2019 Protocols (Adult) Flashcards

Question 1

Q

S-120 Abdominal Discomfort BLS

Answer

A

Ensure patent airway
O2 saturation prn
O2 and/or ventilate prn
NPO
Transport suspected symptomatic aortic aneurysm to facility with surgical resources immediately available

Question 2

Q

S-120 Abdominal Discomfort ALS

Answer

A

Monitor EKG
IV/IO SO adjust prn
Treat pain as per Pain Management Protocol (S-141)

Suspected volume depletion:
-500ml fluid bolus IV/IO SO

Suspected AAA:
-500ml fluid bolus IV/IO SO for BP<80 to maintain a BP of 80, may repeat x1 SO

For nausea/vomiting:
-Zofran 4mg IV/IM/ODT SO, MR x1 q10” SO

Question 3

Q

S-121 Airway Obstruction BLS

Answer

A

For a conscious patient:

Reassure, encourage coughing
O2 prn

For inadequate airway exchange:
airway maneuvers (AHA)
-Abdominal thrusts
-Use chest thrusts in the obese or pregnant patient

If patient becomes unconscious or is found unconscious
-Begin CPR

Once obstruction is removed:

High flow O2, ventilate prn
O2 saturation prn

Question 4

Q

S-121 Airway Obstruction ALS

Answer

A

If patient becomes unconscious or has a decreasing LOC:

Direct laryngoscopy and Magill forceps SO MR prn
Capnography SO prn

Once obstruction is removed:

Monitor EKG
IV/IO SO adjust prn

Question 5

Q

S-122 Allergic Reaction/Anaphylaxis BLS

Answer

A

Ensure patent airway
O2 Saturation prn
O2 and/or ventilate prn
Remove stinger/injection mechanism
May assist patient to self-medicate with own prescribed epinephrine auto-injector or MDI ONE TIME ONLY. Base Hospital contact required prior to any repeat dose.

If available and trained:
-Epinephrine auto-injector 0.3mg IM x1

Question 6

Q

S-122 Allergic Reaction/Anaphylaxis ALS

Answer

A

Monitor EKG
IV/IO SO adjust prn
Capnography SO prn

Hives (Urticaria):
-Benadryl 50mg IV/IM SO

Anaphylaxis:
-Epinephrine 1:1,000 0.3mg IM per SO. MR x2 q5” SO
then
-500ml fluid bolus IV/IO for systolic BP<90 SO
MR to maintain systolic BP>90 SO
-Benadryl 50mg IM/IV SO
-Albuterol 6ml 0.083% via nebulizer SO.
MR SO for respiratory involvement
-Atrovent 2.5ml 0.02% via nebulizer added to first dose of Albuterol SO for respiratory involvement.

Epinephrine 1:10,000 0.1mg IV/IO BHO. MR x2 q3-5” BHO
Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO

Question 7

Q

S-122 Allergic Reaction/Anaphylaxis/Angioedema criteria

Answer

A

Anaphylaxis criteria (may include any):

Unknown exposure : Skin AND Respiratory AND/OR cardiovascular
Likely allergen exposure (eg beesting, peanut): 2/4 systems involved (skin, GI, respiratory, cardiovascular)
Known allergen exposure

Angioedema:
lip/tongue/face swelling/difficulty swallowing/throat tightness, hoarse voice

Question 8

Q

S-123 Altered Neurological Function BLS

Answer

A

Ensure patent airway, O2 and/or ventilate prn
O2 saturation prn
Spinal stabilization prn
Secretion problems, position on affected side
Do not allow patient to walk
Restrain prn
Monitor blood glucose prn (if trained and available)

Symptomatic suspected opiods OD (with respiratory rate <12)*:
(Use caution with opioid dependent pain management patients)
-Naloxone nasal spray 4mg preload single dose device
-Administer full dose in one nostril
OR
-Naloxone assemble 2m syringe and atomizer
-Administer 1mg (1ml) in each nostril

Hypoglycemia (suspected) or patient’s glucometer results read <60
-If patient is awake and able to swallow, give 3 oral glucose tabs or past (15g total).
Patient may eat or drink if able.
-If patient unconscious, NPO

CVA/Stroke:
See S-144 Stroke/Transient Ischemic Attack for details.

Seizures:
Protect airway, and protect from further injury
-Treat associated injuries

Behavioral Emergencies:
(S-422 and S-142)

Question 9

Q

S-123 Altered Neurological Function ALS

Answer

A

Monitor EKG
Capnography SO prn
IV/IO SO adjust prn
Monitor blood glucose prn SO

Symptomatic suspected opioids OD (with respiratory rate <12):
(Use caution in opioid dependent pain management patients)
-Naloxone 2mg IN/IM/IV SO. MR SO, titrate IV dose to effect, to drive respiratory rate.
-If patient refuses transport, give additional Naloxone 2mg IM SO

Hypoglycemia: Symptomatic patient with altered LOC or unresponsive to oral glucose agents:

D50 25Gm IV SO if BS <60
If patient remains symptomatic and BS remains <60 MR SO
If no IV: Glucagon 1ml IM SO if BS <60

Hyperglycemia : Symptomatic patient with diabetic history
-500ml fluid bolus IV/IO if BS >350 or reads high SO x1

Seizures:
A. Ongoing generalized seizure lasting >5 minutes (includes seizure time prior to arrival of prehospital provider) SO
B. Recurrent tonic-clonic seizures without lucid interval SO
C. Eclamptic seizure of any duration SO
-Versed IN/IM/IV/IO SO to a max dose of 5mg (d/c if seizure stops) SO MR x1 in 10 minutes SO. Max 10mg total

Question 10

Q

S-124 Burns BLS

Answer

A

Move patient to a safe environment
Break contact with causative agent
Ensure patent airway, O2 and/or ventilate prn
O2 saturation prn
Treat other life threatenting injuries
Carboxyhemoglobin monitor prn, if available

Thermal burns:
-Do not allow patient to become hypothermic
Burns of <10% body surface area:
-Stop burning with non-chilled water or saline
Burns of >10% body surface area
-Cover with dry dressing and keep warm

Toxic inhalation (CO exposure, smoke, gas, etc.):
-Move patient to safe environment
-100% O2 via mask
For suspected carbon monoxide poisoning for unconscious or pregnant patient
-Consider transport to facility with hyperbaric chamber

Chemical burns:

Brush off dry chemicals
Flush with copious amounts of water

Tar burns:
-Cool with water, transport; do not remove tar

Question 11

Q

S-124 Burns ALS

Answer

A

Monitor EKG
IV/IO SO adjust prn
Treat pain per Pain Management Protocol (S-141)

For patients with >20% partial thickness or >5% full thickness burns and >15 yo:
-500ml fluid bolus IV/IO then TKO SO

In the presence of respiratory distress with bronchospasm:
-Albuterol 6ml 0.083% via nebulizer SO. MR SO

Question 12

Q

Burn Center Criteria

Answer

A

Patients with burns involving:

> 20% BSA partial thickness or
> 5% BSA full thickness
Suspected respiratory involvement or significant smoke inhalation in a confined space
Injury of the face, hands, feet or perenium, or circumferential
Electrical injury due to high voltage; (>120 volts)

Question 13

Q

S-126 Discomfort/Pain Of Suspected Cardiac Origin BLS

Answer

A

Ensure patent airway
O2 saturation prn
Only use supplemental O2 to maintain O2 saturation 94-98%
O2 and/or ventilate prn
Do not allow patient to walk
If systolic BP>100, may assist patient to self-medicate own prescribed NTG SL (maximum 3 doses, including those patient has taken)
May assist with placement of 12 lead
May assist patient to self-medicate own prescribed Aspirin (81mg to max dose of 325mg)

Question 14

Q

S-126 Discomfort/Pain Of Suspected Cardiac Origin ALS

Answer

A

-Monitor EKG
-IV/IO SO adjust prn
-Obtain 12 lead EKG and transmit (if capable).
If STEMI, notify base immediately and transport to appropriate STEMI center.*
-ASA 324mg chewable PO SO

If systolic BP>100:

NTG 0.4mg SL SO. MR q3-5” SO
NTG ointment 1 inch SO
Treat pain per Pain Management Protocol (S-141)

If systolic BP<100:

NTG 0.4mg SL BHO. MR BHPO
Treat pain per Pain Management Protocol (S-141)

Discomfort/Pain of suspected Cardiac Origin with Associated Shock:
-250ml fluid bolus IV/IO without rales SO.
MR to maintain systolic BP>90 SO
If BP refractory to second fluid bolus:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP>90 BHO

Question 15

Q

S-126 Discomfort/Pain Of Suspected Cardiac Origin Note/*Report

Answer

A

Note:

If discomfort/pain is relived prior to arrival, continue treatment with NTG ointment and ASA. ASA should be given regardless of prior daily dose(s).
If any patient has taken an erectile dysfunction medication such as Viagra, Cialis, Levitra within 48 hours, NTG is contraindicated.
May encounter patients taking similar medication for pulmonary hypertension (Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
Report:
12 lead interpretation of STEMI
Bundle Branch Block (LBBB, RBBB).
Poor quality EKG, artifact, paced rhythm, atrial fibrillation or atrial flutter for consideration of false positive reading STEMI.
Repeat the 12 lead EKG only if the original EKG interpretation is NOT ACUTE MI SUSPECTED, and patient’s condition worsens. Do not delay transport to repeat.
Document findings on the PPR and transmit EKG if available and leave EKG with patient.

Question 16

Q

S-127 Dysrhythmias, Unstable Bradycardia BLS

Answer

A

BLS:

O2 and/or ventilate prn
O2 Sat prn

Question 17

Q

S-127 Dysrhythmias, Unstable Bradycardia ALS (Narrow complex)

Answer

A

Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)

Narrow Complex Bradycardia:

Monitor EKG
250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
Atropine 0.5mg IV/IO for pulse <60 SO. MR q3-5” to max 3mg SO

If rhythm refractory to a minimum of Atropine 1mg:
-External cardiac pacemaker SO**
If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO

-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after max Atropine or initiation of pacing) BHO

Question 18

Q

S-127 Dysrhythmias, Unstable Bradycardia ALS (Wide complex)

Answer

A

Unstable Bradycardia with Pulse:
(BP<90 AND chest pain, dyspnea, or altered LOC)

Wide Complex Bradycardia:

Monitor EKG
250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
External cardiac pacemaker SO**

If capture occurs and BP>100, consider medication for discomfort:
-Treat pain per Pain Management Protocol (S-141)
For discomfort related to pacing and not relieved with analgesics and BP>100:
-Midazolam 1-5mg IV/IO SO

-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip, titrate to BP>90 (after initiation of pacing) BHO

If external pacing unavailable:
-may give Atropine 0.5mg IV/IO for pulse <60 SO
MR q3-5” to max 3mg SO

Question 19

Q

S-127 Dysrythmias (Bradycardia Pacing Notes)

Answer

A

*Note:
Document rate setting, milliamps, and capture
External pacing on standing orders should begin with minimum rate set at 60/min. Energy output should be dialed up until capture occurs, usually between 50 and 100mA. The mA should then be increased a small amount, usually about 10%, for ongoing pacing.

Question 20

Q

S-127 Dysrythmias, Supraventricular Tachycardia BLS

Answer

A

O2 and/or ventilate prn

- O2 Sat prn

Question 21

Q

S-127 Dysrythmias, Supraventricular Tachycardia ALS

Answer

A

-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-VSM SO. MR SO
-Adenosine 6mg rapid IV/IO, followed with 20ml NS rapid IV/IO SO
(Patients with history of bronchospasm or COPD BHO)
-Adenosine 12mg rapid IV/IO followed with 20ml NS rapid IV/IO SO
If no sustained rhythm change, MR x1 in 1-2” SO

If patient unstable OR rhythm refractory to treatment:
Conscious (BP<90 AND chest pain, dyspnea, or altered LOC)
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose BHO, MR BHO

Unconscious:
-Synchronized cardioversion at manufacturer’s recommended energy dose SO. MR x3 SO. MR BHO

Question 22

Q

S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter BLS

Answer

A

O2 and/or ventilate prn

- O2 Sat prn

Question 23

Q

S-127 Dysrhythmias, Unstable Atrial Fibrillation/Atrial Flutter ALS

Answer

A

Unstable Atrial Fibrillation/Atrial Flutter:
(BP<90 AND chest pain, dyspnea, or altered LOC)
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO

In presence of ventricular response with heart rate >180:
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion BHPO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose BHPO, MR BHPO

Unconscious:
Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO

Question 24

Q

S-127 Dysrhythmias, Ventricular Tachycardia BLS

Answer

A

O2 and/or ventilate prn

- O2 Sat prn

Question 25

Q

S-127 Dysrhythmias, Ventricular Tachycardia ALS

Answer

A

-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q 8-10” to max 3mg/kg (including initial bolus) SO
OR
-Amiodorone 150mg in 100ml of NS over 10” IV/IO SO
MR x1 in 10” SO

If patient unstable (BP<90 AND chest pain, dyspnea, or altered LOC):
Conscious:
-Midazolam 1-5mg IV/IO prn pre-cardioversion SO
(If age >60 consider lower dose with attention to age and hydration status)
-Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO

Unconscious:
-Synchronized cardioversion at manufacturer’s recommended energy dose SO, MR x3 SO. MR BHO

Question 26

Q

S-127 Dysrhythmias, Reported/Witnessed >2 AICD firing, or >1 AED shock delivered (BLS/ALS)

Answer

A

BLS:
-O2 and/or ventilate prn
-O2 Sat prn
ALS:
-Monitor EKG
-250ml fluid bolus IV/IO without rales SO to maintain BP>90, MR SO

If pulse >60:
-Lidocaine 1.5mg/kg IV/IO SO
MR at 0.5mg/kg IV/IO q8-10” to max 3mg/kg (including initial bolus) SO
OR
-Amiodorone 150mg in 100ml NS over 10” IV/IO SO

Question 27

Q

S-127 Dysrhythmias, VF/Pulseless VT BLS

Answer

A

CPR
10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
Rotate compressor every 2 minutes
Metronome at rate of 110/minute for manual CPR
Team Leader role-CPR quality, monitor, rhythm checks
If arrest witnessed by medical personnel perform CPR until ready to defibrillate
If unwitnessed arrest perform CPR for 2 minutes prior to rhythm check
TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
AED
Assist ventilations with BVM
Monitor O2 Sat

Question 28

Q

S-127 Dysrhythmias, VF/Pulseless VT ALS

Answer

A

Monitor EKG
Defibrillate when ready every 2 min while VF/VT persists
Charge monitor prior to rhythm checks, do not interrupt CPR while charging defibrillation
Capnography
Rhythm check-minimize interruption of compressions less than 5 seconds
IV/IO do not interrupt CPR
Epinephrine 1:10,000 1mg IV/IO q3-5” SO

After first shock if still refractory

Amiodorone 300mg IV/IO, MR 150mg (max of 450mg) SO
OR*
Lidocaine 1.5mg/kg IV/IO, MR x1 q3-5” (max 3mg/kg) SO

-Document EtCO2 during BVM, if zero do not intubate
continue ti ventilate BVM
-Intubate/PAA SO without interrupting compressions
-NG/OG prn SO

If persistent or shock refractory VF/VT after 3 rounds of drugs, contact base hospital for direction

ROSC:

Obtain 12 lead
Ventilate with goal of EtCO2 of 40
Check blood pressure
Transport to closest STEMI Center regardless of 12 lead reading SO

Question 29

Q

S-127 Dysrhythmias, VF/Pulseless VT (Notes)

Answer

A

For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions.
Do not interrupt compressions
Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
EtCO2 <10 = Poor survivability
Use mechanical CPR device if available
Do not over-ventilate
Transport traumatic arrests to trauma centers
Transfer monitor data to QA/QI department if able
Consider reviewing call with crew post event

Question 30

Q

S-127 Dysrhythmias, PEA BLS

Answer

A

CPR
10:1 compression ratio at a rate of 110/min continuous compressions with ventilations every 6 seconds
CPR rotate compressor every 2 minutes
Start metronome at rate of 110/minute for manual CPR
Team Leader role-CPR quality, monitor, rhythm checks
TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
AED
Assist ventilations with BVM
Monitor O2 Sat

Question 31

Q

S-127 Dysrhythmias, PEA ALS

Answer

A

IF PATIENT DOES NOT MEET TOR CRITERIA:

Monitor
Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
Capnography
Rhythm check-minimize interruption of compressions less than 5 seconds
IV/IO do not interrupt CPR
Epinephrine 1:10,000 1mg IV/IO MR q3-5” SO
Document EtCO2 during BVM, if zero do not intubate, continue to ventilate with BVM
Intubate/PAA SO without interrupting compressions
NG/OG prn SO
250ml fluid bolus IV/IO

If persistent PEA after 3 rounds of Epinephrine contact Base Hospital for direction

ROSC:

Obtain 12 lead
Ventilate with goal of EtCO2 of 40
Check blood pressure
Transport to closest STEMI center regardless of 12 lead reading SO

Question 32

Q

S-127 Dysrhythmias, PEA (Notes)

Answer

A

For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of anterior/posterior chest diameter), allow full recoil, and minimize interruptions
Do not interrupt compressions
Compression ratio 10:1 continuous compressions with ventilations every 6 seconds
EtCO2 <10 = Poor survivability
Use mechanical CPR device if available
Do not over-ventilate
Consider reversable caises of PEA (Hyperkalemia, Hypokalemia, Hypovolemia, Hypoxia, Tamponade, Thrombosis)
Transport traumatic arrest to trauma centers
Transfer monitor data to QA/QI department if able
Consider reviewing call with crew post event

Question 33

Q

S-127 Dysrhythmias, Asystole BLS

Answer

A

CPR
10:1 compression ratio at a rate of 110 continuous compressions with ventilations every 6 seconds
CPR rotate compressor every 2 minutes
Start metronome @ rate of 110/minute for manual CPR
Team leader role-CPR quality, monitor, rhythm checks
TAH patients DO NOT perform compressions unless instructed otherwise by VAD or TAH coordinator or Base Hospital
AED
Assist ventilation with BVM
Monitor O2 Sat

Question 34

Q

S-127 Dysrhythmias, Asystole ALS

Answer

A

Monitor EKG
Charge monitor prior to rhythm checks, do not interrupt CPR while charging for defibrillation
Capnography
Rhythm check-minimize interruption of compressions less than 5 seconds
IV/IO do not interrupt CPR
Epinephrine 1:10,000 1mg IV/IO MR q3-5” SO
Document EtCO2 during BVM, if zero do not intubate continue to ventilate with BVM
Intubate/PAA SO without interrupting compressions
NG/OG prn SO

ROSC:

Obtain 12 lead
Ventilate with goal of EtCO2 of 40
Check blood pressure
Transport to closest STEMI Center regardless of 12 lead reading SO

Question 35

Q

S-127 Dysrhythmias, Asystole/TOR Criteria

Answer

A

Termination Of Resuscitation (TOR) Criteria if all these criteria have been met:
1. Victim arrest was not witnessed by EMS
AND
2. No bystander witness of collapse
AND
3. No bystander CPR
AND
4. Never received a rescue shock
AND
5. Never had a return of pulses
THEN
-If there is no improvement and patient is in asystole after continuous resuscitation of less than 20 minutes, base contact is necessary in order to terminate resuscitation BHPO
-If asystolic after 20 minutes resuscitative efforts with no improvement may cease efforts SO. Document the Time of Apparent Death and the name of the paramedic
-If all above criteria for TOR are met, Base hospital contact not required even if ALS interventions performed

Question 36

Q

S-127 Dysrhythmias, Asystole (Notes)

Answer

A

This protocol only applies to asystole arrests of presumed cardiac origin. Drowning, Hypothermia, Electrocution are excluded
Asystolic patients of cadiac origin should not be transported
For drug administration and intubation perform high quality CPR with goal of appropriate rate (110), depth (1/3 of AP chest diameter), allow full recoil, and minimize interruptions
Do not interrupt compressions
Compression rate of 110 with ventilations q 6 seconds
EtCO2 <10 = Poor survivability
Use mechanical CPR device if available
Do not over-ventilate
Transport traumatic arrests to Trauma Centers
Transfer monitor data to QA/QI Department if able
Consider reviewing call with crew post event

Question 37

Q

S-129 Envenomation Injuries BLS/ALS

Answer

A

BLS:
-O2 and/or ventilate prn

Jellyfish sting:

Liberally rinse with salt water, for at least 30 seconds
Scrape to remove stinger(s)
Heat as tolerated (not to exceed 110 degrees)

Stingray or Sculpin injury:
-Heat as tolerated (not to exceed 110 degrees)

Snakebites:

Mark proximal extent of swelling and/or tenderness
Keep involved extremity at heart level and immobile
Remove pre-existing constrictive device

ALS:

IV/IO SO adjust prn
Treat pain per Pain Management Protocol (S-141)

Question 38

Q

S-130 Environmental Exposure BLS

Answer

A

Ensure patent airway
O2 saturation prn
O2 and/or ventilate prn
Remove excess/wet clothing
Obtain baseline temperature

Heat Exhaustion:

Cool gradually
Fanning, sponging with tepid water
Avoid shivering
If conscious, give small amounts of fluids

Heat Stroke:

Rapid cooling
Spray with cool water, fan. Avoid shivering
Ice packs to carotid, inguinal, and axillary regions

Cold Exposure:

Gentle warming
Blankets, warm packs
Dry dressings
Avoid unnecessary movement or rubbing
If alert, give warm liquids
If severe, NPO
Prolonged CPR may be indicated

Near Drowning:
-Spinal motion restriction when indicated

Question 39

Q

S-130 Environmental Exposure ALS

Answer

A

Monitor EKG
IV/IO SO adjust prn

Severe Hypothermia with Cardiac Arrest:

Hold medications
Continue CPR
If defibrillation needed, limit to 1 shock maximum

Suspected Heat Exhaustion/Heat Stroke:
-500ml fluid bolus IV/IO SO, without rales. MR x1 SO

Near drowning:
-CPAP at 5-10cm H2O SO for respiratory distress

Question 40

Q

S-131 Hemodialysis Patient BLS

Answer

A

Ensure patent airway
O2 saturation prn
Give O2
Ventilate if necessary

Question 41

Q

S-131 Hemodialysis Patient ALS

Answer

A

Monitor EKG
Determine time of last dialysis

For immediate definitive therapy only:

IV access in arm that does not have graft/AV fistula SO. Adjust prn
EJ/IO access prior to accessing graft

If unable & no other medication delivery route available:

Access Percutaneous Vas Catheter BHPO if present (apsirate 5ml PRIOR to infusion)
OR*
Access graft/AV fistula BHPO

Fluid overload with rales:
-Treat as per S-136 (CHF/Cardiac)

Symptomatic patient with suspected hyperkalemia (widened QRS complex or peaked T waves):
-Obtain 12 lead EKG
If >72 hours since last dialysis:
-Continuous Albuterol 6ml 0.083% via nebulizer SO
-CaCl2 500mg IV/IO per SO
-NaHCO3 1mEq/kg IV/IO x1 per SO

Question 42

Q

S-131 Hemodialysis Patient (Notes)

Answer

A

Note: Vas-Cath contrains concentrated dose of Heparin which must be aspirated PRIOR to infusion.

SDCPA Educational Notes:
Hyperkalemia patients may be asymptomatic or report the following
- Generalized fatigue - Paresthesias -Palpitations
-Weakness - Paralysis -Hypotension

ECG findings generally correlate with the potassium level, but potentially life-threatening arrythmias can occur without warning at almost any level of hyperkalemia

Early changes: peaked T waves, shortened QT interval, and ST segment depression. These changes are followed by bundle-branch blocks causing a widening of the QRS complex, increases in the PR interval, and decreasing amplitude of the P wave.

Late changes: P wave eventually disappears and the QRS morphology widens to resemble a sine wave. Ventricular Fibrillation or asystole follows.

Question 43

Q

S-122 Decompression Illness/Diving/Altitude Incidents BLS/ALS

Answer

A

BLS:

100% O2 and/or ventilate prn
O2 saturation prn
Spinal stabilization when indicated

ALS:

Monitor EKG
IV/IO SO adjust prn

Question 44

Q

S-122 Decompression Illness/Diving/Altitude Incidents (Presentation)

Answer

A

Diving victims: Any victim who has breathed sources of compressed air below the water’s surface and presents with the following:

Minor presentation: minimal localized joint pain, mottling of the skin surface, localized swelling with pain; none of which are progressive.

Major presentation: symptoms listed above that are sever and/or rapidly progressing, vertigo, altered LOC, progressive paresthesia, paralysis, severe SOB, blurred vision, crepitus, hematemesis, hemoptysis, pneumothorax, trunk pain, or girdle or brand-like burning discomfort.

Major presentation:

All patients with a “major” presentation should be transported to UCSD-Hillcrest
Trauma issues are secondary in the presence of a “major” presentation
If the airway is unmanageable, divert to the closest BEF

Minor presentation:

Major trauma candidate: catchment trauma center
Non-military patients: routine
Active Duty Military Personnel: transport to Military Duty Recompression Chamber

Question 45

Q

S-133 Obstetrical Emergencies BLS

Answer

A

Mother:

Ensure patent airway
O2 saturation prn
O2 and/or ventilate prn
If no time for transport and delivery is imminent (crowning and pushing), proceed with delivery
If no delivery, transport on left side

Routine Delivery:
-Massage fundus if placenta delivered
(do not wait on scene)
-Clamp and cut cord between clamps following delivery (wait 60 seconds after delivery prior to clamping and cutting cord)
-Document name of person cutting cord, time cute, and address
-Place identification bands on mother and infant

Post-Partum Hemorrhage:

Massage fundus vigorously
Baby to breast

Eclampsia (seizures):
-Protect airway, and protect from injury

STAT transport for third trimester bleeding to facility with OB services per base hospital direction

Question 46

Q

S-133 Obstetrical Emergencies ALS

Answer

A

Mother:

Monitor EKG
IV/IO SO adjust prn

Direct to Labor/Delivery area per BHO if >20 weeks gestation

Eclampsia (seizures):
-Versed IN/IM/IV/IO SO to a max dose of 5mg (d/c if seizure stops) SO.
MR x1 in 10” SO. Max 10mg total.

Question 47

Q

S-134 Poisoning/Overdose BLS

Answer

A

Ensure patent airway
O2 saturation prn
O2 and/or ventilate prn
Carboxyhemoglobin monitor prn, if available

Ingestions:
-Identify substance

Skin:

Remove clothes
Brush off dry chemicals
Flush with copious water

Toxic Inhalation:

Move patient to safe environment
100% O2 via mask
Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient

Symptomatic suspected opioid OD with respiratory rate <12: (use with caution in opioid dependent pain management patients)

Naloxone nasal spray 4mg preload single dose device
Administer full dose in one nostril
OR*
Naloxone assemble 2mg syringe & atomizer
Administer 1mg into each nostril

Contamination with commercial grade (“low level”) radioactive material:
-Patients with mild injuries may be decontaminated (removal of contaminated clothing, brushing off of material) prior to treatment and transport. Decontamination proceedings SHALL NOT delay treatment and transport of patients with significant or life-threatening injuries. Treatment of significant injuries is always the priority.

Question 48

Q

S-134 Poisoning/Overdose ALS

Answer

A

Monitor EKG
IV/IO SO adjust prn
Capnography SO prn

Ingestions:
-Charcoal 50Gm PO ingestion with any of the following within 60 minutes SO if not vomiting:
Acetaminophen, colchicine, beta blockers, calcium channel blockers, salicylates, valproate, oral anticoagulants (including rodenticides), paraquat, aminita mushrooms
-Assure patient has gag reflex and is cooperative

Symptomatic suspected opioid OD with respiratory rate <12: (use with caution in opioid dependent pain management patients)

Naloxone 2mg IN/IM/IV SO. MR SO. titrate IV dose to effect
If patient refuses transport, give additional Naloxone 2mg IM SO

Symptomatic Organophosphate poisoning:
-Atropine 2mg IV/IM/IO SO.
MR x2 q3-5” SO. MR q3-5” BHO

Extrapyramidal reactions:
-Benadryl 50mg slow IV/IM SO

Suspected Tricyclic OD with cardiac effects (e.g. hypotension, heart block, or widened QRS):
-NaHCO3 1mEq/kg IV/IO SO

If suspected cyanide poisoning: If cyanide kit is available on site (e.g. industrial site) may administer if patient is exhibiting significant symptoms:

Amyl Nitrate inhalation (over 30 sec) BHPO
Sodium Thiosulfate 25% 12.5Gm IV BHPO
OR*
Hydroxocobalamin (Cyanokit) 5Gm IV BHPO

Question 49

Q

S-134 Poisoning/Overdose (Hyperthermia from Suspected Stimulant Intoxication) BLS only

Answer

A

Initiate cooling measures

- Obtain baseline temperature, if possible

Question 50

Q

S-134 Poisoning/Overdose (Excited Delirium) ALS only

Answer

A

-As soon as able:
Monitor/EKG/Capnography
-High flow O2 SO
-Ventilate SO
-500ml fluid bolus IV/IO SO. MR x1 SO. MR BHO
-Versed 5mg IM/IN/IV SO
MR x1 in 10" SO

Question 51

Q

S-135 Pre-Existing Medical Interventions BLS

Answer

A

Proceed with transport when person responsible for operating the device (the individual or another person) is able to continue to provide this function during transport.
Bring back up equipment/batteries as appropriate

Previously established electrolyte and/or glucose containing peripheral IV lines:

Maintain at preset rates
Turn off when indicated

Previously applied dermal medication delivery systems:
-Remove chest transdermal medication patches when indicated (CPR, shock) SO

Previously established IV medication delivery systems and/or other preexisting treatment modalities with preset rate:
-If the person responsible for operating the device is unable to continue to provide this function during transport, contact BH for direction.
BH may ONLY direct BLS personnel to:
1. Leave device as found OR turn the device off;
THEN
2. Transport patient OR wait for ALS arrival.

Transports to another facility of to home:

No wait period is required after medication administration.
If there is a central line, the tip of which lies in the central circulation, the catheter MUST be capped with a device which occludes the end.
IV solutions with added medications OR other ALS treatment/monitoring modalities require ALS personnel (or RN/MD) in attendance during transport.

Question 52

Q

S-135 Pre-Existing Medical Interventions ALS

Answer

A

Maintain previously established electrolyte and/or glucose containing IV solutions:
-Adjust rate or d/c BHO

Maintain previously applied topical medication delivery systems:
-Remove dermal medications when indicated (CPR, shock) SO

Pre-existing external vascular access (considered to be IV TKO):
-To be used for definitive therapy ONLY

Maintain previously established and labeled IV medication delivery systems with preset rates and/or other preexisting treatment modalities:
-d/c BHO

If no medication label or clear identification of infusing substance:
-d/c BHO

Question 53

Q

S-136 Respiratory Distress BLS

Answer

A

Ensure patent airway
Reassurance
O2 saturation prn
O2 and/or ventilate prn
May assist patient to self-medicate own prescribed MDI ONE TIME ONLY. Base hospital contact required prior to any repeat dose.

Hyperventilation:

Coaching/reassurance
Remove patient from causative environment
Consider underlying medical problem

Toxic Inhalation (CO exposure, smoke gas, etc.)

Move patient to safe environment
100% O2 via mask
Consider transport to facility with hyperbaric chamber for suspected carbon monoxide poisoning for unconscious or pregnant patient

Respiratory Distress with croup-like cough:
-Aerosolized saline or water 5ml via oxygen powered nebulizer/mask. MR prn

Question 54

Q

S-136 Respiratory Distress ALS

Answer

A

Monitor EKG
Capnography monitoring SO prn
IV/IO SO adjust prn
Intubate prn
NG/OG prn per SO

Respiratory Distress Suspected CHF/Cardiac origin:
-NTG SL:
If systolic BP >100 but <150:
-NTG 0.4mg SL SO. MR q3-5" SO
If systolic BP >150:
-NTG 0.8mg SL SO. MR q3-5" SO
If systolic BP >100:
-NTG ointment 1 inch SO
If systolic BP <100:
-NTG 0.4mg SL per BHO MR BHPO

-CPAP at 5-10cm H2O SO

Respiratory Distress Suspected Non-Cardiac:

Albuterol 6ml 0.083% via nebulizer SO. MR SO
Atrovent 2.5ml 0.02% via nebulizer added to first dose of Albuterol SO
CPAP 5-10cm H2O SO

If sever respiratory distress/failure or inadequate response to Albuterol/Atrovent consider:
If history of asthma or suspected allergic reaction:
-Epinephrine 0.3mg 1:1,000 IM SO
MR x2 q5” SO
If no definite history of asthma:
-Epinephrine 0.3mg 1:1,000 IM BHPO
MR x2 q5” BHPO

Question 55

Q

S-136 Respiratory Distress (Notes)

Answer

A

If any patient has taken an erectile dysfunction medication such as Viagra, Cialis, and Levitra within 48 hours, NTG is contraindicated.
May encounter patients taking similar medication for pulmonary hypertension, usually Sildenafil (trade name: Revatio, Flolan, Veletri). NTG is contraindicated in these patients as well.
Use caution with CPAP in patients with COPD, i.e. start low and titrate pressure.
Epinephrine IM: use caution if known cardiac history or history of hypertension or BP >150 or age >40.
Fireline Paramedic (FEMP) without access to oxygen may use MDI delivery for Albuterol in place of nebulizer.

Question 56

Q

S-137 Sexual Assault ALS/BLS

Answer

A

Ensure patent airway
O2 and/or ventilate prn
Advise patient not to bathe or change clothes
Consult with law enforcement on scene for evidence collection

If the patient requires a medical evaluation:

Transport to the closest, most appropriate facility
Law enforcement will authorize and arrange an evidentiary exam after the patient is stabilized.

If only evidentiary exam is needed:
-Should release to law enforcement for transport to a SART facility.

Question 57

Q

S-138 Shock BLS

Answer

A

O2 saturation prn
O2 and/or ventilate prn
Control obvious external bleeding
Treat associated injuries
NPO, anticipate vomiting
Remove any transdermal patch

Question 58

Q

S-138 Shock ALS

Answer

A

Monitor EKG
IV/IO SO
Capnography SO

Shock (suspected cardiac etiology)
-250ml fluid bolus IV/IO without rales SO
MR x1 to maintain BP >90 SO
If BP refractory to second fluid bolus:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate systolic BP >90 BHO

Shock Hypovolemic (Nontraumatic):
-500ml fluid bolus IV/IO SO. MR to maintain BP >90 SO

Shock Hypovolemic (suspected AAA):
-500ml fluid bolus IV/IO SO. MR to maintain BP >80 SO

Shock (suspected Anaphylactic, Neurogenic):
-500ml fluid bolus IV/IO SO. MR to maintain BP >90 SO
If BP refractory to fluid boluses:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IS/Io drip. Titrate BP >90 BHO

Shock (Sepsis):
-Treat as per Sepsis Protocol (S-143)

Question 59

Q

S-138 Shock/S-139 Trauma (Notes/Shock definition)

Answer

A

“Shock” is defined by the following: (age>15 years):

Systolic BP <80 mmHg OR
Systolic BP <90 mmHg AND exhibiting any of the following signs of inadequate perfusion:
1. altered mental status (decreasing LOC, confusion, agitation)
2. tachycardia
3. pallor
4. diaphoresis

Question 60

Q

S-139 Trauma BLS

Answer

A

Ensure patent airway, protecting C-Spine
Control obvious bleeding
Spinal stabilization prn. (Except in penetrating trauma without neurological deficits.)
O2 saturation prn
O2 and/or ventilate prn
Keep warm
Homestatic gauze

Abdominal Trauma:
-Cover eviscerated bowel with saline pads

Chest Trauma:

Cover open chest wound with three-sided occlusive dressing; release dressing if ?tension pneumothorax develops.
Use of chest seal

Extremity Trauma:

Splint neurologically stable fractures as they lie
Use traction splint as indicated
Grossly angulated long bone fractures with neurovascular compromise may be reduced with GENTLE unidirectional traction for splinting per BHO
Apply tourniquet in severely injured extremity when direct pressure or pressure dressing fails to control life-threatening hemorrhage.
In Mass Casualty direct pressure not required prior to tourniquet application

Impaled Objects:
-Immobilize & leave impaled objects in place.
Remove BHPO
EXCEPTION
May remove impaled object in face/cheek or from neck if there is total airway obstruction

Neurological Trauma (head and spine injuries:
-Ensure adequate oxygenation without hyperventilating patient. Goal 6-8 ventilations/minute

Pregnancy of greater than or equal to 6 months:
-Where spinal stabilization precaution is indicated, tilt on spine board 30 degrees.

Blunt Traumatic Arrest:
-Consider pronouncement at scene BHPO

Question 61

Q

S-139 Trauma ALS

Answer

A

Monitor EKG
IV/IO SO
If MTV IV/IO en route SO
500ml fluid bolus IV/IO to maintain BP at 80
Capnography SO prn
Treat pain per Pain Management Protocol (S-141)

Crush injury with extended compression >2 hours of extremity or torso:
Just prior to extremity release:
-500ml fluid bolus IV/IO, then TKO SO
-CaCl2 500mg IV/IO over 30 sec. BHO
-NaHCO3 1mEq/kg IV/IO BHO

Grossly angulated long bone fractures:
Reduce with GENTLE unidirecional traction for splinting SO

Sever Respiratory Distress with unilateral diminished breath sounds and systolic BP <90:
-Needle thoracostomy SO

Blunt Traumatic Arrest:
-Consider pronouncement at scene

Penetrating Traumatic Arrest:
-Rapid transport off scene

Question 62

Q

S-141 Pain Management BLS

Answer

A

Assess level of pain
Ice, immobilize, and splint when indicated
Elevation of extremity trauma when indicated

Question 63

Q

S-141 Pain Management ALS (MILD/MODERATE pain)

Answer

A

Continue to monitor & reassess pain using standardized pain score.
Document vitals signs before and after each medication administration

Special Considerations for All Pain Medications:

Changing route of administration requires BHO
(e. g. IV to IM or IM to IN)
Chaning analgesic requires BHO
(e. g. changing from Fentanyl to Ketamine)
Treatment if BP <100 requires BHO
BHPO required for:
- Isolated head injury -Acute onset sever headache
- Drug/ETOH intoxication -Major trauma with GCS <15
- Suspected active labor

For MILD pain (score 1-3) or MODERATE pain (score 4-6):

without sever hepatic impairment or active liver disease
Acetaminophen 1000mg IV infuse over 15”

Question 64

Q

S-141 Pain Management ALS (MODERATE/SEVERE pain)

Fentanyl

Answer

A

For MODERATE pain (score 4-6) or SEVERE pain (score 7-10):
-or refusal/contraindication to Acetaminophen or Ketamine

Fentanyl: If <65 years of age
-Fentanyl up to 50mcg IV SO
-MR 25mcg IV q5" x2 SO
Maximum total SO dose 100mcg
Intranasal dosing:
-Fentanyl 50mcg IN q15" x2 SO
-3rd dose Fentanyl 50mcg IN BHO

If >65 years of age:
-Fentanyl 25mcg IV SO
-MR 25mcg IV q5" x2 SO
Maximum total SO dose 75mcg IV
Intranasal dosing:
-Fentanyl 25mcg IN q15" x2 SO
-3rd dose Fentanyl 25mcg IN BHO

Special considerations for Cardiac Chest Pain & Cardiac Pacing:
-Fentanyl 25mcg IV x1 SO

Answer 65

A

Morphine, if Fentanyl unavailable:
-Morphine 0.1mg/kg IV SO
-MR in 5” at half of initial IV dose SO
-MR in additional 5” at half of the initial IV dose BHO
Intramuscular dosing:
-Morphine 0.1mg/kg IM SO
-MR in 15” at half of the initial IM dose SO
-MR in additional 15” at half of the initial IM dose BHO

Special considerations for Cardiac Chest Pain & Cardiac Pacing:
-Administer Morphine 0.05mg/kg IV x1 SO

Answer 66

A

Additional option for trauma, burns, or envenemation injuries:
For MODERATE-SEVERE pain (score >5):

Ketamine requirements:

> 15 years old
AND with GCS if 15
AND not pregnant
AND no known or suspected alcohol or drug intoxiation
AND have not received opioid analgesic in past 6 hours (prior to medical arrival)

-Ketamine 0.2mg/kg in 100ml of NS SLOW IV drip over 15” SO
Maximum for any single IV dose is 20mg
-MR x1 in 15” if pain remains MODERATE or SEVERE SO
Intranasal dosing:
-Ketamine 0.5mg/kg IN (50mg/ml concentration) SO
Maximum for any single IN dose is 50mg
-MR x1 in 15” if pain remains MODERATE or SEVERE SO

Answer 67

A

-Ensure patent airway, O2 and/or ventilate prn
-O2 saturation prn
-Treat life threatening injuries
-Attempt to determine if behavior is relayed to injury, illness, or drug use.
-Restrain only if necessary to prevent injury.
Document distal neurovascular status q15”.
Avoid unnecessary sirens.
-Consider law enforcement support and/or evaluation of the patient
-Law enforcement could remove taser barbs,
but EMS may remove bards.

Answer 68

A

Monitor EKG
IV SO adjust prn
Capnography SO

For combative patient:
-Versed 5mg IM/IN/IV SO. MR x1 in 10” SO

Note:

For combative patient IN or IM Versed is preferred route to decrease risk of injury to patient and personnel.
Use caution when considering Versed use with ETOH intoxication. Can result in apnea.

Answer 69

A

Consideration for patients presenting with taser barbs:

Taser discharge for simple behavioral control is usually benign and does not require transport to BEF for evaluation.
Patients, who are injured, appear to be under the influence of drugs, present with altered mental status, or symptoms of illness should have a medical evaluation performed by EMS personnel, and transported to a BEF.
If barbs are impaled in an anatomically sensitive location such as the eye, face, neck, finger/hand, or genetalia do not remove the barb; the patient should be transported to a BEF.

For removal of taser barbs:

Ensure wires are disconnected from weapon
Stabilize/stretch skin around dart
Grasp dart by metal body
Remove dart in single quick/firm motion
Clean wound with antiseptic wipe and apply dressing

Answer 70

A

O2 saturation prn
O2 and/or ventilate prn
NPO, anticipate vomiting
Remove any transdermal patch
Obtain baseline temperature

Answer 71

A

Monitor EKG
IV/IO SO
Capnography SO prn

Suspected Sepsis:
If history suggestive of infection and two or more of the following are present, suspect sepsis and report:
1. Temperature >100.4 or <96.8
2. HR >90
3. RR >20

Administer:
-500ml fluid bolus IV/IO regardless of blood pressure or lung sounds SO
After initial fluid bolus: If BP <90
-500ml fluid bolus IV/IO regardless of lung sounds SO x1

If BP refractory to fluid boluses:
-Dopamine 400mg/250ml @ 10-40mcg/kg/min IV/IO drip. Titrate BP >90 BHPO

Answer 72

A

For patients with symptoms suggestive of TIA or stroke with onset of symptoms known to be <6 hours in duration:
Expedite transport
Make initial notification early to confirm destination
Notify accepting stroke receiving center of potential stroke code patient en route
Get specific last known well time in military time (hours:minutes)
Bring witness to ED, or if witness unable to ride on ambulance obtain accurate contact number
Allow witness to accompany patient into ED, or provide contact information to ED upon arrival
Use supplemental O2 to maintain O2 sat at least 94%
Keep HOB at 15 degree elevation

If trained and available:

Obtain blood glucose, if blood glucose <60 mg/dl treat per hypoglycemia:
If patient is awake and able to swallow, give 3 oral glucose tabs or paste (15g total). Patient may eat or drink, if able.
Of patient is unconscious, NPO
Use Prehospital Stroke Scale in the assessment of possible TIA or stroke patients (facial droop, arm drift, and speech abnormalities)
Provide list of all current medications, especially anticoagulants to the ED upon arrival
If systolic BP <120 mmHg, place head of the stretcher flat, if tolerated

Answer 73

A

Obtain blood glucose, if blood glucose <60 mg/dl treat per hypoglycemia
Large bore antecubital IV
250ml fluid bolus IV/IO without rales SO to maintain BP >120, MR SO

Answer 74

A

Upon identification of a scene involving suspected or known exposure of nerve agent:

Isolate area
Notify dispatch of possible Mass Casualty Incident with possible Nerve Agent involvement
DO NOT ENTER AREA

If exposed:

Blot off agent
Strip off all clothing, avoiding contact with outer surfaces
Flush affected area(s) with copious amounts of water
Cover affected area(s)

If you begin to experience any signs/symptoms of nerve agent exposure, for example:

Use SLUDGE pneumonic: (Salivation, Lacrimation, Urination, Defecation, Gastric complications, Emesis)
Increased secretions (tears, saliva, runny nose, sweating)
Diminished vision
SOB
Nausea, vomiting, diarrhea
Muscle twitching/weakness

NOTIFY THE INCIDENT COMMANDER (or dispatch if no IC) immediately of your exposure and declare yourself a patient
Self Treat Immediately per the Acuity Guidelines listed under ALS

Answer 75

A

-Triage, decontaminate and treat patient based on severity of symptoms SO

Mild: miosis, rhinorrhea, increasing dyspnea, fasiculations, sweating:

Atropine autoinjector (or 2mg) IM
2-PAM Cl autoinjector (or 600mg) IM

Moderate: headache, weakness, miosis, rhinorrhea, dyspnea/wheezing (if inhaled), increased secretions, generalized fasiculations, muscle weakness, GI effects:

Atropine autoinjector (or 2mg) IM, MR x1 in 5-10”
2-PAM Cl autoinjector (or 600mg) IM, MR x1 in 5-10”
Diazepam autoinjector, or Midazolam 5mg IM if Diazepam autoinjector not available

SEVERE: unconscious, seizures, muscle weakness, fatigue, flaccid, paralysis, apnea, bardycardia, heart block, or tachycardia:
Initial dosing:
-Atropine autoinjector (or 2mg) IM x3 doses in succession
-2-PAM Cl autoinjector (or 600mg) IM x3 doses in succession
-Diazepam autoinjector, or Midazolam 10mg IM if Diazepam autoinjector not available, for seizure activity
-O2/intubate
Ongoing treatment:
-Atropine autoinjector (or 2mg) IM, MR q3-5” until secretions diminish
-2-PAM Cl autoinjector (or 600mg) IM, MR x1 in 3-5”
-For continuous seizure activity, MR Midazolam 10mg IM in 10”

Answer 76

A

Pediatric doses: Weight/Atropine/2-PAM Cl/Midazolam

<20kg = 0.5mg/100mg/2.5mg
20-39kg = 1mg/300mg/5mg
>40kg = 2mg/600mg/10mg

For doses less than the amount in the autoinjector, use the medication vial and administer with a syringe.

Consider: For frail, medically compromised, hypersensitive, or renal failure patients administer half doses of Atropine and 2-PAM Cl

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2019 Protocols (Adult) Flashcards

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