Adult Protocols

Question 1

Bradycardia

Answer 1

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

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

SO

If rhythm refractory to a minimum of atropine 1 mg:

External cardiac pacemaker per SO
If capture occurs and systolic BP ≥100, consider medication for discomfort:

Treat per Pain Management Protocol (S-141)
For discomfort related to pacing not relieved with analgesics and BP ≥100:

Midazolam 1-5 mg IV/IO SO
Dopamine 400 mg/250 ml at 10-40 mcg/kg/min IV/IO drip, titrate to systolic BP >90 (after max atropine or initiation of pacing) BHO

WIDE COMPLEX BRADYCARDIA

• Monitor EKG
• 250 ml fluid bolus IV/IO with clear lungs SO to maintain BP >90, MR SO

External cardiac pacemaker per SO
If capture occurs and systolic BP ≥100, consider medication for discomfort:

Treat per Pain Management Protocol (S-141)
For discomfort related to pacing not relieved with analgesics and BP ≥100:

Midazolam 1-5 mg IV/IO SO
Dopamine 400 mg/250 ml at 10-40 mcg/kg/min IV/IO drip, titrate to systolic BP >90 BHO

(after initiation of pacing)

If external pacing unavailable,

May give atropine 0.5 mg IV/IO for pulse <60 SO. MR q3-5 minutes to max of 3 mg SO

Question 2

SVT Superventricular Tachycardia

Answer 2

Supraventricular Tachycardia (SVT):

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain systolic BP >90, MR SO
• VSM SO. MR SO
• Adenosine 6 mg IV/IO, followed with 20 ml NS IV/IO SO (Patients with history of bronchospasm or COPD BHO )
• Adenosine 12 mg IV/IO followed with 20 ml NS IV/IO SO

If no sustained rhythm change, MR x1 in 1-2 minutes SO

If patient unstable OR rhythm refractory to treatment:
Conscious (Systolic BP <90 and chest pain, dyspnea, or altered LOC):

Midazolam 1-5 mg IV/IO prn pre-cardioversion . If age >60, consider lower dose with attention to age and hydration status.

Synchronized cardioversion at manufacturer’s recommended energy dose , MR

Unconscious:

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

Question 3

Unstable AFIB/Aflutter

Answer 3

Unstable Atrial Fibrillation/Atrial Flutter (Systolic BP <90 AND chest pain, dyspnea or altered LOC):

• Monitor EKG/O2 Saturation prn
• 250 ml fluid bolus IV/IO without rales SO MR to maintain systolic BP >90 SO

In presence of ventricular response with heart rate >180: Conscious:

Midazolam 1-5 mg 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

Question 4

Ventricular Tachycardia (VT)

Answer 4

Ventricular Tachycardia (VT):

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

If patient unstable (Systolic BP <90 and chest pain, dyspnea or altered LOC): Conscious:

Midazolam 1-5 mg 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 x 3 SO. MR BHO

Unconscious:

Synchronized cardioversion at manufacturer’s recommended energy dose

SO. MR x 3 SO. MR BHO

Question 5

Reported/witnessed ≥x2 AICD firing, or ≥1 AED shock delivered

Answer 5

Reported/witnessed ≥x2 AICD firing, or ≥1 AED shock delivered:

• Monitor EKG
• 250 ml fluid bolus IV/IO without rales SO to maintain systolic BP >90, MR SO

If pulse >60:

• Lidocaine 1.5 mg/kg IV/IO SO. MR at 0.5 mg/kg IV/IO q8-10 minutes, to a max of 3 mg/kg (including initial bolus) SO

OR

• Amiodarone 150 mg in 100 ml of NS over 10 minutes IV/IO SO

Question 6

VF/Pulseless VT

Answer 6

VF/Pulseless VT

• Monitor EKG
• Defibrillate when ready every 2 min while VF/VT persists
• 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 1 mg IV/IO q 3-5 minutes SO

• After 1st shock if still refractory, 300 mg Amiodarone IV/IO MR 150 mg (max of 450 mg) OR 1.5 mg/kg Lidocaine IV/IO MR x1 in 3-5 minutes (max 3 mg/kg) 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
• 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 7

PEA

Answer 7

PEA: 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 1 mg IV/IO may repeat every 3-5 minutes 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
• 250 ml 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 8

Asystole

Answer 8

Asystole:

• 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 1 mg IV/IO may repeat every 3-5 minutes 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

Termination of Resuscitation (TOR) Criteria

If all these criteria have been met:

• Victim arrest was not witnessed by EMS AND
• No bystander witness of collapse AND
• No bystander CPR AND
• Never received a rescue shock AND
• 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 of the above criteria for TOR are met, Base Hospital Contact not required even if ALS interventions performed.

Question 9

ABDOMINAL DISCOMFORT/GI/GU (NON-TRAUMATIC)

BLS

Answer 9

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 10

ABDOMINAL DISCOMFORT/GI/GU (NON-TRAUMATIC)

ALS

Answer 10

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

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

Suspected AAA:
• 500 ml fluid bolus IV/IO SO, for BP <80 to maintain a

BP of 80, may repeat x1 SO

For nausea or vomiting:
• Zofran 4 mg IV/IM/ODT SO, MR x 1 q10” SO

Question 11

AIRWAY OBSTRUCTION (Foreign Body)

BLS

Answer 11

For a conscious patient:

• Reassure, encourage coughing • O2 prn

For inadequate air 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 12

AIRWAY OBSTRUCTION (Foreign Body)

ALS

Answer 12

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 13

ALLERGIC REACTION/ANAPHYLAXIS

BLS

Answer 13

 Ensure patent airway

 O2 Saturation prn

 O2 and/or ventilate prn

 Remove stinger/injection mechanism

 May assist patient to self-medicate 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 14

ALLERGIC REACTION/ANAPHYLAXIS

ALS

Answer 14

 Monitor EKG
 IV/IO SO adjust prn
 Capnography SO prn

Hives (Urticaria)

 Benadryl 50 mg IV/IM SO Anaphylaxis

Anaphylaxis:

 Epinephrine 1:1,000 0.3 mg IM per SO. MR x2 q5 minutes SO

then

 500 ml fluid bolus IV/IO for systolic BP <90 SO. MR to maintain systolic BP >90 SO

 Benadryl 50 mg IM/IV SO

 Albuterol 6 ml 0.083% via nebulizer SO. MR SO for

respiratory involvement

 Atrovent 2.5 ml 0.02% via nebulizer added to the first

dose of Albuterol SO for respiratory involvement

 Epinephrine 1:10,000 0.1 mg IV/IO BHO. MR x2 q3-

5 minutes BHO

 Dopamine 400 mg/250 ml @ 10-40 mcg/kg/min IV/IO drip. Titrate systolic BP >90 BHO

_Anaphylaxis criteria (may include any):_
1. Unknown exposure: Skin and respiratory and/or

cardiovascular
2. Likely allergen exposure (e.g. bee sting, peanut,:

2/4 systems involved (skin, GI, respiratory,

cardiovascular)
3. Known allergen exposure

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

Question 15

ALTERED NEUROLOGIC FUNCTION (NON-TRAUMATIC)

ALS

Answer 15

 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 2 mg IN/IM/IV SO. MR SO, titrate IV dose to effect, to drive the respiratory rate.

 If patient refuses transport, give additional Naloxone 2 mg IM SO

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

D50 25GmIVSOifBS<60mg/dL
 If patient remains symptomatic and BS remains

<60 mg/dL MR SO
 If no IV: Glucagon 1 ml IM SO if BS <60 mg/dL

Hyperglycemia:
Symptomatic patient with diabetic history

 500 ml fluid bolus IV/IO if BS >350 or reads high SO, x1

Seizures:

For:

Ongoing generalized seizure lasting >5

minutes (includes seizure time prior to arrival

of prehospital provider) SO

Recurrent tonic-clonic seizures without lucid

interval SO

Eclamptic seizure of any duration SO

Give:
 Versed IN/IM/IV/IO SO to a max dose of 5 mg

(d/c if seizure stops) SO, MR x1 in 10 minutes SO. Max 10 mg total.

Question 16

ALTERED NEUROLOGIC FUNCTION (NON-TRAUMATIC)

BLS

Answer 16

 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 opioids OD (with respiratory rate <12)*:
(Use caution in opioid dependent pain management patients)

 Naloxone nasal spray 4mg preloaded single dose device

 Administer full dose in one nostril OR

 Naloxone assemble 2 mg syringe and atomizer

 Administer 1 mg (1 ml) into each nostril

Hypoglycemia (suspected) or patient’s glucometer results read <60 mg/dL

 If patient is awake and able to swallow, give 3 oral glucose tabs or paste (15 g total). Patient may eat or drink, if able.

 If patient is unconscious, NPO

CVA/Stroke:

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

Seizures:

 Protect airway, and protect from injury  Treat associated injuries

Behavioral Emergencies (S-422 and S-142)

Question 17

BURNS

ALS

Answer 17

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

For patients with >20% partial thickness or >5% full thickness burns and >15 yo:

• 500 ml fluid bolus IV/IO then TKO SO

In the presence of respiratory distress with bronchospasm:

• Albuterol 6 ml 0.083% via nebulizer SO. MR SO

Question 18

BURNS

BLS

Answer 18

• 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 threatening injuries
• Carboxyhemoglobin monitor prn, if available

Thermal burns:

• Burns of <10% body surface area, stop burning with non-chilled water or saline

For burns >10% body surface area, cover with dry dressing and keep warm

Do not allow the patient to become hypothermic

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

Chemical burns:

• Brush off dry chemicals
• Flush with copious amounts of water

Tar burns:

• Cool with water, transport; do not remove tar

Question 19

DISCOMFORT/PAIN OF SUSPECTED CARDIAC ORIGIN

ALS

Answer 19

Monitor EKG

IV SO adjust prn

Obtain 12 Lead EKG and transmit (if capable).

If STEMI, notify base immediately and transport to

appropriate STEMI center*

ASA 324 mg chewable PO SO

If systolic BP >100:
• NTG 0.4 mg SL SO. MR q3-5 minutes SO
• NTG ointment 1 inch SO
• Treat pain per Pain Management Protocol (S-141)

If systolic BP <100:
• NTG 0.4 mg SL BHO. MR BHPO
• Treat pain per Pain Management Protocol (S-141)

Discomfort/Pain of suspected Cardiac Origin with Associated Shock:

• 250 ml fluid bolus IV/IO without rales SO. MR to maintain systolic BP >90 SO

If BP refractory to second fluid bolus:

• Dopamine 400 mg/250ml @ 10-40 mcg/kg/min IV/IO drip. Titrate to systolic BP >90 BHO

Question 20

DISCOMFORT/PAIN OF SUSPECTED CARDIAC ORIGIN

BLS

Answer 20

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 (81 mg to max dose of 325 mg)

Question 21

ENVENOMATION INJURIES

BLS

Answer 21

• 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

Question 22

ENVENOMATION INJURIES

ALS

Answer 22

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

Question 23

ENVIRONMENTAL EXPOSURE

BLS

Answer 23

• 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 24

ENVIRONMENTAL EXPOSURE

ALS

Answer 24

• 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:

• 500 ml fluid bolus IV/IO SO, without rales MR x1 SO

Near Drowning:

• CPAP at 5-10 cm H20 SO for respiratory distress

Question 25

HEMODIALYSIS PATIENT

BLS

Answer 25

• Ensure patent airway • O2 Saturation prn
• Give O2
• Ventilate if necessary

Question 26

HEMODIALYSIS PATIENT

ALS

Answer 26

• 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 (aspirate 5 mL 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 6 ml 0.083% via Nebulizer SO • CaCl2 500 mg IV/IO per SO
• NaHCO3 1 mEq/kg IV/IO x1 per SO

Question 27

DECOMPRESSION ILLNESS/DIVING/ALTITUDE RELATED INCIDENTS

BLS

Answer 27

• 100% O2, and/or ventilate prn
• O2 Saturation prn
• Spinal stabilization when indicated

Question 28

DECOMPRESSION ILLNESS/DIVING/ALTITUDE RELATED INCIDENTS

ALS

Answer 28

• Monitor EKG
• IV/IO SO adjust prn

Question 29

OBSTETRICAL EMERGENCIES

BLS

Answer 29

MOTHER:

Ensure patent airway

O2 Saturation prn

O2 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 cut, 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 30

OBSTETRICAL EMERGENCIES

ALS

Answer 30

MOTHER:
• Monitor EKG

• IV/IO SO adjust prn
Direct to Labor/Delivery area per BHO gestation.

Eclampsia (seizures):

if >20 weeks

Give:
• Versed IN/IM/IV/IO SO to a max dose of 5 mg

(d/c if seizure stops) SO, MR x1 in 10 minutes SO. Max 10 mg total.

Question 31

POISONING/OVERDOSE

BLS

Answer 31

 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 (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

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

 Naloxone nasal spray 4mg preloaded single dose device

 Administer full dose in one nostril OR

 Naloxone assemble 2 mg syringe and 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 32

POISONING/OVERDOSE

ALS

Answer 32

 Monitor EKG
 IV/IO SO adjust prn
 Capnography SO prn

Ingestions:

 Charcoal 50 Gm PO ingestion with any of the following within 60 minutes SO if not vomiting:

oAcetaminophen, colchicine, beta blockers, calcium channel blockers, salicylates, valproate, oral anticoagulants (including rodenticides), paraquat, amanita mushrooms

 Assure patient has gag reflex and is cooperative.

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

 Naloxone 2 mg 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 2 mg IV/IM/IO SO. MR x2 q3-5 minutes SO. MR q3-5 minutes BHO

Extrapyramidal reactions:

 Benadryl 50 mg slow IV/IM SO

Suspected Tricyclic OD with cardiac effects (e.g., hypotension, heart block, or widened QRS):

 NaHCO3 1 mEq/kg IV/IO SO

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

 Amyl nitrite inhalation (over 30 seconds) BHPO  Sodium thiosulfate 25%, 12.5 grams IV BHPO

OR

 Hydroxocobalamin (Cyanokit) 5 g IV BHPO

Question 33

PRE-EXISTING MEDICAL INTERVENTIONS

BLS

Answer 33

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 rates:
If the person responsible for operating the device is unable to continue to provide this function during transport, contact the 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 or 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 34

PRE-EXISTING MEDICAL INTERVENTIONS

ALS

Answer 34

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 35

RESPIRATORY DISTRESS

BLS

Answer 35

 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 5 ml via oxygen powered nebulizer/mask. MR prn

Question 36

RESPIRATORY DISTRESS

ALS

Answer 36

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

Respiratory Distress Suspected CHF/cardiac origin:

 NTG SL: If systolic BP >100 but <150:

o NTG 0.4 mg SL SO. MR q3-5 minutes SO If systolic BP >150:

o NTG 0.8 mg SL SO. MR q3-5 minutes SO If systolic BP >100:

o NTG Ointment 1inch SO If systolic BP <100:

o NTG 0.4 mg SL per BHO MR BHPO  CPAP at 5-10 cm H2O SO

Respiratory Distress Suspected Non-Cardiac:

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

If severe respiratory distress/failure or inadequate response to Albuterol/Atrovent consider:

If history of asthma or suspected allergic reaction:
 Epinephrine 0.3 mg 1:1000 IM SO. MR x2 q5 minutes

SO

If no definite history of asthma:

 Epinephrine 0.3 mg 1:1000 IM BHPO MR x2 q5 minutes BHPO

Question 37

SEXUAL ASSAULT

BLS and ALS

Answer 37

• 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 38

SHOCK

BLS

Answer 38

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

Question 39

SHOCK

ALS

Answer 39

• Monitor EKG
• IV/IO SO
• Capnography SO prn

Shock (suspected cardiac etiology):

250 ml fluid bolus IV/IO without rales SO. MR x1 to maintain BP >90 SO

If BP refractory to second fluid bolus:

Dopamine 400 mg/250 ml @ 10-40 mcg/kg/min IV/IO drip. Titrate BP >90 BHO

Shock Hypovolemic (Non-traumatic):

500 ml fluid bolus IV/IO SO, MR to maintain BP >90 SO

Shock Hypovolemic (suspected AAA):

500 ml fluid bolus IV/IO SO, MR to maintain BP >80 SO

Shock (suspected Anaphylactic, Neurogenic):

500 ml fluid bolus IV/IO SO. MR to maintain BP >90 SO

If BP refractory to fluid boluses:

Dopamine 400 mg/250 ml @ 10-40 mcg/kg/min IV/IO drip. Titrate BP >90 BHO

Shock (Sepsis):

Treat as per Sepsis Protocol (S-143)

Question 40

TRAUMA

BLS

Answer 40

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

Hemostatic 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 .

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 41

TRAUMA

ALS

Answer 41

• Monitor EKG
• IV/IO SO
• If MTV IV/IO en route SO
• 500 ml fluid bolus IV/IO to maintain BP at 80
• Capnography SO prn
• Treat pain as per Pain Management Protocol (S-141)
• *Crush injury with extended compression >2 hours of extremity or torso:**
• *Just prior to extremity being released:**

• 500 ml fluid bolus IV/IO, then TKO SO

CaCl2 500 mg IV/IO over 30 seconds BHO

NaHCO3 1 mEq/kg IV/IO BHO

Grossly angulated long bone fractures:

• Reduce with gentle unidirectional traction for splinting SO

Severe 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 42

TRIAGE, MULTIPLE
PATIENT INCIDENT/MASS CASUALTY INCIDENT/ANNEX D

BLS and ALS

Answer 42

One person will assume responsibility for all scene medical communication.

Only one (1) BH will be contacted during the entire incident.

Prehospital providers will utilize Simple Triage and Rapid Treatment (START) guidelines to determine priorities of treatment and transport.

If staffing resources are limited, CPR need not be initiated for arrest victims, however, if CPR has been initiated prior to arrival of ALS personnel or briefly during assessment, discontinue only if one of the following occurs or is present*:
1. Subsequent recognition of obvious death SO

2. BHPO
3. Presence of Advance Health Care Directive that specifies DNR status, DNR Form/Order or

Medallion SO
4. Lack of response to brief efforts in the presence of any other potentially salvageable patient

Requiring intervention SO

Radio communication for multi-patient incident (MPI) need only include the following on each patient: 1. Patient number assignment (i.e., #1, #2 . . .)

2. Age
3. Gender
4. Mechanism
5. Chief complaint
6. Abnormal findings
7. Treatment initiated
8. ETA
9. Destination
10. Transporting unit number

Radio Communication for mass casualty incident (MCI) or Annex D activation need only include the following on each patient:

1. Patient number if assigned (i.e., #1, #2 . . .)
2. Triage category (Immediate, Delayed, Minor)
3. Destination
4. Transporting unit number

Question 43

PAIN MANAGEMENT

ALS

Answer 43

• Continue to monitor and reassess pain using standardized pain scores • Document vital signs before and after each medication administration

Special Considerations for All Pain Medications:

1. Changing route of administration requires(e.g., IV to IM or IM to IN) BHO
2. Changing analgesic requires (e.g., changing from fentanyl to ketamine) BHO
3. Treatment if BP <100 requires BHO
4. BHPO required for:

• Isolated head injury
• Acute onset severe 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 severe hepatic impairment or active liver disease Acetaminophen: 1000 mg IV over 15 minutes SO

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 50 mcg IV SO
• MR 25 mcg IV q5 minutes x2 SO
• Maximum total SO dose 100 mcg IV

INTRANASAL DOSING:
• Fentanyl 50 mcg IN q15 minutes x2 SO • 3rd dose fentanyl 50 mcg IN BHO

If >65 years of age:
• Fentanyl 25 mcg IV SO
• MR 25 mcg IV q5 minutes x2 SO
• Maximum total SO dose is 75 mcg IV

INTRANASAL DOSING:
• Fentanyl 25 mcg IN q15 minutes x2 SO • 3rd dose fentanyl 25 mcg IN BHO

Special considerations for Cardiac Chest Pain & Cardiac Pacing:

• Fentanyl 25 mcg IV x1 SO

MORPHINE, If fentanyl unavailable:
• Morphine 0.1 mg/kg IV SO
• MR in 5 minutes at half of the initial IV dose SO
• MR in additional 5 minutes at half of the initial IV dose BHO

INTRAMUSCULAR DOSING:
• Morphine 0.1 mg/kg IM SO
• MR in 15 minutes at half of the initial IM dose SO
• MR in additional 15 minutes at half of the initial IM dose BHO

Special considerations for Cardiac Chest Pain & Cardiac Pacing:

• Administer morphine 0.05 mg/kg IV x1 SO

Additional option for trauma, burns, or envenomation injuries:

For MODERATE-SEVERE pain (score ≥ 5):

KETAMINE requirements:

≥15 years old
AND with GCS of 15
AND not pregnant
AND no known or suspected alcohol or drug intoxication
AND have not received opioid analgesic in past 6 hours (prior to medic arrival)

• Ketamine 0.2 mg/kg in 100 ml of NS SLOW IV drip over 15 minutes SO Maximum for any IV dose is 20mg
• MR x 1 in 15 minutes if pain remains MODERATE or SEVERE SO

INTRANASAL DOSING:
• Ketamine 0.5mg/kg IN (50 mg/ml concentration) SO

Maximum for any IN dose is 50 mg
• MR x 1 in 15 minutes if pain remains MODERATE or SEVERE SO

Question 44

PAIN MANAGEMENT

BLS

Answer 44

Assess level of pain

Ice, immobilize, and

splint when indicated

Elevation of extremity trauma when indicated

Question 45

PSYCHIATRIC/BEHAVIORAL EMERGENCIES

BLS

Answer 45

Ensure patent airway, O2 and/or ventilate prn

O2 Saturation prn

Treat life threatening injuries

Attempt to determine if behavior is related 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 patient.

Law enforcement could remove taser barbs, but EMS may remove barbs.

Question 46

PSYCHIATRIC/BEHAVIORAL EMERGENCIES

ALS

Answer 46

• Monitor EKG
• IV SO adjust prn • Capnography SO

For Combative patient:

o Versed 5 mg IM/IN/IV SO, MR x1 in 10” SO

Question 47

SEPSIS

BLS

Answer 47

• O2 Saturation prn
• O2 and/or ventilate prn
• NPO, anticipate vomiting
• Remove any transdermal patch

• Obtain baseline temperature

Question 48

SEPSIS

ALS

Answer 48

• 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
2. RR >20

Administer:
• 500 ml fluid bolus regardless of blood pressure

or lung sounds IV/IO SO

• 500 ml fluid bolus if BP <90 regardless of lung sounds SO x1 after initial fluid bolus

If BP refractory to fluid boluses:

Dopamine 400 mg/250 ml @ 10-40 mcg/kg/min IV/IO drip. Titrate BP >90 BHPO.

Question 49

STROKE AND TRANSIENT ISCHEMIC ATTACK

BLS

Answer 49

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 saturation 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 (15

g total). Patient may eat or drink, if able.
• If patient is unconscious, NPO

Use the 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.

Question 50

STROKE AND TRANSIENT ISCHEMIC ATTACK

ALS

Answer 50

Obtain blood glucose, if blood glucose <60 mg/dl treat per hypoglycemia

Large bore antecubital IV

250 ml fluid bolus IV/IO without rales SO to maintain BP >120, MR SO

Question 51

NERVE AGENT EXPOSURE AND AUTOINJECTOR USE

BLS

Answer 51

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 clothing

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

Question 52

NERVE AGENT EXPOSURE AND AUTOINJECTOR USE

ALS

Answer 52

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

Mild: Miosis, rhinorrhea, increasing dyspnea, fasiculations, sweating o Atropine autoinjector (or 2mg) IM
2-PAM Cl autoinjector (or 600 mg) IM

Moderate: Headache, weakness, miosis, rhinorrhea, dyspnea/wheezing (if inhaled) , increased secretions, generalized fasiculations, muscle weakness, GI effects
o Atropine autoinjector (or 2 mg) IM, MR x1 in 5-10”
o 2-PAM Cl autoinjector (or 600 mg) IM, MR x1 in 5-10” *Diazepam autoinjector or midazolam 5 mg IM if diazepam autoinjector not available

Severe: Unconscious, seizures, muscle weakness, fatigue, flaccid, paralysis, apnea, bradycardia, heart block or tachycardia

Initial dosing:
o Atropine autoinjector (or 2 mg) IM x3 doses in succession
o 2-PAM Cl autoinjector (or 600 mg) IM x3 doses in succession *Diazepam autoinjector, or midazolam 10 mg IM if diazepam autoinjector not available, for seizure activity
o O2 /intubate

Ongoing treatment:
o Atropine autoinjector (or 2 mg) IM, MR q3-5” until secretions diminish
o 2-PAM Cl autoinjector (or 600 mg) IM, MR x1 in 3-5”
o For continuous seizure activity, MR midazolam 10 mg IM x1 in 10”

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