl not allowed
D50W Give as D10. Dilute 0.5 g = 1 ml D50 with 4 ml NS. Rpt x 1 after 10 min.
Dopamine 10 mcg/min = 1 gtt/60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000 Asthma/Allergy not allowed
0.1 mg = 0.1 ml ET dose in arrest q 3-5 min if IV/IO unobtainable
Epi 1:10,000 0.01 mg = 0.1 ml IV/IO q 5 min in arrest and bradycardia
Epi 1:100,000 Mix 0.1 mg = 1 ml Epi 1:10,000 with 9 ml NS. Give slow IV push, titrate to symptoms.
Etomidate 0.3 mg = 0.15 ml for age > 7 weeks
Fentanyl not allowed
Glucagon 0.05 mg = 0.05 ml
Lidocaine not allowed
Lorazepam IV/IO: Dilute 50%. 0.05-0.1 mg = 0.05-0.1 ml dilute mix SIVP titrated to effect; rpt x 1 in 5
min if seizure persists. IM: 0.1 mg = 0.05 ml undiluted; rpt x 1 in 5 min if seizure persists.
Morphine not allowed
Narcan 0.1 mg = 0.1 ml q 3 min prn
Nitronox not allowed
Sodium Bicarb dilute 50%, Give 1 mEq = 2ml of dilute mix. May repeat 0.5 mEq = 1 ml of dilute mix q 10
minutes x 2
Sux 2 mg = 0.1ml
Tetracaine not allowed
Fluid Bolus 10 ml q 5-10 min x 2 rpt
Synch CV not allowed
Defib 2 joules rpt @ 4 joules
Pacing 140/min; begin @ 60 mA
ET tube 2.5 / ETCO2 Detector: not allowed
Gastric tube: orogastric only
VS --> HR: 110 - 160 BP: 36 /14 - 58/36 R: 30 - 60
107 MOM 3.0

4.4 pounds 2 kg
Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.2 mg = 0.2 ml of dilute mix
rpt q 3 min x 2 @ 0.2 mg = 0.4 ml
D50W Give as D10. Dilute 1 g = 2 ml D50 with 8 ml NS. Rpt x 1 after 10 min.
Dopamine 20 mcg/min = 1 gtt/ 30 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Lidocaine not allowed
Lorazepam IV/IO: Dilute 50% 0.1-0.2 mg = 0.1-0.2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5
Sodium Bicarb dilute 50%. Give 2 mEq = 4ml of dilute mix, may repeat 1 mEq = 2 ml of dilute mix q 10
minutes x 2
Sux 4 mg = 0.2 ml
Fluid Bolus 10 ml/kg = 20 ml q 5-10 min prn x 2 rpt
Pacing 140/ min; begin @ 60 mA
ET Tube 2.5 or 3.0 / ETCO2 Detector: Not allowed
Gastric tube orogastric only
VS --> HR: 110 - 160 BP: 44/22 - 66/42 R: 30 - 60
108 MOM 3.0

7 pounds 3 kg
Adenocard Dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.3 mg = 0.3 ml of dilute mix
rpt q 3 min x 2 @ 0.6 mg = 0.6 ml
Lidocaine 3 mg = 0.15 ml q 10 min x 2 rpt
Sodium Bicarb dilute 50%. Give 3 mEq = 6 ml of dilute mix, may repeat 1.5 mEq = 3ml of dilute mix q 10
minutes x 2
Sux 6mg = 0.3ml
Fluid Bolus 10 ml /kg = 30 ml q 5-10 min prn x 2 rpt
ET Tube 3.0 / ETCO2 Detector: not allowed
VS --> HR: 110 - 160 BP: 42/26 - 66/48 R: 30 - 60
109 MOM 3.0

9 pounds 4 kg
Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.4 mg = 0.4 ml of dilute mix, rpt q 3
min x 2 @ 0.8 mg = 0.8 ml
Atropine 0.1 mg = 1.0 ml q 5 min x 1 rpt
Epi 1:1000 Asthma/Allergy not allowed
Fentanyl 4 mcg IV/IO (0.08 ml); 6 mcg IN (0.12 ml)
Lorazepam IV/IO: Dilute 50%. 0.2-0.4 mg = 0.2-0.4 ml dilute mix SIVP titrated to effect; rpt in 5 min
if seizure persists. IM: 0.4 mg = 0.2 ml undiluted; rpt x 1 in 5 min if seizure persists.
Morphine 0.4 mg = 0.04 ml q 20 min x 1 rpt
Sodium Bicarb dilute 50%. Give 4 mEq = 8 ml of dilute mix, may repeat 2 mEq = 4 ml of dilute mix q 10
minutes x 2
Sux 8 mg = 0.4 ml
ET Tube 3.0 or 4.0 / ETCO2 Detector: not allowed
VS --> HR: 110 - 160 BP: 56/30 - 80/50 R: 30 - 60
110 MOM 3.0

11 pounds 5 kg
Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.5 mg = 0.5 ml of dilute mix, rpt q 3 min x
2 @ 1.0 ml
Albuterol-neb Unit dose PRN via blow by into face. 5 mg in 3 ml NS for severe symptoms.
Benadryl 5 mg = 0.1 ml q 5 min x 1 rpt
Epi 1:1,000 Asthma/Allergy 0.05 mg = 0.05 ml SC q 10 min x 2 rpt
Fentanyl 5 mcg IV/IO (0.1 ml); 7.5 mcg IN (0.15 ml)
min. if seizure persists. IM: 0.5 mg = 0.25 ml undiluted; rpt x 1 in 5 min. if seizure persists.
Sodium Bicarb (do not dilute) 5mEq = 5 ml, may repeat 2.5 mEq q 10 min x 2
Sux 10 mg = 0.5 ml
Synch CV 3 joules rpt @ 5 joules rpt @ 10 joules
ET Tube 3.0 or 4.0 / ETCO2 Detector: not allowed
VS --> HR: 110 - 160 BP: 56/30 - 80/50 R: 30 - 60
111 MOM 3.0

13 pounds 6 kg
Adenocard dilute 2 ml with 4 ml NS to 6 mg/6 ml, administer 0.6 mg = 0.6 ml of dilute mix.
rpt q 3 min x 2 @ 1.2 mg = 1.2 ml
Atropine 0.12 mg = 1.2 ml q 5min x 1 rpt
Dopamine 60 mcg / min = 1 gtt/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Lorazepam IV/IO: Dilute 50%. 0.3-0.6 mg = 0.3-0.6 ml dilute mix SIVP titrated to effect; rpt in 5 min
Narcan 0.6 mg = 0.6 ml q 3min prn
Sodium Bicarb (do not dilute) 6 mEq = 6 ml, may repeat 3 mEq q 10 min x 2
Sux 12 mg = 0.6 ml
Fluid Bolus 120 ml q 5- 10 min x 2 rpt
ET Tube 3.0 or 4.0 / ET CO2 Detector: not allowed
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
112 MOM 3.0

15 pounds 7 kg
Adenocard 0.7 mg = 0.23 ml rpt q 3 min x 2 @ 1.4 mg = 0.46 ml
Benadryl 7 mg = 0.14 ml q 5 x 1 rpt
Dopamine 70 mcg/ min = 7 gtts/ 60 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Narcan 0.7 mg = 0.7ml q 3 min prn
Sodium Bicarb (do not dilute) 7 mEq = 7 ml, may repeat 3.5 mEq q 10 min x 2
Sux 14 mg = 0.7 ml
Fluid Bolus 140 ml q 5-10 min x 2 rpt (l. ringers)
Defib 14 joules rpt @ 28 joules rpt @ 50 joules
ET Tube 3.0 or 4.0
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
113 MOM 3.0

17 pounds 8 kg
D50W dilute 50%, 4 g = 16 ml D25W q 10 min x 1 rpt
Dopamine 80 mcg/min = 2 gtts/15 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Etomidate 2.4 mg = 1.2 ml
min if seizure persists. IM: 0.8 mg = 0.4 ml undiluted; rpt x 1 in 5 min. if seizure persists.
Sux 16 mg = 0.8 ml
ET Tube 3.0 or 4.0
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
114 MOM 3.0

20 pounds 9 kg
D50W dilute 50%, 4.5 g = 18 ml D25W, q 10 min x 1 rpt
Sodium (do not dilute) 9 mEq = 9 ml, may repeat 4.5 mEq q 10 min x 2
Bicarb
SUX 18 mg = 0.9 ml
Fluid Bolus 180 ml q 5-10 x 2 rpt (l. ringers)
Synch CV 5 joule rpt @ 9 joules rpt @ 18 joules
ET Tube 3.0 or 4.0
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
115 MOM 3.0

22 pounds 10 kg
Amiodarone 50 mg = 1 ml. Physician contact required.
Atropine 0.2 mg = 2 ml q 5 min x 1 rpt
Dopamine 100mcg/min = 1 gtt/6 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
1.0 mg ET dose in arrest q 3-5 min if IV/IO unobtainable
Epi 1:10,000 0.1 mg = 1 ml IV/IO q 5 min in arrest and bradycardia
Lorazepam IV/IO: Dilute 50%. 0.5-1 mg = 0.5-1 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if
seizure persists. IM: 1 mg = 0.5 mlundiluted; rpt x 1 in 5 min. if seizure persists.
Morphine 1 mg = 0.1 ml q 20 min x 1 rpt
Narcan 1 mg = 1 ml q 3 min prn
Sux 20 mg = 1.0 ml
Fluid Bolus 200ml q 5-10 min x 2 rpt (l. ringers)
ET Tube 4.0 or 5.0
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
116 MOM 3.0

26 pounds 12 kg
Dopamine 120 mcg/ min = 1 gtt/ 5 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Narcan 1.2 mg= 1.2 ml q 3 min prn
Sux 24 mg = 1.2 ml
ET Tube 4.0 or 5.0
VS --> HR: 120 - 160 BP: 74/50 - 100/70 R: 30 - 60
117 MOM 3.0

31 pounds 14 kg
D50W dilute 50%, 7 g = 28 ml D25W, q 10 min x 1 rpt
Epi 1:10,000 0.14 mg= 1.4 ml IV/IO q 5 min in arrest and bradycardia
Etomidate 4.2mg = 2.1 ml
Lorazepam IV/IO: Dilute 50%. 0.7-1.4 mg = 0.7-1.4 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min
Sux 28 mg = 1.4 ml
ET Tube 4.0 or 5.0
VS --> HR: 90 - 140 BP: 80/50 - 112/80 R: 24 - 40
118 MOM 3.0

35 pounds 16 kg
Nitronox prn
Sux 32 mg = 1.6 ml
Tetracaine 1-2 gtts max
ET Tube 5.0 or 6.0
VS --> HR: 80 - 110 BP: 82/50 - 112/78 R: 22 - 34
119 MOM 3.0

40 pounds 18 kg
Etomidate 5.4 mg = 2.7 m
Nitronox prn
Sodium (do not dilute) 18 mEq = 18 ml, may repeat 9 mEq q 10 min x 2
Bicarb
Sux 36 mg = 1.8 ml
Fluid Bolus 360 ml q 5-10 x 2 rpt (l. ringers)
ET Tube 5.0 or 6.0
VS --> HR: 80 - 110 BP: 82/50 - 112/78 R: 22 - 34
120 MOM 3.0

44 pounds 20 kg
Epi1:1,000 Asthma/Allergy 0.2 mg = 0.2 ml SC q 10 min x 2 rpt
Etomidate 6.0 mg = 3.0ml
Lidocaine 20 mg = 1 ml q 10 min x 2 rpt
Lorazepam IV/IO: Dilute 50%. 1-2 mg = 1-2 ml dilute mix SIVP titrated to effect; rpt x 1 in 5 min if
seizure persists. IM: 2 mg = 1 ml undiluted; rpt x 1 in 5 min if seizure persists.
Nitronox prn
Sodium (do not dilute) 20mEq = 20 ml, may repeat 10 mEq q 10 min x 2
Bicarb
Sux 40 mg = 2.0 ml
ET Tube 5.0 or 6.0
VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30
121 MOM 3.0

55 pounds 25 kg
D50W (do not dilute) 12.5 g =25ml D50W, q 10 min x 1 rpt
Dopamine 250 mcg / min = 5 gtts/12 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Epi 1:1,000 Asthma/Allergy 0.25 mg = 0.25 ml SC, q 10 min x 2 rpt
Epi 1:10,000 0.25 mg= 2.5 ml IV/IO q 5 min in arrest and bradycardia
Nitronox prn
Sux 50 mg = 2.5 ml
Synch CV 13 joules rpt @ 25 joules @ 50 joules
ET Tube 5.0 or 6.0
VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30
122 MOM 3.0

66 pounds 30 kg
Atropine 0.5 mg = 5 ml q 5 x 1 rpt
Benadryl 30 mg = 0.6 ml q 5 min rpt x 1 @ 20 mg = 0.4 ml
D50W (do not dilute) 15 g = 30 ml D50W, q 10 min x 1 rpt
Dopamine 300 mcg / min = 5 gtts/10 seconds (Mix 150mg (3.75ml) of dopamine in 250ml NS)
Lidocaine 30mg = 1.5 ml q 10 min x 2 rpt
Nitronox prn
Sodium (do not dilute) 30 mEq = 30 ml, may repeat 15 mEq q 10 min x 2
Bicarb
Sux 60 mg = 3.0 ml
ET Tube 6.0 or 7.0
VS --> HR: 75 - 100 BP: 84/54 - 120/80 R: 18 - 30
123 MOM 3.0

77 pounds 35 kg
Atropine 0.5 mg = 5 ml q 5 x 1 rpt
Benadryl 35 mg = 0.7 ml q 5 min x 1 rpt @15 mg = 0.3 ml
D50W (do not dilute) 17.5 g =35ml D50W, q 10 min x 1 rpt
Nitronox prn
Sux 70 mg = 3.5 ml
Fluid Bolus 500 ml q 5-10 x 2 rpt ( LR )
ET Tube 6.0 or 7.0
VS --> HR: 60 - 90 BP: 94 /62 - 140/88 R: 12 - 16
124 MOM 3.0

Appendix
APGAR Scores
Sign 0 1 2
Heart rate Absent <100 >100
Resp effort Absent Weak cry Strong cry

Hypoventilation Good effort
Muscle tone Limp Some flexion Active
Reflex None Some motion Crying/active

irritability
Color Blue/pale Body pink All pink

Extremities blue
Infant Burn Chart
125 MOM 3.0

Child Burn Chart
126 MOM 3.0

Section 4: Medical Operations

The Medical Operations section is not intended to be a complete guide to all AFD documents;
however, it provides a ready reference for certain specific information not contained elsewhere.
Hyperlinks to EMS-relevant Procedures and Instructions (P&Is), Standard Operating Guidelines
(SOGs) and manuals is found below. The documents can be found on the G Drive in the AFD
Documents Folder.
It is expected all personnel are familiar with the departmental documents listed and included
below, as well as those that are not.
EMS P&Is, SOGs, and Manuals
C-4 Contagious Disease, Epidemic, and Pandemic Emergencies
C-5 Concealed and Unsecured Weapons
M-4 Multi-Victim Incidents (MVI)
M-4 Multi-Victim Incidents (MVI) Reinforced Table
N-3 Notifications of Death of a Patient
R-3 Roles and Responsibilities of MICU Personnel on Non-EMS Incidents
900-35 Education and Special Duty Pay (Appendix 6: EMS)
900-41 Private Ambulance Service Dispatch
901-2 Infectious Disease Prevention and Control
901-4 Epidemic or Pandemic Emergencies
902-7 Continuing Medical Education
903-3 Biomedical Equipment
903-5 Controlled Substances
905-7 Medical Control
905-8 Operation Quickstart
905-9 Medical Operations Manual
AFD Metropolitan Medical Response System Manual (includes 905-11 MMRS MMST)
AFD EMS CQI Manual
AFD HIPAA Manual
State of Alaska EMS Mandatory Reporting Requirements
127 MOM 3.0

EMS Incident Disposition

Use the following procedures when radioing dispatch with EMS incident dispositions:
• When transporting a patient, the MICU should notify dispatch of the hospital transporting
to, the transport status, and the number of patients being transported. The dispatcher
must be certain to enter all of these data points, particularly the number of patients.
• If a patient refuses transport, the unit responsible for the patient report should notify
dispatch of “patient refused transport”. The dispatcher should select this choice for the
unit disposition.
• If the unit arrives and finds no patient, then they should notify dispatch of “location, no
patient”. The dispatcher should select this choice for the unit disposition. Personnel are
reminded to review below for the definition of a “patient”. It is a violation of department
policy to report “location, no patient” to avoid completion of a PCR.
• If the units are cancelled en route, the dispatcher should select as the disposition
“canceled by agency on-scene” and include which agency canceled and the reason for
the cancellation in the comments.
Definition of Patient
A patient is defined as:
• Anyone who makes a first party call to 911 for EMS,
• anyone who claims to have an illness or injury to whom we have responded or otherwise
encountered,
• and anyone who on examination either by the significance of mechanism or findings may
have an injury or illness.
Note: A multi-person event will require best judgment of PM or EMS provider.
A Patient Care Report (PCR) is required for all patients except for a Public Assist that does not
involve an injury or potential for injury given mechanism or situation.
Destinations for Hemodialysis (HD) and Peritoneal Dialysis (PD)

Patients
There are a number of medical problems experienced by HD and PD patients that can be treated
only by very timely dialysis. Any delay in the appropriate treatment for these patients can result in
worse patient outcomes. It is often very difficult for the field provider to exclude the patient’s need
for dialysis. It is therefore policy that HD and PD patients are delivered to the appropriate facility
of either Alaska Regional Hospital (ARH) or Providence Alaska Medical Center (PAMC.) These
are the two local hospitals that provide in-house hemodialysis. It is the policy of the Anchorage,
Girdwood, and Chugiak EMS systems that:
• Municipality of Anchorage Area Wide EMS providers will identify all patients being
transported who are actively receiving either HD or PD.
• ALL HD and PD patients with a medical complaint or serious medical or traumatic problem
must be transported to one of the two local dialysis hospitals regardless of the hospital’s
diversion status if both are on diversion.
• During times of EMS diversion it is desirable that a pre-alert be given to the receiving hospital
via AFD Dispatch and that the reason for destination choice is because of a dialysis patient.
• The ONLY exclusion to this policy is if the receiving hospital has declared an “internal
disaster.”
128 MOM 3.0

Destination of Patients with Psychiatric Problems

Providence Hospital now has a psychiatric emergency department. All non-native patients who
are transported by AFD for problems of a purely psychiatric nature should preferentially be taken
to Providence Hospital.
Included problems:
• Severe depression with or without suicidal ideation.
• Severe anxiety not associated with substance abuse.
• Pure behavioral or emotional problems including apparent psychosis, mania, delusions, etc.
• Stable suicide attempts.
Excluded problems:
• Drug dependency or withdrawal.
• Acute intoxication.
• Possible medical problem or trauma thought possibly responsible for an altered
sensorium.
ANMC would still like its beneficiaries to be transported preferentially to ANMC.

Providence Hospital, Alaska Regional and ANMC ER’s will still handle the patients with “excluded
problems” as before.
Direct Admit Patients

The care of most patients will be transferred to hospital staff in the receiving facility Emergency
Department. This policy allows the MICU crew to rapidly return to service and be available for an
emergency response.
There are situations, however, when it is in the best interest of the patient to proceed directly to a
specific area of the hospital other than the Emergency Department and effect the transfer of
patient care at that location. These situations include the following patient dispositions:
• Patients directly admitted to Intensive Care or Coronary Care Units.
• Obstetric patients greater than 16 weeks gestation who are in active labor or where there
is any indication of fetal distress will be taken directly to Labor and Delivery.
• Patients being directly admitted to other units whose comfort would be significantly
compromised from excessive movement, e.g., multiple orthopedic injuries or extensive
burns.
• Cardiac cath lab patients when it can be determined either through AFD Dispatch or the
receiving facility Emergency Department that the cath lab is ready to receive the patient
without excessive delay (< 10 minutes).
Exceptions to this policy can be granted by the EMS Battalion Chief on a case by case basis.
Any question regarding interpretation of this policy will be immediately referred to the EMS
Battalion Chief.
Dispatch Alerting to First Defibrillation

All personnel are required to notify dispatch immediately of the first defibrillation of a ventricular
fibrillation/pulseless ventricular tachycardia delivered by an AFD crew during a Code 99.
It is anticipated that this should occur after the radio declaration of a Code 99, and will be tracked
as statistical data.
An example of an appropriate radio notification would be: “Alarm, Engine 1, first shock delivered.”
129 MOM 3.0

ePCR Completion
• All ePCRs including non-transports will be completed prior to the end of the shift.
• Transport ePCRs will be completed prior to leaving the hospital. Call Dispatch via
landline for extension of out-of-service time.
• The only exception is when the ambulance is dispatched prior to report completion.
• Personnel will respond to all dispatches without delay.
• When dispatched prior to ePCR completion, the report will be completed and faxed to the
receiving hospital as soon as possible after the response. This will take a priority over all
other activities.
• Any exception requires prior approval of an EMS Battalion Chief.
Hospital Alerts
The disruption which is caused by an alert which is inappropriate or inaccurate may be more than
an inconvenience suffered by the hospital; it may lead to complications in patient care. The
hospital alert system was intended to be another adjunct in emergency patient care which should
be a benefit for the whole team – both pre-hospital providers and in-hospital providers. The alert
system should not be used when only a high index of suspicion is present. Care should be taken
to only use the alert system when the proper criteria are met.
Alert status is given to the hospital based on the AFD paramedic’s impression that a patient has a
high likelihood of requiring an intervention at the hospital due to the presence of a new stroke,
severe trauma or acute coronary syndrome with elevated ST segments. Radio reports to the
hospital will start with the type of alert, followed by the patient transport status.
STEMI Alert
STEMI: S-T Segment Elevation Myocardial Infarction
• Age 35 or greater
• Acute onset of symptoms
• Symptoms consistent with acute coronary syndrome (ACS) that must include the
following:
o “Visceral” chest pain: squeezing, pressure, aching, band-like, etc and may have
associated jaw or arm pain, diaphoresis, SOB
• 12 lead ECG showing >1mm of ST-segment elevation in at least 2 contiguous limb leads
or >2mm in 2 or more contiguous precordial leads and that must have a “tombstone” or
other convex morphology
o Flat, concave or other patterns are no longer sufficient to justify this alert.
• ALL FOUR INDICATORS ABOVE ARE REQUIRED
• Note the presence of Q-waves if seen.
• QRS MUST be <0.12 (i.e. NO BUNDLE BRANCH BLOCK) unless it is definitively known
in a timely manner that the BBB is new.
• LVH must be absent: measure largest major deflections at V1 or V2 (S wave) and V5 or
V6 (R wave). If >35, possible LVH: do not call STEMI alert
• Dispatch pre-notification: alert dispatch at the earliest time to pre-alert the hospital that
they will be receiving a STEMI unless you are ready to give a report.
• Dispatch prenotification information:
o ECG shows STEMI and patient meets the criteria in 1-5 above
o Note if cardiogenic shock or other severe symptomatolgy present
o Gender
o Age
o Weight
130 MOM 3.0

o Approximate ETA
• Maximize use of scene time: in patients with likely ACS and STEMI, use your team to
rapidly acquire data as you are treating the patient. Move to MICU as quickly as is
deemed safe for the patient.
• Help minimize transfer to cath lab times: changeover in the ED take a surprising amount
of time. Simple maneuvers such as EMS removing the patient’s shirt prior to starting an
IV shaves off time and lessens the chance of losing the IV. Other ways that we can help
with a smooth handoff will be explored.
Trauma Alert
• Victim of a penetrating or blunt trauma that by mechanism of injury and/or physical
findings suggesting a high likelihood of requiring immediate surgery or admission to the
ICU for stabilization.
• Isolated head injuries, particularly those due to penetrating trauma will not usually require
trauma alert.
Stroke Alert
• Field neurological exam is positive for focal neurological deficit suggestive of
cerebrovascular accident (CVA).
• Strong evidence that symptoms began within the preceding 3 hours.
• Pt had no severe neurological conditions preceding this event.
• The patient is alert.
• There are no obvious signs of contraindications to the use of fibrinolytic agents such as:
o Age less than or equal to 18 y/o
o CVA or head trauma within the preceding 3 months
o Major surgery in the last 14 days
o History of intracranial hemorrhage
o Rapidly resolving symptoms of stroke
o GI or GU bleeding within the preceding 21 days
o No seizure at onset of stroke
Arrival Times at Hospital

All Anchorage Area Wide EMS providers engaged in the transport of a patient to an area hospital
will notify AFD Dispatch of MICU arrival at hospital only at the point when:
1. They have actually arrived on the ‘ramp’ at the ED.

2. The hospital garage doors, when used, are fully open.
This policy adjustment is a result of ongoing dialogue regarding the STEMI policy, and is part of
an area wide statistical effort to capture accurate times in all incidents involving patients suffering
from Myocardial Infarction. It is important to note that this shall apply to all patients transported by
EMS providers and shall be strictly adhered to.
Questions may be directed to an on duty AFD EMS Battalion Chief.
Hospital Disposition of Code 99, Status 1 and Status 2 Pediatric

Patients and Pre-term Labor
Pediatric patients 12 years old and under who are stable enough to bypass the closest hospital
but who are expected to require admission to a Pediatric Intensive Care Unit (PICU) should be
131 MOM 3.0

transported to either Providence Alaska Medical Center Hospital or to Alaska Native Medical
Center, as appropriate, rather than to Alaska Regional Hospital or Elmendorf Hospital. This also
applies to any OB patient less than 34 weeks gestation who is in pre-term labor. Critical care
pediatric resources are concentrated at Providence and ANMC and are thus more capable of
providing the best in-patient care for this patient population. Early notification of the receiving
facility is crucial to allow them to assemble the needed resources in the ER.
Pediatric or OB patients requiring immediate life-saving interventions will, as per existing policy,
be taken to the closest appropriate Emergency Department. The exercise of good paramedic
clinical judgment will be the determining factor in distinguishing the proper disposition of these
patients on a case-by-case basis.
Hospital Radio Report Format/Patient Status

1. Report MICU designator and estimated time of arrival.
2. Report patient status*.
3. Report patient age and sex.
4. Report chief/complaint/mechanism of injury and brief pertinent history.
5. Report level of consciousness.
6. Report respiratory rate, depth and effort.
7. Report pulse rate and, if applicable, ECG rhythm.
8. Report blood pressure.
9. Report physical exam findings.
10. Report treatment provided and patient response.
11. State patient physician preference, if any.
*
Patient Status
The patient status code is determined by the following guidelines:

• Code 99-Cardiac Arrest
• Status One- Unstable, immediate threat to life or limb.
• Status Two- Stable at this time, potential threat to life or limb.
• Status Three- Stable with no potential threat to life or limb.
Radio reports should be as brief as possible while still conveying necessary information.
Medical Consumables Expiration Dates

During daily and Monday apparatus inventory checks of medical consumables, please be aware
that most if not all of these supplies have expiration dates and need to be exchanged with
replacements from EMS Supply when expired. Checks of medical consumables found in station
storage lockers should be made weekly as well, if not on Monday then another day identified by
the station Senior Captain.
If a parenteral medical consumable is in an undamaged and unopened package with a printed

expiration date, it should be considered sterile and should remain unopened until used or rotated
out upon expiration (e.g., IV catheters, IV tubing, and medications).
Expiration dates are determined as follows:
1. If a medical consumable or date sensitive medical device has an expiration date which
shows only the month and year (e.g., 5/07), it expires on the last day of that month.
132 MOM 3.0

2. If a medical consumable or date sensitive medical device has an expiration date which
lists day, month and year (e.g., 5/15/07), it expires on that day.
All expired or damaged medical consumables should be removed from AFD inventory.
Medication Use and Patient Safety

Patient safety is the highest priority for the prehospital care providers of the Anchorage Fire
Department EMS. As part of a more comprehensive Error Free Drug Program, the Medication
Use and Patient Safety protocol will be one of several initiatives aimed at eliminating the chance
of errors during the course of drug administration to patients within the Anchorage Area Wide
EMS System.
General
• Medication errors are a preventable cause of harm to patients.
• Many medications including intravenous (IV) solutions appear similar and it is imperative
that one confirm the name, concentration and expiration date found on the label.
• The AFD will strive to avoid all medication and IV infusion errors through education,
training and strict adherence to the best-demonstrated practice of medication
administration and IV solution infusion.
Guidelines
• All personnel authorized to administer a given medication or IV infusion will be familiar
with its indications, warnings and contraindications.
• All personnel who are involved in patient care and in assisting providers with medication
administration including IV infusions will be familiar with medications used by AFD and be
able to accurately identify these agents and their packaging.
• Such personnel will periodically demonstrate competence in this activity.
Administration of Medications and IV Infusions

• Select medication and IV infusion fluid based upon clinical setting as per the MOM.
• Select proper dose.
• Reconfirm that proper medication and IV infusion fluid, and proper dose and drip rate, is
to be given.
• Review allergies and medication list to confirm that no contraindication to the medication
exists.
• If more than one provider is involved in drawing up medications, it is the responsibility of
the provider administering the medication to visually reconfirm the safety checks listed
above as well as to confirm that the medication in a syringe is the desired medication by
checking the label of the bottle from which it was drawn.
• Prior to attaching a properly assembled IV infusion set to a properly catheterized patient,
the individual starting the IV will visually confirm that the IV has been assembled utilizing
the proper IV fluid solution.
Errors
• If a medication is given or an IV infused in error, the first priority is to assess any
immediate adverse reaction to the patient as well as to anticipate other potentially
delayed consequence.
• Depending on the circumstance it may be appropriate to notify the patient at the time of
the incident or later.
• Notify the receiving physician of the error and any corrective action.
• Notify your shift EMS Battalion Chief.
133 MOM 3.0

• Complete a FD-1 to the AFD Medical Director with a carbon copy to the EMS Battalion
Chiefs and the Assistant Chief of EMS.
Patient Safety and EMS Medical Supplies
Patient safety is the responsibility of all Municipality of Anchorage EMS providers regardless of
department affiliation, rank, or medical certification/licensure. In the interest of patient safety the
Anchorage Fire Department is instituting the following procedures for all departments and
personnel maintaining and restocking medical supplies from AFD EMS supply sources (area
hospitals, EMS Supply, and in-station stores):
• It is the responsibility of the individual restocking medical supplies to confirm the contents
of all supplies including but not limited to the correct medications and concentrations, IV
solutions, expiration dates and compatibility with other medical supplies.
• Any member who discovers a discrepancy or incompatibility involving medical supplies
within the station or during apparatus inventory checks will immediately notify their
company officer (or designated officer or EMS Supply Officer for the Chugiak and
Girdwood departments).
o The on-duty AFD EMS Battalion Chief will be immediately notified of this event.
• Any member who discovers a discrepancy or incompatibility involving AFD medical
supplies at the area hospitals or with EMS Supply will immediately notify the on-duty AFD
EMS Battalion Chief.
• The EMS Supply room will be secured after each access for restocking unless the EMS
Supply Technician is present within the room.
• The supply room at Providence Alaska Medical Center and the supply cabinets at Alaska
Regional Hospital will be secured after each access for restocking.
Utilizing ICS for Code 99 Resource Management

In order to comply with P&I 905-2 and SOG I-2, personnel are instructed to establish a command
structure to manage resources during the course of a Code 99 response.
The initial dispatch will assign the responding resources to a tactical channel for cardiac arrest
and respiratory arrest responses.
Upon confirmation of Code 99 by the first arriving unit(s), command will be established and
named, and a tactical channel will be requested if one has not already been assigned.
Command may be assumed by the EMS Battalion Chief upon arrival on scene.
Perimortal Policy
This section shall define AFD policy regarding situations that involve patients that have been
determined to be beyond resuscitation. Included are guidelines and information pertaining to
SUID, obvious death, those patients that do not respond to advanced life support resuscitation
efforts, and expected home death/Comfort-One patients
It is the policy of the AFD to assume that a reasonable chance of resuscitation exists unless
otherwise addressed in this document.
134 MOM 3.0

SUID (Sudden Unexpected Infant Deaths)

Policy
In recognition of CDC guidelines concerning death scene investigation for victims of SUID it shall
be the policy of the Anchorage Fire Department not to transport those patients under twelve
months of age believed to have expired as a result of sudden infant death syndrome in
circumstances when no resuscitation efforts have been undertaken.
Obvious Death/Decision Not to Resuscitate

Policy
It is AFD policy for the first arriving crew to begin resuscitation on any patient without pulse or
respiration unless one or more of the following signs are present. If there is any doubt whether or
not the patient meets this criterion, then CPR with BLS adjuncts shall be initiated. Resuscitative
efforts shall continue until the first arriving MICP or EMT determines that the patient is beyond
resuscitation and/or an emergency department physician is contacted and consulted.
• Evidence of non-recent death:
o Rigor mortis (NOTE: only valid if hypothermia clearly not a factor).
o Dependent lividity (NOTE: area to check depends upon position of patient).
o Any evidence of decomposition.
• Explosive gunshot wound(s) to the head.
• Severe injury obviously incompatible with life.
• Submersion greater than one hour.
• Suspected death due to hypothermia with the following signs:
o Core temp < 60 degrees.
o Patient has ice in the airway.
o Generalized or total body frozen skin/tissue which is more than localized
frostbite.
Procedure
The first arriving apparatus that determines the patient to be beyond resuscitation based upon the
above criteria shall advise dispatch of an “11-29“ and recommend the closest ALS unit amend to
code yellow; all other responding units shall be in service. The first arriving MICP or EMT will
confirm the initial assessment and complete all required documentation. In the case of dispatch
advising 11-29 per APD/AST then only the closest ALS unit will continue code yellow.
Documentation
The first arriving MICP or EMT shall complete a patient care report, specifically recording the
physical findings which support the decision not to resuscitate based on the criteria established in
this policy (NOTE: The assessment/impression portion of the narrative should be documented as
“Beyond resuscitation“ or “No chance of resuscitation“). Any decisions not to resuscitate made
upon consultation with a physician must have the time of contact and the name of the physician
included in the documentation.
Exceptions to this policy

• Triage decisions in multiple patient incidents.
• An inability to gain access to the patient. This would include:
o Entrapment
o APD/AST denying access to the scene or patient. If this is the case attempt to
obtain the name and badge number of the officer for documentation.
o Situations that would place rescuers/AFD personnel in grave danger.
• Decisions based upon direct consultation with an emergency room physician, or with an
identified MD on scene. Delays in Physician contact must be fully documented.
135 MOM 3.0

Patients Unresponsive to CPR

Policy
Decisions by paramedics or EMTs to discontinue advanced life support resuscitation efforts
outside the hospital, once those efforts are underway, require consultation with an emergency
department physician. Contact must be made prior to discontinuing resuscitative efforts.
Documentation
The name of the consulted MD and the time of contact must be clearly documented on the
completed patient care report.
Traumatic Cardiac Arrests
• Resuscitation efforts should be withheld in victims of penetrating or blunt trauma with

injuries obviously incompatible with life:
o Decapitation.
o Hemicorporectomy.
o Significant time lapse since pulselessness, including dependent lividity, rigor
mortis, and decomposition.
• Blunt Trauma - Resuscitation efforts may be withheld in any blunt trauma patient who,
based upon a MICPs thorough primary patient assessment, is found:
o Pulseless and apneic.
o Asystolic in ECG leads I - III.
• Penetrating Trauma - Resuscitation efforts may be withheld in any penetrating trauma
patient who, based upon a MICPs thorough primary patient assessment, is found:
o Pulseless and apneic.
o Absence of papillary reflexes or spontaneous movement.
o Asystolic in ECG leads I – III.
• Cardiopulmonary arrest patients in whom the mechanism of injury does not correlate with
clinical condition, suggesting a non-traumatic cause of the arrest, should have standard
resuscitation initiated.
• Termination of resuscitation efforts should be considered in trauma patients with EMS-
witnessed cardiac arrest and 15 minutes of unsuccessful resuscitation and CPR.
• Traumatic cardiac arrest patients with a transport time to an emergency department of
more than 15 minutes after the arrest is identified may be considered non-salvagable,
and termination of resuscitation should be considered.
Comfort One/Do Not Resuscitate

Policy
When AFD is called to respond to a confirmed expected home death or Comfort-One patient, the
nearest ALS engine or MICU will respond code yellow to confirm that the patient is without signs
of life. If another call of an emergency nature is received, and the unit responding is the closest
available, that unit will divert to the emergency call and an additional ALS Engine or MICU will be
dispatched to the original call. It is the responsibility of the EMT or MICP to assess the needs of
the family for emotional support and ascertain whether logistical assistance in dealing with the
deceased is required. The APD chaplain may be contacted through AFD dispatch to assist the
family or caregivers of the patient at the discretion of the AFD EMT or MICP.
Procedure
The responding EMT or MICP will carefully evaluate pulse and respiration before verbal
confirmation of death is reported to APD or the patient’s family. It should be noted that an ECG is
not required nor is it preferred. Physical findings must be documented completely on the patient
care report. If upon arrival, the family requests resuscitation or if there is a conflict among the
136 MOM 3.0

family, resuscitation may be undertaken if no signs of non recent death are present. Additionally,
if the patient still has measurable vital signs and the family requests transport without
resuscitation an AFD MICU will transport to a receiving facility. Contact the patient’s personal
physician or the receiving emergency department physician if special requests are made or if
there are questions regarding treatment.
Public Inebriate Incident Disposition

• All persons encountered during incidents that meet the criteria of a patient per the MOM
may only be transported to an area hospital. Transports to the CSP Transfer Station,
Brother Francis Shelter or Beans Café are not authorized destinations.
• Customer service rides of public inebriates that EMS providers deem to not meet the
definition of a patient per the MOM to the CSP Transfer Station, Brother Francis Shelter
and Beans Café are prohibited per P&I 900-32 (Customer Service Rides), section 1.4:
At no time will any person professionally deemed to be inebriated (or otherwise
incapable of maintaining responsibility for his or her actions) be permitted to ride in
fire department vehicles under this Procedure or its associated Policy.
• All patients that meet the MOM definition of a patient shall be documented via a Patient
Care Report, regardless of disposition. 911 responses to Man Down calls involving
patient contact with public inebriates are not Public Assists.
• EMS providers that triage a public inebriate to APD or CSP for transport to the CSP
Transfer Station, Brother Francis Shelter or Beans Café shall document the encounter in
the Advanced EMS tab in FireRMS, to include an EMS narrative.
Requesting APD Assistance

From this point forward, the term “10-34 Code” is to be used when requesting the assistance of
a couple of APD officers, code red. As always, immediately provide a brief reason of the need if
at all possible.
• The purpose of this change is to have AFD personnel use the same vernacular as APD,
in order to minimize any miscommunication or delay in summoning their assistance. This
should be particularly beneficial when AFD personnel are being physically assaulted and
don’t have time to elaborate the reason for the request. Although this scenario rarely
occurs, when it does AFD dispatchers will notify APD dispatch of the “10-34 code” and
will provide any pertinent information they have such as the location and type of call.
• In situations where the assistance of many APD officers is needed code red, continue to
use the term “10-33” to make the request as outlined in P&I 905 -10: Fire/EMS
Communications. This will send every available APD Officer.
• When requesting APD code yellow, continue to use plain language terminology. Note
that for verbal assaults, it’s APD’s policy to send responding units code yellow.
• In summary: AFD’s communications policy now allows the use of two “10” codes, both of
which are used to summon APD assistance code red. For your safety, memorize and
use them appropriately.
Examples
• “Alarm, Engine 7, 10-34 code for a combative patient” (assumes AFD dispatch knows E-
7’s location).
• “Alarm, Medic 9, 10-34 code” (crew is unable to provide a reason for the request and
assumes AFD dispatch knows M-9’s location. As soon as possible, M-9 must provide
more information).
• “Alarm, Medic 3, 10-33 for shots fired” (assumes AFD dispatch knows M-3’s location).
• “Alarm, Engine 1, 10-33 for a riot at the Egan Center.”
137 MOM 3.0

Safety Modification to Mixed EMS Responses

Company Officers and MICU Firefighter/Paramedics should make every effort to avoid causing
accidents as a result of Code Red/Yellow responses. Two apparatus of different response codes
following closely together can cause confusion to civilian drivers, potentially causing accidents
and other driving hazards. If both apparatus are responding from the same location, here are
some suggestions for avoiding this situation:
Both Units Respond Code Yellow

• If no significant delays are anticipated and the patient information provided by Dispatch
indicates a stable situation, then a Code Yellow response is acceptable.
• Studies by other organizations reveal that the time saved between an emergent and non-
emergent response has little, if any, impact on patient outcomes.
• In some cases, responding Code Red disrupts the flow of traffic so much that it is actually
faster to respond non-emergent with the flow of traffic.
Don’t Follow so Close

• It is permissible for the second apparatus to slow their response out of the station when
responding together.
• Let the first apparatus clear the station, get into traffic and depart the immediate area.
• After traffic has returned to a reasonable normal flow, then depart.
• 30% of engine companies are cancelled while enroute to mixed responses and the vast
majority of patients fall within the Status 3 category.
• For those rare, but more critical patients, life-saving interventions are going to be
performed by the first arriving Code Red unit.
Both Units Respond Code Red

• If you’re still uncomfortable responding both units Code Yellow or providing adequate
spacing between units, then respond Code Red.
• Under no circumstances should two apparatus respond together at different response
levels.
If you are responding from different locations and intersect along the way, make sure to
follow the above rules.
Transfer of Care/Return to Service Policy

MICU crews delivering a patient to a receiving facility have the following responsibilities:
• Continue all necessary patient care until a full transfer of information has been made to
ensure patient safety and continuity of care. This occasionally involves a short interim
period if an emergency department is very busy.
• Give a full, face-to-face verbal report to the receiving employee who will accept and
continue care.
• Deliver a written copy of the Patient Care Report before leaving, unless another response
interrupts completion. Return or fax a completed copy of the PCR at the earliest
opportunity when it is not possible to leave one at the time of transfer.
• Return the MICU to response-ready condition as soon as possible after completing
necessary patient care and verbal reporting duties, and place the unit in service.
138 MOM 3.0

Transport Policy for the Mat-Su Regional Medical Center

The Mat-Su Regional Medical Center (MSRMC) is located at 2500 S. Woodworth Loop off of
Trunk Road, at Mile 35.5 of the Parks Highway (near the Parks and Glenn Highway interchange).
Per recent updates in policy, MOA employees are allowed to drive MOA vehicles into the Kenai
or Mat-Su Boroughs, at their own discretion and without securing prior permission, provided they
are on MOA business.
EMS providers should use the following guidelines when faced with the issue of transporting
patients to the Mat-Su Regional Medical Center (MSRMC):
• EMS providers who transport to MSRMC must make contact with MSRMC Emergency
Department prior to initiating transport. MSRMC must accept the patient prior to the
transport.
• Contact with MSRMC Emergency Department must be made via cell/landline phone at
(907) 746-5123 (or -5124). MSRMC does not have radio capabilities.
• MOA EMS providers who may transport to MSRMC will not be able to complete an ePCR
at MSRMC. An ePCR should be completed as soon as possible and faxed to MSRMC
Emergency Department at: (907) 861-6851.
AFD AFD
Patient Status MICU’s operating MICU’s operating in Chugiak Girdwood
in Anchorage Eagle River/Chugiak
1 Anchorage Area Anchorage Area
Closest Hospital* ** Closest Hospital* **
(inc. code 99) Hospitals Hospitals
Anchorage Area Anchorage Area 1. Anchorage Area Hospitals Anchorage Area
2
Hospitals Hospitals 2. MSRMC** Hospitals
Anchorage Area Anchorage Area 1. Anchorage Area Hospitals Anchorage Area
3
Hospitals Hospitals 2. MSRMC** Hospitals
* The determining line for proximity to MSRMC vs. AK. Regional Hospital is the Glenn Hwy, approximately Chugiak High School
** MSRMC must be consulted as to patient acuity/condition, and accept the patient before transport is initiated to MSRMC
139 MOM 3.0

Appendix A: Approved Medical Abbreviations
A-
a before
AAOx3 awake, alert, oriented x 3 [person/place/time]
A&O x 4 - alert and oriented to person, place, time and event
ab abortion ,*SAB spontaneous AB
abd. abdomen
ABG arterial blood gas
abs. absent
ACLS advanced cardiac life support
ACS acute coronary syndromes
admin. administer
AED automatic external defibrillator
AICD automatic implanted cardioverter-defibrillator
AIDS acquired immune deficiency syndrome
ALS advanced life support
AMA against medical advice
AMI acute myocardial infarction
amp ampule
Amp. amputation
amt. amount
ant anterior
A&O alert and oriented
AOS arrived on scene
APAP acetominophen (Tylenol)
ASA aspirin (acetylsalicylic acid)
ASAP as soon as possible
AV atrial/ventricular
B-
BBP blood borne pathogen

BCP birth control pills
BG blood glucose
b.i.d twice a day
bilat. bilateral
BLS basic life support
BM bowel movement
BOW: bag of water
BP blood pressure
B/S breath sounds
BS blood sugar
BVM bag valve mask (Ambu Bag™)
C-
c with
CA cancer
Ca calcium
CABG coronary artery bypass graft ("cabbage")
CAD coronary artery disease
cal. caliber
140 MOM 3.0

CC chief complaint
cc cubic centimeter
CCU Cardiac Care Unit
CHF congestive heart failure
cl. clear
cm. centimeter
cm3 cubic centimeter
CT CAT scan
CNS central nervous system
CO2 carbon dioxide
CO carbon monoxide
C/O complains of
conc. concentration
cond. condition
COPD chronic obstructive pulmonary disease
CPR cardiopulmonary resuscitation
CSF cerebral spinal fluid
CSM circulation, sensation and movement.
CVA cerebrovascular accident
D-
d day
D5W 5% dextrose in water
D50 50% dextrose
DBP diastolic blood pressure
DC disconnect
D/C discontinue
D&C Dilation and curettage
Defib. defibrillation
Deform. deformity
DI diabetes insipidus
DIC disseminated intravascular coagulation
dig. digtalis
disloc. dislocated
DM diabetes mellitus
DNR do not resuscitate
DOB date of birth
DOE dyspnea on exertion
dsg. dressing
DTR deep dendon reflexes
DT's delerium tremens
Dx diagnosis
E-
ea. each
EBL estimated blood loss
ECG electrocardiogram
ED Emergency Department
EDC estimated date of confinement
EEG electroencephalogram
EENT ears, eyes, nose and throat
e.g. for example
EKG electrocardiogram (old, from German electrokardiogram)
EMD Emergency Medical Dispatcher
141 MOM 3.0

EMS Emergency Medical Services

EMS-C Emergency Medical Services for Children
EMT Emergency Medical Technician
EMT-P Paramedic
Epi. epinephrine
ER Emergency Room
ET endotracheal (tube)
ETA estimated time of arrival
ETCo2 end-tidal Co2 (detector)
ETOH ethanol (ethyl alcohol)
ETT endotracheal tube
exam examination
F-
F Fahrenheit
FB foreign body
FD fire department
fem. femoral
FF firefighter
FH family history
FHT fetal heart tones
fl. fluid
flex. flexion
freq. frequency
FROM full range of motion
ft. foot, feet
Fx fracture
G-
gm gram
ga. gauge
gal. gallon
GB gallbladder
GC gonorrhea
gd. good
gen. general
gluc. glucose
GI gastrointestinal
GM seizure grandmal seizure
gr. grain
G 0 1,2, etc. gravida (must have number following)
grav. gravida
GOA gone on arrival
GSW gunshot wound
gtts drops
GU genito-urinary
H-
h hour
HA H/A headache
Hb hemoglobin
HEENT head, eyes, ears, nose, and throat
HEPA high efficiency particulate aspirator
142 MOM 3.0

Hep-B,HBV Hepatitis B (or A, C, D)

Hg mecury
HIV human immunodeficiency virus
H&P history and physical
HPI history of present illness
HR heart rate
h.s. at bedtime
HTN hypertension
Hx history
I-
ICP intracranial pressure

ICS Incident Command System
ICU Intensive Care Unit
IM intramuscular
info. information
inj. injury
irreg. irregular
iu international units
IUD intrauterine device
IV intravenous
IVD IV drip
IVDA IV drug abuse
IVP intravenous push
IVPB intravenous piggy back
J-
J. joule
jct. junction
JVD juglar venous distension
K-
K potassium
KCL potassium chloride
KED Kendricks Extrication Device™
kg kilogram
KVO keep vein open
L-
L. liter
L left
lac. laceration
lat. lateral
lb. pounds
LBBB left bundle branch block
LBP low back pain
L&D labor and delivery
lg. large
lig. ligament
liq. liquid
LLQ left lower quadrant
LMP last menstrual period
143 MOM 3.0

LOC level of consciousness (in Glasgow scale)

LOC loss of consciousness
LPM liters per minute (oxygen)
LPN Licensed Practical Nurse
LR lactated Ringers (IV solution)
L. left
LUQ left upper quadrant
M-
m. meter
mA milliamps
MAE moves all extremities
mand. mandible
MAST Medical Anti Shock Trousers™ (see PASG)
mcg microgram
MCI mass casualty incident
MCL1 modified chest lead 1
MCL 6 modified chest lead 6
MD medical doctor
mEq milliequlivants
mg milligram
Mg magnesium
MI myocardial infarction
MICP Mobile Intensive Care Paramedic
MICU Mobile Intensive Care Unit
misc. miscellaneous
ml. milliliters
mm. millimeter
mo month
M/O months old
mod. moderate
MOI mechanism of injury
MRI magnetic resonance imaging
MS Morphine Sulfate
M/S motor and sensory (i.e.; M/S intact x4 ext)
MSDS Material Safety Data Sheet
multip. multiparous
musc. muscle
MVA motor vehicle accident
MVI multi-victim incident
N-
NA not applicable (available)

Na sodium
NaCl sodium chloride
NAD no acute (apparent) distress
NaHCO3 sodium bicarbonate
narc. narcotic
NC nasal cannula
NCT narrow complex tachycardia
neg. negative
Neuro. neurological
NG nasogastric
NKDA no known drug allergies
144 MOM 3.0

norm. normal
NP Nurse Practitioner
NPO nil per os (nil per mouth)
NRB non-rebreathing (mask)
NS normal saline
NSAID non-steroidal anti-inflammatory drug
NSR normal sinus rhythm
NTG nitroglycerin
N&V nausea and vomiting
O-
O2 oxygen
OB obstetrics
Ob/Gyn obstetrics/gynecology
occ. occasional
OCP oral contraceptive pill
OD. overdose
OTC over the counter
oz. ounce
P-
p after (superscript hyphen over p)

P 1,2, etc. parity (must be followed by # and used with gravida)
PA, PA-C Physician Assistant
palp. palpation
parox. paroxysmal
PASG pneumatic anti-shock garment
PAC premature atrial contraction/complex
PAT paroxysmal atrial tachycardia
PCN penicillin
PCR patient care record/report
PD police department
PE pulmonary embolus, or physical exam
PEA pulseless electrical activity (cardiac)
PERL pupils equal and reactive to light
PERLA pupils equal and reactive to light and accommodation
PERRL pupils equal, round, and reactive to light
PERRLA pupils equal, round, and reactive to light and accommodation
peds. pediatrics
PID pelvic inflammatory disease
PIH pregnancy induced hypertension
PMH past medical history
PMS pulse, motor, sensory
PMS premenstrual syndrome
PND paroxysmal nocturnal dyspnea
pneumo.,ptx pneumothorax
p.o. by mouth
post. posterior
POV privately owned vehicle
PPE personal protective equipment
preg. pregnant
prep. prepare
PRN as necessary/needed
PROM premature rupture of membranes
145 MOM 3.0

prox. proximal
PT patient
PTCA percutaneous transluminal coronary angioplasty
PTOA prior to our arrival
PVC premature ventricular contraction
Q-
q each, every
q.d. each day
q.h. each hour
q.i.d. four times a day
qt. quart
R-
R rate
R right
RBBB right bundle branch block
resp. respirations
RL Ringer’s lactate (IV solution)
RLQ right lower quadrant
Rm room
RMA refuse[s] medical assistance
RN Registered Nurse
ROM range of motion
RSI rapid sequence intubation
RT Respiratory Therapist
RUQ right upper quadrant
Rx prescription/medication
S-
s without
SABA supplied air breathing apparatus
sal. saline
SAR search and rescue
SBP systolic blood pressure
SCBA self contained breathing apparatus
SCUBA self contained underwater breathing apparatus
SUIDS sudden unexpected infant death syndrome
SA sinus node (sinoatrial)
SIVP slow intravenous push
SL sublingual
SOB shortness of breath
SOP standard operating procedure
SpO2 oxygen saturation (peripheral/pulse)
SQ subcutaneous
S&S signs and symptoms
SR sinus rhythm
STAT immediately
STD sexually transmitted disease
std. standard
sup. superior
supp. suppository
Surg. surgery or surgeon
146 MOM 3.0

SVT supraventricular tachycardia

Sx symptoms/signs
T-
T temperature
tab. tablet
TB tuberculosis
TCA tricyclic anti-depressant
TIA transient ischemic attack
t.i.d. three times a day
TKO to Keep Open
TM tympanic Membrane
tol. tolerate(d)
TPR temperature, Pulse, Respirations
trach. tracheostomy
tract. traction
Tx treatment
U-
ug micrograms
UOA upon our arrival
URI upper respiratory infection
UTI urinary tract infection
V-
Vv. vein
VA Veteran's Administration (US Government)
VD venereal disease
VF ventricular fibrillation
VFD volunteer fire department
V-fib ventricular fibrillation
vol. volume
vs vital signs
VT,V-tach ventricular tachycardia
W-
WBC white blood count

WCT wide complex tachycardia
WD warm/dry
wk. week
WNL within normal limits
WPD warm, pink, dry (skin signs)
WPW Wolf-Parkinson-White
wt. weight
X-
X-fer transfer
Y-
Y/O, y.o. years old
147 MOM 3.0

Appendix B: MOM 3.0
This revision table recognizes the major changes and additions that have occurred in AFD EMS
between the electronic versions of the MOM 2007 v. 2.0 (September 21, 2005) and this new
edition.
MOM 3.0
MOM 3.0 Change, Addition -Changes to and additions of new
protocols and medications.
-Overall layout changed with decreased
size and use of hyperlinks.
Cover Change Revision and date added.
Introduction Change -Updated intro from Dr. Levy.
-Updated language from P&I
Contact Telephone Change Updated contact numbers for
Numbers Providence Hospital.
Table of Contents Change Updated to reflect changes.
Section 1: Adenosine Change Reversed to MOM 2007 dosage.
Section 1: Vecuronium Change New medication added.
Section 2: Adult IO Therapy Change Updated protocol.
Section 2: AED Algorithm Change Updated algorithm.
Section 2: Amputations Change Updated to reference Tourniquet
Protocol.
Section 2: Anaphylaxis Addition New protocol and guidelines added.
Section 2: Chest Pain Change Updated.
Section 2: EMT-II and EMT- Addition Added EZ-IO use in unconscious adult
III Patient Care Protocol patients.
Section 2: External Addition New algorithm added.
Hemorrhage
Section 2: General Trauma Change Updated with new language.
Guidelines
Section 2: Pediatric IO Change Updated and moved to Section 3.
Therapy
Section 2: Post Cardiac Addition New protocol added.
Arrest Cooling
Section 2: Post Change Updated algorithm.
Resuscitation Care
Algorithm
Section 2: Pulseless Arrest Change Updated algorithm.
Algorithm
Section 2: Tourniquet Addition New equipment and protocol added.
Section 2: Triage (START Addition Moved from Appendix A.
Table)
Section 2: Appendix Change -Removed APGAR table, Child, and
Infant Burn Tables; moved to Section 3.
-Removed equipment-specific
information; hyperlinked from protocols.
Section 3: Pediatric IO Addition Added new protocol.
Therapy
Section 3: Neonate/Small Addition Updated protocol to reflect treatment on
Infant IO Therapy patients <3 kg.
148 MOM 3.0

Section 3: Transporting the Addition New equipment and transport

Pediatric Patient guidelines added.
Section 3: Appendix Addition Added APGAR table, Child, and Infant
Burn Tables.
Section 4: Medical Addition Modified contents of Section 5:
Operations Administrative moved to this section.
Section 4: ePCR Change Updated with new language.
Completions
Section 4: Medication Change Removed and updated (see next line).
Expiration Dates
Section 4: Medical Added New guideline.
Consumables Expiration
Dates
Section 4: Patient Change Removed and update is found in P&I
Transports 900-41 Private Ambulance Service
Dispatch
Section 5: Administrative Change State of Alaska Mandatory Reporting
updated with material from ADM 07-18
Reporting Requirements; moved to
Section 4: Medical Operations.
Appendix A: Multi-Victim Change START table moved to Section 2; MVI
Incident (MVI) and START contents hyperlinked in Section 3.
Triage
Appendix B: MMRS Change Moved to document and hyperlinked in
Section 4.
Appendix C: Approved Change Moved to Appendix A.
Medical Abbreviations
Appendix D: MOM 3.0 Change, Addition Update and add; changed to Appendix
B.
149 MOM 3.0

Anchorage (AK) Protocols (2008)

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ANCHORAGE FIRE DEPARTMENT

Medical Operations Manual

Michael Levy, M.D., FACEP, FACP

Erich Scheunemann, MICP

Anne Sigsworth, MICP

Introduction to MOM 3.0

Procedure and Instruction (Extracted from P&I 905-9, 7/08)

Contact Telephone Numbers

Alaska Division of Family and Youth Services 269-4000

Introduction to MOM 3.0 ......................................................................................................................................2

Gastric Intubation ...........................................................................................................................49

Precordial Lead Placement ............................................................................................................96

Section 1: Standing Medication Orders

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Adult Dose (IV/IO)

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Dopamine Drip Chart for Adults

FOR A CONCENTRATION OF 1600 μg of DOPAMINE PER MILLILITER SOLUTION:

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

• Not permitted without physician contact.

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Protocol Reference and How Supplied

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Adult dose (IV/IO)

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Side Effects and Adverse Reactions

Section 2: Treatment Protocols

General Guidelines for All EMS Providers

General Approach to the Patient

EMT-I/ETT Patient Care Protocol

Multi-victim/Mass Casualty Incident

EMT-II Patient Care Protocol

Additional Authorized Activities

EMT-III Patient Care Protocol

Additional Authorized Activities

Scope of Practice for EMT-II and EMT-III

Airway and Ventilation

Bag-Valve-Mask Ventilation (BVM)