Treatment

Question 1

Medical: Abdominal Pain

Answer 1

Caution:
Pregnancy should be considered in female patients prior to administration of pain
medications
BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Fluid bolus in the presence of hypotension
• Nausea/Vomiting
o Zofran 4 mg over a minimum of 30 seconds
PHYSICIAN CONSULT
• Consider Pain Management
• Nasogastric tube if indicated (prolonged transport time, GI bleed,
distention, and hematemesis)
PEDIATRIC
• Nausea/Vomiting
o Zofran 0.1 mg/kg over a minimum of 30 seconds, not to exceed 4 mg
PHYSICIAN CONSULT
• Consider Pain Management
• Nasogastric tube if indicated (prolonged transport time, GI bleed,
distention, and hematemesis)

Question 2

Medical: Adrenal Insufficiencies

Answer 2

Indications
 Patient MUST have a history of Adrenal Insufficiency (Primary Adrenal
Insufficiency, Addison’s disease, Secondary Adrenal Insufficiency, Congenital
Adrenal Hyperplasia.)
 Patients exhibiting Symptoms of Adrenal Crisis which include: Hypotension,
shock, and hypoglycemia.
 Adrenal Crisis is usually precipitated by: a history of corticosteroid use that has
been abruptly discontinued, trauma, or infection.
Caution
 In addition to administration of Solu-Cortef all other clinical findings should be
managed (e.g. arrhythmias, hypotension, and dehydration)
BLS
 Vitalize/Prioritize
 Oxygen/Airway
ALS
 EKG monitor
 Consider 12 lead EKG
 IV 0.9% NaCL KVO or Saline Lock
 Fluid bolus in the presence of hypotension aggressively up to 2000 cc’s
 Solu-Cortef 100mg
o Administer over 30 – 60 seconds
 If hypotension persists, refer to Medical Shock Syndrome
 Obtain blood glucose reading
o Hyper/hypoglycemia, refer to Diabetic
Pediatric
 Pediatrics greater than 5 kg
o Solu-Cortef 2mg/kg max 100mg IV, IM, IO
 Fluid Bolus
o Pediatrics: 20 cc/kg
o Neonates: 10 cc/kg
 If hypotension persists, refer to Medical Shock Syndrome

Question 3

Medical: Allergic Reaction

Answer 3

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Attempt to identify the cause of the reaction. Remove source if possible (e.g.
stinger from bee)
 Assist patient with personal Epi Pen and/or inhaler if indicated
ALS
 Consider aggressive airway management if indicated; refer to Pharmaceutical
Assisted Intubation
 EKG monitor
 IV 0.9% NaCl KVO or Saline lock
Mild Reaction (itching and hives)
 Benadryl 25 mg
Moderate Reaction (dyspnea, wheezing, chest tightness, or edema)
 Albuterol 2.5 mg and Atrovent 0.5 mg, repeat Albuterol as needed
o Consider CPAP for severe distress with nebulized Albuterol 2.5 mg
 Set PEEP to 5 cmH2O and titrate to 7.5 cmH2O as needed
 Benadryl 50 mg
 Pepcid 20 mg IVP over 2 minutes
 Solu-Cortef 100 mg
o Administer over 30 – 60 seconds
 Epinephrine 1:1,000 0.3 mg SQ or IM repeated every 20 minutes to total of (3)
doses
o Alternate extremities
Severe Reaction (Hypotension, e.g. anaphylactic shock)
 CARDIAC ARREST IMMINENT - Epinephrine 1:10,000 0.3 mg IVP/IO
 Benadryl 50 mg IVP/IO
 Pepcid 20 mg IVP over 2 minutes
 Solu-Cortef 100 mg
o Administer over 30 – 60 seconds
 Albuterol 2.5 mg and Atrovent 0.5 mg via nebulizer; repeat Albuterol as needed
o Consider CPAP for severe distress with nebulized Albuterol 2.5 mg
 Set PEEP to 5 cmH2O and titrate to 7.5 cmH2O as needed
 Hypotension – Refer to Medical Shock Syndrome
Medical
Rev. Oct 2020
PEDIATRIC
 Albuterol 2.5 mg/3 cc NaCl or sterile water via nebulizer
 Benadryl 1 mg/kg
 Epinephrine 1:1,000 0.01 mg/kg SQ (0.01 cc/kg) max single dose not to exceed
0.3 mg
 Pediatrics greater than 2 years old
o Solu-Cortef 2mg/kg max 100 mg IV, IM, IN
 Hypotension – Refer to Medical Shock Syndrome

Question 4

Medical: Altered Level of Consciousness

Answer 4

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Protect from injury / Restrain PRN
 Attempt to identify cause (e.g. stroke, diabetic, head injury, overdose, and
seizures)
ALS
 EKG monitor
 IV 0.9% NaCl KVO or Saline lock
 Abnormal BGL, refer to Diabetic Emergencies
 Hypotension – Refer to Medical Shock Syndrome
 Narcan 0.4mg, titrate in 0.4mg increments to EtCO2 35 – 45 mmHg or improved
mentation allowing airway to be maintained
o Max cumulative dose 10 mg
o If EtCO2 monitoring not available, titrate to a resp. rate of 10 – 12 breaths
per minute or improved mentation allowing airway to be maintained
 Consider chemical sedation in violent patients, refer to Sedation
 Consider physical restraints in violent patients, refer to Restraints
PEDIATRIC
 Hypotension – Refer to Medical Shock Syndrome
 Narcan 0.01 mg/kg initial dose
o Subsequent Dose: 0.1 mg/kg to a Max cumulative dose of 2 mg
o Treatment Goal (one of the following):
 EtCO2 35 – 45 mmHg
 Improved mentation allowing airway to be maintained
 EtCO2 monitoring not available, titrate to a resp. rate of 10 – 12
breaths per minute
 Consider chemical sedation in violent patients, refer to Sedation
 Consider physical restraints in violent patients, refer to Restraints

Question 5

Medical: Asthma

Answer 5

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Assist patient with personal auto–inhaler
ALS
 EKG Monitor
 IV 0.9% NaCl 250 cc/hr
 Albuterol 2.5 mg and Atrovent 0.5 mg via nebulizer, may repeat Albuterol after 10
minutes
o If no improvement after initial nebulizer treatment, consider the use of
CPAP with inline nebulized Albuterol 2.5 mg only
 Set PEEP to 5 cmH2O and titrate to 7.5 cmH2O as needed
o Continuous nebulizer treatments may be appropriate (Albuterol 2.5 mg
only) with or without CPAP if in severe distress
 Solu-Cortef 100 mg
o Administer over 30 – 60 seconds
 Epinephrine 1:1,000 0.3 mg SQ or IM
o Repeat 20 minutes after first dose in opposite extremity if needed
 Magnesium Sulfate 2 gm/10 cc 0.9% NaCl over 3 min, may repeat twice to a max
of 6 gm
PEDIATRIC
 IV 0.9% NaCl 2 cc/kg bolus
 Epinephrine 1:1,000 0.01 mg/kg (0.01 cc/kg) SQ or IM, max 0.3 mg
 Albuterol 2.5 mg/3 cc NaCl or sterile water via nebulizer
o May repeat after 20 minutes
 Pediatrics greater than 2 years old
o Solu-Cortef 2mg/kg max 100 mg IV, IM, IN

Question 6

Medical: Chronic Obstructed Pulmonary Disease

COPD

Answer 6

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Low flow (2–4 LPM) to maintain SaO2 > 94%
 NRB appropriate if SaO2 lower than 90%
ALS
 EKG Monitor
 IV 0.9% NaCl KVO or Saline lock
 Albuterol 2.5 mg and Atrovent 0.5 mg via nebulizer, may repeat Albuterol after 10
minutes
o If no improvement after initial nebulizer treatment, consider the use of
CPAP with inline nebulized Albuterol 2.5 mg
 Set PEEP to 5 cmH2O and titrate to 7.5 cmH2O as needed
o Continuous nebulizer treatments may be appropriate (Albuterol 2.5 mg
only) with or without CPAP if in severe distress
 Solu-Cortef 100 mg
o Administer over 30 – 60 seconds
 Assess for secondary signs of cardiac failure: edema, JVD, rales, refer to
CHF/PE
PEDIATRIC
 Albuterol 2.5 mg/3 cc NaCl or Sterile water via nebulizer
 Pediatrics greater than 2 years old
o Solu-Cortef 2mg/kg max 100 mg IV, IM, IN

Question 7

Medical: Diabetic Emergencies

Answer 7

Caution:
In pregnancy or stroke patients, PHYSICIAN CONSULT must be obtained prior to
Dextrose or Glucagon administration
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Assist with the administration of oral glucose if patient is conscious
ALS
• EKG Monitor
• Obtain blood glucose reading
• IV 0.9% NaCl KVO or Saline lock, 250 cc/hr if blood glucose level > 300 mg/dl
• Thiamine100 mg if alcohol abuse is suspected with hypoglycemia
o Administer prior to Dextrose
• Dextrose 50% 25 g if blood glucose level is less than 60 mg/dL
• Glucagon 1 mg IM or IN if no IV access
• Repeat BGL check within 15 minutes
• Repeat Dextrose 50% 25 g PRN
Physician Consult
• Administration of Dextrose after Glucagon administration
• IO access for administration of dextrose
o Exhaust all means of IV access
PEDIATRIC
• Newborn/Neonate (Birth to 28 Days) with BGL less than 45 mg/dL
o Dextrose 10% 2 mL/kg IVP slow (minimum 30 seconds)
§ Expel 40 cc of Dextrose 50% and draw 40 cc of 0.9% NaCl
• Infant/Pediatric
o Dextrose 25% 2 ml/kg IVP slow (minimum 30 seconds)
§ Expel 25 cc of Dextrose 50% and draw up 25 cc of 0.9% NaCl
• Glucagon
o 0.5 mg for children less than 20 kg
o 1.0 mg for children more than 20 kg

Question 8

Medical: Dialysis Problems

Answer 8

BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG Monitor
• IV 0.9% NaCl KVO or Saline lock
• Cautious fluid bolus in presence of hypotension
o Reassess lung sounds after each 100 cc bolus
• If IV access is unobtainable, access dialysis port if applicable (critical patient’s
only)
• Blood glucose level, refer to Diabetic Emergencies
• For cardiac arrest with suspected hyperkalemia
o Calcium Chloride 10 cc of a 10% solution
o Sodium Bicarbonate 8.4% 1 mEq/kg

Question 9

Medical: Hypertension

Answer 9

Caution:
• 180 mmHg systolic or 110 mmHg diastolic (with associated signs and symptoms) shall
be the hypertensive limits for consideration of treatment
• Patients with a history of chronic hypertension may require a higher than normal systolic
blood pressures to maintain cerebral perfusion. This should be considered when
administering medications to treat blood pressure.
• Medication administration should be limited to hypertensive crisis.
• Symptoms include: severe chest pain, severe headache with confusion or blurred
vision, N/V, epistaxis, shortness of breath, and seizures.
Contraindication
• Do not use labetalol with heart rates below 60 BPM.
Treatment Goals
• Target blood pressure 160-180 mmHg systolic, diastolic pressure less than 110 mmHg
or relief of signs and symptoms of a hypertensive crisis
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Confirm with two (2) sets of vital signs
o Confirm hypertension in opposite extremity, if possible, prior to treatment
• Place the patient supine during drug administration
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Labetalol 20 mg slow over 2 minutes
o After 10 minutes, may repeat at 40 mg slow over 2 minutes
o Obtain additional blood pressures immediately prior to and every 5 minutes after
drug administration
OR
• Nitroglycerine transdermal 15 mg (1 inch)
• Nitroglycerin IV via Dial-A-Flow
o Initiate at 20 mcg/min IV
o Increase 10 mcg/min every 5 minutes until desired response
o Obtain additional blood pressures immediately prior to and every 5 minutes after
drug administration
Physician Consult
• Third and subsequent doses of labetalol at 80 mg increments to a maximum total of 300
mg.

Question 10

Medical: Shock Syndromes

Non-traumatic Shock: Hypovolemic, Anaphylaxis, Septic, Cardiogenic, Neurogenic

Answer 10

Epinephrine is preferred in Allergic Reaction.
Dopamine is preferred in Congestive Heart Failure/PE, Sepsis, Cardiogenic Shock
and Adrenal Insufficiencies.
Patients suspected of having a Right Ventricular Infarct may require up to 2 Liters of
fluid prior to initiating inotropic agents.
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Supine positioning as tolerated by patient
ALS
• EKG Monitor
• Large Bore IV 0.9% NaCl
o Fluids wide open to maintain systolic > 100 mmHg
o Consider inotropic agents if no change after 500 mL (40 mL/kg for
pediatrics; 20 mL/kg for neonates)
• Dopamine 5 – 20 mcg/kg/min titrated to effect
OR
• Epinephrine 1:100,000 1 – 2 mL over 60 seconds q 3 – 5 minutes
o May be used to stabilize the patient while other therapies are initiated
o See Appendix E, Infusion Rates, for mixing
OR
• Epinephrine Infusion 2 – 10 mcg/min
Pediatric
• Dopamine 5 – 20 mcg/kg/min titrated to effect
OR
• Epinephrine 1:100,000 1 mcg/kg over 60 seconds q 3 – 5 minutes
o May be used to stabilize the patient while other therapies are initiated
o See Appendix E, Infusion Rates, for mixing
OR
• Epinephrine Infusion 0.1 mcg/kg/min
o Titrate to a max of 0.5 mcg/kg/min if persistent hypotension

Question 11

Medical: Nausea/Vomiting

Answer 11

BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG Monitor
• IV 0.9% NaCl KVO or Saline lock
• Zofran 4 mg over a minimum of 30 seconds
• Nasogastric tube (prolonged transport time, GI bleed, distention, and
hematemesis)
PEDIATRIC
• Zofran 0.1 mg/kg over a minimum of 30 seconds, not to exceed 4 mg
PHYSICIAN CONSULT
Nasogastric tube (prolonged transport time, GI bleed, distention, and
hematemesis)

Question 12

Medical: Obstetrics/Gynecology

Answer 12

Caution:
 Pre-eclampsia may develop as long as 6 weeks after childbirth
 Hypertension in pregnant patients (possible pre-eclampsia) shall be considered
for blood pressures above 140/90 or 20 mmHg above normal blood pressure
BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Positioning
o Transport the patient in the left lateral recumbent position if possible
o In event of abnormal presentation (e.g. foot, buttocks, hand or face), place
the patient in the knee-chest or left lateral recumbent position with
immediate transport
 Delivery
o Slow, controlled delivery of the head; apply pressure to perineum
o Suction oropharynx, then nasopharynx
o Observe for meconium staining; if present, consider tracheal suctioning
utilizing meconium aspirator
o If respiratory effort does not improve, consider intubation/LMA
o Double clamp cord at 10 and 12 inches from abdomen, then cut between
the clamps
o Dry, stimulate and maintain body temperature
 Post-Partum
o Check APGAR at 1 and 5 minutes (Appendix C)
o Assess for post-partum hemorrhage
ALS
 EKG Monitor
 Obtain BGL
 IV 0.9% NaCl KVO large bore preferred
 SEIZURES OR COMA (ECLAMPTIC)
o Magnesium Sulfate loading dose of 4 gm over 3 minutes
o Magnesium Sulfate maintenance drip 2 gm/50 cc at 50 cc/hr
PHYSICIAN CONSULT
 Pre-Eclampsia
o Magnesium Sulfate loading dose 4 gm over 15 minutes
o Magnesium Sulfate maintenance drip 2 g/50 cc at 50 cc/hr
 Seizures unresolved by magnesium sulfate Refer to Seizures

Question 13

Medical: Pain Management

Answer 13

Caution:
Pain medications may produce respiratory depression
Indications:
Relief of moderate to severe pain: e.g. trauma, fractures, dislocations, kidney stones,
and burns
BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Monitor patient’s level of consciousness and respiratory status
ALS
 EKG monitor
 IV 0.9% NaCl KVO or Saline lock if stable
 Fentanyl 1 mcg/kg over 2 minutes, titrated to effect, not to exceed 3 mcg/kg
OR
Morphine 1-5 mg, titrated to effect
 Zofran 4 mg over a minimum of 30 seconds
If opioids are not managing the pain or contraindicated
 Ketamine 0.25 mg/kg over 60 seconds to a maximum of 25 mg
o May repeat every 10 minutes prn
PEDIATRIC
 Fentanyl 1 mcg/kg over 2 minutes, titrated to effect, not to exceed 3 mcg/kg
OR
Morphine 0.1 mg/kg, titrated to effect
 Ketamine 0.25 mg/kg over 60 seconds to a maximum of 25 mg
o May repeat every 10 minutes prn
 Zofran 0.1 mg/kg over a minimum of 30 seconds, not to exceed 4 mg

Question 14

Medical: Pharmaceutical Assisted Intubation (PAI)

Answer 14

Contraindications:
 Succinylcholine is contraindicated in any patients with a family history of
Malignant Hyperthermia, skeletal muscle myopathies, and hyperkalemia
 Ketamine as an induction agent is contraindicated in suspected increased ICP patients with hypertension
Caution:
 Have ALL airway devices and equipment (Suction, Bougie, secondary airway
devices) ready
 Neuromuscular blockade does not alter the patient’s pain level or level of
response
 Use sedation prior to the use of paralytics AND post intubation after the use of
Etomidate
 Consider pain management for trauma patients regardless of level of sedation
Paralytic Administration
FTO/FTC or a Flight Medic must be present in order to administer paralytics except when circumstances prohibit. If Scene Management dictates the FTO/FTC is needed in another critical capacity, he/she may temporarily relinquish the paralytics to the most appropriate released paramedic on scene for administration.
 Two released paramedics must attend the patient during tracheal intubation o One must be the paramedic receiving the paralytics
 Both paramedics must agree that paralytics are appropriate to administer
BLS
 Vitalize/Prioritize
 Pre-oxygenate the patient for a minimum of 2 minutes via NRM or BVM. Use
adjuncts when appropriate.
 Continuous oxygenation via NC at 15 lpm during all intubation procedures in
conjunction with NRM or BVM
ALS
 EKG Monitor
 IV 0.9% NaCl
Pre-Medication
 Sepsis/Adrenal Insufficiencies when etomidate is used for induction o Solu-Cortef 100 mg over 30 – 60 seconds
 Bradycardia (Unresponsive to oxygenation)
o Atropine 0.5 mg for HR less than 60 bpm
 Fentanyl 1 mcg/kg IVP

Induction
 Etomidate 0.3 mg/kg, may repeat once for a max dose of 0.6 mg/kg OR
 Ketamine 2 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion
Neuromuscular Blockade (Induction)
 Rocuronium 1 mg/kg
If Rocuronium is not available:  Norcuron 0.1 mg/kg
o Initial onset within 2 – 3 min with maximum effects within 3 – 5 min If Norcuron is not available:
 Succinylcholine 1.5 mg/kg
Post Intubation Sedation (If further sedation is required)
 Versed 2.5 mg over 2 min
o May repeat to a max dose of 10 mg to maintain adequate sedation
OR
 Ketamine 1 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion (Concentration no greater than 50 mg/mL) o May repeat q 5 – 10 minutes as needed to maintain sedation
If Versed or Ketamine is unavailable/contraindicated:  Ativan 1mg IV/IO
o May repeat q 3 – 5 minutes to as needed to maintain adequate sedation o Maximum cumulative dose: 4 mg
PHYSICIAN CONSULT must be obtained to exceed the maximum indicated benzodiazepine dose
 Etomidate is preferred in patients presenting with ICP
 Ketamine in preferred in patients with Asthma, COPD, Sepsis, Hypotension
(medical or traumatic)

Neuromuscular Blockade (Post-intubation Paralysis)
 Rocuronium 1 mg/kg, repeat dosing as indicate OR
 Norcuron 0.1 mg/kg, repeat dosing as indicated
PEDIATRIC
Pre-Medication
 Sepsis/Adrenal Insufficiencies when etomidate is used for induction o Solu-Cortef 2 mg/kg over 30 – 60 seconds
 Sepsis: pediatrics over 2 years old
 Adrenal Insufficiencies: pediatrics over 5 kg  Bradycardia (Unresponsive to oxygenation)
o Atropine 0.02 mg/kg for HR less than 60 bpm not to exceed 0.5 mg  Consider pain management, refer to Pain Management
Induction
 Etomidate 0.3 mg/kg, may repeat once for a max dose of 0.6 mg/kg OR
 Ketamine 2 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion
Neuromuscular Blockade
 Rocuronium 1 mg/kg
If Rocuronium is not available:  Norcuron 0.1 mg/kg
o Initial onset within 2 – 3 min with maximum effects within 3 – 5 min If Norcuron is not available:
 Succinylcholine 2 mg/kg
 Etomidate is preferred in patients presenting with ICP
 Ketamine in preferred in patients with Asthma, COPD, Sepsis, Hypotension

Post Intubation Sedation:
 Versed: 0.1 mg/kg
o Titrate to effect in 0.1 mg/kg increments not to exceed 0.4 mg/kg or 6 mg
OR
 Ketamine 1 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion (Concentration no greater than 50 mg/mL) o May repeat q 5 – 10 minutes as needed to maintain sedation
If Versed or Ketamine is unavailable/contraindicated:  Ativan 0.1 mg/kg IV/IO
o May repeat q 3 – 5 minutes to as needed to maintain adequate sedation o Maximum cumulative dose: 4 mg
PHYSICIAN CONSULT must be obtained to exceed the maximum indicated benzodiazepine dose
Neuromuscular Blockade (Post-intubation Paralysis if needed)
 Rocuronium 1 mg/kg, repeat dosing as indicate OR
 Norcuron 0.1 mg/kg, repeat dosing as indicated

Complications
Suspected Malignant Hyperthermia (MH)
Indications:
 Signs of Malignant Hyperthermia include increasing EtCO2, trunk or total body
rigidity, trismus, tachycardia
Contact receiving ER immediately upon onset of suspected Malignant Hyperthermia. Offer MHAUS hotline# 1-800-644-9737
PHYSICIAN CONSULT - Request dose for all medications
 Hyperventilate with 100% O2
 Sodium Bicarbonate
 Cool patient with ice packs to surface areas (MH ONLY)
 Calcium Chloride
 Albuterol
Caution:
 Duchenne’s Muscular Dystrophy can cause sudden cardiac arrest post
Succinylcholine administra

Question 15

Medical: Sedation

Answer 15

Indications:
 Intubation
 Cardioversion
 External pacing
 Combative patient – Refer to Excited Delirium
Caution:
 Benzodiazepines may cause respiratory depression or compromise
 When administering, observe for signs of hypotension or respiratory depression
 CAPNOGRAPHY MUST BE MONITORED WHEN A PATIENT IS SEDATED
 EtCO2 monitoring
 Anesthetic spray to posterior pharynx (for intubation)
 Versed 2.5 mg over 2 min
o May repeat to a max dose of 10 mg to maintain adequate sedation OR
 Ketamine 1 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion (Concentration no greater than 50 mg/mL) o May repeat q 5 – 10 minutes as needed to maintain sedation
If Versed or Ketamine is unavailable/contraindicated:  Ativan 1mg IV/IO
o May repeat q 3 – 5 minutes to as needed to maintain adequate sedation o Maximum cumulative dose: 4 mg
PHYSICIAN CONSULT
 Benzodiazepine doses greater than the maximum indicated dose

Pediatric
 Versed: 0.1 mg/kg
o Titrate to effect in 0.1 mg/kg increments not to exceed 0.4 mg/kg or 6 mg
OR
 Ketamine 1 mg/kg IV/IO over 60 seconds
o Dilute 100mg/mL concentration with equal parts of 0.9% NaCl or sterile
water for IV/IO infusion (Concentration no greater than 50 mg/mL) o May repeat q 5 – 10 minutes as needed to maintain sedation
If Versed or Ketamine is unavailable/contraindicated:  Ativan 0.1 mg/kg IV/IO
o May repeat q 3 – 5 minutes to as needed to maintain adequate sedation o Maximum cumulative dose: 4 mg
PHYSICIAN CONSULT must be obtained to exceed the maximum indicated benzodiazepine dose

Question 16

Medical: Seizures

Answer 16

Caution:
• Refer to OB/GYN Guideline in pregnant/postpartum patients (Eclampsia)
• Consider infectious disease as etiology of seizure (Meningitis, Encephalitis). Use
appropriate PPE/ BSI.
• Use caution not to over cool a febrile patient to the point of shivering. Use of PO
medications should be avoided in patients with decreased level of consciousness.
• The preferred route of Versed administration in seizures is intranasal
• Neuromuscular blockade does not suppress seizure activity
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Protect from injury
• Consider Spinal Motion Restriction precautions if suspected injury
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Obtain BGL
• Ativan1mg,mayberepeatedtoamaxof4mg
OR
• Versed 2.5 mg over 2 minutes, may repeat initial dose to a maximum of 10 mg
• Consider use of neuromuscular blockade in cases of status epilepticus, refer to
Pharmaceutical Assisted Intubation
Physician Consult
• Seizures unresolved by magnesium sulfate in the pregnant patient
PEDIATRIC
• Febrile seizures
o Treatfebrileseizuresbycooling(Avoidrapidtemperaturechangeandshivering) o ConsiderAtivanorVersedifseizuresarecontinuous
o Children’sAcetaminophenliquid10mg/kgPOwhenlevelofconsciousness
permits
• Idiopathic (non–febrile) seizures
o Ativan0.1mg/kg,nottoexceed4mg OR
o Versed 0.1 mg/kg IV/IO not to exceed 2 mg per administration. May be repeated every 3 min to a maximum cumulative dose of 0.3 mg/kg or 6 mg
OR
o Versed0.2mg/kgIM/INone-timedosenottoexceed6mg
• Consider use of neuromuscular blockade in cases of status epilepticus, refer to
Pharmaceutical Assisted Intubatio

Question 17

Medical: Sepsis

Answer 17

Criteria for issuing a Sepsis Alert;
 The patient is at least 18 years of age,
 Suspected or confirmed infection, through history (antibiotic therapy) and/or
signs/symptoms
 Exhibits any two of the signs listed below:
1. Temperature ≥ 100.4 F OR ≤ 96.8 F (not due to activity or environment)
2. Heart rate ≤ 60 or ≥90 (not due to activity or environment)
3. Respiratory rate ≤ 12 or ≥ 20
 EtCO2 ≤ 25 mmHg
BLS
Rev. Oct 2020
Sepsis
 Vitalize/Prioritize
 Oxygen/Airway
 Trendelenberg positioning as tolerated by patient
ALS
 EKG monitor
 IV 0.9% NaCl to maintain systolic pressure ≥ 100 mmHg
o Administer fluid bolus in 250 mL increments at wide open rate  Assess lung sounds after each bolus
 Maximum 4 liters
 Abnormal BGL, refer to Diabetic Emergencies

Question 18

Medical: Sickle Cell Anemia

Answer 18

BLS
• Vitalize/Prioritize
• Oxygen/Airway (High-flow if indicated)
ALS
• EKG monitor
• IV 0.9% NaCl infusion 250 cc/hr
• Consider pain management, refer to Pain Management
PEDIATRIC
• Consider pain management, refer to Pain Management

Question 19

Medical: Stroke

Answer 19

Caution:
 PHYSICIAN CONSULT: Administration of Dextrose/Glucagon
 Provide rapid, undelayed transport to Lawnwood Regional Medical Center or
Cleveland Clinic Tradition Hospital for all Stroke Alerts
Contraindication:
 Do not use labetalol with heart rates below 60 BPM.
o Maintain O2 saturation at 94% or greater, initiate at 4 LPM and titrate to effect unless in significant respiratory compromise

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Elevate patient’s head no more than 30 degrees
 Evaluate for stroke alert and notify Communications if Stroke Alert issued
o Onset within the last 24 hours
 Complete Stroke Alert form
ALS
 EKG Monitor
 Obtain BGL
 IV 0.9% NaCl KVO or Saline lock
Patients meeting Stroke Alert Criteria
 Labetalol 10 mg over 2 minutes with systolic pressure > 220 mmHg
PHYSICIAN CONSULT
 Labetalol administration to patients suffering from signs and symptoms of
a stroke but do not meet Stroke Alert Criteria
 Refer to Diabetic Emergencies if applicable

Question 20

Cardiac: Acute Coronary Syndrome (ACS)

Answer 20

Clinicians should carefully consider the diagnosis of ACS even in the absence of typical chest discomfort. Consider ACS in patients with:
• Anginal equivalent symptoms, such as dyspnea (LV dysfunction), palpitations, presyncope, and syncope (ischemic ventricular rhythms)
• Atypical left precordial pain or complaint of indigestion or dyspepsia
• Atypical pain in the elderly, women, and persons with diabetes
Contraindications:
• Aspirin or aspirin based products are contraindicated in:
o Children16yearsofageoryoungerduetoReye’ssyndrome o Allergy
Caution:
• PHYSICIAN CONSULT should be obtained in the following:
o Presenceofsuspectedrightventricularinfarctpriortoadministrationof
nitrates, narcotics
o Withholdingnitratesonnon-hypotensiveCardiacAlertpatients
• In presence of hypotension, refer to Cardiogenic Shock Syndrome
• Narcotic medication administration is indicated for ischemic pain not relieved by
nitroglycerine
• Rapid, undelayed transport
• Administer 3 SL NTG doses and NTG TD prior to considering IV NTG
BLS
• Vitalize/Prioritize
• Oxygen/Airway
o Maintain O2 saturation at 94% or greater, initiate at 4 LPM and titrate to effect unless in significant respiratory compromise
ALS
• EKG monitor
• 12 Lead EKG
o V4RshouldbeevaluatedifanySTelevationinleadsII,III,aVF
• Evaluate for Cardiac Alert
• IV 0.9% NaCl KVO
o Evidenceofrightventricularinfarct(STelevationinleadV4R)withassociated
hypotension may require as much as 2,000 cc
o MultipleIVsarepreferredfortheCardiacAlertpatient
• Aspirin 324 mg chewable Physician Consult for Pregnancy
• Nitroglycerine
o 0.4mgSL(mayadminister1SLpriorto12leadorIVaccess)
§ Repeat at 3 – 5 min intervals up to a total of three (3)
o 15mg(1”)paste(maybeadministeredconcurrentlywithSLnitroglycerine)
o If any of the following are present after 3 SL doses: Recurrent pain, persistent
ischemia (ST segment changes), persistent ACS symptoms or hypertension
§ 20 mcg/min IV infusion via dial-a-flow, increased 10 mcg/min every 3-5
minutes until pain is relieved
• Consider pain management if refractory to nitroglycerine, refer to Pain Management

Question 21

Cardiac: Asystole/ PEA

Answer 21

Verify DNR Orders on completed DOH Form 1896
BLS
• Vitalize/Prioritize
• CPR
• Airway - King Airway/LMA
• Apply AED
ALS
• Secure Airway
• EKG
• IV 0.9% NaCl, large bore if possible
• Epinephrine 1:10,000 1 mg every 3-5 minutes
• Consider possible causes: 5H’s and 5T’s (See Cardiac Arrest Management)
• Calcium Chloride 10 mg/kg if patient on calcium channel blocker or history of
renal failure
• Sodium Bicarbonate 8.4% 1 mEq/kg ONLY for suspected hyperkalemia, TCA
OD, or preexisting metabolic acidosis
• Consider Glucagon 1 mg IVP for suspected beta blocker overdose
PHYSICIAN CONSULT
Consider termination of efforts after 20 minutes of treatment with no change
PEDIATRIC
• Epinephrine every 3-5 minutes
o Epinephrine 0.01 mg/kg (0.1cc/kg) 1:10,000, max 1 mg o Epinephrine 0.1 mg/kg (0.1cc/kg) 1:1,000 via ETT
• Sodium Bicarbonate 8.4% 1 mEq/kg for suspected hyperkalemia, TCA OD, or preexisting metabolic acidosis
o Use Sodium Bicarbonate 4.2% solution for infants (under 1 y/o)

Question 22

Cardiac: Bradycardia

Answer 22

BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG monitor
o Do not delay patient treatment to acquire 12-lead EKG in unstable
patients
• IV 0.9% NaCl
o Fluid bolus in the presence of hypotension
• Consider immediate transcutaneous pacing in critical/unstable patients
• Symptomatic:
o Atropine 0.5 mg, repeated as necessary every 3-5 minutes up to a total of 3 mg
o Consider any of the following refractory to Atropine: o Transcutaneous pacing
§ Pt severely symptomatic or delay in drug administration consider pacing before Atropine
§ Anterior-posterior pad placement is preferred
§ Consider sedation if possible, refer to Sedation OR
o Dopamine 5-10 mcg/kg/min OR
o Epinephrine 2-10 mcg/min
PEDIATRIC
*Only administer Atropine for bradycardia due to suspected elevated vagal tone or primary AV block
Heart rate:
< 100 bpm - Support Airway (O2/Ventilations) < 60 bpm with poor perfusion - start CPR
• Epinephrine 0.01 mg/kg (0.1 cc/kg) 1:10,000 every 3-5 minutes, max 1 mg
o Epinephrine 0.1 mg/kg (0.1 cc/kg) 1:1,000 every 3-5 minutes via ETT, max
2 mg
• Transcutaneous pacing
o Profound symptomatic bradycardia refractory to BLS and ALS
o Anterior–posterior position is preferred
• Atropine 0.02 mg/kg every 3-5 minutes, Max cumulative dose 0.03-0.04 mg/kg
o Minimum dose 0.1 mg
o Maximum single dose 0.5 mg

Question 23

Cardiac: Cariogenic Shock

Answer 23

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Supine positioning as tolerated by patient
ALS
 EKG monitor
 12 Lead EKG
o V4R should be evaluated if any ST elevation in leads II,III, aVF  IV 0.9% NaCl, large bore preferred, Wide-open rate
o Stop fluid bolus if pulmonary edema results
 Evidence of right ventricular infarct (ST elevation in lead V4R)
o Treat hypotension with cautious fluid bolus up to 2,000 cc
 Hypotension – Refer to Medical Shock Syndrome
 Congestive Heart Failure/Pulmonary Edema consider intubation and treat per
guideline
 Suspected myocardial infarction, refer to Acute Coronary Syndrome
PEDIATRIC
 Hypotension – Refer to Medical Shock Syndrome

Question 24

Cardiac: Congestive Heart Failure/Pulmonary Edema

Answer 24

Caution:
 If patient is febrile, PHYSICIAN CONSULT is indicated before administering nitroglycerine
 Patients should be considered febrile when oral temperatures exceed 100.4 ̊ F
 Administration of nitrates should be done with caution in patients with right
ventricular infarct. PHYSICIAN CONSULT should be obtained in the presence of suspected right ventricular infarct prior to continued administration of nitrates or morphine.
BLS
 Vitalize/Prioritize
 Oxygen/Airway (high flow)
 Palpate body temperature and/or check oral temperature
ALS
 EKG monitor
 12 Lead EKG
o V4R should be evaluated if any ST elevation in leads II, III, aVF  Consider using CPAP early
o Set PEEP valve to 10 cmH2O
 IV 0.9% NaCl KVO or Saline lock
 Nitroglycerine - Moderate to severe distress, administer IV nitroglycerine as soon
as possible
o 0.4 mg SL (may administer 1 SL prior to 12 lead or IV access)
 may repeat every 5 min to a total of three (3) doses (1.2 mg)
o 1 inch paste (may be administered concurrently with SL nitroglycerine) o 20 mcg/min IV infusion via dial-a-flow, increased 10 mcg/min every 3–5
minutes
 Stop infusion if hypotension develops (systolic pressure less than
100 mmHg)
 Hypotension – Refer to Medical Shock Syndrome
PEDIATRIC
 Hypotension – Refer to Medical Shock Syndrome

Question 25

Cardiac: Tachycardia

Answer 25

Caution:
• Consider underlying etiology prior to treatment (e.g. sepsis, fever, blood loss (GI bleed),
acute exacerbation of respiratory ailment)
• Adenosine administration shall be immediately followed by a 20 cc IV/IO push (10 cc for
pediatrics and infants)
• Heart Rates less than 150 bpm rarely require medication administration or electrical
therapy
• Physician Consult indicated for any antidysrhythmic medication administration for stable patients with a history of WPW
• Unstable signs and symptoms include: altered mental status, hypotension, chest pain with suspected MI, pulmonary edema. Presence of these symptoms requires immediate, aggressive intervention (synchronized cardioversion, defibrillation)
Contraindication
• Amiodarone is contraindicated in patients with an allergy to iodine

BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• IV 0.9% NaCl KVO or Saline lock
• EKG
• 12-lead
o If elevation in contiguous Leads II, III, aVF: Perform a V4R to evaluate for right- sided AMI
• Attempt Vagal Maneuvers for narrow rhythms
Narrow Regular Rhythm (SVT)
• Adenosine 6 mg rapid push
o Ifnoconversion/effectafter1-2minutes,repeatat12mg
• Choose One
o Cardizem0.25mg/kgover2minutes
§ If no effect after 15 minutes, 0.35 mg/kg over 2 minutes o Verapamil5mgover2minutes
§ If no effect after 15 minutes, 10 mg over 2 minutes
• Unstable or refractory to pharmacology
o Considersedation,refertoSedation o SynchronizedCardioversion
§ Initial shock 100 J, progressively increase to 200 J

Narrow Irregular Rhythm (Atrial Fibrillation)
• Choose One
o Cardizem0.25mg/kgover2minutes
§ If no effect after 15 minutes, 0.35 mg/kg over 2 minutes o Verapamil5mgover2minutes
§ If no effect after 15 minutes, 10 mg over 2 minutes
• Unstable or refractory to pharmacology
o Considersedation,refertoSedation o SynchronizedCardioversion
§ Initial shock 120 J, progressively increase to 200 J
Wide Regular Rhythm
• Amiodarone 150 mg over 10 minutes
o RepeatasneededifVentricularTachycardiapersists
§ Maintenance drip: 1 mg/min infusion
• Lidocaine 1-1.5 mg/kg (Only if Amiodarone is unavailable or contraindicated)
o Allsubsequentbolusesshallbehalftheinitialbolusgivenevery5-10minutesto a cumulative dose of 3 mg/kg
§ Maintenance drip: 1-4 mg/min infusion
• Adenosine 6 mg rapid push (Monomorphic only)
o Ifnoconversion/effectafter1-2minutes,repeatat12mg
• Unstable or refractory to pharmacology
o Considersedation,refertoSedation o SynchronizedCardioversion
§ Initial shock 100 J, progressively increase to 200 J
Wide Irregular Rhythm (Possible WPW or Pre-Excited Atrial Fibrillation)
• Primary treatment if unstable is synchronized cardioversion
§ Initial shock 120 J, progressively increase to 200 J
o Considersedation,refertoSedation
• Physician Consult indicated for any antidysrhythmic medication administration
Wide Irregular, Polymorphic Rhythm (possible Torsades de Pointes)
• Treat as Ventricular Fibrillation/Pulseless Ventricular Tachycardia
• Immediate defibrillation
o Initialdefibrillationis120J,secondat150J,thirdandsubsequentat200J
• Consider Magnesium Sulfate 1-2 g

PEDIATRIC
Narrow complex (QRS ≤ 0.09 sec)
• Adenosine 0.1 mg/kg, max of 6 mg
o Ifnoconversionafter1-2minutes,0.2mg/kg,max12mgrapidpush
Wide Complex
Obtain Physician Consult for antiarrhythmic medications
Unstable or Refractory to Pharmacology
• Synchronized Cardioversion 1 J/kg
• May repeat at 2 J/kg
• Consider sedation, refer to Sedation
PHYSICIAN CONSULT
• Narrow or wide complex tachycardia refractory to Adenosine and/or cardioversion
• Amiodarone 5 mg/kg over 30 minutes

Question 26

Cardiac: Ventricular Ectopy

Answer 26

Caution:
• Underlying etiology should be considered prior to treating ventricular ectopy. Primary
intervention should be treating the transient ischemia.
• Antiarrhythmic treatment of ectopy should be limited to patients presenting with
significant symptoms (e.g. severe chest pain, hypotension, altered mentation, salvos,
and runs of V-tach)
• Although the loading dose of Lidocaine does not need to be reduced in the pulseless
patient, the maintenance dose should be decreased by 50% in the presence of jaundice, acute MI, congestive heart failure, circulatory shock, JVD, unconsciousness or in patients older than 70 years old
Contraindications
• Amiodarone is contraindicated in patients with an allergy to iodine
BLS
• Vitalize/Prioritize
• Oxygen Airway
ALS
• EKG Monitor
• 12-Lead EKG
o V4RshouldbeevaluatedifanySTelevationincontiguousleadsII,III,and/or aVF
• IV 0.9% NaCl or Saline lock
• Amiodarone 150 mg over 10 minutes
o RepeatasneededifVentricularEctopypersists
o Maintenance drip: 1 mg/min infusion
• Lidocaine 1 mg/kg (Only if Amiodarone is unavailable or contraindicated)
o Repeatas0.5mg/kgevery5-10minutes,toamaxof3mg/kg o Maintenancedrip:1-4mg/min

Question 27

Cardiac: Ventricular Fibrillation/Pulseless V-Tach

Answer 27

BLS
 Vitalize/Prioritize
 Oxygen/Airway
 Apply AED
ALS
 Immediate defibrillation
o Initial defibrillation is 120J, second at 150J, third and subsequent at 200J
 Secure Airway
 IV/IO Access
 Epinephrine 1:10,000 1 mg every 3-5 minutes
 Antiarrhythmic
o Amiodarone 300 mg
 Second dose: 150 mg after 3-5 minutes  Maintenance drip: 1 mg/min infusion OR
o Lidocaine 1.5 mg/kg
 Second and Third dose: 0.75 mg/kg every 3-5 minutes  Maintenance drip: 1-4 mg/min infusion
 Irregular/Polymorphic VT (Torsades de Pointes) o Magnesium Sulfate 1-2 g
PEDIATRIC
 Immediate defibrillation
o 2 J/kg initial setting
o 4 J/kg for second shock
o ≥4 J/kg all subsequent shocks (Max of 10 J/kg or 200J)
 Secure airway - ETT or secondary airway device
 IV/IO Access
 Epinephrine every 3-5 minutes
o Epinephrine 0.01 mg/kg (0.1 cc/kg) 1:10,000, max 1mg
o Epinephrine 0.1 mg/kg (0.1 cc/kg) 1:1,000 via ETT  Antiarrhythmic
o Amiodarone 5 mg/kg, may be repeated twice to a maximum cumulative dose of 15 mg/kg
 Max single dose: 300 mg
OR
o Lidocaine 1mg/kg, repeated every 3-5 minutes to a total of 3 mg/kg  Maintenance drip: 20 - 50 mcg/kg/min
 Irregular/Polymorphic VT (Torsades de Pointes)
o Magnesium Sulfate 25 - 50 mg/kg max 2 g over 2 minutes

Question 28

Trauma/Environment:

Bites and Stings

Answer 28

BLACK WIDOW
Bites and Stings
BLS
Benzodiazepines are preferred for pain management
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Ativan 1 mg increments, max of 4 mg
OR
• Versed: 2.5 mg over 2 minutes, may repeat once after 5 minutes
• Consider pain management
PHYSICIAN CONSULT
• Calcium Chloride 10% (request dosage from ED Physician)
• Benzodiazepine doses greater than the maximum indicated dose
PEDIATRIC
• Ativan 0.1 mg/kg increments, max of 4 mg OR
• Versed: 0.1 mg/kg IV/IO not to exceed 2 mg total dose per administration. May be repeated every 3 minutes to a maximum cumulative of 6 mg.
• Consider pain management, refer to Pain Management
PHYSICIAN CONSULT
• Calcium Chloride 10% (request dosage from ED Physician)
• Benzodiazepine doses greater than the maximum indicated dose

BROWN RECLUSE
BLS
• Vitalize/Prioritize
• Oxygen/Airway
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Consider pain management, refer to Pain Management
PEDIATRIC
• Consider pain management, refer to Pain Management MARINE INJURIES
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Irrigate area with 0.9% NaCl
• Remove barbs or tentacles if visible (scrape off to avoid releasing more poison)
• Observe for shock or allergic reaction, refer to appropriate Treatment Guideline
ALS
• EKG monitor
• IV 0.9% NaCl KVO or Saline lock
• Consider pain management, refer to Pain Management
PEDIATRIC
• Consider pain management, refer to Pain Management

SNAKE BITES
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Mark initial edematous area
• Keep patient calm
• If snake is DEAD, bring to ED for identification
ALS
• EKG Monitor
• IV 0.9% NaCl KVO or Saline lock
• Allergic reaction, refer to Allergic Reaction
PHYSICIAN CONSULT
• Consider pain management, refer to Pain Management
PEDIATRIC
PHYSICIAN CONSULT
• Consider pain management, refer to Pain Management
Contraindication:
The use of ice, tourniquet or constricting bands is contraindicated
Caution:
If a tourniquet is applied prior to arrival, PHYSICIAN CONSULT is indicated prior to removing the tourniquet

Question 29

Trauma/ Environment: Burns

Answer 29

Contraindication:
OPAs, NPAs, King Airways, and LMAs in all potential inhalation burn patients
Caution:
• Burn patients are at high risk of developing hypothermia. Keep patients warm.
• Aggressive airway management is indicated for ALL potential inhalation burn
patients regardless of respiratory distress level
• Cricothyrotomy Kit should be readily available
• Consider Consensus Burn Formula regarding infusion rates during extended
transports (See Pharmacology Section)
• Consider Cyanokit for possible smoke inhalation patients if indicated
BLS
• Vitalize/Prioritize
• Oxygen/Airway
• Remove or cool heat source if present (e.g. tar, clothing)
• Cool compress dressing only on 1st degree burns with sterile saline (do not apply
ice directly to burns)
• Consider Kool-A-Burn for 1° and 2° degree burns less than 15% BSA
• Dry, sterile burn sheet for 2° burns greater than 15% BSA and all 3° burns
• Use Rule of Nines or Palm method (Appendix C) to determine percentage of
body surface area involved in burn
• Assess for Trauma Alert criteria (2° and 3° burns ≥ 15% BSA)
o Burn Center Referral Criteria (all must be without concurrent trauma): 2° and 3° burns ≥ 15%BSA or significant burns to hands, feet, face, genitalia, or inhalation
o Patients meeting Burn Center Criteria require immediate FTO Notification
• Chemical burns: Consult Special Ops for gross decontamination measures
• Consider Spinal Motion Restriction in presence of possible trauma (e.g. fall)
ALS
• EKG monitor
• IV 0.9% KVO or Saline lock, two (2) large bore lines preferred in significant burns
• Consider pain management, refer to Pain Management
PEDIATRIC
• Establish IV access and consider administering fluids burns meeting flight criteria
• Consider pain management, refer to Pain Management