Paramedic Certificate - Cloud Object Storage · 2013-02-07 · 2 Bradycardia / A.V. Blocks Basic...

Polk State College

EMS Protocols

Paramedic Certificate Treatment Parameters

Polk State EMS Program

Clinical Education Office

Revised: February 7th, 2013

Polk State College

EMS Protocols

Cardiac 1. Angina / Myocardial Infarction

2. Supraventricular Bradycardia and A.V. Blocks

3. A - Fib / Flutter

4. Supraventricular Tachycardia

5. Ventricular Tachycardia with a Palpable Pulse

6. Torsades de Pointes

Cardiac Arrest 7. Asystole

8. PEA

9. V-Fib / Pulseless V-Tachycardia

Medical Emergencies

10. Abdominal Pain

11. Allergic Reaction / Anaphylactic Shock

12. Altered Mental Status

13. Asthma / COPD

14. Behavioral Emergency

15. Rapid Sequence Intubation (RSI) - Adult

16. Pulmonary Edema

17. Seizure

18. Overdose and Poisonings

19. Overdose Tricyclic and Tetracyclic Antidepressant

Anticholergenic Poisoning/Organophosphates Overdose

20. Overdose Antipsychotic / Acute Dystonic Reaction, Carbon Monoxide,

Cocaine & Sympathomimetic Overdose

21. Overdose Beta Blocker Toxicity

22. Overdose Calcium Channel Blocker Overdose

Trauma Emergencies

23. Adult Trauma Transport

24. Adult Pain Management

Pediatric Emergencies

Polk State College

EMS Protocols

25. Rapid Sequence Intubation (RSI)

26. Allergic Reaction / Anaphylactic Shock

27. Altered Mental Status

28. Bronchospasm

29. Supraventricular Bradycardia

30. Supraventricular Tachycardia (SVT)

31. Ventricular Tachycardia with a Palpable Pulse

32. Overdose, Poisoning or Ingestion

33. Seizure

Pediatric Cardiac Arrest

34. Asystole

35. Pulseless Electrical Activity (PEA)

36. Ventricular Fibrillation / Pulseless Ventricular Tachycardia

Pediatric Trauma Emergencies

37. Pain Management

38. Trauma Transport

Polk State College

EMS Protocols

1

Angina / Myocardial Infarction

Initial Medical Care (Oxygen, IV, Monitor)

Record and monitor vital signs

Initiate cardiac monitoring, record and evaluate EKG strip.

AMI (STEMI) is indicated if 12 Lead indicates > 1mm ST elevation in: • Lead II, III, AVF (Inferior Wall MI) (Check V4R)

• V1, V2 (Septal Wall MI)

• V3, V4 (Anterior Wall MI)

• V5, V6, Lead I, AVL, or (Lateral Wall MI)

• Any 2 contiguous leads Do not interpret ST elevation in ECGs presenting with right or left BBB.

Baby ASA (4) 324 mg, chewed. (81 mg each)

Nitroglycerin (Nitrostat) 0.4 mg SL spray, at 5 minute intervals until Nitroglycerin Drip established.

Contraindicated in patients:

Systolic BP < 90 mm Hg / Viagra use in past 24 hrs

Use with caution in acute Inferior Wall MI, (Assess V4R to rule out RVI)

NOTE: Ensure IV line started, SBP < 110 mm Hg and be prepared to administer IV NS boluses at 200-300

ml if hypotension develops)

Nitroglycerin Drip at 10 mcg / minute via infusion regulator. Titrate and increase at 5 mcg / minute

increments every 3 - 5 minutes until relief of discomfort or systolic B/P <100 mm Hg.

If pain unrelieved by Nitro Drip, Morphine Sulfate 2 mg slow IVP every 5 minutes (Maximum 10 mg)

Contraindicated in patients: Systolic BP < 90 mm Hg / Use with caution in acute Inferior Wall MI,

(Assess V4R to rule out RVI)

Promethazine (Phenergan) 12.5 mg diluted with 9 ml of NS or RL slow IVP for severe vomiting.

If BP < 90 mm Hg systolic, administer 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg

Polk State College

EMS Protocols

2

Bradycardia / A.V. Blocks

Basic Life Support

Secure airway and administer supplemental oxygen


Advanced Life Support

Advanced airway/ventilatory management as needed

Initiate cardiac monitoring, record and evaluate EKG strip

Record and evaluate 12-lead EKG

Do not delay treatment by obtaining EKG unless diagnosis is in question

Record & monitor oxygen saturation

IV 0.9% NaCl KVO or IV lock

If systolic BP < 90 mm/ Hg, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg

Symptomatic (B/P <90 AND altered mental status AND signs of shock)

Atropine 0.5 B 1.0 mg fast IVP repeat every 3 minutes as needed (Maximum 3mg)

(Consider TCP before Atropine if 2nd II or 3 AV Blocks)

Administer sedation if needed

Midazolam (Versed) 2.5mg slow IVP

Initiate transcutaneous pacing using Demand Mode

Start at lowest MA=s until electrical capture with pulses achieved.

Verify mechanical capture, if not, continue increase in MA until mechanical capture

Start rate at 70 or default and increase rate to achieve systolic BP > 90mm Hg

(Maximum 100 beats/minute)

If above unsuccessful

Dopamine (Intropin) infusion at 5-20 mcg/kg/minute IV titrated to maintain systolic

BP > 90 mm/Hg

If drug induced, treat as per specific drug overdose

Calcium Chloride 1 gram IV for calcium channel blocker OD

Avoid if patient on digoxin/Lanoxin

Asymptomatic

Place Transcutaneous Pacing on standby and use in demand mode if needed

Medical Control

Contact medical control for Epinephrine (Adrenalin) infusion at 2-10 mcg/minute IV.

NOTE: Epinephrine (Adrenalin) 2mg in a 250 ml bag equates to 15 gtts / 2 mcg

Polk State College

EMS Protocols

3

Atrial Fibrillation / Atrial Flutter

Basic Life Support

Secure airway - Administer supplemental oxygen




Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG

Heart Rate > 150 beats/minute

Do not delay treatment if patient is unstable by obtaining EKG unless diagnosis is in question



Stable (BP > 90 mm Hg)

Rate > 150 beats/minute B and wide complex or WPW history

Advise ED physician if patient has had rhythm > 48 hours

Unstable (BP < 90 mm Hg AND altered consciousness AND Heart Rate > 150 beats/minute.

Sedation if needed


Synchronized Cardioversion

1st energy level 100 J Biphasic

If no response 150 J Biphasic


Additional Drugs to consider:

Diltiazem (cardizem) 0.25 mg/kg slow IVP

Verapamil (Calan, Isoptin) 2.5 mg slow IVP

Polk State College

EMS Protocols

4

Supraventricular Tachycardia

SVT

Basic Life Support









IV 0.9% NaCl KVO or IV lock - Initiate in Antecubital fossa if possible

(E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)

NOTE: Assess etiology – Only treat if cardiac related

Stable or borderline (Rate >150):

Vagal maneuvers (Valsalva or cough)

Adenosine phosphate (Adenocard) 6 mg rapid IVP over 1-3 seconds with 10cc flush

If no response in 2 minutes, 12 mg rapid IVP over 1-3 seconds with 10cc flush


If no response in 2 minutes, repeat 12 mg IVP over 1-3 seconds with 10cc flush (Total of 30 mg)

Unstable with serious signs and symptoms ((B/P <90 AND altered mental status AND signs of shock)

(Ventricular rate > 150):

May give brief trial of Adenosine (Adenocard) 6mg rapid IVP over 1-3 seconds with 10 cc flush

Sedation if needed



First energy level 50 J Biphasic





Polk State College

EMS Protocols

5

Ventricular Tachycardia with Pulse

Basic Life Support








In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are

unreliable in excluding VT as cause of wide complex tachycardia


IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)

Stable

Amiodarone (Cordarone) 150 mg IV over 10 minutes every 10-15 minutes (Maximum of 450 mg

total.)

Additional Medication to consider: Procainamide (Pronestyl) 20 mg / min until:

1) A maximum of 1 gram or 17mg/kg

2) Rhythm subsides

3) QRS widens by greater than 50%

4) Hypotension ensues

Unstable wide complex tachycardia (B/P <90 AND altered mental status AND signs of shock)

Sedation if needed: Midazolam (Versed) 2.5mg slow IVP


o 1st energy level 100 J Biphasic

o If no response, 150 J Biphasic

o If no response 150 J Biphasic


o If delays in synchronization occur and clinical condition is critical, go immediately to

unsynchronized shocks.

Following electrical Cardioversion

o If no antiarrythmic agent was given: Amiodarone (Cordarone) 150 mg IV over 10 minutes

o If Amiodarone (Cordarone) was given:

VT Reoccurs repeat at 150 mg IV over 10 minutes every 10-15 minutes (Maximum 450 mg

cumulative total dose)

Polk State College

EMS Protocols

6

Torsades de Pointes

Basic Life Support








In general, assume wide complex tachycardia is ventricular tachycardia as EKG and clinical criteria are

unreliable in excluding VT as cause of wide complex tachycardia


IV 0.9% NaCl (E/Z IO if 2 unsuccessful attempts at IV and patient is symptomatic)

Magnesium Sulfate 2 g slow IV in 10 ml NS over 1-2 minutes

If no response, perform Cardioversion - if clinical condition permits sedate before Cardioversion

Sedation if needed







If delays in synchronization occur and clinical condition is critical, go immediately to unsynchronized shocks






Polk State College

EMS Protocols

7

Asystole

Begin immediate CPR 1. 30:2 at 100 compressions / minute with minimal pauses

NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS

arrival, provide effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200

high quality compressions/rate of 100 /min with Interposed ventilation at a rate of 10 bpm)

Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated


Endotracheal Intubation (Max 2 attempts)

Combitube if unable to intubate in appropriate patients

Confirm airway device placement with assessment and detection device (ETCO2) and capnography.

Continue CPR with no pause for ventilation.

IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV)

Epinephrine (Adrenalin) 1:10,000 1 mg IVP or IO (2 mg ETT) repeated every 3-5 minutes

Consider and treat possible causes

1. Hypoxia / Acidosis - (Hyperventilate)

2. Hypothermia – Warm Patient

3. Hypovolemia – Fluid bolus (200-300 cc up to 1-2 liters)

4. Hyperkalemia

5. Tablet (Drug) overdoses (see specific drug OD/toxicology section)

a. Beta blocker OD - Glucagon 2 mg IVP

b. Calcium channel blocker OD - Calcium Chloride 1 gram IV

i. Avoid if patient on Digoxin / Lanoxin

c. Narcotic OD - Naloxone (Narcan) 2 mg slow IVP

Polk State College

EMS Protocols

8

Pulseless Electrical Activity

(PEA)


NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS

arrival, provide effective CPR for 2 minutes. (200 high quality compressions/rate of 100 /min with

interposed ventilation at a rate of 10 bpm)

Continue high quality CPR with minimal interruptions and rescue breathing with BVM (100% oxygen) as indicated



Combitube if unable to intubate in appropriate patients

Confirm airway device placement with assessment and detection device (ETCO2) and capnography.

Continue CPR with no pause for ventilation.

IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV

Epinephrine (Adrenalin) 1:10,000 1 mg fast IVP or IO (2 mg ETT) repeated every 3-5 minutes

Potential PEA cause Treatment

Hypovolemia (most common cause) Normal Saline 200 – 300cc Bolus up to 1-2 Liters IV

Hypoxia / Hydrogen ion – acidosis Open/secure airway and ventilate

Hyperkalemia Call for orders

Hypothermia Active core rewarming

Tablets (drugs) Beta blocker OD - Glucagon 2 mg IVP

Calcium channel blocker OD - Calcium Chloride 1 gram IV

Avoid if patient on Digoxin / Lanoxin

Narcotic OD - Naloxone (Narcan) 2 mg IVP

Tamponade, cardiac Normal Saline 1-2 Liters IV

(In hospital pericardiocentesis)

Tension pneumothorax Plural Decompression

Thrombosis (Coronary / Pulmonary) (In hospital thrombolytics, cardiac cath.)

Polk State College

EMS Protocols

9

V-Fib / Pulseless V-Tach


NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide

effective CPR for 2 minutes while preparing to evaluate for defibrillation. (200 high quality compressions/rate of

100 /min with Interposed ventilation at a rate of 10 bpm

Apply monitor/defibrillator

If V-Fib / Pulseless V-Tachycardia identified:

Defibrillate at 150J biphasic (360 J monophasic) followed by immediate CPR beginning with

compressions. Perform 200 high quality compressions/rate of 100 p/m with ventilations at a rate of 10

bpm (2) minute cycles

Repeat defibrillation x1 at 150 J biphasic (360j mono-phasic) as indicated at end of each CPR cycle

Continue rescue breathing with BVM (100% oxygen) without CPR if pulse present


- King Airway (If available)

- Endotracheal Intubation (Max 2 Attempts)

- Combitube if unable to intubate in appropriate patients

Confirm airway device placement with exam and detection device (EtCO2 and Capnography)

IV 0.9% NaCl wide open (E/Z IO if 2 unsuccessful attempts at IV)

Epinephrine 1mg (Adrenalin) fast IVP/IO every 3- 5 minutes (2 mg ETT if no IV or IO access.)

Defibrillate 150 J Biphasic (or 360 J Monophasic) Bfollowed by immediate CPR for two minutes. This

step may be repeated as indicated at end of two minute CPR cycles.

Antiarrythmic/additional medications B administer sequentially (in the order listed) and defibrillate as indicated at

end of 2 minute CPR cycles-followed with immediate CPR.

Amiodarone (Cordarone) 300 mg IVP/IO may repeat 1 time at 150mg after 10 minutes,

Reassess patient for conversion between each intervention above.

Polk State College

EMS Protocols

10

Abdominal Pain / GI Bleeding

Basic Life Support



Nothing by mouth (NPO)






IV 0.9% NaCl KVO (if condition warrants)

If BP < 90 mm / Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic

BP > 90 mm Hg


For patients with severe vomiting:

Promethazine (Phenergan), 12.5 mg slow IVP

Polk State College

EMS Protocols

11

Allergic Reaction / Anaphylactic Shock

Basic Life Support

Secure airway and administer supplemental oxygen (100%)


Nothing by mouth (NPO)






Mild Reaction (Itching/Hives)

Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg) May be administered IM if no IV access


Cimetidine (Tagamet) 300 mg in 100cc over 5-10 minutes

Moderate Reaction (Dyspnea, Wheezing, Chest tightness)

Albuterol 2.5 mg (Proventil) and Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft

May repeat once in 20 minutes

Diphenhydramine (Benadryl) 1 mg/kg IV (Maximum 50 mg)

May be administered IM if no IV access available



Severe systemic reaction (BP < 90 mm Hg, stridor, severe respiratory distress)

Administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90 mm Hg

Epinephrine (Adrenalin) 1:1,000 0.3 mg SQ




May be administered IM if no IV access available



Methylprednisolone (Solu-Medrol) 125 mg slow IVP

Imminent Cardiac Arrest or Cardiopulmonary Arrest:

Epinephrine (Adrenalin) 1:10,000 0.5 mg IVP (instead of 1:1,000 SQ)



Polk State College

EMS Protocols

12

Altered Mental Status Basic Life Support


Record / monitor vital signs and Blood Glucose level

Nothing by mouth, unless patient is a known diabetic and is able to self-administer Glucose paste, orange

or apple juice

Assess for etiology



Initiate cardiac monitoring, record and evaluate EKG strip and record and evaluate 12-lead EKG

Record & monitor oxygen saturation & end-tidal C02 (if available)


If Hypoglycemic (Blood glucose < 60 mg/dL) with IV access


If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose

Dextrose 50% 25 gm Slow IVP

May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dL

If Hypoglycemic (Blood glucose < 60 mg/dL) without IV access

Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to

self-administer oral agent or

Glucagon 1 mg IM

If Drug (narcotic) overdose suspected

Naloxone (Narcan) 2 mg slow IVP

If no IV access has been established, administer Naloxone (Narcan) 2.0mg IM.

Polk State College

EMS Protocols

13

Asthma / COPD

Basic Life Support









If Acute Bronchospasm (wheezing)

Note: Patient may present with CLEAR diminished lung sounds due to the inability to move air because

they are so constricted.

If Asthma History - Albuterol (Proventil) 2.5 mg via updraft.


Repeat Albuterol (Proventil) 2.5 mg via updraft x2 as needed

Ipratropium Bromide 0.02% (Atrovent) 0.5 mg/ 2.5 ml via updraft


If COPD History - Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide 0.02% (Atrovent) 0.5

mg/2.5 ml via updraft

o May repeat in 20 minutes x2

o If patient condition deteriorates, Utilize CPAP at 5.0 cmH20



If patient experiences decreased level of consciousness with respiratory failure OR poor ventilatory effort (with

hypoxia unresponsive to supplemental 100% oxygen) OR unable to maintain patent airway, intubation is indicated.

If conscious sedation needed proceed with RSI protocol

Polk State College

EMS Protocols

14

Behavioral Emergencies

Basic Life Support



Restrain as needed for patient/crew safety



Begin cardiac monitoring, record and evaluate EKG strip and evaluate 12-lead EKG


IV 0.9% NaCl KVO (if condition warrants)

o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic

BP > 90 mm Hg

For patients with extreme agitation resulting in interference with patient care or patient/crew safety

o Midazolam (Versed)

< 70 kg 5 mg IM

> 70 kg 10 mg IM

Select MAO inhibitors

Nardil (Phenelzine)

Parnate (Tranylcypromine)


Haloperidol (Haldol) < 60 kg 5 mg IM

> 60 kg 10 mg IM.

Medical Control

Call Medical Control if further sedation needed

Repeat Haloperidol (Haldol) 5 mg IV or IM

Polk State College

EMS Protocols

15

Rapid Sequence Induction (RSI)

Adult

REMEMBER – ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES

PRECEDENT OVER TRAUMA SCENE TIME!!!

This protocol is only to be utilized under the following circumstances:

TRAUMA

BMR <= 4 (UNCONSCIOUS – withdraws to painful stimulus)

Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS – localizes painful stimulus)

Unstable traumatic airway condition as assessed by the Paramedic

MEDICAL - As specified in specific protocols

Basic Life Support

Secure airway - Administer supplemental oxygen 100% via BVM device


Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history)

Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before

utilizing King Airway


Begin cardiac monitoring, record and evaluate EKG strip

Visually evaluate oropharynx for indications of difficult intubation situation. If no visual indications present,

then proceed with RSI.

IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV)

If no seizure:

o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched) o If clenched induce paralysis with Succinylcholine 1.5 mg/kg IV

o Confirm tube placement with CO2 detector color change

o Provide oxygenation between intubation attempts (Maximum of 2 attempts, then SALT or Combitube)

o Midazolam (Versed) 5 mg IV if Succinylcholine is given or needed for continued sedation.

May repeat for a Midazolam (Versed) 5 mg IV for sedation

If seizure: o Lidocaine (Xylocaine) 1mg/kg IV if Head Injury

o Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation

o Midazolam (Versed) 5 mg IV for sedation if needed.

o Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO2

detector color change

o If two (2) endotrachael attempts fail, begin BCLS procedures, control airway and ventilate with BVM

and airway adjunct

Polk State College

EMS Protocols

16

Pulmonary Edema

Basic Life Support









Only if Wheezing is present:

Albuterol (Proventil) 2.5 mg AND Ipratropium Bromide .02% (Atrovent) 0.5 mg/2.5 ml via updraft


Contraindicated if: HR > 150 or systolic BP > 180 mm Hg

Nitroglycerin (Nitrostat) 0.4 mg spray SL every 5 minutes, until Nitroglycerin drip established at 10mcg/min via

infusion regulator. Contraindicated if: Systolic BP < 90 mm Hg

Viagra taken within 24 hrs


Furosemide (Lasix) 1 mg / kg to a maximum of 100mg

Utilize CPAP at 10.0 cm H2O. Evaluate effectiveness and need for intubation If patient experiences decreased level of

consciousness with respiratory failure OR

poor ventilatory effort (with hypoxia unresponsive to supplemental 100% oxygen) OR

unable to maintain patent airway, intubation is indicated.

If conscious sedation needed to effect intubation proceed with RSI protocol

Dopamine (Intropin) infusion at 5-20 mcg/kg/min titrated as needed if systolic BP < 90 mm Hg

Polk State College

EMS Protocols

17

Seizure Basic Life Support



Protect patient from injury




Record and evaluate 12-lead EKG if seizure has stopped


Blood Glucose measurement

IV 0.9% NaCl KVO or IV lock (medications only for active seizures)

If Hypoglycemic (Blood glucose < 60 mg/dL) with IV access

Additional Drugs: If malnourished or Alcohol history Thiamine 100 mg IV with initial Dextrose

NOTE: Must be given PRIOR to or in conjunction with Dextrose.

Dextrose 50% 25 gm Slow IVP

May repeat as needed every 5 or 10 minutes to Blood Glucose > 100 mg/dL

If Hypoglycemic (Blood glucose < 60 mg/dL) without IV access

Glucose paste (Glutose) or other oral glucose agent (e.g. orange juice) if patient alert enough to self

administer oral agent or

Glucagon 1 mg IM

Midazolam (Versed) 2.5 mg slow IVP repeat once for a maximum of 5 mg

If NO IV access:

Midazolam (Versed) 5 mg slow IVP repeat once for a maximum of 10 mg

Polk State College

EMS Protocols

18

Overdose and Poisonings

NOTE: General considerations for any overdose or poisoning include determining the particular agent(s) involved, the

time of the ingestion/exposure, and the amount ingested. Bring empty pill bottles, etc., to the receiving facility.

See HAZMAT protocol for exposure to hazardous materials.

Basic Life Support

Secure airway and administer supplemental oxygen (100%)


Nothing by mouth (depending on agent, patient may be at risk for seizure or rapid loss of consciousness with

subsequent aspiration)




Record & monitor 02 saturation

IV 0.9% NaCl KVO

o If BP < 90 mm Hg systolic, administer boluses of 0.9% NaCl at 200-300 ml until systolic BP > 90

mm Hg

Antidepressants Category Drugs Overdose Effects

Tricyclic

antidepressants

Amitriptyline (Elavil, Endep, Etrafon,

Vanatrip, Levate)

Hypotension

Anti-cholinergic effects (tachycardia,

seizures, altered mental status,

mydriasis)

AV conduction blocks, prolonged

QT interval, wide QRS, VT and VF

Clomipramine (Anafranil)

Doxepin (Sinequan, Zonalon, Triadapin)

Imipramine (Tofranil, Impril)

Nortriptyline (Aventyl; Pamelor, Norventyl)

Desipramine (Norpramin)

Protriptyline (Vivactil)

Trimipramine (Surmontil)

(Limbitrol) Amitriptyline + chlordiazepoxide

Other Cyclic

Antidepressants

Maprotiline (Ludiomil) Ludiomil is similar to tricyclics,

Asendin produces mostly seizures Amoxapine (Asendin)

Bupropion (Wellbutrin) Minimal-moderate seizures

Trazodone (Desyrel, Trazorel) Less seizures and cardiac effects than

tricyclics

Selective

Serotonin Reuptake

Inhibitors (SSRI’s)

Citalopram (Celexa) Hypertension, tachycardia, agitation,

diaphoresis, shivering, tremor,

muscle rigidity

Malignant Hyperthermia

Fluoexitine (Prozac)

Fluvoxamine (Luvox)

Paroxetine (Paxil)

Sertraline (Zoloft)

Polk State College

EMS Protocols

19

Overdose

Tricyclic and Tetracyclic Antidepressant

Basic Life Support

Secure airway and administer supplemental oxygen 100%




Begin cardiac monitoring, record and evaluate EKG strip and 12-lead EKG


IV 0.9% NaCl KVO

If wide QRS, hypotension, or arrhythmias present:

Consider: Sodium Bicarbonate 1mEq / kg IVP

Anticholinergic Poisoning/Organophosphates

Basic Life Support

Wear protective clothing including masks, gloves, and eye protection.

Toxicity to ambulance crew may result from inhalation or topical exposure.

Any traces of contamination must be removed from the vehicle prior to the next transport.



Decontaminate patient

o Remove clothing

o Irrigate with normal saline – may also use soap and water

o Contain run-off of toxic chemicals when flushing





IV 0.9% NaCl KVO o Remember SLUDGE: Salivation, Lactation, Urination, Defecation, GI, Emesis

o If signs of severe toxicity, (severe respiratory distress, bradycardia, heavy respiratory secretions – do

not rely on pupil constriction to diagnose or to titrate medications)

o Atropine 2.0 mg fast IVP every 5 min – titrate until respiratory secretions/distress begins to

decrease

Polk State College

EMS Protocols

20

Antipsychotic/Acute Dystonic Reaction

Commonly used Antipsychotic and Antipsychotic related medicines (e.g. antiemetics) in medical practice include, but are not

limited to the following: Prochlorperazine (Compazine) Promethazine (Phenergan) Thorazine

Prolixin Haloperidol

Basic Life Support







IV 0.9% NaCl KVO

For Dystonic reactions, administer

Diphenhydramine (Benadryl) 25 mg IVP.

Repeat Diphenhydramine (Benadryl) 25 mg IVP if inadequate response, in 10 minutes

Carbon Monoxide

Basic Life Support







IV 0.9% NaCl KVO

Draw blood and place with cold pack

Consider transport to hyperbaric chamber

Cocaine and Sympathomimetic Overdose

Basic Life Support







IV 0.9% NaCl KVO

For patients with Sympathomimetic toxidrome (hypertension, tachycardia, agitation):

o Midazolam (Versed) < 70 kg - 2.5 mg slow IVP

> 70 kg - 5 mg slow IVP

Polk State College

EMS Protocols

21

Beta Blocker Toxicity

Commonly used Beta Blockers(lol) in medical practice include but are not limited to the following:

Propranolol (Inderal) Atenolol (Tenormin) Metroprolol (Lopressor) Nadolol (Corgard)

Timolol (Blocadren) Labetolol (Trandate) Esmolol (Brevibloc) Acebatolol (Sectral)

In addition beta-blockers are contained in many combination drugs. It is the beta-blocker component that leads to

specific toxicity. Combination beta-blocker drugs include, but are not limited to the following:

Corzide (Nadolol/bendroflumethlazide) Inderide (Propranolol/HCTZ)

Inderide LA (Propranolol/HCTZ) Lopressor HCT (Metoprolol/HCTZ)

Tenoretic (Atenolol/Chlorthalidone) Timolide (Timolol/HCTZ)

Ziac (Bisoprolol/HCTZ)

Basic Life Support







IV 0.9% NaCl KVO If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at 200-300ml until systolic BP > 90

mm Hg

For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) with

(1) bradycardia with rate < 60 or

(2) Heart block, including third degree heart block and high grade second degree heart blocks i.e. Mobitz Type II

second degree

Administer the following agents

Atropine 0.5 mg IV, may repeat X 2

If no response, begin Transcutaneous Pacing

Medical Control

Dopamine (Intropin) infusion, or additional orders if cardiovascular toxicity persists

Polk State College

EMS Protocols

22

Calcium Channel Blockers

Calcium Channel Blockers include:

Amlodipine (Norvasc) Felodipine (Plendil, Renedil) Isradipine (DynaCirc) Nicardipine (Cardene)

Verapamil (Calan) Nifedipine (Procardia, Adalat) Diltiazem (Cardizem)

Basic Life Support







IV 0.9% NaCl KVO o If BP < 90 mm Hg systolic administer boluses of 0.9% NaCl at 200-300ml until systolic

BP > 90 mm Hg

For patients with cardiovascular toxicity (chest pain, syncope, SBP < 90 mm Hg, altered mental mentation) (1)

bradycardia with rate < 60 or (2) Heart block, including third degree heart block and high grade second degree

heart blocks i.e. - Mobitz Type II second degree

Administer the following agents

o Atropine 0.5 mg fast IV, may repeat X 2

o If no response, Calcium Chloride 1 gram IV

Avoid if patient taking digoxin (Lanoxin)

o If no response, may repeat Calcium Chloride 1 gram IV

o If no response, begin transcutaneous pacing

Medical Control

Dopamine (Intropin) or epinephrine infusion, or additional orders if cardiovascular toxicity persists

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EMS Protocols

23

Adult Trauma Triage Criteria

COMPONENT

BLUE

RED

AIRWAY

RESPIRATORY RATE > = 30 / MINUTE

Active Airway Assistance Beyond Administration of

Oxygen

CIRCULATION

Sustained Heart Rate

> 120

(1) Lack of Radial Pulse With Sustained H/R > 120

OR (2) B/P < 90 mm / hg

BEST MOTOR

RESPONSE

(Pinch of the inner thigh)

BMR = 5

(1) BMR < = 4

OR (2) EXHIBITS PRESENCE OF PARALYSIS

OR (3) Suspicion of Spinal Cord Injury OR Loss of

Sensation

CUTANEOUS

(1) Soft Tissue Loss via Degloving Injuries

OR (2) Major Flap Avulsions > 5 Inches

OR (3) GSW To Extremities of The Body

(1) Amputation Proximal To Wrist / or Ankle

OR (2) 2nd / 3rd Degree Burns To > 15 % TBSA

OR (3) Penetrating Injury To Head, Neck, Torso

( Excluding superficial wounds where the depth of the

wound can be determined) LONG BONE FRACTURE

S/S of Single Long Bone FX Site Resulting

From a MVC OR Fall > 10 Feet

S/S of 2 OR more Long Bone FX Sites

(SEE LONG BONE DEFINITION BELOW)

AGE

> 55

MECHANISM OF

INJURY

(1) Ejection From Vehicle

(EXCEPT: ATVS, Motorcycles, Bicycles,

Open Body of Pick-ups, Mopeds

OR (2) Driver Impact of Steering Wheel

Causing Deformity

LONG BONES ARE DEFINED AS

1. Radius AND Ulna,

2. Humerus

3. Femur

4. Tibia AND Fibula

Adult Pain Management

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EMS Protocols

24

Basic Life Support

Establish patient responsiveness

If trauma suspected, stabilize spine

Assess Airway/Breathing/Oxygenation

Assess perfusion and circulation , obtaining a baseline blood pressure

Assess mental status

Assess baseline pain level (0-10 scale), (0 = no pain, 10 = worst pain)

Administer nothing by mouth (NPO)


Assess airway/breathing and ensure no airway intervention or ventilation needed

Begin cardiac monitoring

Record and monitor oxygen saturation

IV 0.9% NaCl KVO

Perform a focused history and detailed physical examination en route to the hospital if patient status and

management of resources permit.

Analgesic agents may be administered if patient has severe pain and one of following

o Extremity injury including long bone fracture in the presence of multi-system trauma. (Pt must be

alert, normotensive)

o Burn without airway, breathing, or circulatory compromise

o Medical Control Contact required for Sickle crisis with pain that is typical for that patient’s sickle

cell disease

o Acute chest pain – see chest pain protocol for management

Agents for pain control

Phenergan (Promethazine) 6.25 mg diluted in 5ml 0.9% NaCl slow IVP

Morphine Sulfate 2 mg slow IVP every 5 minutes until pain relief achieved (Maximum 10 mg)

(Maximum 20 mg for burns)

Reassess the patient frequently

Polk State College

EMS Protocols

25

Rapid Sequence Induction (RSI)

Pediatric

REMEMBER – ESTABLISHMENT OF A PATENT AIRWAY IS FIRST PRIORITY AND TAKES

PRECEDENT OVER TRAUMA SCENE TIME!!!

This protocol is only to be utilized under the following circumstances:

TRAUMA

BMR <= 4 (UNCONSCIOUS – withdraws to painful stimulus)

Head Injury with BMR <=5 with clenched teeth (UNCONSCIOUS – localizes painful stimulus)

Unstable traumatic airway condition as assessed by the Paramedic

MEDICAL - As specified in specific protocols

Basic Life Support

Secure airway - Administer supplemental oxygen 100% via BVM device


Evaluate RSI criteria for inclusion - Rule out seizure related to acute Head Injury (not epileptic history)

Evaluate and grade airway (1, 2, 3, 4). If grade 3 or 4 airway, intubation attempts limited to one (1) before

utilizing King Airway



IV 0.9% NaCl wide open, (E/Z IO if 2 unsuccessful attempts at IV)

If no seizure:

Atropine 0.02 mg/kg fast IVP

Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP

Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched)

Induce paralysis with Succinylcholine 2.0 mg/kg slow IVP over 15-30 seconds

Confirm tube placement with CO2 detector color change

Provide oxygenation between intubation attempts (Maximum of 2 attempts, then OPA/NPA)

Midazolam (Versed) 0.1 mg/kg slow IVP if Succinylcholine has been given or for continued sedation. May

repeat once to a maximum of 5 mg.

If seizure:

Atropine 0.02 mg/kg IV

Information: Atropine Minimum of 0.1 mg or 1cc / fast IVP

Etomidate (Amidate) 0.3 mg/kg IV; attempt intubation (if still clenched)

Fentanyl (Sublimaze) 6 mcg/kg IV for sedation if needed

Intubate gently using cricoid pressure, visualizing landmarks and confirming tube placement with CO2 detector

color change

Provide oxygenation between intubation attempts (Maximum of 2 attempts, then BVM and airway adjunct

Midazolam (Versed) 0.1 mg/kg slow IVP for continued sedation. May repeat once to a maximum of 5 mg. .

Medical Control

Contact medical control for continued sedation or higher dosage of medication to facilitate intubation

Polk State College

EMS Protocols

26

Allergic Reaction / Anaphylactic Shock

(Pediatric)

Basic Life Support

Establish responsiveness


Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed

Assess perfusion and circulation





If patient meets criteria for anaphylactic shock

Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg SQ (max individual dose 0.3 mg)

o Massage the injection site vigorously for 30-60 seconds

Epinephrine (Adrenalin) 1:1,000 solution of 0.01 mg/kg is equal to 0.01cc/kg SQ

If bronchospasm is present in a patient with adequate ventilation,

o Albuterol (Proventil) 2.5 mg via nebulizer over a 10-15 minute period

If bronchospasm persists,

o Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes

Reassess patient for signs of anaphylactic shock. If criteria are still present repeat

o Epinephrine (Adrenalin) 1:1,000 solution at 0.01 mg/kg (0.01cc/kg)

(Maximum individual dose 0.3 mg) via SQ injection.


Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml

Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP


If evidence of shock,

If IV access cannot be obtained, place intraosseous needle (IO).

Administer fluid bolus of 0.9% NaCl at 20 ml/kg set to maximum flow rate IV or IO

After reassessment, if shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.

Diphenhydramine (Benadryl) 1.0 mg/kg IV or deep IM (maximum individual dose 50 mg)

Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature

throughout the examination

Polk State College

EMS Protocols

27

Altered Mental Status

Pediatric

This protocol is intended for pediatric patients with an altered mental status of unknown etiology.

Basic Life Support



Airway/Breathing/Oxygenation - Assist breathing/ventilation if needed




If signs or respiratory distress, failure or arrest are present refer to the appropriate protocol

If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% as necessary.

Use a non rebreather mask or blow-by as tolerated

Initiate cardiac monitoring and determine rhythm

IV 0.9% NaCl KVO, if IV access cannot be obtained after 2 attempts proceed with E/Z IO

Determine blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)

(NOTE: The following dosages are equivalent to 0.5g/kg)

D10W 5 ml/kg for neonates

D25W 2 ml/kg for children 2 years

D50W 1 ml/kg for children > 2 years

IF IV or IO access is unavailable:

< 20 kg, Glucagon 0.5 mg IM

> 20 kg, Glucagon 1.0 mg IM

Repeat Dextrose once if

Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood glucose and no change

in mental status

If patient has continued altered mental status

Naloxone (Narcan) 0.1 mg/kg (Maximum individual dose 2.0 mg) via IV or IO route

If IV or IO unavailable administer same dose endotracheally or IM

If evidence of shock

If IV access cannot be obtained, and 5 years place intraosseous needle (IO)

Fluid bolus 0.9% NaCl at 20 ml/kg

If shock persists, repeat bolus X 2 to a maximum total of 60 ml/kg.



Polk State College

EMS Protocols

28

Bronchospasm

Pediatric

Basic Life Support

Assess airway and breathing and administer oxygen

If breathing adequate, place child in a position of comfort and administer high-flow oxygen 100% with

non-rebreather mask or blow-by as tolerated

Assess circulation and perfusion


Obtain and record pulse oximetry reading

Assist breathing/ventilation if needed

If bronchospasm

Albuterol (Proventil) 2.5 mg via nebulizer over 10-15 minutes

If bronchospasm persists, repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20-minutes

If patient shows signs of respiratory distress or failure with clinical evidence of bronchospasm or a history of

asthma and inadequate ventilation

Epinephrine (Adrenalin) 1:1,000 at 0.01 mg/kg (max 0.3 mg) subcutaneously

Repeat Albuterol (Proventil) 2.5 mg via nebulizer once in 20 minutes AND Epinephrine every 15

minutes as needed x 2. NOTE: May administer at same time nebulizer is being administered


Ipratropium Bromide (Atrovent) 0.02% 0.5 mg/2.5 ml

Methylprednisolone (Solu-Medrol) 2 mg / kg to a maximum of 125 mg slow IVP

Magnesium Sulfate 50mg/kg IV over 5-10 minutes

Initiate transport and perform focused history and detailed physical examination en route to the hospital if patient status

and management of resources permit.

Reassess the patient frequently

Polk State College

EMS Protocols

29

Bradycardia

Pediatric


Advanced airway/ventilatory management as needed / Obtain and record pulse oximetry reading


Initiate chest compressions if signs of severe cardiopulmonary compromise are present in an infant (< 1 year)

or neonate and the heart rate remains slower than 60 beats per minute despite oxygenation and ventilation

Identify and treat possible causes of bradycardia

If hypoxia open airway - assist breathing If hypothermic – rewarm

If signs of severe cardiopulmonary compromise

IV 0.9% NaCl KVO – NOTE: If IV cannot be obtained after 2 attempts, AND the patient shows signs

of severe cardiopulmonary compromise, proceed with E/Z IO access.

Do not delay transport to establish access

*Check blood glucose and treat glucose < 60 mg/dl (0.5 – 1 g/kg)





If signs of severe cardiopulmonary compromise persist: Use 1st route available

Epinephrine (Adrenalin) 1:10,000 at 0.01 mg/kg (Max 1 mg) via IV/IO

Repeat dose every 3-5 minutes until either the bradycardia or severe cardiopulmonary compromise

resolves

If signs of severe cardiopulmonary compromise persist despite epinephrine and above measures

Atropine at 0.02 mg/kg via IV, IO, (0.2cc/kg)

Minimum dose is 0.1 mg and Maximum individual dose is 0.5 mg / child and 1.0 mg / adolescent

May repeat once after 3-5 minutes until maximum dose reached.

If severe cardiopulmonary compromise persists despite epinephrine/atropine

If weight is < 15 kg apply pediatric external pads, 15 kg apply adult external pacer pads use lowest

energy that causes every pacer impulse to result in ventricular capture (pulse)

If severe cardiopulmonary compromise persists despite pacing

Dopamine (Intropin)infusion at 5-20 mcg/kg/minute IV

Medical Control

Repeated administration of Epinephrine (Adrenalin) and Atropine

Polk State College

EMS Protocols

30

Supraventricular Tachycardia

Pediatric Basic Life Support



Airway/Breathing/Oxygenation


Assess patient to ensure etiology and this is cardiac in nature!


Assist airway, ventilation if needed




IV 0.9% NaCl KVO

If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary

compromise, proceed with E/Z IO access.

Do not delay transport to obtain vascular access






Supraventricular tachycardia (HR > 220 Infants, >190 Child) with severe cardiopulmonary compromise

Adenosine (Adenocard) 0.1 mg/kg (0.1cc/3kg)

Max individual dose 6.0 mg via rapid IV/IO bolus at the port closest to the IV hub.

Repeat Adenosine (Adenocard) twice at 0.2 mg/kg if needed (Maximum individual dose 12 mg)

If Adenosine is unsuccessful and patient still has severe cardiopulmonary compromise

See Medical Control box for possible sedation orders

Medical Control

Sedate the patient before Cardioversion as permitted by Medical Direction

Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg)

Synchronized Cardioversion at 0.5 - 1.0 joules/kg

May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules)

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EMS Protocols

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Ventriclular Tachycardia (With Pulse)











IV 0.9% NaCl KVO

If IV cannot be obtained after 2 attempts, AND the patient shows signs of severe cardiopulmonary

compromise, proceed with E/Z IO access.

Do not delay transport to obtain vascular access






Amiodarone (Cordarone) 5mg/kg IV over 10 minutes (Mix in a 100cc bag – 1ml/kg)

If vascular access is not readily available AND the patient is poorly perfused

See Medical Control box for possible sedation orders

Medical Control

Sedate the patient before Cardioversion as permitted by Medical Direction

Midazolam (Versed) 0.1 mg/kg IV (Maximum individual dose 5.0mg)

Synchronized Cardioversion at 0.5-1.0 joules/kg

May repeat at 2 joules/kg to maximum of 4 joules/kg (max individual dose 360 joules)

Polk State College

EMS Protocols

32

Overdose / Poisoning or Ingestion











IV 0.9% NaCl KVO

If respiratory depression is present and a narcotic overdose is suspected,

Administer Naloxone (Narcan) at 0.1 mg/kg (Maximum dose 2.0 mg) via IV, IO, or IM route

Treatment for specific toxic exposures:

Organophosphates

Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg)

Calcium channel and B-blocker overdose

Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg if inadequate response

Atropine 0.02 mg/kg fast IVP or IO (minimum dose 0.1 mg) for symptomatic bradycardia, if

inadequate response

Calcium Chloride 0.3 ml/kg slow IV over 2 minutes for calcium channel blocker overdose

Dystonic reactions –acute uncontrollable muscle contractions

Diphenhydramine (Benadryl) 1 mg/kg IV or deep IM (Maximum dose 50 mg)

Medical Control

Contact Medical Control for questions concerning individual toxic exposures and treatments.

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Seizure

Pediatric

Basic Life Support










IV 0.9% NaCl KVO

If IV access cannot be obtained AND patient in shock, proceed with E/Z IO access



o D10W 5 ml/kg for neonates

o D25W 2 ml/kg for children 2 years

o D50W 1 ml/kg for children > 2 years

o Glucagon 0.5 mg if less than 20 kg; or 1.0 mg if greater than 20 kg

Repeat dextrose once if Blood glucose remains < 60 mg/dl after treatment OR cannot determine blood

glucose and no change in mental status.

Administer anticonvulsants IV slowly over 1-2 minutes if patient in status epilepticus

(More than 10 minute seizure, or more than 1 seizure without awakening)

Midazolam (Versed) 0.1 mg/kg IV (Max. individual dose 5 mg) OR if no IV

Midazolam (Versed) 0.2 mg/kg IM (Max. individual dose 10 mg)

Medical Control

Contact Medical Control for any further orders, questions, or assistance.

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EMS Protocols

34

Asystole

Pediatric

Establish patient responsiveness - If spine trauma suspected, stabilize spine

Confirm Cardiac Arrest: Begin CPR (Two minute cycles of 30:2 or 15:2 with two rescuers)

NOTE: If estimated down-time is 5 minutes or longer without adequate CPR prior to Fire/EMS arrival, provide effective

CPR for 2 minutes while preparing to evaluate rhythm. (200 high quality compressions/rate of 100 per minute with

Interposed ventilation)

Apply heart monitor as soon as available.

Follow Non-traumatic Cardiac Arrest Protocol

Confirm the presence of Asystole in two leads

Maintain adequate ventilation via BVM with 100% oxygen

o Endotracheal Intubation (Max 2 attempts)

o Assess effective ventilations with exam, and ETCO2/capnography

o If unable to intubate, maintain adequate ventilations via BVM with airway adjunct and 100% oxygen.

IV 0.9% NaCl KVO, if signs of severe cardiopulmonary compromise; proceed with E/Z IO access.

Using the most readily available route, administer

Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg IV or IO, repeat every 3-5 min.

Potential Asystole cause Treatment

Hypovolemia (most common cause) Normal Saline 20 cc / kg may repeat times 2

(to a maximum total of 60ml/kg)



Hypoglycemia (Blood glucose < 60 mg/dL) - Dextrose 50% 25 gm Slow IVP

Tablets (drugs) Calcium channel blocker OD - Glucagon 0.5 mg < 20 kg or 1 mg > 20 kg

If no response: Atropine 0.02 mg/kg

If no response: Calcium Chloride 30 mg/kg Narcotic OD - Naloxone (Narcan) 0.1 mg/kg

Tamponade, cardiac Normal Saline 20 m1/ kg (In hospital pericardiocentesis)

Tension pneumothorax Plural Decompression (20 gauge needle)

Trauma (In hospital surgery)

Maintain the child’s body temperature throughout the examination

Medical Control

Contact Medical Control for any further orders, questions, or assistance.

Polk State College

EMS Protocols

35

Pulseless Electrical Activity (PEA)

Pediatric


Establish patient responsiveness / If trauma suspected, stabilize spine

Confirm apnea and pulselessness and administer CPR

o (Two minute cycles of 30:2 or 15:2 with two rescuers)

Apply heart monitor soon as available.

Maintain adequate ventilation via BVM with airway adjunct (OPA) and 100% oxygen


Assess effective ventilations with exam, EtCo2 and capnography.

If unable to intubate, maintain adequate ventilations via BVM with airway adjunct and 100% oxygen

Follow Nontraumatic Cardiac Arrest Protocol

Treat suspected cause of PEA if known:

Potential PEA cause Treatment

Hypovolemia (most common cause) Normal Saline 20 cc / kg may repeat times 2

(to a maximum total of 60ml/kg)



Hypoglycemia (Blood glucose < 60 mg/dL) - Dextrose 50% 25 gm Slow IVP

Tablets (drugs) Calcium channel blocker OD - Glucagon 0.5 mg < 20 kg or 1 mg > 20 kg

If no response: Atropine 0.02 mg/kg

If no response: Calcium Chloride 30 mg/kg Narcotic OD - Naloxone (Narcan) 0.1 mg/kg

Tamponade, cardiac Normal Saline 20 m1/ kg (In hospital pericardiocentesis)

Tension pneumothorax Plural Decompression (20 gauge needle)

Trauma (In hospital surgery)

If PEA persists, using the most readily available route

Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg IV or IO, repeat every 3-5 min.

Flush medication port with 10-20 ml of normal saline after each dose



Perform focused history and detailed physical examination en route to the hospital if patient status and

management of resources permit.

Reassess frequently

Polk State College

EMS Protocols

36

V-Fib / Pulseless V-Tachycardia

Pediatric


Establish patient responsiveness / if spinal trauma suspected, stabilize / Apply heart monitor soon as available

Confirm apnea and pulselessness and administer CPR (Two minute cycles of 30:2 or 15:2 with two

rescuers)

Defibrillate at 2.0 j/kg (maximum of 200 joules) or equivalent biphasic followed by immediate CPR for

two minutes.

Continue ventilations via BVM/ETT with 100% oxygen throughout resuscitation/post resuscitation

efforts as indicated.


Assess effective ventilations with exam, EtCo2 and capnography.

Confirm the presence of ventricular fibrillation/pulseless ventricular tachycardia using the most readily available route

administer:

Epinephrine (Adrenalin) 1:10,000 of 0.01 mg/kg (1cc/kg) IV or IO, repeat every 3-5 min.

Flush medication port with 10-20 ml of normal saline after each dose

Defibrillate at 4.0 j/kg (maximum of 360 joules) or equivalent biphasic followed by immediate CPR for

two minutes. May repeat this step as indicated at end of two minute CPR cycles.

Amiodarone (Cordarone) 5 mg/kg IV/IO (1cc/kg) bolus. Repeat at 2.5 mg/kg one time if needed.

o Magnesium 50 mg/kg IV/IO for torsades de pointes or hypomagnesaemia

Defibrillate at 4.0 J/kg within 30-60 seconds after each medication at end of two minute CPR cycles.

IF VF or pulseless VT reoccurs after successful defibrillation, repeat defibrillation using the last energy level that

restored perfusing rhythm

Expose the child only as necessary to perform further assessments. Maintain the child’s body temperature throughout the

examination

Perform focused history and detailed physical examination en route to the hospital if patient status and management of

resources.

Polk State College

EMS Protocols

37

Pain Management

Pediatric

Basic Life Support

Establish responsiveness / Mental Status








Obtain baseline blood pressure


IV 0.9% NaCl KVO

Analgesic agents may be administered if patient has severe pain and one of following

Extremity injury including long bone fracture in the presence of multi-system trauma.

o (Patient must be alert, normotensive)

Burn without airway, breathing, or circulatory compromise

Typical sickle cell crisis for patient

Agents for pain control

Phenergan (Promethazine) 6.25 mg diluted in 5ml 0.9% NaCl slow IVP

Morphine Sulfate 1 mg slow IVP every 5 minutes until pain relief achieved (Maximum 10 mg)

Reassess the patient every 5 minutes

After drug administration note adequacy of ventilation and perfusion

Medical Control

Contact Medical Control for questions concerning pain control in children not meeting above criteria

Polk State College

EMS Protocols

38

Pediatric Trauma Triage Criteria

COMPONENT

BLUE

RED

SIZE (1) 11 KG ( 24 LBS) OR LESS

OR (2) The body length is equivalent to this

weight on a PEDIATRIC LENGTH AND

WEIGHT EMERGENCY TAPE

AIRWAY

(1) Intubated

OR (2) Breathing is Assisted Through Manual Jaw

Thrust, Suctioning, Adjuncts

CONSCIOUSNESS

(1) Symptoms of Amnesia

OR (2) Loss of Consciousness

(1) Altered Mental Status OR

(2) COMA OR

(3) Presence of Paralysis OR

(4) Suspicion of Spinal Cord Injury OR

(5) Loss of Sensation

CIRCULATION (1) Only Carotid or Femoral Pulses

Palpable, But Radial and Pedal Pulses are

not Palpable

OR (2) SBP < 90 MM / HG

(1) Faint or Nonpalpable Carotid or Femoral

Pulses

OR (2) SBP < 50 MM / HG

FRACTURE Signs / Symptoms of a Single Closed Long

Bone Fracture

(EXCLUDING ISOLATED WRIST OR

ANKLE FRACTURE)

(1) Any Open Long Bone Fracture

OR (2) Multiple Fracture / Dislocation Sites

(EXCLUDING WRIST / ANKLE FRACTURE

AND DISLOCATIONS)

CUTANEOUS

(1) Amputation Proximal to Wrist or Ankle

OR

(2) Major Tissue Disruptions

(Flap, Avulsions, Degloving Injuries)

OR (3) 2nd or 3rd Degree Burns to > 10 % TBSA

OR

(4) Any Penetrating Injury to Head, Neck or

Torso (Excluding Superficial Injuries Where

The Depth of The Wound Can Be Determined)

Altered Mental Status:

Drowsiness

Lethargy

Inability to follow commands

Unresponsiveness to voice, or totally unresponsive.

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