Initial ALS Test

Question 1

What is the Tx for ADULT anaphylaxis without shock

Answer 1

1. IV/IO access
   Benadryl
   IV/IO/IM – 50 mg
2. Epinephrine 1 mg/mL, if not already administered by
   BLS personnel
   o IM - 0.3 mg
   o May repeat q 5 minutes if patient remains in distress
3. Albuterol (if wheezing is present)
   o Nebulizer – 5 mg/6 mL
   o May repeat as needed

Question 2

What is the Tx for ADULT anaphylaxis WITH shock

Answer 2

Epinephrine 10mcg/mL
o 1mL (10mcg) every 2 minutes, slow IV/IO push
o Titrate to SBP of greater than or equal to 90mm/Hg
* Initiate 2nd IV/IO
Normal Saline
o IV/IO bolus – 1 Liter
o May repeat x 1 as indicated

Question 3

Tx for PEDS Anaphylaxis WITHOUT Shock

Answer 3

Epinephrine 1 mg/mL, if not already administered by BLS
personnel
o IM – 0.01 mg/kg up to 0.3mg
o May repeat q 5 minutes if patient remains in distress
Albuterol (if wheezing is present)

• Patient ≤ 30 kg
  o Nebulizer – 2.5 mg/3 mL
  o Repeat as needed
• Patient > 30kg
  o Nebulizer – 5 mg/6 Ml
  o Repeat as needed

Question 4

Tx PEDS Anaphylaxis WITH shock

Answer 4

Epinephrine 10mcg/mL
o 0.1mL/kg (1mcg/kg) every 2 minutes, slow IV/IO push
o Max single dose of 1mL or 10mcg
o Titrate to SBP of greater than or equal to 80 mm/Hg
* Initiate 2nd IV if possible or establish IO
Normal Saline
o IV/IO bolus – 20 mL/kg
o May repeat x 1 as indicated

Question 5

Tx for 17kg Peds with Anaphylaxis WITH shock?

Question 6

Tx for ALC (Altered LOC) Adult

Answer 6

IV/IO Access
Determine Blood Glucose level, if not already performed
by BLS personnel or post oral glucose administration

If less than 60 mg/dl
* D10W
o IV/IOPB-100 mL (10 g)-Rapid Infusion
* Glucagon (If no IV access)
o IM – 1 mg
Recheck Blood Glucose level 5 min after Dextrose, or 10 min after
Glucagon administration
If still less than60 mg/dl
* D10W
o IV/IOPB-150 mL (15 g)-Rapid Infusion

Question 7

Tx - PEDS Altered LOC

Answer 7

IV/IO Access
Determine Blood Glucose level, if not already performed
by BLS personnel or post oral glucose administration

If less than 60 mg/dl
* D10W
o IV/IOPB-5 mL/kg-Rapid Infusion
o Max 100 mL
* Glucagon (If no IV/IO access)
o IM – 0.1 mL/kg
o Max 1 mg
Recheck Blood Glucose level 5 min after Dextrose or 10 min
after Glucagon administration
If still less than 60 mg/dl
* D10W
o IV/IOPB-7.5 mL/kg-Rapid Infusion
o Max 150 mL

Question 8

? AEIOUPITS

Answer 8

A - Alcohol
O - Overdose. I - Infection
E - Epilepsy U - Uremia P - Psychiatric
I - Insulin T - Trauma
S – Stroke

Question 9

Tx Adult behavioral emergencies

Answer 9

IV/IO Access
For Extreme Agitation
* Midazolam
o IM – 5mg or 10 mg (5mg/ml)
o IV/IO – 2 mg
* Repeat 1 mg q 2 min as
needed
* Max 5 mg
When safe to perform, determine blood
glucose leve

Question 10

Tx PEDIATRIC behavioral emergencies

Answer 10

IV/IO Access
For Extreme Agitation
* Midazolam
o IM – 0.1 mg/kg
* Max 5 mg
o IV/IO – 0.1 mg/kg
* Repeat q 2 min as needed
* Max single dose 2 mg
* Max total dose 5 mg
When safe to perform, determine blood
glucose level

Question 11

Tx for Bites and Stings

Answer 11

Animal/insect bites:
* Flush site with sterile water
* Control bleeding
* Apply bandage
Snake bites/envenomation:
* Mark the edge of the inflammatory process ASAP and then every 10-15
minutes
* Remove rings and constrictions
* Immobilize the affected part in a neutral position
* Avoid excessive activity
Bee stings:
* If present, quickly remove stinger
* Apply ice pack
Jellyfish stings:
* Rinse thoroughly with normal saline
o DO NOT:
* Rinse with fresh water
* Rub with wet sand
* Apply heat
All other marine animal stings:
* If present, remove barb
* Immerse in hot water if available
Administer oxygen as indicated
All bites other than snake bites may be treated as a BLS call

Question 12

Are snakebites ALS or BLS?

Answer 12

ALS

Question 13

Pediatric Rule of 9s

Answer 13

Question 14

Adult Rule of 9s

Answer 14

Question 15

ALS standing order for ADULT Burns

Answer 15

IV/IO access
Pain Control – per Policy 705.19
If TBSA greater than 10% or hypotension is
present:
* Normal Saline
o IV/IO bolus – 1 Liter

Question 16

PEDS standing order for PEDS Burns

Answer 16

IV/IO access
Pain Control – per Policy 705.19
If TBSA greater than 10% or hypotension is
present:
* Normal Saline
o IV/IO bolus – 20 mL/kg

Question 17

Tx for Pain Control (with and without Fentanyl)

Answer 17

IV/IO access
Cardiac Monitor
Pain 5 out of 10 or greater and SBP > 90 mmHg
Fentanyl
* IV/IO - 1 mcg/kg over 1 minute, OR IN/IM – 1mcg/kg
* Max single dose 100 mcg
* May repeat q 5 minutes for persistent pain to a max total dose 200 mcg
* Repeat doses should be administered IV/IO if vascular access obtained

If Fentanyl unavailable;
Ondansetron - Per 705.15 Nausea/Vomiting Policy
* Repeat x 1 in 10 minutes for nausea or > 2 doses of Morphine
Morphine
* IV/IO - 0.1 mg/kg over 1 minute
* Max single dose 10 mg
* May repeat ½ initial dose x 2 q 5 min
OR
Morphine
* IM - 0.1 mg/kg
* Max single dose 10 mg
* May repeat ½ initial dose x 2 q 15 min

Question 18

PEDS Cardiac Arrest / PEA

Answer 18

Assess for and treat underlying cause
IV/IO access
* PRESTO Blood Draw
Epinephrine* 0.1mg/mL
Administer ASAP goal ≤6 minutes
* IV/IO 0.01mg/kg (0.1 mL/kg) q 6 min
* Repeat x 2, max of 3 dose during initial arrest.
* If ROSC then re-arrest an additional 3 doses may
be administered.
Normal Saline
* IV/IO bolus- 20 mL/kg
ALS Airway Management
* If unable to ventilate by BLS measures, initiate
appropriate advanced airway procedures in accordance
with policy 710.
When one of the following is a suspected cause of arrest:
History of Renal Failure/Dialysis
* Calcium Chloride
o IV/IO – 20 mg/kg
o Repeat x 1 in 10 min
* Sodium Bicarbonate
o IV/IO – 1 mEq/kg
o Repeat x 2 0.5 mEq/kg q 5 min
Tricyclic Antidepressant Overdose
* Sodium Bicarbonate
o IV/IO – 1 mEq/kg
o Repeat x 2 0.5 mEq/kg q 5 min
Beta Blocker Overdose
* Glucagon
o IV/IO – 0.1 mg/kg up to 10 mg when available
Calcium Channel Blocker Overdose
* Calcium Chloride
o IV/IO – 20 mg/kg
o Repeat x 1 in 10 min
* Glucagon
o IV/IO – 0.1 mg/kg up to 10 mg when available

Question 19

ALS Tx for VF/VT

Answer 19

Defibrillate
* Defibrillate q 2 minutes as indicated
o Lifepak 360 Joules
o Zoll 200 Joules
IV or IO access & PRESTO Blood draw
Epinephrine* 0.1 mg/mL
Administer ASAP goal ≤6 minutes
* IV/IO –1 mg (10 mL) q 6min
* Repeat x 2 for max of 3 doses during initial arrest.
* If ROSC then re-arrest an additional 3 doses may be
administered.
Amiodarone
* IV/IO – 300 mg – after second defibrillation
* If VT/VF persists, 150 mg IV/IO in 3-5 minutes
Normal Saline
* IV/IO bolus 1 Liter
ALS Airway Management
* If unable to ventilate by BLS measures, initiate
appropriate advanced airway procedures in
accordance with policy 710.
When Torsades de Pointes is identified:
o Magnesium Sulfate
o IV/IO – 2 g over 2 min
o Repeat x 1 in 5 min
Treat underlying causes when identified:
Renal Failure / History of Dialysis:
o Calcium Chloride
o IV/IO – 1g
o Repeat x 1 in 10 min
o Sodium Bicarbonate
o IV/IO – 1 mEq/kg
o Repeat 0.5 mEq/kg x 2 q 5 min
Tricyclic Antidepressant Overdose:
* Sodium Bicarbonate
o IV/IO – 1 mEq/kg
o Repeat 0.5 mEq/kg x 2 q 5 min

Question 20

When is Amiodarone administered in VF?

Answer 20

After second defibrillation

Question 21

For PEDS VCF/VT, what is the drug dosing and Joule setting

Answer 21

Defibrillate
* Defibrillate q 2 minutes as indicated using escalating
joules doses
o 2, 4, 6, 8 joules/kg
IV or IO access & PRESTO Blood Draw
Epinephrine* 0.1mg/mL
Administer ASAP goal ≤ 6 minutes
* IV/IO – 0.01mg/kg (0.1 mL/kg) q 6 min
* Repeat x 2 for max of 3 dose during initial arrest.
* If ROSC then re-arrest and additional 3 doses may
be administered.
Amiodarone
* IV/IO – 5 mg/kg – after second defibrillation
* If VT/VF-persists, repeat 5 mg/kg x 2 q 3-5 minutes
Normal Saline
* IV/IO 20 mL/kg bolus

Question 22

What dos APGAR stand for?

Answer 22

Question 23

Tx for Crush Syndrome

Answer 23

Crush Syndrome
* Initiate 2nd IV/IO access
* Normal Saline
o IV/IO bolus – 1 Liter
* Sodium Bicarbonate
o IV/IO mix – 1 mEq/kg
* Added to 1st Liter of Normal Saline
* Albuterol
o Nebulizer – 5 mg/6 mL
* Repeat as needed
* Pain Control– Per Policy 705.19
* Release compression
* Monitor for cardiac dysrhythmias
* For cardiac dysrhythmias:
o Calcium Chloride
* IV/IO slow push – 1 g over 1 min
For continued shock
* Repeat Normal Saline
o IV/IO bolus – 1 Liter
For persistent hypotension after fluid bolus:
* Epinephrine 10 mcg/mL
o IV/IO slow push - 1 mL (10 mcg) every 2
minutes
o Titrate to SBP of greater than or equal to 90
mm/Hg

Question 24

Additional info on Crush Syndrome

Answer 24

Additional Information:
* Potential Crush Syndrome – Continuous crush injury to torso or extremity above wrist or ankle for 2 hours or less.
* Crush Syndrome – Continuous crush injury to torso or extremity above wrist or ankle for greater than 2 hours.
* Dysrhythmias are usually secondary to Hyperkalemia. ECG monitor may show: Peaked T-waves, Absent P-waves, widened QRS
complexes, bradycardia
* Calcium Chloride and Sodium Bicarbonate precipitate when mixed. Strongly consider starting a second IV (if feasible) for
administration of Calcium Chloride

Question 25

Tx for Heat Emergencies (Adult)

Answer 25

If patient is altered, determine blood glucose if not already performed by BLS personnel or post oral glucose administration If less than 60 mg/dl, refer to Policy 705.03 IV/IO access Normal Saline * IV/IO bolus – 1 Liter o Caution with cardiac and/or renal history o Repeat x 1 for persistent hypotension

Question 26

? Acceptable heart rates and respiratory rates for hypothermia?

Answer 26

Acceptable range for severe hypothermia:  Respiratory Rate: at least 4 breaths per minute  Heart rate: at least 20 beats per minute

Question 27

ALS Tx for hypothermia

Answer 27

If patient is altered, determine blood glucose if not already performed by BLS personnel or post oral glucose administration If less than 60 mg/dl, refer to Policy 705.03 IV/IO access (if needed for medication or fluid administration) * If administering fluid, avoid administering cold fluids.

Question 28

Adult ALS Tx for Hypovolemic Shock

Answer 28

IV/IO access Normal Saline * IV/IO bolus – 1 Liter o Repeat x 1 for persistent signs of shock Traumatic Injury * Do not delay transport for IV/IO attempts * Tranexamic Acid – For patients 15 years of age and older as indicated in VCEMS Policy 734 o IV/IOPB - 1g TXA in 100mL NS over 10 minutes * Refer to Policy 705.01- Trauma Treatment Guidelines, for fluid administration o Goal is to maintain SBP of ≥ 80 mmHg o Patients 65 years and older, maintain SBP of ≥ 100 mmHg

Question 29

? Indications for Zofran?

Answer 29

Indications for Ondansetron: 1. Moderate to severe nausea or vomiting. 2. Potential for airway compromise secondary to suspected/actual head injury when cervical immobilization is used. 3. Prior to MS administration

Question 30

Zofran dosing (ADULT & PEDS)

Answer 30

ADULT IV/IO access * Cardiac Monitor * Ondansetron o PO – 4 mg ODT * May repeat x 1 in 10 min o IV/IM/IO – 4 mg * May repeat x 1 in 10 min PEDS Ages 6 months up to 5 years * Ondansetron o PO – 2 mg ODT o IV/IM/IO – 0.1 mg/kg Ages ≥ 5 Years * Ondansetron o PO – 4 mg ODT o IV/IM/IO – 0.1 mg/kg

Question 31

? Parameters for withholding resuscitation in extreme preterm neonates (

Answer 31

* Resuscitation efforts may be withheld for extremely preterm infants (< 21 weeks or < 9 inches long). Sensitivity to the desires of the parent(s) may be considered. If uncertain as to gestational age, begin resuscitation. * A rising heart rate is the best indicator of adequate PPV.

Question 32

? neonatal CPR parameters

Answer 32

If HR < 60 bpm ◦ CPR at 3:1 ratio  Continue CPR until HR > 60 bpm

Question 33

? parameters for ensuring adequate circulation whilst resuscitating neonate

Answer 33

If HR between 60 and 100 bpm ◦ PPV with BVM and ROOM AIR at 40-60 breaths per minute  Continue PPV until infant maintains HR >100 bpm

Question 34

How do you correct hypoxia in a neonate

Answer 34

Correct Hypoxia * If no improvement after 90 seconds of ROOM AIR CPR, add supplemental O2 until HR > 100

Question 35

Tx for NEONATAL Aystole / PEA OR persistent bradycardia (<60 bpm)

Answer 35

For asystole/PEA or persistent bradycardia < 60 bpm * Epinephrine 0.1mg/mL o IV/IO – 0.01mg/kg (0.1mL/kg) q 3-5 min * Normal Saline o IV/IO bolus – 10mL/kg

Question 36

Adult ALS for Overdose

Answer 36

IV/IO access Suspected opioid overdose with respirations less than 12/min and significant ALOC * Naloxone, if not already administered by BLS personnel or if patient continues with decreased resp rate and significant ALOC o IN – 4 mg in 0.1 mL, may repeat x1, Max of 8 mg o IM – 2 mg q 5 min o IV/IO – 0.4 mg q 1min * Initial max 6 mg o May repeat as needed to maintain respirations greater than 12/min

Question 37

Adult ALS for Stimulant / Hallucinogenic Overdose

Answer 37

Stimulant/Hallucinogen Overdose * Midazolam o IV/IO – 2 mg * Repeat 1 mg q 2 min as needed * Max 5 mg o IM – 0.1 mg/kg o Max 5 mg

Question 38

Tx for dystonic Rxn (in an O/D)

Answer 38

Dystonic Reaction * Benadryl * IV/IO/IM – 50 mg

Question 39

? Fentanyl dosing for ADULTS Max single dose? Max TOTAL dose?

Answer 39

Fentanyl * IV/IO - 1 mcg/kg over 1 minute, OR IN/IM – 1mcg/kg * Max single dose 100 mcg * May repeat q 5 minutes for persistent pain to a max total dose 200 mcg * Repeat doses should be administered IV/IO if vascular access obtained

Question 40

? Parameters for treating a seizure as a BLS call?

Answer 40

Patients with a known seizure disorder or uncomplicated, apparent pediatric febrile seizures, no longer seizing and with a normal postictal state, may be treated as a BLS call.

Question 41

? Midazolam dose (IM) for seizures? ? Max dose?

Answer 41

IV/IO access If not already performed by BLS personnel, determine Blood Glucose level, and treat according to VC EMS policy 705.03 – Altered Neurologic Function Persistent Seizure Activity * Midazolam (Give to actively seizing pregnant patients prior to magnesium) * IM – 0.1 mg/kg Max 5 mg

Question 42

? Midazolam dose (IV/IO) for seizures? ? Max dose?

Answer 42

* IV/IO – 2 mg Repeat 1 mg q 2 min as needed Max 5 mg

Question 43

? PEDS Midazolam (IV/IO) dosing? How often can you repeat? What is the MAX DOSE

Answer 43

IV/IO – 0.1mg/kg, Repeat q 2 min as needed. Max single dose 2 mg Max total dose 5 mg

Question 44

When do you use MgSO4 during seizures?

Answer 44

Women 20 weeks gestation to one week postpartum & No Known Seizure History * Magnesium Sulfate o IV/IOPB – 4 g in 50 mL D5W infused over 10 min * Slow or stop infusion if bradycardia, heart block, or decreased respiratory effort occur

Question 45

ALS x for SOB / Pulmonary Edema

Answer 45

Nitroglycerin * SL or lingual spray – 0.4 mg q 1 min x 3 o Repeat 0.4 mg q 2 min o No max dosage o Hold for SBP < 100 mmHg If not already performed by BLS personnel, Initiate CPAP for moderate to severe distress Perform 12-lead ECG (Per VCEMS Policy 726) IV/IO access If wheezes are present and suspect COPD/Asthma, consider: * Albuterol o Nebulizer – 5 mg/6 mL * Repeat as needed

Question 46

? If pulmonary edema patient becomes hypotensive?

Answer 46

If patient presents or becomes hypotensive * Epinephrine 10 mcg/mL o 1mL (10 mcg) q 2 minutes, slow IV/IO push o Titrate to SBP of greater than or equal to 90 mm/Hg

Question 47

Adult SOB / Wheezes protocol

Answer 47

If not already performed by BLS personnel, consider CPAP for both moderate and severe distress Moderate Distress * Albuterol o Nebulizer – 5 mg/6 mL o MDI with spacer -4 puffs (360 mcg) is an acceptable alternative to nebulized Albuterol o Repeat Albuterol as needed Severe distress * Epinephrine 1 mg/mL, if not already administered by BLS personnel o IM - 0.3mg  May repeat q 5 minutes if patient still in distress and unable to obtain vascular access. * Albuterol o Nebulizer – 5 mg/6 mL * Repeat as needed

Question 48

? SOB / wheezes that does not improve with initial epinephrine administration

Answer 48

Severe Distress, not improving with prior epinephrine administration * Epinephrine 10 mcg/mL o 1 mL (10 mcg) q 2 minutes, slow IV/IO push o Titrate to overall improvement in work of breathing

Question 49

PEDS - SOB/Wheezes (Moderate Distress)

Answer 49

Moderate Distress * Albuterol o Patients ≤ 30 kg o Nebulizer – 2.5 mg/3 mL o MDI with spacer -2 puffs (180 mcg) is an acceptable alternative to nebulized Albuterol o Patients > 30 kg o Nebulizer – 5 mg/6 mL o MDI with spacer -4 puffs (360 mcg) is an acceptable alternative to nebulized Albuterol o Repeat Albuterol as needed

Question 50

PEDS - SOB/Wheezes (Severe Distress) What is distress persists beyond initial Epi?

Answer 50

Severe Distress * Epinephrine 1 mg/mL, if not already administered by BLS personnel o IM – 0.01 mg/kg up to 0.3mg * May repeat q 5 minutes, if patient remains in distress and unable to obtain vascular access. Establish IV/IO access Severe Distress, not improving with prior epinephrine administration * Epinephrine 10mcg/mL o 0.1mL/kg (1mcg/kg) every 2 minutes, slow IV/IO push o Max single dose of 1mL or 10mcg o Titrate to overall improvement in work of breathing.

Question 51

Tx Croup Mild Severe (Stridor or respiratory distress)

Answer 51

Suspected Croup- Mild * Normal Saline o Nebulizer/Aerosolized Mask – 5 mL Suspected croup - Severe (stridor or respiratory distress) * Nebulized 1 mg/mL Epinephrine o Patients less than 30 kg o Nebulizer – 2.5 mg/2.5 mL o Patients 30 kg and greater o Nebulizer – 5 mg/5 mL

Question 52

Tx SVT - ADULT (Mild to moderate) What are the max doses of the med?

Answer 52

Valsalva maneuver IV/IO access Stable - Mild to moderate chest pain/SOB Adenosine o IV/IO – 6 mg rapid push immediately followed by 10-20 mL NS flush No conversion or rate control Adenosine o IV/IO –12 mg rapid push immediately followed by 10-20 mL NS flush o May repeat x 1 if no conversion or rate control. (TOTAL MAX = 30mg)

Question 53

? Tx ADULT Unstable SVT

Answer 53

Unstable - ALOC, signs of shock or CHF Synchronized Cardioversion o Zoll 100, 120, 150, 200 Joules o Lifepak 100, 200, 300, 360 Joules o Consider sedation prior to cardioversion for special circumstances.

Question 54

? Pain / sedation med prior to cardioversion?

Answer 54

Fentanyl o 1 mcg/kg IV/ IO / IN prior to electrical therapy

Question 55

? Adult cardioversion settings?

Answer 55

Zoll 100, 120, 150, 200 Joules Lifepak 100, 200, 300, 360 Joules

Question 56

PEDS cardioversion settings

Answer 56

0.5, 1, 2, 4, 6, 8 joules/kg

Question 57

PEDS SVT Protocol

Answer 57

Valsalva maneuver IV/IO access Stable - Mild to moderate chest pain/SOB Adenosine o IV/IO – 0.1 mg/kg (max 6 mg) rapid push immediately followed by 10-20 mL NS flush No conversion or rate control Adenosine o IV/IO – 0.2 mg/kg (max 12 mg) rapid push immediately followed by 10-20 mL NS flush o May repeat x 1 if no conversion or rate control

Question 58

ADULT initial Tx for symptomatic bradycardia

Answer 58

IV/IO access Obtain 12-lead ECG Atropine * IV/IO – 0.5 mg (0.1 MG/mL) If initial Atropine is transiently effective, or patient remains bradycardic without hemodynamic compromise. * May repeat Atropine 0.5 mg IV/IO q 5 min to a total max dose of 3 mg.

Question 59

With symptomatic brady, what is the next line of Tx (ADULT) after intial drug intervention?

Answer 59

Transcutaneous Pacing (TCP) * Should be initiated only if patient has signs of hypoperfusion * Should be started immediately for 3º heart blocks and 2º Type 2 (Mobitz II) heart blocks * If pain is present during TCP o Pain Control– per policy 705.19

Question 60

With symptomatic brady what If patient remains hypotensive (SBP less than 90mmHg)

Answer 60

Normal Saline * 500 mL IV/IO bolus * May repeat x 1 for total of 1,000 mL

Question 61

Tx for For suspected hyperkalemia (during symptomatic bradycardia)

Answer 61

For suspected hyperkalemia * Calcium Chloride o IV/IO – 1 g  Withhold if suspected digitalis toxicity * Sodium Bicarbonate o IV/IO – 1 mEq/kg o Repeat 0.5 mEq/kg x 2 q 5 min

Question 62

Tx for symptomatic bradycardia for a 15Kg patient

Answer 62

IV/IO access * IV/IO access only if patient in extremis * Epinephrine 10 mcg/mL o 0.1 mL/kg (1 mcg/kg) q 2 minutes, slow IV/IO push o Max single dose of 1 mL or 10 mcg o Titrate to SBP of greater than or equal to 80 mm/Hg

Question 63

When should transcutaneous pacing (TCP) be initiated?

Answer 63

Should be initiated only if patient has signs of hypoperfus.on