2023 Protocols

Question 1

Anaphylaxis vs Allergic Reaction

Answer 1

Anaphylaxis - systemic response involving 2 or more organ systems or any involvement of upper and or lower respiratory system or any derangement of vital signs

Question 2

Any involvement of the respiratory system (wheezing, stridor) or oral/facial edema will be
treated as

Answer 2

Anaphylaxis

Question 3

ALS Treatment of Allergic Reaction

Answer 3

1. Consider Diphenhydramine 50mg – PO/IM/IV.
2. Consider vascular access.
3. Cardiac monitoring
4. Reassess

Question 4

ALS Treatment of ANAPHYLAXIS

Answer 4

Epinephrine: 1:1,000
a. 0.3 mg IM (Max dose 0.9 mg).
b. May repeat in 15 minutes up to three (3) doses if symptoms persist.
2. Establish large-bore vascular access with normal saline (NS); titrate to systolic B/P ≥ 90
mmHg
3. Diphenhydramine: 50 mg IV/IO/IM.
4. Cardiac and SpO2 monitoring.
5. Albuterol: 5 mg (6 ml unit dose) HHN for wheezing. Reassess after the first treatment.
May be repeated as needed for respiratory distress.
6. Consider CPAP.
7. If no signs of improvement and the patient is in extremis (stridor, persistent hypotension,
etc.):
a. Epinephrine: 0.01 mg/ml (10mcg/ml)-0.5-2 ml every 2-5 minutes (5-20mcg) IV/IO for
stridor and hypotension. Titrate to a minimal systolic B/P > 90 mmHg OR a total of
0.5 mg. is given.
NOTE: Epinephrine should be used cautiously in patients > 35 years old or with a history of
CAD or HTN.
1. Inadequate response to Epinephrine and the patient is on Beta Blockers:
a. Glucagon 1 mg IV/IO given over one (1) minute. May give IM if no vascular access or
delay is anticipated.

Question 5

Hypoglycemia Criteria

Answer 5

Hypoglycemia:
1. Decreased responsiveness (Glasgow Coma Score < 14)
2. Blood Glucose level ≤ 60mg/dl.
3. History of Diabetes

Question 6

ALS Treatment Hypoglycemia

Answer 6

initiate vascular access.
2. If blood glucose > 60 mg/dl, consider other causes of decreased sensorium.
3. If blood glucose ≤ 60 mg/dl, treat as follows:
* Dextrose 10-12.5 grams IV. If blood sugar remains ≤ 60 mg/dl, give additional
Dextrose 12.5-15 grams IV. May repeat for a total of 50 grams.
NOTE: Concentrations of 10% Dextrose (D10) or 50% Dextrose (D50) may be used

Question 7

Hypoglycemia If IV access is unavailable or delay is anticipated

Answer 7

Glucagon: 1 mg Intramuscular (IM).
8002.02-Page 2 of 3
* Establish IO access and administer Dextrose 10-12.5 grams IV. If blood sugar
remains ≤ 60 mg/dl, give additional Dextrose 12.5-15 grams IV. May repeat for a
total of 50 grams.
6. In the event of glucometer failure, administer 10-12.5 grams of Dextrose or 1 mg of
Glucagon based on clinical assessment.

Question 8

Hyperglycemia symptoms

Answer 8

Hyperglycemia:
1. Blood Glucose Level ≥ 350mg/dl
2. History of Diabetes
3. Weakness
4. Confusion
5. Nausea/Vomiting
6. Fruity-smelling breath
7. Shortness of Breath
8. Coma

Question 9

Hyperglycemia ALS Treatment

Answer 9

Perform blood glucose determination; if blood glucose ≥ 350 mg/dl and there is no
evidence of fluid overload, initiate vascular access and administer a Normal Saline bolus
of 500ml.

Question 10

ALOC Causes

Answer 10

For any Altered Level of Consciousness (ALOC), consider AEIOUTIPS:
Alcohol Trauma
Epilepsy Infection
Insulin Psychiatric
Overdose Stroke or Cardiovascular
Uremia

Question 11

Treatable Seizures

Answer 11

1. Active Seizures.
2. Focal Seizures with respiratory compromise.
3. Recurrent seizures without lucid interval.

Question 12

ALS Seizure Treatment

Answer 12

Supplemental 02 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and
flow rate of O2 possible.
3. Initiate vascular access.
4. Perform blood sugar determination. refer to PD# 8002 – Diabetic Emergencies.
5. Midazolam:
* 0.1mg/Kg in 2 mg increments slow IV push or IN-titrate to seizure control (max dose
6 mg).
* If IV or IN is not available, Midazolam may be given IM - 0.1 mg/Kg (max dose 6 mg)
8003.02-Page 2 of 2
in a single IM injection (may be split into 2 sites if sufficient muscle mass is not
present for a single injection site).
6. **Diazepam:
* May substitute Diazepam when there is a recognized pervasive shortage of
Midazolam. 5-10 mg IVP to control seizures. If no IV access, 10 mg IM. May repeat
once. Max dose 20 mg.
7. Cardiac Monitoring.

Question 13

Symptoms of suspected Narcotic Overdose

Answer 13

1. Decreased responsiveness (Glasgow Coma Score < 14).
2. Inability to respond to simple commands
3. Respiratory insufficiency or respiratory rate < 8.
4. Pinpoint pupils.
5. Bystander or patient history of drug use, or drug paraphernalia on site.

Question 14

GCS Glasgow Coma Scale

Answer 14

Best eye response (4)

1 No eye opening
2 Eye opening to pain
3 Eye opening to sound
4 Eyes open spontaneously

Best verbal response (5)
1 No verbal response
2 Incomprehensible sounds
3 Inappropriate words
4 Confused
5 Orientated
6 Best motor response (6)

No motor response.
1 Abnormal extension to pain
2 Abnormal flexion to pain
3 Withdrawal from pain
4 Localizing pain
5 Obeys commands

Question 15

Narcotic Overdose ALS Treatment

Answer 15

1. Initiate vascular access, and titrate to a SBP > 90 mm Hg.
2. Naloxone:
   * Preferred routes are IV or *Intranasal (IN). Can also be given IM when IV or IN is
   difficult or impossible. 1mg increments up to 6mg IV push, IN or IM; titrated to
   adequate respiratory status. If IN Naloxone cannot be titrated it should be given
   per manufactures specified direction.
   * Do not administer if advanced airway is in place and patient is being adequately
   ventilated.
3. Perform blood glucose determination, if blood glucose ≤ 60 mg/dl, refer to PD# 8002
   Diabetic Emergencies.
4. Airway adjuncts as needed
5. Cardiac monitoring.

Question 16

ABD Pain ALS Treatment

Answer 16

1. Establish vascular access for any of the following, with Normal Saline and titrate to a systolic
   blood pressure of ≥ 90 mmHg.
   * Hemodynamically unstable/Hypo-perfusion
   * Concurrent respiratory compromise
   * Glasgow Coma Score ≤13
   * Significant hemorrhage
   * Pulsatile abdominal mass
   * Suspected ectopic pregnancy
   * May establish an IV for pain management
2. Establish cardiac monitoring
3. Pain Control: For severe pain, consider administration of pain medications per
   PD# 8066 – Pain Management Policy
4. Consider treating nausea and/or vomiting per PD# 8063 – Nausia and/or Vomiting

Question 17

Amputations Treatment

Answer 17

Dress stump with a dry sterile dressing. Place amputated part in a sterile, dry
container or bag and close. Place the first container in the second container or bag
and tie it closed. Place in melting ice. Amputated part should not come in direct
contact with ice or water.

Question 18

Evisceration Treatment

Answer 18

Cover with large sterile saline-soaked dressing. Do not replace abdominal contents

Question 19

Hemorrhage Control:

Answer 19

The best method of control is direct pressure. If unable to control with direct
pressure, see PD# 8065 – Hemorrhage

Question 20

Impaled Object Treatment

Answer 20

Only to be removed when its presence interferes with CPR or impaled object
interferes with the airway.

Question 21

Open Chest Wound Treatment

Answer 21

Cover with an occlusive dressing and tape on three sides loosely. If signs of tension
pneumothorax develop (distended neck veins, cyanosis, tracheal shift, absent
breath sounds on one side, falling BP, dyspnea), remove the dressing, allow air to
escape, and reapply dressing

Question 22

Orthopedic trauma treatment

Answer 22

Check for a pulse before and after splinting and document.
* If angulated and NO pulse, then attempt to gently straighten unless pain or
resistance is met, and splint.
* If angulated, stable, and GOOD pulse, splint in position unless transport would be
compromised.
* Open fractures should be treated with a moist sterile dressing and not reduced. The
exception would be a traction splint to an open femur fracture. In this case, it is
essential to notify hospital staff (as well as written documentation) of the presence
of an open fracture.

Question 23

Head Trauma Treatment

Answer 23

If in shock, treat according to shock protocol. 100% O2 via Non-Rebreather Mask
* Scalp hemorrhage can be life-threatening and will be dressed with a pressure
dressing for signs of significant bleeding or active brisk/heavy bleeding. Check for:
a. Alertness
b. Verbal response
c. Pain response
d. Unresponsiveness

Question 24

ALS Trauma Treatment Protocol

Answer 24

Advanced airway adjuncts as needed - confirm advanced airway placement with continuous
waveform capnography.
2. Cardiac monitoring and SpO2
3. Establish large-bore Intravenous (IV) access with normal saline (NS)/ titrate to a Systolic
Blood Pressure (SBP) ≥ 90mmHg for patients meeting Trauma Triage Criteria. If patient
meets physiological criteria, start a second large bore IV.
4. Decompression of Tension Pneumothorax:
a. Indications:
* Unilateral decreased breath sounds with a history of chest trauma and:
* Severe respiratory distress and/or
* SBP ≤ 90 mmHg or loss of radial pulse due to shock
OR
b. Traumatic arrest with evidence of chest trauma or suspicion that a tension
pneumothorax is contributing to the arrest.
c. If an indication is present: Decompression of a tension pneumothorax should be
immediately accomplished with insertion of a 3.25” 14 gauge chest decompression
needle in the 3rd or 4th intercostal space, midaxillary line.
d. Subsequently, if all the criteria are met for tension pneumothorax on the opposite side,
needle decompression should be performed on that side.
8015.27-Page 3 of 3
e. Decompression of suspected pneumothorax in traumatic arrest should be performed
bilaterally.
NOTE: If conditions preclude access to the midaxillary approach, decompression can be attempted
by placing a needle on the affected side at the 2nd intercostal space, midclavicular line.
5. Orthopedic Trauma:
* Patients presenting in severe pain from amputation and/or suspected extremity
fracture(s), including hip or shoulder injuries or dislocations, consider administration
of pain medication per PD# 8066 – Pain Management.

Question 25

Tension Pneumo Indications

Answer 25

• Unilateral decreased breath sounds with a history of chest trauma and:
• Severe respiratory distress and/or
• SBP ≤ 90 mmHg or loss of radial pulse due to shock

Question 26

Dystonic Reaction Symptoms and Treatment

Answer 26

A dystonic reaction occurs as an idiosyncratic reaction to a phenothiazine compound.
Frequently no clear history or medication use is obtainable; therefore, this reaction should
be treated based on its clinical presentation.
C. Although diphenhydramine is used to treat this reaction, it is not an allergic reaction to the
medication. The patient should be informed of this distinction. Dystonic reactions, which
may require field treatment to alleviate patient discomfort, may present as the following:
1. Facial grimacing with poor ability to voluntarily relax tensed facial muscles.
2. Torticollis or twisted posturing of the neck.

1. Establish vascular access.
2. Cardiac Monitoring
3. DIPHENHYDRAMINE- 50 mg IV (preferred) or IM
4. Monitor and reassess patient after administration of DIPHENHYDRAMINE

Question 27

Overdose / Poison Ingestion Treatment

Answer 27

1. Establish vascular access.
2. Cardiac Monitoring and SPO2.
3. Initiate transport as soon as possible.

Question 28

Beta Blocker OD Treatment

Answer 28

Beta Blockers/Calcium
Channel Blockers

IF SBP<90 Fluid challange of 500ml NS max dose 1000cc
If HR <50 and SBP <90 Atropine: 1mg IV/IO, repeat q5min Max dose 3mg
After max dose of atropine reached and sbp <90 and HR<50
Push Dose Epi
0.01 mg/ml (10mcg/ml)
Dose - .5-2ml (5-20mcg) IV/IO every 2-5 minutes titrate to sbp>90
consider pacing if vitals are not above the 90 50

Question 29

Trycyclic and related overdose treatment

Answer 29

Fluid challange of 1000NS for SBP <90
Sodium Bicarb
1mEq/Kg slow IV push if any of the following signs of cardiac toxicity are present
-HR >120bpm
-SBP<90
QRS complex > 0.12 seconds
Seizures
PVC > 6 per minute

Question 30

Cardiac Dysrhythmias H & T’s

Answer 30

1. Hypovolemia
2. Hypoxia
3. Hydrogen Ion (acidosis)
4. Hypo-/hyperkalemia
5. Hypoglycemia
6. Hypothermia
7. Tamponade (Cardiac)
8. Thrombosis (coronary or pulmonary)
9. Tension Pneumothorax
10. Trauma (hypovolemia, increased ICP)
11. Toxins

Question 31

Adult Bradycardia Criteria

Answer 31

Protocol applies to adults who are symptomatically bradycardic with a heart rate of < 50 bpm documented by
monitor, a systolic blood pressure (SBP) < 90 mmHg, -AND- other signs or symptoms of hypoperfusion that may
include decreased sensorium, diaphoresis, chest pain, capillary refill greater than two seconds, cool extremities, or
cyanosis.
*
* Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest concentration and flow rate of O2
as possible. Profound bradycardia may require Cardiopulmonary Resuscitation (CPR)

Question 32

Adult Bradycardia Initial Treatment

Answer 32

Electrocardiogram Monitoring; Perform a 12-Lead ECG.
Establish vascular access with Normal Saline; titrate to
SBP ≥ 90 mmHg.
Advanced airway adjuncts as needed.

Question 33

Adult Bradycardia - No Block - Treatment

Answer 33

Atropine .5-1mg IV/IO
push every 3-5 minutes until max dose of 3mg total given

TCP at 80 bpm adjust mA to capture

If SBP remains < 90mmHG
after Atropine/TCP:
Push Dose Epinephrine
0.01 mg/ml (10mcg/ml)
Dose: 0.5-2 ml (5-20mcg)
IV/IO every 2-5 minutes.
Titrate to SBP > 90 mmHg.
NOTE: Monitor SBP while
administering/titrating.

Question 34

Adult Bradycardia - Block Treatment

Answer 34

Transcutaneous Cardiac
Pacing (TCP) without delay
at 80 bpm, adjust mA to
capture.
Atropine 0.5mg IV/IO shall
be given if administration
does not delay TCP.

If SBP remains < 90mmHG
after Atropine/TCP:
Push Dose Epinephrine
0.01 mg/ml (10mcg/ml)
Dose: 0.5-2 ml (5-20mcg)
IV/IO every 2-5 minutes.
Titrate to SBP > 90 mmHg.
NOTE: Monitor SBP while
administering/titrating.

Question 35

Versed Used for sedation dosing

Answer 35

Midazolam
if needed for sedation:
* IV/IO/IN/IM- 4mg.
* May give an additional
2mg dose.
* IV/IO preferred route.
Titrate to patient comfort.
* Max dose of 6 mg

Question 36

Atropine use in Bradycardia - what to avoid

Answer 36

*Atropine should be avoided
in patients with acute MI in
12-Lead setting as defined in

Question 37

Adult Tachycardia With Pulses Criteria - Basic Treatment

Answer 37

Adult Tachycardia with Pulses
Narrow QRS HR > 150; Wide QRS HR > 120
Supplemental O2 as necessary to maintain SpO2 ≥ 94%.
Electrocardiogram Monitoring.
Perform a 12 lead ECG if possible
Establish vascular access with Normal Saline TKO; titrate to systolic blood pressure (SBP

Question 38

Adult Tachycardia Stable vs unstable criteria

Answer 38

Persistent Tachycardia Causing:
* Hypotension
* Acutely altered mental status
* Signs of shock
* Ischemic chest discomfort
* Acute heart failure

Question 39

Adult Tachycardia Unstable Wide QRS - Becomes Stable after shock still wide treatment

Answer 39

Consider Versed 4mgIVIOINIM
may give 2mg dose additional IVIO preferred max dose 6mg
Sync Cardioversion
100j
200j
max
check rhythm after each shock

Now wide but stable
Amiodarone 150mg IV/IO over 10 minutes
transport

Question 40

Adult Tachycardia Unstable - Post Shock -Wide QRS Still Unstable

Answer 40

Amiodarone 150. mg IVP/IO
Sync cardioversion
max dose energy
transport

Question 41

Adult Tachycardia Unstable - Post Shock - Narrow Unstable

Answer 41

Sync Cardioversion
max energy, check rhythm
transport

Question 42

Adult Tachycardia Unstable - Post Shock - Narrow Stable

Answer 42

Transport

Question 43

Adult Tachycardia Stable Wide

Answer 43

Transport

Question 44

Adult Tachycardia Stable Narrow What decision do we come to

Answer 44

A fib
A Flutter
S tach

Question 45

Adult tachycardia stable narrow not afib flutter or stach

Answer 45

Confirm SVT
Valsalva
if no response consider
Adenosine 6mg rapid IVIO followed by 20ml NS rapid flush
if no response after 2 minutes
Adenosine 12mg IVIO push followed by 20ml NS rapid flush

Question 46

Adult tachycardia - If a rhythm is wide irregular or monitor will not sync, and the pt is critical, treat as..

Answer 46

VF with unsynchronized defibrillationSynchronized cardioversion doses:
-100J
-200J
-Max setting
If no response to the initial shock, increase dose in a stepwise
fashion for subsequent cardioversions to a maximum of 4
attempts

Question 47

Burn ALS Treatment

Answer 47

Advanced Airway: Consider early if evidence of airway burns.
2. Cardiac Monitoring, Sp02 monitoring, and ETCO2 monitoring for intubated patients.
3. Initiate large bore vascular access in patients with major burns (>9%).
* Titrate to systolic blood pressure of ≥ 90 mmHg.
8025.19-Page 2 of 2
* Administer 500 ml normal saline fluid bolus to all adult patients with a Total Body
Surface Area (TBSA) of burns ≥ 50%
* When possible the preferred vascular access site is an unburned area.
4. Pain Management: If partial or full thickness burn with moderate to severe pain and without
evidence of or mechanism of internal head, chest, or abdominal injury , consider pain meds

Question 48

Any pt with the following shall be transported to UCD Burn Center…

Answer 48

Partial thickness >9% of body surface.
* Any electrical or any chemical burn.
* Evidence of possible inhalation injury.
* Any burn to the face, hands, feet, genitalia, perineum, or major joints.

Question 49

When assessing burns easiest method

Answer 49

Rule of Palm: The palm of the person who is burned (not fingers or wrist area) is about 1% of the
body. Use the person’s palm to measure the body surface area burned.

Question 50

Respiratory Distress - Mild definition

Answer 50

• The patient is able to speak full sentences; the patient may have an
  elevated pulse and blood pressure; the patient may be diaphoretic and weak; mental
  status is unaffected; no cyanosis is present.

Question 50

Respiratory Distress - Moderate definition

Answer 50

• The patient is able to speak a few words; the patient may have an
  elevated pulse and blood pressure; the patient may be diaphoretic and weak; mental
  status is unaffected; mild cyanosis of lips and digits may be present.

Question 51

Respiratory Distress - Severe Distress

Answer 51

The patient is unable to speak; the patient may have
decreased/elevated pulse and/or decreased/elevated blood pressure; mental status is
altered; more central and profound cyanosis is present.

Question 52

Caveats to Respiratory Distress

Answer 52

A. Patients may have several disease processes together, producing shortness of breath.
Wheezing may occur in diseases other than asthma, and peripheral edema may occur
in settings other than congestive heart failure (CHF). Assessment should usually yield a
single treatment plan. Commit yourself to a single assessment - you may modify this
assessment based on response to therapy and as additional information becomes
available, modify the treatment plan.
B. Patients may have diseases producing shortness of breath that cannot be relieved with
any prehospital treatments. Some patients will present to the prehospital personnel so
far in respiratory failure that maintenance/establishment of an airway together with
expeditious transport are the only treatments possible.
C. Pulmonary edema in the setting of CHF will usually have collaborating signs such as:
1. History of CHF and medications such as diuretics and/or angiotensin-converting
enzyme (ACE) inhibitors.
2. Peripheral edema.
3. Jugular venous distension (JVD).
8026.22-Page 2 of 2
4. Frothy pulmonary secretions.
D. Continuous Positive Airway Pressure (CPAP) and Bi-PAP, are highly effective at
improving respiratory distress and should be attempted if available in all patients with
moderate and severe respiratory distress. In general, one provider should monitor and
manipulat

Question 53

Acute Respiratory Distress Basic Treatment

Answer 53

Assess ABC’s limit physical exertion, reduce anxiety
* Consider oxygen therapy per Respiratory Distress: Airway management PD # 8020
* Cardiac Monitor and SpO2., ETCO2 (continuous waveform) when available.
* Consider vascular access but do not delay airway management or treatment.
* Early contact with receiving hospital.

Question 54

Asthma/COPD Mild Distress Criteria and treatment

Answer 54

Mild distress, sob , cough

Albuterol 2.5 5mg via HHN mask or inline neb may repeated doses

Question 55

Asthma/COPD Moderate/Severe Distress Criteria and treatment

Answer 55

Cyanosis, accessory muscle use, inability to speak > 3 word sentences, severe wheezing SOB

Albuterol 5mg via HHN mask or inline neb - continous albuterol for persistant dyspnea
CPAP
Epi 1:1000 0.3mg IM
for pt with severe asthma/bronchospasm ONLY
CAUTION - Epinephrine should be used
cautiously in patients > 35 years
old, or with a history of CAD or
HTN

Question 56

CHF/Pulmonary Edema Treatment Mild Distress Criteria and treatment

Answer 56

Mild Distress - mild wheezing SOB, cough
if wheezing is present - Albuterol 2.5-5mg via HHN may repeat
NTG SL - 0.4mg q5min Hold NTG if SBP<90

Question 57

When to not admin NTG

Answer 57

**Do Not Administer NTG if patient is
taking PDE-5 inhibitors within last 48hrs
for Erectile Dysfunction or Pulmonary
HTN:
i.e Sildenafil (VIAGRA®, REVATIO),
Tadalafil (CIALIS®), Vardenafil
(LEVITRA®) or equivalent.

Question 58

CHF/Pulmonary Edema Moderate Severe Distress Criteria Treatment

Answer 58

Cyanosis, accessory muscle use, inability to speak >3 word sentences , Diaphoresis, pedal edema, ect

IF wheezing Albuterol - 2.5 - 5mg via HHN may repeat

NTG -SBP 90-150 mmHg: 0.4 mg SL
SBP 150-200 mmHg: 0.8 mg SL
SBP > 200 mmHg:1.2 mg SL
May repeat titrated doses every
5 minutes based on repeat BP.
Hold NTG if BP < 90 mmHg.

Question 59

Respiratory Distress With SBP < 90 Treatment

Answer 59

For SPB ≤ 90 mmHG
Push Dose Epinephrine
Epinephrine 0.01mg/ml (10mcg/ml)
DOSE: 0.5-2 ml (5-20 mcg) IV/IO
every 2-5 minutes.
Titrate to SBP > 90 mmHg.
NOTE: Monitor SBP while
administering/titrating.

Question 60

Hypothermia Treatment ALS

Answer 60

1. Advanced airway adjuncts as needed.
2. Cardiac Montitoring
3. Consider vascular access.
4. Monitor and reassess.
5. If in cardiac arrest, refer to PD# 8031 – Medical Cardiac Arrest.
6. Transport

Question 61

Hyperthermia Treatment ALS

Answer 61

1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest
   concentration and flow rate of O2 possible.
2. Airway adjuncts as needed.
3. Place the patient in a cool area and remove clothing as appropriate.
4. Transport
   If sweating is absent, proceed with cooling patients as rapidly as possible (cool
   packs on neck, in the axilla and inguinal areas; fanning and misting, if possible, undress patient,
   cover with a sheet, and wet thoroughly.)
   ALS
5. Advanced airway adjuncts as needed.
6. Consider vascular access.
7. Cardiac Monitoring
8. Transport

Question 62

Snake Bite Treatment

Answer 62

1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest
   concentration and flow rate of O2 possible.
2. Airway adjuncts as needed.
3. Assess the site of the wound for swelling and redness from stings/bites.
4. Immobilize affected extremity at or slightly below the level of the heart.
5. Keep the patient at rest.
6. Transport
7. Pre-alert receiving hospital of the possible need for antivenom if moderate to severe
   venomous snake bite is noted.
   NOTE: If the patient is experiencing signs and symptoms of anaphylaxis, treat per
   PD# 8001 – Allergic Reaction/Anaphylaxis.
   8028.15-Page 3 of 3
   Degree of Envenomation Presentation
   None Punctures or abrasions; some pain or
   tenderness at the bite.
   Mild Pain, tenderness, and edema at the bite;
   perioral paresthesias may be present.
   Moderate Pain, tenderness, erythema, edema
   beyond the area adjacent to the bite;
   often, systemic manifestations and mild
   coagulopathy.
   Severe Intense pain and swelling of entire
   extremity, often with severe systemic
   signs and symptoms; coagulopathy
   Life-threatening Marked abnormal signs and symptoms;
   severe coagulopathy

*DO NOT APPLY ICE OR A TOURNIQUET TO THE SITE *
*DO NOT BRING THE DEAD SNAKE TO THE HOSPITAL; TAKE A PICTURE IF POSSIBLE
ALS
1. Assess for anaphylaxis and treat per PD# 8001
Stings / Bites:
BLS
1. Supplemental O2 as necessary to maintain SpO2 ≥ 94%. Use the lowest
concentration and flow rate of O2 possible.
2. Airway adjuncts as needed.
3. Assess skin for swelling, redness, and rash. If extremity, check distal circulation,
sensation, and movement
4. Keep affected extremities at the level of the heart and immobilize.
5. Transport
Apply ice for insect bites, not snake bites.
NOTE: If the patient is experiencing signs an

Question 63

Hazardous Materials Treatment Organophosphate or carbamate pesticides with SLUDGE

Answer 63

ATROPINE
* 2 mg IV push, repeat every 3-5
minutes until secretions improve

Albuterol

Question 64

Chest Pain Treatment

Answer 64

1. ABC’s/Routine Care-Supplemental O2 as necessary to maintain SPO2 ≥ 94%. Use the
   lowest concentration and flow rate of O2 as possible.
2. Aspirin (ASA) - Administer 324mg chewable ASA orally, except in cases of allergy to
   ASA. Concurrent anticoagulation therapy is not a contraindication for ASA administration.
   If ASA is not administered, the reason shall be documented in the ePCR.
3. Transport
   ALS
4. Assessment, treatment, and transport should occur concurrently when a single good
   quality Electrocardiogram (ECG) is completed. Scene time for suspected STEMI patients
   should be ≤ 10 minutes when possible.
5. Pulse oximetry shall be used.
6. Cardiac monitor
7. Obtain 12-Lead ECG.
8. If the patient ECG is consistent with an acute STEMI by software algorithm interpretation,
   the following shall be performed without delay:
   * Transmit the 12-lead ECG to the closest designated STEMI center.
   * Transport to the closest designated STEMI center.
   * Perform a Pre-Alert notification to the closest designated STEMI center.
   * The primary impression of STEMI must be documented in the ePCR.
   * A copy of all 12-Lead ECGs shall be delivered with the patient.
   NOTE: NTG is contraindicated in the setting of a STEMI.
   8030.26-Page 2 of 2
9. If 12-lead ECG is NOT consistent with an acute STEMI:
   * Administer NTG 0.4 mg sublingual if Systolic Blood Pressure (SBP) >90mmHg.
   May be repeated every 5 minutes.
   * Titrate subsequent NTG to pain relief as long as the SBP> 90 mmHg while
   simultaneously establishing vascular access.
   * Absence of vascular access shall not preclude use of NTG as long as all other
   criteria are met.
   Caution: NTG shall not be given to patients who have taken PDE-5 inhibitors [Avanafil,
   Sildenafil, Tadalafil, Vardenafil, Vardenafil, or equivalent] within the last 48 hours.
10. Establish vascular access.
    Special Considerations:
11. If NTG is contraindicated or after the third (paramedic-administered) NTG, the patient
    does not have relief of chest discomfort/pain; the paramedic may elect to administer pain
    medication as per Policy# 8066 (Pain Management)
12. If patient is nauseated and/or vomiting refer to Policy# 8063 (Nausea/Vomiting).
13. Hemodynamically unstable patients (SBP < 90 mmHg) with an acute STEMI ECG shall
    be transported to the time closest facility providing interventional cardiac catheterization
    services.

Question 65

Non traumatic Cardiac Arrest Protocol Considerations

Answer 65

A. High-quality Cardiopulmonary Resuscitation (CPR) is fundamental to the management
of all cardiac arrest rhythms. Periodic pauses in CPR should be as brief as possible and
only as necessary to assess rhythm, shock VF/VT, and perform a pulse check when an
organized rhythm is detected.
B. CPR must be performed with a “Chest Compressions, Airway, Breathing” sequence
(C-A-B) to emphasize the importance of maintaining blood flow with good compressions.
C. Performing CPR while a defibrillator is readied for use is strongly recommended for all
patients in cardiac arrest.
D. Advanced airway placement shall be confirmed with ETCO2 detection device or
waveform capnography.
E. Vascular access, drug delivery, and advanced airway placement should not cause
significant interruptions in chest compressions or delay defibrillation.
F. Treatment on scene- Movement of a patient may interrupt CPR or prevent adequate
depth and rate of compressions. Consider resuscitative efforts on scene to maximize
chances of Return of Spontaneous Circulation (ROSC).
G. Whenever feasible, and safe to do so, transport the medical Durable Power of Attorney
(DPOA) or immediate family member with the patient to the hospital. DPOA and
immediate family members can provide medical insight and consent for special therapies
or termination of resuscitation to hospital staff.
H. Perform an early Pre-Alert notification to the receiving hospital.

Question 66

Non traumatic Cardiac Arrest Protocol Post Resuscitation Considerations

Answer 66

A. Any patient with an initial shockable rhythm (VT or VF or shocked by an AED) who has a
ROSC during any part of the resuscitation and who is transported, shall be transported to
a STEMI center
8031.26-Page 2 of 3
1. Any other cardiac arrest patient who is transported, shall be transported to the time
closest hospital.
B. Intravenous (IV) or Intraosseous (IO) fluids should be placed at, to keep open (TKO)
unless hypotension is present.
C. Post-resuscitation bradycardia, hypotension, shock, and pulmonary edema.
1. Bradycardia, refer to PD# 8024 – Cardiac Dysrhythmias.
2. Congestive Heart Failure/Pulmonary Edema refer to PD# 8026 – Respiratory Distress.
3. Hypotension/Shock
a. Normal Saline 1000 ml bolus, may repeat once to achieve Systolic Blood Pressure
(SBP) > 90 mmHg. Reassess vital signs after each bolus
b. Push Dose Epinephrine 0.01 mg/ml (10mcg/ml).
* Dose: 0.5-2 ml every 2-5 minutes (5-20mcg). Titrate to SBP ≥ 90 mmHg.
NOTE: Once ROSC is obtained, monitor SBP frequently while
administering/titrating.

Question 67

Termination of Resuscitation Considerations:

Answer 67

A. Consider termination of resuscitation efforts after twenty (20) minutes of Advanced Life
Support (ALS) care if BOTH of the following are present:
1. Pulseless, apneic, or agonal, respirations with no signs of life (non-reactive pupils, no
response to pain, no spontaneous movement).
2. Asystole, or Pulseless Electrical Activity with HR ≤ 40 bpm.

Question 68

Cardiac Arrest ALS Treatment Asystole PEA

Answer 68

IV, IO, AIrway, Cardiac Montor pads
CPR 2 min IVIO access , epi every 3-5 minutes, consider advanced airway, capnography
no shockable rhythm
CPR 2 min

Question 68

Cardiac Arrest ALS Treatment VF/VT

Answer 68

CPR 2 min IV IO Shock
CPR 2 min , epi every 3-5 min , consider advanced airway, capno
shock , cpr amiodarone

Question 69

CPR Epi dose

Answer 69

1mg every 3-5 minutes

Question 70

Amiodarone CPR Dose

Answer 70

First dose 300mg bolus
Second dose 150mg

Question 71

Traumatic Cardiac arrest Considerations

Answer 71

A. The pathophysiology of traumatic cardiac arrest differs from medical cardiac arrest and
is primarily due to one of or a combination of factors: hypovolemia, obstruction of blood
flow, and hypoxia.
B. The initial cardiac rhythm for most patients in survivable traumatic cardiac arrest is
pulseless electrical activity (PEA). Traumatic cardiac arrest PEA is most often a very low
output state due to hypovolemia.
C. Traumatic cardiac arrest patients undergoing resuscitation shall be transported as
quickly as possible to the hospital.
D. Patients with trauma in cardiac arrest who by prehospital presentation may have
suffered a medical event before trauma shall undergo medical cardiac arrest
resuscitation per PD# 8031 – Non-Traumatic Cardiac Arrest, with attention and
appropriate management to emergent trauma needs (hemorrhage control,
pneumothorax decompression as indicated, and orthopedic immobilization as indicated)
E. There is no evidence-based medical support for the use of medications in traumatic
cardiac arrest. In traumatic arrest, Epinephrine and Amiodarone are NOT indicated in
traumatic cardiac arrest. Epinephrine will not correct arrest caused by a tension
pneumothorax, cardiac tamponade, or hemorrhagic shock. If there is any doubt as to the
cause of arrest, treat as a non-traumatic arrest.

Question 72

Traumatic Cardiac Arrest Treatment

Answer 72

Treat immediate threats to life
2. External hemorrhage control per PD# 8065 - Hemorrhage Control
3. Airway and Breathing: Clear airway when indicated, place OPA, BVM ventilations
4. Chest Compressions: Chest compressions should be performed when possible without
delaying transport or other treatments
8032.01-Page 2 of 3
ALS
1. Optimize Oxygenation/Ventilation
* Advanced airway as needed per policy
* Advanced airway placement shall be confirmed with ETCO2 detection device or
waveform Capnography
2. Correct potential obstructive shock - Maintain high Index of suspicion for tension
pneumothorax, Bilateral needle thoracostomy per PD# 8015 – Trauma
3. Treat potential exsanguination
* Obtain two (2) large-bore IV or IO access
* 1 Liter normal saline bolus simultaneously via each IV/IO
* Utilize pressure bag for rapid fluid administration
* Reassess lung sounds after each Liter
* Repeat IV fluid during arrest until SBP>90 or a maximum of 4 liters administered
4. Treat Cardiovascular Collapse
* High-quality CPR
* ECG monitoring and appropriate defibrillation per PD# 8031 – Cardiac Arres

Question 73

Traumatic Arrest - Post-Resuscitation Considerations:

Answer 73

A. Any traumatic cardiac arrest patient who has a Return of Spontaneous Circulation (ROSC)
during any part of the resuscitation, and who is transported, shall be transported to a
Trauma Center.
B. Intravenous (IV) or Intraosseous (IO) fluids should be placed wide open with pressure
bags.
C. If palpable pulse becomes present:
* Re-assess for and control external hemorrhage
* Administer TXA as indicated per PD# 8065 – Hemorrhage Control
* Titrate normal saline to SBP ≥ 90 mmHg or palpable peripheral pulses

Question 74

Traumatic Cardiac Arrest Flowchart

Answer 74

Do they meet obvious death
no - Is the patient pulseless, apneic, or have
agonal respiration with no signs of life and
absence of all pulses or wide complex
asystole by monitor with PEA < 40?
No - * Start CPR
* Prepare for Immediate
Transport
* Treat reversible causes
* Do not administer Epinephrine

Question 74

Childbirth - prolapsed cord

Answer 74

• Immediately place mother on high
  flow O2
• Place mother in knee-chest
  position.
• Insert gloved hand into vagina and
  gently push presenting part off
  cord.
• Cover exposed cord with wet
  saline dressing.
• When the head is crowning with
  the prolapsed cord, immediate
  delivery is the most rapid means
  of restoring O2 to the infant

Question 75

Childbirth Head

Answer 75

• Control the decent of the fully crowned head with your
  gloved hand cupped over the cranium.. If cord is around
  neck, gently slip it over the head or across the shoulder.
  If cord cannot be removed, gently clamp the cord in 2
  locations approximately 1 cm apart and cut the cord
  between the clamps. Support the head; do not allow the
  presenting part to press on the cord.
• When head delivered, gently lower the head to deliver the
  anterior (upper) shoulder. Once shoulder is delivered,
  gently raise the head to deliver the posterior (lower)
  shoulder. Prepare for remainder of the baby’s body to be
  delivered.
• Hold baby in slightly head down position.
• Clamp and cut cord. Leave a minimum of 6 inches of
  cord for the umbilicus. There is no hurry to cut the cord
• Dry and warm the baby.

Question 76

Childbirth Breach or footing

Answer 76

Avoid compression of the cord by
presenting part.
* Allow delivery to progress
passively until baby’s waist
appears.
* When legs and buttocks are
delivered, the head can be
assisted out.
* If head does not deliver in 1-2
min. insert a gloved hand into the
vagina and create an airway for
the infant.

Question 77

Post Birth Treatment

Answer 77

APGAR of 7 or greater-dry, place skin to skin
with mother or if mother refuses, wrap
warmly, place cap on baby’s head and
proceed to assess mother
* Suctioning should be reserved for babies
who have an obvious obstruction to
spontaneous breathing or require positive
pressure ventilation. See Neonatal
Resuscitation, PD#9009.
* Always consider the possibility of multiple
births.
* Consider blow-by oxygen. Heated
humidification systems are preferable to cool
mist systems, which can produce
hypothermia in the infant

Question 78

Child Birth Considerations

Answer 78

Newborn patients needing resuscitation should be treated in accordance with PD# 9009 -
Neonatal Resuscitation.
* Newborns can suffer from hypothermia, which can occur in minutes.
* Keep baby at or below the level of the mother’s heart until cord is clamped.
* Do not pull on the umbilical cord.
* Expedite transport if there is partial delivery of the infant and no further progress after 1-2
minutes.
* Any patient in labor, or who delivers in the field will be taken to a facility with labor and
delivery services. Consideration should be given to the patient’s pre-determined hospital
for delivery, if possible.

Question 79

Multiple Births

Answer 79

If Multiple Births:
* Clamp cord of first baby before the second is born
* Care for the babies as you would a single delivery
* Maintain identity of first born

Question 80

Spinal Restricitons Procedure

Answer 80

A. All patients suffering traumatic injuries shall be assessed for the possibility of spinal injury,
including history and exam, including a neurologic exam of all extremities and inspection
and palpation of the entire spine.
B. Establish and secure an airway while maintaining neutral inline immobilization.
C. Assess the head and neck for obvious injuries and distended neck veins while providing
neutral inline immobilization for the head and neck.
D. SMR, when indicated, should apply to the entire spine due to the risk of noncontiguous
injuries.
E. An appropriately sized cervical collar is a critical component of SMR and should be used to
limit movement of the cervical spine whenever SMR is employed.
8044.15-Page 2 of 3
F. The remainder of the spine should be stabilized by keeping the head, neck, and torso in
alignment. This can be accomplished by placing the patient supine on a long backboard, a
scoop stretcher, a vacuum mattress, or an ambulance gurney.
G. If elevation of the head is required, the device used to stabilize the spine should be elevated
at the head while maintaining alignment of the neck and torso. SMR cannot be properly
performed with a patient in a sitting position.
H. Transport.

Question 81

Spinal Restrictions Indications

Answer 81

A. Indications for SMR following blunt trauma include:
1. Midline neck or back pain and/or tenderness
2. Altered level of consciousness (e.g., GCS < 15, evidence of intoxication)
3. Focal neurologic signs or symptoms (e.g., numbness or motor weakness)
4. Anatomic deformity of the spine
5. Distracting circumstances (e.g., emotional distress, communication barrier, or age > 65
or < 5 years of age), or injury (e.g., long bone fracture, de-gloving or crush injuries, large
burns, etc.) or any similar injury that impairs a patient’s ability to contribute to a reliable
history and/or examination
B. If the above criteria are not met, but there is still suspicion of a spinal column or spinal cord
injury, the patient should be placed in SMR.
C. Prehospital providers may utilize SMR for any trauma patient who, based on their clinical
assessment, may have suffered a spinal injury.
D. There is no role for SMR in isolated penetrating trauma.

Question 82

Spinal Restrictions Special Notes

Answer 82

A. Moving the head into a neutral inline position is contraindicated if:
1. There is pain upon starting movement
2. There is muscle spasm or back pressure upon attempting movement
3. Patient holds head angulated (tilted) to the side, and the patient cannot move the head
4. The head is rigidly held to one side
5. The maneuver cannot be safely achieved due to space or other considerations
B. In these cases, the patient shall be immobilized in the position in which they are found. SMR
does not take precedence over the airway, respiratory, and cardiovascular stabilization of
the critical trauma patient.
C. If attempting to apply SMR to a combative patient would cause further detriment, abort the
procedure and document in ePCR. Notify ED staff on arrival regarding indications for SMR
but the inability to apply due to combative patient.
D. If modified spinal restrictions are used, documentation in the PCR is required to clearly
explain why SMR could not be performed.

Question 83

Stroke Definitions - Onset, lKN, Wake Up

Answer 83

A. Stroke - A condition of impaired blood flow to a patient’s brain resulting in brain
dysfunction, most commonly through occlusion or hemorrhage.
B. Onset of Symptoms - The specific date and time when current symptoms were known to
have started.
C. Last Known Normal/Well - When the “onset of symptom” cannot be reliably determined
(no witness or a poor historian), the Last Known Well time is the most recent time a
reliable historian can say the patient was at their baseline health without current
symptoms.
D. Wake Up Stroke - Patient awakens with stroke symptoms that were not present prior to
falling asleep.
E. Suspected Stroke - Suspected Stroke with one (1) new onset of lateralizing neurological
signs; and/or two (2) unexplained new altered level of consciousness (Glasgow Coma
Scale < 14) without response to Glucose, Glucagon, or Naloxone (excluding head injury).
Protocol:
A. If possible, document a reliable time of day that the patient was last observed to be normal
either by the patient or witness. A patient who wakes up with symptoms is considered as
having an UNKNOWN time of onset.

Question 84

Stroke Treatment ALS

Answer 84

1. Advanced airway adjuncts as needed.
2. Cardiac Monitoring.
3. Determine Cincinnati Prehospital Stroke Scale (CPSS). Normal response is 0,
   Abnormal is 1, Maximum Score is 3.
4. Initiate vascular access. If time allows, without delaying transport, initiate a second
   access line. Minimum 20g in AC when possible.
5. If CPSS is >0, and “last seen normal” *time, including wake-up Stroke, is twenty-four
   (24) hours or less, the patient is to be taken to a certified stroke center.
6. Prehospital personnel will contact the receiving hospital and clearly announce:
   “Stroke Alert” and give the following information if available:
   * Last time of day observed to be “normal,” reported by bystanders.
   * Patient’s name, date of birth, or medical record number, if known.
   * Baseline Mental Status.
7. When possible and safe to do so, transport a family member or Durable Power of
   Attorney (DPOA) or obtain and relay to the receiving hospital the name/contact
   information of the individual(s) who can verify the time of onset of symptoms or last
   known normal/well time.
   *If CPSS is=0, OR “last seen normal” time is > twenty-four (24) hours, the patient is NOT a
   “stroke alert,” and destination is per Policy PD# 5050 – Destination.

Question 85

Continued Combative pt treatment

Answer 85

Continued Combativeness: If the patient remains combative despite restraint such that
further harm to the patient or providers is possible.
Midazolam:
a) Intravenous (IV) - 0.1 mg/Kg (max dose 6 mg) slow IV push in 2 mg incrementstitrate to the reduction in agitation.
b) Intranasal (IN) – 0.1 mg/Kg (max dose 6 mg) one-half dose in each nares.
c) Intramuscular (IM) - 0.1 mg/Kg (max dose 6 mg) in single IM injection (may be split
into two sites if sufficient muscle mass is not present for a single injection).
2. Monitor Patient:
a) ECG Monitoring: Monitor closely for respiratory compromise. Assess and document
mental status, vital signs, and extremity exam (if restrained) at least every five (5)
minutes.
b) SPO2 Monitoring
c) Supplemental O2 as necessary to maintain Sp02 ≥ 94%. Use lowest concentration
and flow rate of O2 as possible.

Question 86

Nausea Vomit ALS Treatment

Answer 86

1. Advanced airway adjuncts as needed.
2. Cardiac Monitoring for possible dysrhythmias.
3. Consider vascular access and titrate to SBP ≥ 90mmHg.
4. Ondansetron:
   * 4mg PO/SL/IM/IV/IO.
   * For IV or IO Ondansetron, administer slowly (over one (1) minute) to prevent
   syncope.
5. For persistent vomiting, may repeat x one (1) for max dose of eight (8) mg.
6. Withhold from first trimester (< 12 weeks) pregnant patients not already using Ondansetron

Question 87

Pain Management Note

Answer 87

NOTE: Analgesic medications should be considered in ALL patients complaining of pain. With the
exception of Ketamine and Acetaminophen, analgesics should be avoided if the patient’s systolic
blood pressure (SBP) is <90 mmHg, respiratory rate (RR) is ≤ 10 breaths per minute, and/or
decreased sensorium or suspicion of traumatic brain injury.

Question 88

Pain Management ALS Treatment

Answer 88

1. Advanced Airway adjuncts as needed.
2. Cardiac and SpO2 monitoring.
3. Initiate vascular access.
4. Document the pain scale (sample scale attached below) with initial assessment/vital signs
   after each administration of medication and after all procedures.
5. Pain medications shall be titrated to relief if the pain is not effectively managed with BLS
   pain management methods.
   a. Acetaminophen For patients with mild to moderate pain)
   * 1000 mg IV/IO infusion over 15 minutes.
   * 1000 mg PO.
   * Do not repeat.
   b. Ketorolac (For patients with mild to moderate pain)
   * 15 mg slow IV/IO push or 30 mg IM.
   * Do not repeat.
   8066.11-Page 2 of 3
   c. Fentanyl Citrate (For patients with moderate to severe pain)
   * 1 mcg/kg (maximum single dose 100 mcg) slow IV, IO, or IN every 5
   minutes. Maximum cumulative dose of 3 mcg/kg (300 mcg) total.
   d. Morphine Sulfate (if Fentanyl is unavailable)
   * 0.1 mg/kg (maximum single dose 10mg) slow IV, IO, or IN every 5 minutes. A
   maximum cumulative dose of 0.2 mg/kg (20 mg).
   e. Ketamine (For patients with moderate to severe pain)
   * Mix 0.3 mg/kg Ketamine (maximum single dose = 30mg) in 50-100cc normal
   saline solution (NSS) or D5W and administer slow IV drip over ten (10)
   minutes.
   * If pain remains at, or returns to, moderate or severe, you may administer a
   second dose of 0.3 mg/kg Ketamine (max dose=30 mg) in 50-100cc NSS or
   D5W and administer slow IV drip over ten (10) minutes.
   Precautions/Contraindications:
6. Check the patient’s allergies before administering any medication.
7. Ketamine should be avoided in the following patients:
   * Chest pain of suspected cardiac origin.
   * Pregnancy.
8. Ketorolac should be avoided in the following patients:
   * Active bleeding.
   * Active wheezing.
   * Age < 4 years old or > 65 years old.
   * Allergy to Non-Steroidal Anti-inflammatory agents (NSAIDs).
   * Current Anticoagulation therapy.
   * Head or Multisystem trauma.
   * History of peptic ulcer disease of upper GI bleeding.
   * History of renal disease or kidney transplant.
   * Known or suspected pregnancy.
   * Suspected Sepsis or Septic Shock

Question 89

Sepsis definition

Answer 89

A. Sepsis:
Sepsis can be a rapidly progressing, life-threatening condition due to SIRS (systemic
infection). Sepsis must be recognized early and treated aggressively to prevent
progression to shock and death. The most important pre-hospital interventions for
Sepsis/SIRS patients include:
1. Recognition of potential Sepsis/SIRS
2. Early and aggressive fluid resuscitation
3. Pre-arrival “Sepsis Alert” notification to receiving facility.

Question 90

B. Systemic Inflammatory Response Syndrome (SIRS):

Answer 90

A generalized inflammatory response to a non-specific injury and includes at least 2 of
the following criteria;
1. Body temperature of > 38 C (100.4 F) or < 36 C (96.8 F).
2. Respiratory rate > 20 breaths per minute.
3. Heart rate > 90 bpm.

Question 91

Sepsis Indications

Answer 91

A. Treatment interventions and pre-arrival notification shall occur for patients meeting
BOTH of the following pre-hospital sepsis criteria:
1. Confirmed or suspected presence of infection:
a. By history from the patient, family, or care home.
b. By signs or symptoms of urinary tract infection, respiratory infection, or skin
infection.
c. Older Adults or immune-compromised patients with otherwise unexplained
ALOC and no findings to suggest acute STROKE per PD# 8060 – Stroke.
8067.06-Page 2 of 2
AND
2. Any two (2) of the following criteria:
a. Temperature of >38 °C (100.4 °F) or < 36 °C (96.8 °F) (Acquired by EMS or if
reported by patient, family, or care home).
b. Respiratory rate >20 breaths per minute.
c. Heart rate > 90 beats per minute.
d. SBP < 90 mmHg
e. Waveform capnography, if available, with a reading of < 25mmHg

Question 92

Sepsis Treatment

Answer 92

1. Use Supplemental oxygen as necessary to maintain Sp02 ≥ 94%. Use lowest
   concentration and flow rate of 02 as possible.
2. Perform blood glucose determination
3. Conduct a pre-arrival “Sepsis Alert” notification to the receiving facility.
4. Transport
   ALS
5. Cardiac Monitoring
6. Establish vascular access.
   * Administer a 500 ml bolus of Normal Saline to ALL patients regardless of
   Systolic Blood Pressure (SBP).
   * If SBP remains < 90 mmHG, repeat 500 ml bolus of NS until SBP > 90 mmHG.
   Total amount of fluid not to exceed 2000 ml. Recheck vital signs and lung sounds
   after every 500 ml bolus.
   * Give boluses in rapid succession if SBP remains < 90 mmHG.
   * Albuterol if wheezing and SOB per PD# 8026 – Respiratory Distress.
7. If SBP remains < 90 mmHg after four (4) fluid boluses:
   * Push Dose Epinephrine 0.01 mg/ml (10mcg/ml).
   DOSE: 0.5-2 ml (5-20mcg) every 2-5 minutes (5-20mcg) IV/IO
   Titrate to SBP > 90 mmHg
   NOTE: Monitor SBP while administering/titrating.

Question 93

Trauma Destination Protocol

Answer 93

A. Any patient who is suffering from an acute injury or suspected acute injury shall have the
Trauma Triage Criteria (Policy #5053) applied by prehospital care personnel
B. Transportation units, both ground, and air shall transport CTPs who are the subject of
any 9-1-1, emergency, or non-emergency response, to the time closest appropriate
designated trauma center (Policy #5053). If direct medical oversight is necessary, it shall
be provided by the receiving Sacramento County Emergency Medical Services Agency
(SCEMSA) designated trauma center
C. All CTPs ≤14 years of age will be transported to a designated pediatric trauma center
i.e., University California Davis Medical Center (UCDMC) with the following exceptions:
1. Pediatric patients without an effective airway may be transported to the nearest
available facility for emergent airway establishment
2. Pediatric trauma patients under Cardiopulmonary Resuscitation (CPR) shall be
transported to the time closest trauma facility
3. If UCDMC is closed to pediatric trauma, pediatric patients shall be taken to the
time closest trauma center
4. Pediatric patients with a tourniquet in place will be transported to UCDMC
D. Any adult patient with a tourniquet in place shall be transported to the appropriate
trauma center.
E. The paramedic with a NCTP may utilize a SCEMSA-designated trauma base station for
direct medical oversight.
5052.19-Page 2 of 2
F. The CTP without an effective airway shall be transported to the closest available hospital
with an emergency department for stabilization prior to transfer to a designated trauma
center when a life-threatening respiratory condition exists, i.e. obstructed airway or
unrelieved tension pneumothorax.
G. The NCTP who, in the judgment of a base hospital, requires immediate surgical
intervention or other services of a designated trauma center shall be transported to a
designated trauma center.
H. Direct medical oversight shall be obtained from a SCEMSA-designated trauma center for
any CTP refusing to be transported to a designated trauma center to guide prehospital
emergency personnel in arriving at a destination decision.
I. Any patient who meets trauma triage criteria, and who has an LVAD shall be transported
to UCDMC.

Question 94

Trauma Triage Physiological Criteria

Answer 94

Assess Physiologic Trauma Criteria:
Unable to follow commands (motor GCS < 6)
Respiratory rate <10 or >29 breaths per minute
Respiratory distress or need for respiratory support
Note: “Respiratory support: Anything other than supplemental 02
Sustained heart rate > 120 beats per minute
Room-air pulse oximetry < 90
Age 0-9: SBP < 70mm Hg + (2x age years)
Age 10-64 years: SBP < 90 mmHG OR HR > SBP
Age ≥ 65 years: SBP < 110 mmHg OR HR > SBP

Question 95

Trauma Triage Anatomic Criteria

Answer 95

Anatomic Criteria
* All penetrating injuries to the head, neck, torso, and
extremities proximal to the elbow and knees
* Skull deformity, suspected skull fracture
* Suspected Flail Chest, wall instability, or deformity
* Suspected fracture of Two or more proximal long-bone
* Crushed, de-gloved, mangled, or pulseless extremity
proximal to wrist or ankle, or pulseless extremity
* Amputation proximal to wrist or ankle
* Suspected pelvic fracture
* Suspected spinal injury with new motor or sensory loss
* Active bleeding requiring a tourniquet or wound packing
with continuous pressure

Question 96

Trauma Triage Mechanism Criteria

Answer 96

Mechanism of Injury Criteria:
* Falls
Adults: > 10 feet (one story is equal to 10 feet)
Children: > 10 feet
Low level falls in young children (age ≤ 5 years) or older
adults (age ≥ 65 years) with significant head impact
* High risk auto crash
Intrusion: >12 inches occupant site; > 18 inches any site
(including roof)
NOTE: Intrusion refers to interior compartment intrusion, as
opposed to deformation which is exterior damage.
* Ejection (partial or complete) from motorized vehicle or livestock
* Death in same passenger compartment
* Child (Age 0-9) unrestrained or in unsecured child safety seat)
* Auto vs. pedestrian/bicyclist thrown , run over, or with significant
(>20 mph) impact
* Motorcycle crash > 20 mph

Question 97

Trauma Triage Special Considerations

Answer 97

SPECIAL CONSIDERATIONS WHEN
TRIAGING CRITICAL TRAUMA
Any patient at the extremes of age (pediatric and
adult) who has suffered an injury and/or where
physical examination or assessment is difficult.
Critical Trauma Patients who do not meet
physiological criteria with the following conditions
will be transported to UCDMC:
- Traumatic amputations proximal to the wrist and/
or the ankle
- Traumatic burns > 9% Total Body Surface Area
- Chemical or Electrical Burns
- Evidence of possible inhalation injury
- Any Burn to the face, hands, feet, genitalia,
perineum or major joints
Patients ≤ fourteen (14) years of age will be
transported to UCDMC if they meet any trauma
triage condition with the following exceptions:
- Pediatric Critical Trauma patients with no effective
established airway may be transported to the
closest available facility excluding the VA per
PD# 5050.
- Regardless of age, Traumatic Cardiopulmonary
Resuscitation patients shall be transported to the
time closest designated trauma center.
Regardless of age, VAD patients who meet critical
trauma criteria shall be taken to UC Davis Medical
Center.
Emergency Medical Service Provider Judgment:
Some patients not meeting clearly defined trauma
triage criteria may still have a severity of injury
warranting trauma center care. If the patient does
not meet trauma center criteria but the Paramedic
feels that trauma center care is still warranted,
transport to a trauma center. (Document Reason)
Possible examples of such patients include:
Patients taking anticoagulation medications,
excluding aspirin, or a history of bleeding disorders.
A clear history of loss of consciousness.
Pregnancy > 20 weeks.

Question 98

Determination of Death - Definition

Answer 98

A. Visual examination: Viewing the body with sufficient proximity and lighting to assure
existence of the death determining condition.
B. Physical examination: Palpation of the body and exposing the area as necessary to
determine the existence of the condition.
C. Absence of palpable pulses: Absence of pulses after palpating for carotid pulses for at
least ten (10) seconds.
D. Asystole by monitor: Cardiac monitor shows asystole in two (2) leads.
E. Rigor Mortis: Physical examination with rigidity in jaw and one limb.
F. Livor Mortis: Discoloration appearing on dependent parts of the body after death as a
result of cessation of circulation, stagnation of blood and settling of blood by gravity

Question 99

Obvious Death Confirmation Criteria

Answer 99

1. Decapitation
2. Incineration of the torso and/or head
3. Decomposition
4. Separation or destruction of brain and/or heart from the body
5. Rigor Mortis
6. Livor Mortis

Question 100

Determination of death ALS

Answer 100

Determination of Death- Paramedic only:
A. Traumatic injuries (if appropriate; respect the possibility of a crime scene):
1. Absence of all pulses, and
2. Asystole by monitor in two (2) leads, or
3. Pulseless electrical activity (PEA) with heart rate ≤ 40 bpm.
B. Documented submersion ≥ 60 minutes.
C. In all other circumstances (except Do Not Resuscitate cases) full resuscitation will be
initiated.
D. In all cases when death has been determined, notification of the Coroner’s office or law
enforcement shall be done. Follow the direction of the Coroner’s office/law
enforcement as to who has custody of the body. Evidence of a hospice patient
receiving care from a physician or registered nurse who is a member of a hospice care
interdisciplinary team, within twenty (20) days before death does not require coroner
notification. When the investigating agency releases prehospital personnel, only then
may they depart the scene. In all cases, if requested by the Coroners Office,
documentation will be forwarded within 72 hours or sooner.

Question 101

DNR Definitions

Answer 101

A. Emergency Medical Technician (EMT) shall apply to EMTs and Paramedics.
B. Do not resuscitate (DNR) means the patient will not receive chest compressions,
defibrillation, assisted ventilation, endotracheal intubation, or cardiotonic medications. This
does not exclude other treatments, especially those treatments directed to the pain and
comfort of the patient.
C. The State of California Emergency Medical Services Authority (EMSA) approved form
Physician Orders for Life-Sustaining Treatment (POLST) is recommended for
documenting do not resuscitate orders.
a. Comfort-Focused Treatment (as defined in the POLST form) “primary goal of
maximizing comfort” (eg, relieving pain, using oxygen, suctioning, and manual
treatment of airway obstruction).
b. Selective Treatment (as defined in the POLST form) “goal of treating medical
conditions while avoiding burdensome measures (eg, administer IV fluids, use of
CPAP or BiPAP, but DO NOT INTUBATE)
D. DNR Medallion: MedicAlert® medallion, which states “Do Not Resuscitate - EMS” (or
similar medallion as approved by the EMSA).
E. Aid-in-Dying Drug: A drug determined and prescribed by a physician for a qualified
individual, which the qualified individual may choose to self-administer to bring about
death due to terminal illness. The prescribed drug may take effect within minutes to
several days after self-administration.
F. End of Life Option Act: This California state law authorizes an adult, eighteen (18) years or
older, who meets certain qualifications and who has been determined by attending
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physician to be suffering from a terminal disease to make a request for an “aid-in-dying
drug” prescribed for the purpose of ending life in a humane and dignified manner.

Question 102

DNR Protocol

Answer 102

Protocol:
A. All patients who do not meet the “Determination of Death Criteria” as outlined in
SCEMSA PD #2033 – Determination of Death or criteria outlined in this policy shall
receive resuscitation efforts.
B. Any EMT or Paramedic who is presented with one of the following at the initiation of
patient care or at any time during patient care may discontinue resuscitation efforts:
1. An EMSA POLST form
2. A completed Prehospital DNR Request Form stating, “Do Not Resuscitate,” “No
Code,” or “No CPR.”
3. A written or electronic order stating, “Do Not Resuscitate,” “No Code,” or “No CPR”
signed by a physician, with the patient’s name and date the order was signed;
4. A written Advance Health Care Directive document or wallet card, including the DNR
portion of a “Living Will” or equivalent, identifying the designated agent who declines
resuscitation on behalf of the patient. Resuscitation attempts shall not be delayed
by attempts to contact the designated agent
5. The patient is wearing a DNR medallion
C. If the patient is conscious and states he/she wishes resuscitative measures, all DNR
orders shall be ignored.
D. The presence of a DNR order, the physician, nurse practitioner, or physician assistant’s
name signing the order, and the date of the order are to be documented on the Patient
Care Report (EMS Form).
E. The DNR form (original or copy), DNR medallion, or a copy of the valid DNR order from
the patient’s medical record shall be taken to the hospital with the patient.
F. If there are any questions regarding a patient’s DNR status, EMS shall provide for
patient comfort, including basic life support cardiopulmonary resuscitation, if indicated,
and utilize direct medical oversight.
G. Paramedic providers shall follow the medical interventions indicated on the POLST form
within their local scope of practice. Utilize direct medical oversight for any questions.
H. DNR Patients with POLST forms that indicate “Selective treatment, request medical
transfer ONLY if comfort needs cannot be met at current location” or “Comfort-focused
treatment” may qualify for no transportation if all of the following apply:
1. After the assessment, the medic determines that the patient’s comfort needs are
being met at their current location.
2. The patient or DPOA agrees that the patient’s needs are being met at their current
location.
3. Discussion with direct medical control indicates that the patient’s comfort needs are
being met at their current location.

Question 103

DNR Notes

Answer 103

In the event that a DNR patient being transported dies en route, the following shall occur:
* Do not cross a county line, as deaths need to be reported and processed in the county
in which they occur.
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* If the destination was a hospital, continue on to that facility (if it’s in the same county),
or select a new destination facility in the same county.
* If the transport was from a hospital to another destination (care facility, home, etc.),
return to the hospital of origin if in the same county, or continue on to the original
destination if in the same county as the expiration.
* If the receiving facility or home will not accept the deceased, contact the coroner to
assist with disposition.