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Nassau Regional Emergency Medical Services
Protocol Update
2014 updated January 20, 2014
Protocol Update
1
Nassau Regional Emergency Medical Services
Advanced Life Support
Policy, Procedure, and Policy, Procedure, and
Protocol Manual
2014 2
Section III – Protocol - Table of Contents Approved/
Revised Effective
Airway Management / Respiratory Arrest III. A 10/30/13 4/01/14
Medication Facilitated Intubation III. B 10/30/13 4/01/14
Vascular Access III. C 10/30/13 4/01/14
Hypoperfusion / Shock III. D 10/30/13 4/01/14
Pain Management III. E 10/30/13 4/01/14
Procedural Sedation III. F 10/30/13 4/01/14
Severe Nausea / Vomiting III. G 10/30/13 4/01/14
Trauma III. H 10/30/13 4/01/14
Asthma / Bronchospasm III. I 10/30/13 4/01/14
COPD III. J 10/30/13 4/01/14
Acute Pulmonary Edema III. K 10/30/13 4/01/14
Anaphylaxis III. L 10/30/13 4/01/14
Acute Coronary Syndrome / Chest Pain III. M 10/30/13 4/01/14
Cardiac Arrest - VF / Pulseless VT III. N 10/30/13 4/01/14
Cardiac Arrest - Asystole / PEA III. O 10/30/13 4/01/14
Post Resuscitation - Return of Circulation III. P 10/30/13 4/01/14
Wide Complex Tachycardia w/ pulse III. Q 10/30/13 4/01/14
Narrow Complex Tachycardia III. R 10/30/13 4/01/14
Symptomatic Bradycardia III. S 10/30/13 4/01/14
Altered Mental Status III. T 10/30/13 4/01/14
Seizures / Status Epilepticus III. U 10/30/13 4/01/14
Stroke / Transient Ischemic Attack III. V 10/30/13 4/01/14
Behavioral Emergency III. W 10/30/13 4/01/14
Poisoning / OD / Toxic Exposure III. X 10/30/13 4/01/14
Obstetric / Pregnancy related III. Y 10/30/13 4/01/14
Hazardous Materials Treatment (Restricted Distribution) III. Z 10/30/13 4/01/04 3
Special Notes:
Currently, Nassau County REMSCO does not mandate Controlled Substances,
CPAP/BIPAP or Hypothermia procedures for ROSC. These items are considered the
standard of care and agencies are encouraged to adopt these items with approval of
their agency Medical Director.
Complete vitals must be assessed prior to the administration of any vaso-active
medications.
Nasal route of administration is preferred when the patient is violent, with seizures, or
if provider safety is compromised.
If D50 is unavailable - D10w may be used
4
Critical Care
& Paramedic Airway Management / Respiratory Arrest Protocol III. A
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o BLS airway management
o BLS foreign body obstruction techniques as appropriate
o Use a Magill forceps to remove possible obstruction
o Oxygen as appropriate o Oxygen as appropriate
o Pulse oximetry, waveform capnography, cardiac monitor as appropriate
o Endotracheal intubation *
- monitor waveform capnography throughout transport.
- use a colorimetric CO2 detector as a secondary device.
- 2 attempts only - consider alternate airway device.
o Establish IV access
o Naloxone (Narcan) 2.0 mg IV/IO/ IN - for suspected narcotic overdose
Paramedic
o Needle decompression - for suspected tension pneumothorax
5
Critical Care
& Paramedic Airway Management / Respiratory Arrest Protocol III. A
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o CPAP / BIPAP (if available)
Naloxone 2.0 mg IV/IO/ IN o Naloxone (Narcan) 2.0 mg IV/IO/ IN
o Needle decompression - for suspected tension pneumothorax
o Needle cricothyroidotomy (Paramedic Only)
6
Protocol III. A – Updates
Standing Orders
Narcan 2mg IV/IO/IN
Paramedic Only
Needle Decompression
Medical Control Options
CPAP/BiPAP
Needle Cricothyroidotomy (Paramedic only)
7
Paramedic
ONLY Medication Facilitated Intubation Protocol III. B
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
Paramedic only
o BLS Airway management
o Obtain vascular access as appropriate
o Cardiac monitor as appropriate
o Pre-oxygenate, position the patient appropriately
o Contact Medical Control for sedation medications.
o Post - Endotracheal intubation
- monitor waveform capnography throughout transport.
- use a colorimetric CO2 detector as a secondary device.
- 2 attempts only - consider alternate airway device.
8
Paramedic
ONLY Medication Facilitated Intubation Protocol III. B
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options: (if available)
o If the patient is conscious prior to performing endotracheal intubation,
contact medical control for prehospital sedation (if available)
• Diazepam (Valium) 5-10 mg IV/IO (if hemodynamically stable) • Diazepam (Valium) 5-10 mg IV/IO (if hemodynamically stable)
repeat dose may be given as necessary (max total dose 20 mg)
or
• Midazolam (Versed) 1-5 mg IV/IO/IN
repeat dose may be given as necessary (max total dose 5 mg)
or • Lorazepam (Ativan) 2-4 mg IV/IO/IN
repeat dose may be given as necessary (max total dose 4 mg)
or
• Etomidate (Amidate) 0.3 mg/kg rapid IV/IO push (max dose 20mg)
After intubation,
• Diazepam (Valium) 5mg IV/IO for continued sedation.
9
Protocol III. B – Updates
Medical Control OptionsParamedic Only
Diazepam 5-10 mg IV/IODiazepam 5-10 mg IV/IO
Lorazepam 2-4 mg IV/IO
Diazepam 5 mg IV/IO
Etomidate 0.3 mg/kg rapid IV/IO
Midazolam 1-5 mg IV/IO/IN
10
DIAZEPAM (Valium)
Class
Benzodiazepine
Interactions
Diazepam is incompatible with many medications. Whenever Diazepam
is given intravenously in conjunction with other drugs, the IV line should beis given intravenously in conjunction with other drugs, the IV line should be
adequately flushed.
Pharmacokinetics
Onset : 1-5 minutes IV; 15-30 minutes IM
Duration : peak effects 15-60 minutes
Dose / RouteAdult: Diazepam (Valium) 5-10 mg IV/IO (PR if no access) max 20 mg total
Pedi: Diazepam IV/IO slowly over 2 minutes, repeat (PR if no access)
Protocols Adult - III.B, III.F, III.P, III.U, III.W, III.X, III.Y Pedi - P9 11
MIDAZOLAM (Versed)
Class
Benzodiazepine
PharmacokineticsOnset : 1-3 minutes IV/IN; 15-30 minutes IMOnset : 1-3 minutes IV/IN; 15-30 minutes IM
Duration : Peak effects variable (30-60 minutes)
Dose / Route
Adult: Midazolam (Versed) 1- 5 mg IV/IO/IN (max total dose 5 mg)
Pedi: Midazolam, slowly over 2 minutes. If no response within 5 min. repeat
(PR if no access)
Protocols Adult - III.B, III.F, III.P, III.U, III.W, III.X, Pedi - P9
12
LORAZEPAM (Ativan)
Class
Benzodiazepine, anticonvulsant, sedative
Pharmacokinetics
Onset: 1-5 minutes IV; 15-30 minutes IM
Peak effects : 15-20 minutes IV; 2 hours IMPeak effects : 15-20 minutes IV; 2 hours IM
Duration: 6-8 hours
Dose / Route
Lorazepam (Ativan) 2-4 mg IV/IO/IN/IM
(total max dose 4 mg)
Note: Lorazepam must be refrigerated at 2-8 degree Celsiusor 35-46 degree Fahrenheit. Per NYS Bureau of Narcotics
Enforcement and EMS regulation.
Protocols Adult - III.F, III.U, III.W, III.X, Pedi - P913
Class
Sedative hypnotic
Pharmacokinetics
Onset: 10-20 seconds
Peak effects < 1 minute
Etomidate (Amidate)
Peak effects < 1 minute
Duration: 3-5 minutes
Dose / Route
Etomidate (Amidate) 0.3mg/kg IV/IO
(total max dose 20 mg)
Protocols Adult - III.B, III.F, III.Y Pedi - NONE
14
Critical Care
& Paramedic Vascular Access / Fluid & Medication Management Protocol III. C
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Saline lock or KVO I.V. line with normal saline may be used.
o Patients that require rapid volume IV drip, at least one (1) large bore IV line
with normal saline should be established. with normal saline should be established.
o Peripheral veins should be used as a primary site. The external jugular vein
(EJ) may be used in extremis for adult patients if no other site is accessible.
o An intraosseous (IO) device may be used for patients in complete vascular
collapse via Proximal Tibia ONLY. Drug administration via this route utilizes
doses identical to those used for IV administration.
o In the absence of intravenous access, intranasal (IN) with an appropriate
atomizer device may be used if available.
The only drugs approved for this route are Naloxone (Narcan), Lorazepam (Ativan),
Midazolam (Versed) and Fentanyl .
(this is the preferred route for violent patients, seizures, or if provider safety is compromised)
15
Protocol III. C – Updates
Intra Nasal Drugs: Narcan , Lorazepam, Midazolam, Fentanyl
16
Critical Care
& Paramedic Hypoperfusion / Shock Protocol III. D
Approved: 10/30/13
Effective: 4/01/14
Do Not delay transport
Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor
o IV fluid bolus - titrate to SBP 90
(No more than 2 liters unless ordered by medical control)
If adrenal cortical insufficiency (Addison's) / hyperplasia is confirmed *
o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)
Paramedic
o Needle Decompression - for suspected tension pneumothorax
17
Critical Care
& Paramedic Hypoperfusion / Shock Protocol III. D
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Dopamine drip 5-20 mcg/kg/min IV/IO
o Norepinephrine (Levophed) (2-4 mcg/min- initial dose) IV/IO (max 30 mcg/min) - large vein if possible
Continue IV Drip beyond 2 Liters o Continue IV Drip beyond 2 Liters
o Hospital Diversion
o Needle Decompression - for suspected tension pneumothorax
o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)
NOTE: Adrenal insufficiency / hyperplasia is confirmed by patient record,
family or medic alert tag
18
Protocol III. D – Updates
Standing OrdersHydrocortisone Sodium Succinate 2 mg/kg IV/IO
Paramedic OnlyNeedle DecompressionNeedle Decompression
Medical Control Options
Hydrocortisone Sodium Succinate 2 mg/kg IV/IO
Dopamine Drip 5-20 mcg/kg IV drip IV/IO
Norepinephrine 2-4 mcg/min IV/IO
19
Class
Sympathetic agonist
Pharmacokinetics
Onset: Immediate
Peak effect: 1-2 minutes
Norepinephrine (Levophed)
Peak effect: 1-2 minutes
Duration: N/A
Half-life: Short 1-2 minutes
Dose / Route
Norepinephrine (Levophed) 2-4 mcg/min IV/IOMaximum 30 mcg/min
Large vein access- if possible
Protocols Adult - III.D, III.K, III.L, III.P, Pedi - NONE20
Norepinephrine (Levophed)
ClassCorticosteroid and anti-inflammatory
Pharmacokinetics
Onset: Immediate
Peak effect: 4-6 Hours
Hydrocortisone (Solu-Cortef)
Peak effect: 4-6 Hours
Duration: 24-36 hours
Dose / Route
Hydrocortisone (Solu-Cortef ) 2 mg/kg IV/IO Adult
Maximum dose 100 mg
2 mg/kg IV/IO Pediatric
Protocols Adult - III.D Pedi – P11
22
Critical Care
& Paramedic Pain Management (Non-cardiac) Protocol III. E
Approved: 10/30/13
Effective: 4/01/14
To provide relief from severe pain for patients with:
• Burns without hemodynamic compromise
• Isolated extremity fractures/dislocations with severe pain and long
transport or disentanglement time
• Any other condition deemed appropriate by Medical control.
Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor
o Ketorolac (Toradol) 30 mg IV (over 1 minute) / IM (ages 14- 65 only)
Paramedic
o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IM (if available)
o Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory depression
If nausea or vomiting occurs - refer to protocol III. G 23
Critical Care
& Paramedic Pain Management (Non-cardiac) Protocol III. E
Approved: 1/16/13
Effective:
Medical Control Options:
o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IM (max 20mg total) (if available)
o Ketorolac (Toradol) 30 mg IV (over 1 minute) / IM (ages 14-65 only)
o Fentanyl 1mcg/kg IV/IO/IM/IN (max 100 mcg)
If Hypoventilation after Morphine administration
o Naloxone (Narcan) 0.4-2.0 mg IV/IO/IM/ IN
24
Protocol III. E – Updates
Standing Orders
Paramedic Only
Morphine Sulfate 2- 10 mg (0.1 mg/kg) IV/IM
Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - for respiratory
depression
Medical Control Options
Fentanyl 1mcg/kg IV/IO/IN/IM
Narcan 0.4 -2 mg IV/IO/IN/IM
25
Class
Narcotic analgesic
Pharmacokinetics
Onset: Immediate (IV), 15-30 min (IM)
Duration: 2-7 hours
Morphine Sulfate
Duration: 2-7 hours
Dose / Route
Morphine Sulfate 2-10 mg (0.1mg/kg) IV IM
Maximum 20mg Total
Often administered with antiemetic to prevent nausea/vomiting
Protocols Adult - III.E, III.F, Pedi - NONE26
Critical Care
& Paramedic Procedural Sedation Protocol III. F
Approved: 10/30/13
Effective: 4/01/14
Conscious patients requiring synchronized cardioversion or pacing
Standing Orders:
o Airway management
o Vascular access o Vascular access
o Cardiac monitor
27
Critical Care
& Paramedic Procedural Sedation Protocol III. F
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options: (if available)
o Diazepam (Valium) 5-10 mg IV/IO
o Midazolam (Versed) 1-5 mg IV/IO/IN
o Lorazepam (Ativan) 2-4 mg IV/IO/IN
o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IO o Morphine sulfate 2-10 mg (0.1 mg/kg) IV/IO
o Etomidate (Amidate) 0.15 mg/kg IV/IO (max 10mg total)
o Fentanyl 1mcg/kg IV/IO//IN (max 100 mcg)
If nausea or vomiting:
o Ondansetron (Zofran) 4 mg IV/IO , may be repeated
28
Protocol III. F – Updates
Medical Control Options
Fentanyl 1 mcg/kg IV/IO/IN/IM
Ondansetron 4 mg IV/IO
Diazepam 5-10 mg IV/IO
Midazolam 1-5 mg IV/IO/IN
Lorazepam 2-4 mg IV/IO/IN
Etomidate 0.15 mg/kg IV/IO
Morphine Sulfate 2-10 mg IV/IO
29
Critical Care
& Paramedic Severe Nausea / Vomiting Protocol III. G
Approved: 10/30/13
Effective: 4/01/14
Adult patients with persistent vomiting or severe nausea
Consider and treat any underlying cause (i.e. poisoning , Myocardial ischemia, etc.)
Standing Orders: Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor
Paramedic
o Ondansetron (Zofran) 4 mg IV/IO, over 2 minutes (may be repeated one time)
Medical Control Options:
o Ondansetron (Zofran) 4 mg IV/IO, may be repeated 30
Protocol III. G – Updates
Standing Orders
Paramedic OnlyOndansetron 4mg IV/IO
Medical Control Options
Ondansetran 4mg IV/IO
31
Class
Antiemetic
Pharmacokinetics
Onset: Immediate
Peak effect: 15-30 Minutes
Ondansetron (Zofran)
Peak effect: 15-30 Minutes
Duration: 4-8 Hours
Dose / Route
Ondansetron (Zofran) 4 mg IV/IO
Over two (2) minutes
Protocols Adult - III.E, III.F, III.G, Pedi - NONE32
Class
Narcotic analgesic
Pharmacokinetics
Onset: Immediate
Peak effects: 3-5 min
Fentanyl
Peak effects: 3-5 min
Duration: 30- 60 minutes
Dose / Route
Fentanyl 1 mcg/kg IV/IO/IM/IN- Pain Management
1 mcg/kg IV/IO/IN – Procedural Sedation, ROSC
(Max 100 mcg total)
Protocols Adult - III.E, III.F, III.M, III.P, Pedi - NONE33
Critical Care
& Paramedic TRAUMA Protocol III. H
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o BLS trauma measures as appropriate
o Airway management
o Treat for shock - per protocol o Treat for shock - per protocol
o Pain management - per protocol
Paramedic
o Needle decompression if tension pneumothorax
34
Critical Care
& Paramedic TRAUMA Protocol III. H
Approved: 10/30/13
Effective: 4/01/14
Standing Orders (continued):
Burns: (thermal & electrical)
o Transport to a Burn Center if there is a manageable airway
o Cover with sterile / clean dry dressing or may use Water-Jel (or equivalent) if < 10% body surface area
Crush injuries: for patients with entrapment / compression of greater than one hour,
especially when a large muscle mass/group is involved.
Treatment should begin BEFORE the patient is removed if possible.
o Monitor for dysrhythmias during the period immediately after release.
o Consider Albuterol 0.083% 2.5 mg for possible hyperkalemia (peaked T-waves / wide QRS)
wheezing or bronchospasm.
o Keep affected limb at level of the heart.
35
Critical Care
& Paramedic TRAUMA Protocol III. H
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Continue normal saline bolus 500 ml - 1000 ml
o Sodium Bicarbonate 1 mEq/kg IV/IO (at 10 minute intervals)
o Calcium chloride 1gm IV/IO o Calcium chloride 1gm IV/IO
o Needle decompression if tension pneumothorax
NOTE: Administration of narcotic analgesics is contraindicated in patients with burns
involving the face and/or airway.
36
Protocol III. H – Updates
Standing Orders
Paramedic OnlyNeedle Decompression
Medical Control Options
Albuterol Sulfate 2.5mg (Crush Injury - hyperkalemia, wheezing or
bronchospasm)
Sodium Bicarbonate 1mEq/kg IV/IO
Calcium Chloride 1gm IV/IO
37
Critical Care
& Paramedic Asthma / Bronchospasm Protocol III. I
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management
o Vascular access as appropriate
o Cardiac monitor as appropriate
o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer
o Repeat Albuterol 2.5 mg via Nebulizer
o CPAP/ BIPAP (if available)
Paramedic
For severe presentation:
o Epinephrine 1:1000 0.3 mg IM/SQ
o Dexamethasone 12 mg IV/IO/IM
or o Methylprednisolone 125 mg IV/IO/IM
38
Critical Care
& Paramedic Asthma / Bronchospasm Protocol III. I
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Albuterol 2.5 mg via Nebulizer
o Ipratropium (Atrovent) 500 mcg via Nebulizer
o Epinephrine 1:1000 0.3 IM/SQ o Epinephrine 1:1000 0.3 IM/SQ
o Magnesium sulfate 2 gm IV/IO - (over 10-20 minutes)
o CPAP/ BIPAP (if available)
o Dexamethasone 12 mg IV/IO/IM
o Methylprednisolone 125 mg IV/IO/IM
39
Protocol III. I – Updates
Standing OrdersCPAP / BiPAP
Paramedic Only
Epinephrine 1:1,000 0.3mg IM/SQEpinephrine 1:1,000 0.3mg IM/SQ
Dexamethasone 12mg IV/IO/IM
Methylprednisolone 125mg IV/IO/IM
Medical Control Options
CPAP / BiPAP
Epinephrine 1:1,000 0.3mg IM/SQ
Dexamethasone 12mg IV/IO/IM
Methylprednisolone 125mg IV/IO/IM
Magnesium Sulfate 2gm IV/IO 40
Critical Care
& Paramedic C.O.P.D. Protocol III. J
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
o Cardiac monitor as appropriate
o Albuterol 0.083% 2.5 mg and Ipratropium (Atrovent) 0.02% 500 mcg via Nebulizer
o Repeat Albuterol 2.5 mg via Nebulizer
o CPAP/ BIPAP (if available)
Paramedic
For severe presentation:
o Dexamethasone 12 mg IV/IO/IM
or o Methylprednisolone 125 mg IV/IO
41
Critical Care
& Paramedic C.O.P.D. Protocol III. J
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Albuterol 2.5 mg via Nebulizer
o Ipratropium (Atrovent) 500 mcg via Nebulizer
o CPAP/ BIPAP (if available)
o Dexamethasone 12 mg IV/IO/IM
o Methylprednisolone 125 mg IV/IO
42
Protocol III. J – Updates
Standing OrdersCPAP / BiPAP
Paramedic Only
Dexamethasone 12mg IV/IO/IM
Methylprednisolone 125mg IV/IO
Medical Control Options
CPAP / BiPAP
Dexamethasone 12mg IV/IO/IM
Methylprednisolone 125mg IV/IO
43
Critical Care
& Paramedic Acute Pulmonary Edema Protocol III. K
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor / 12 lead ECG
o Nitroglycerin 0.4 mg SL or SL spray
If Systolic B/P is ≥ 120 or ≥ 100 with IV access
o CPAP/ BIPAP (if available)
44
Critical Care
& Paramedic Acute Pulmonary Edema Protocol III. K
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Nitroglycerin 0.4 mg SL or SL spray
o Furosemide 40-100 mg IV/IO
o Dopamine drip 5-20 mcg/kg/min IV/IO (titrated to effect)
o Norepinephrine 2-4 mcg/min- IV/IO o Norepinephrine (Levophed) 2-4 mcg/min- initial dose IV/IO (max 30 mcg/min)
- large vein if possible
o CPAP/ BIPAP ( if available)
NOTE: Patients who have used medications for erectile dysfunction within the last 72 hours
should not be given Nitroglycerin unless otherwise directed by Medical control.
45
Protocol III. K – Updates
Standing Orders
CPAP / BiPAP
Medical Control Options
CPAP / BiPAP
Norepinephrine 2-4 mcg/min IV/IO
46
Critical Care
& Paramedic Anaphylaxis Protocol III. L
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor
o Epinephrine 1:1000 0.3 mg IM
or o Epinephrine Autoinjector 0.3 mg IM
o IV fluid bolus (No more than 2 liters unless ordered by medical control)
o Albuterol 0.083% 2.5 mg via Nebulizer - for bronchospasms
o Repeat Albuterol 2.5 mg via Nebulizer (max 3 doses)
o Diphenhydramine 50 mg IV/IO/ IM
o Dexamethasone 12 mg IV/IO/IM
or o Methylprednisolone 125 mg IV/IO
47
Critical Care
& Paramedic Anaphylaxis Protocol III. L
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Epinephrine 1:1000 0.3 mg IM
o Albuterol 2.5 mg via nebulizer
o Diphenhydramine 50 mg IV/IO/IM o Diphenhydramine 50 mg IV/IO/IM
o Continue Fluid challenge beyond 2 liters
o Dexamethasone 12 mg IV/IO/IM
o Methylprednisolone 125 mg IV/IO
o Epinephrine drip 2-10 mcg/min IV/IO
o Norepinephrine (Levophed) (2-4 mcg/min- initial dose) IV/IO (max 30 mcg/min) - large vein if possible
o Dopamine drip 5-20 mcg/kg/min IV/IO (only if Epinephrine or Norepinephrine is unavailable)
48
Protocol III. L– Updates
Standing Orders
Epinephrine 1:1,000 0.3mg IM or Epi Auto injector .3 mg
Albuterol Sulfate 2.5 mg nebulizer
Diphenhydramine 50 mg IV/IO/IM Diphenhydramine 50 mg IV/IO/IM
Dexamethasone 12 mg IV/IO/IM
Methylprednisolone 125 mg IV/IO
Medical Control Options
Methylprednisolone 125mg IV/IO
Norepinephrine 2-4 mcg/min IV/IO
Dexamethasone 12 mg IV/IO/IM49
Class
Corticosteriod
Pharmacokinetics
Onset: 1 Hour
Peak effect : 1 hour
Dexamethasone (Decadron)
Peak effect : 1 hour
Duration: Variable
Dose / Route
Dexamethasone (Decadron) 12 mg IV/IO/IM
Protocols Adult - III.I, III.J, III.L, Pedi – P4
50
Class
Corticosteriod and anti-inflamatory
Pharmacokinetics
Onset: Immediate
Duration: 8-24 hours
Methylprednisolone (Solu-Medrol)
Duration: 8-24 hours
Dose / Route
Methylprednisolone (Solu-Medrol) 125 mg IV/IO Adult
2 mg/kg IV/IO Pediatric
Protocols Adult - III.I, III.J, III.L, Pedi – P4, P6, P7
51
Critical Care
& Paramedic Acute Coronary Syndrome / Chest Pain Protocol III. M
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management
o Vascular access o Vascular access
o Aspirin 325 mg. (chewed)
o Cardiac monitor / 12 lead ECG *
o Nitroglycerin 0.4 mg SL or SL spray - (If SBP ≥ 120 or ≥ 100 with IV)*
Caution with inferior wall MI's
52
Critical Care
& Paramedic Acute Coronary Syndrome / Chest Pain Protocol III. M
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Transport to nearest PCI capable hospital *
o Aspirin 325 mg (chewed)
o Nitroglycerin 0.4 mg SL or SL spray
o Morphine Sulfate 2-10 mg IV/IO o Morphine Sulfate 2-10 mg IV/IO
o Fentanyl 1mcg/kg IV/IO/IM/IN (max 100 mcg)
o Fluid challenge
o Dopamine drip 5-20 mcg/kg/min IV/IO (titrated) - for hypotension
o Norepinephrine (Levophed) (2-4 mcg/min- initial dose) IV/IO (max 30 mcg/min) - large vein if possible
* NOTES:
Medical Control Physician will make the determination to divert to PCI center based on transmitted 12-lead.
If transmission is NOT possible, advise Physician of machine interpretation or field interpretation.
Patients who have used medications for erectile dysfunction within the last 72 hours should not be given
Nitroglycerin unless otherwise directed by Medical control.
53
Protocol III. M– Updates
Medical Control Options
Fentanyl 1mcg/kg IV/IO/IM/IN
Norepinephrine 2- 4 mcg/min IV/IONorepinephrine 2- 4 mcg/min IV/IO
Dopamine Drip 5-20mcg/kg/min IV/IO
54
Critical Care
& Paramedic Cardiac Arrest - VF / Pulseless VT Protocol III. N
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o CPR per AHA guidelines - limit interruptions in chest compressions*
o If NO CPR in progress - perform 2 minutes - check pulse /rhythm
o Defibrillate (max joules) - repeat every 2 minutes if no rhythm change o Defibrillate (max joules) - repeat every 2 minutes if no rhythm change
o Establish IV/IO access - without CPR interruption (≥18g if possible)
o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes May use Vasopressin 40 units IV/ IO (1
st or 2
nd dose) - if available
o Airway management - including waveform capnography (keep ETCO2 >10)
o Cardiac monitor
o Amiodarone 300 mg IV/IO
Contact medical control
55
Critical Care
& Paramedic Cardiac Arrest - VF / Pulseless VT Protocol III. N
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Epinephrine 1:10,000 1 mg IV/IO
o Defibrillate (max joules)
o Amiodarone 150 mg IV/IO (2nd dose)
o Magnesium sulfate 1-2 gm IV/IO o Magnesium sulfate 1-2 gm IV/IO
o Sodium bicarbonate 1 mEq/kg IV/IO
o Calcium chloride 1 gm IV/IO
NOTE: CPR should not be paused for procedures or to administer medications.
Continue CPR while defibrillator charges. If possible - rotate chest compressors q 2 min.
All medications should be followed by a normal saline flush.
Consider & treat underlying causes if possible:
Hypoxia, Hypovolemia, Hypothermia, Hyper / Hypokalemia, Hydrogen Ion (acidosis)
Trauma, Tension pneumothorax, Tamponade, Toxin/Overdose, Thrombosis/Embolus
56
Protocol III. N – Updates
Standing Orders
Vasopressin 40 units IV/IO
Medical Control OptionsMedical Control Options
Sodium Bicarbonate 1mEq/kg IV/IO
Calcium Chloride 1 gm IV/IO
57
ClassNonadrenergic vasoconstrictor, Pituitary antidiuretic hormone
Pharmacokinetics
Onset: 1- 3 minutes IV
Vasopressin (Pitressin)
Onset: 1- 3 minutes IV
Duration: 30-60 minutes IV
Dose / Route
Vasopressin (Pitressin) 40 Units Single Dose
Replaces 1st or 2nd dose Epi in Cardiac Arrest
Protocols Adult - III.N, Pedi - NONE
58
Critical Care
& Paramedic Cardiac Arrest - Asystole / PEA Protocol III. O
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o CPR per AHA guidelines - limit interruptions in chest compressions*
o If NO CPR in progress - perform 2 minutes - check pulse /rhythm
o Establish IV/IO access - without CPR interruption (≥18g if possible)
o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes o Epinephrine 1:10,000 1 mg IV/IO - repeat every 3-5 minutes May use Vasopressin 40 units IV/ IO (1
st or 2
nd dose) - if available
o Airway management - including waveform capnography (keep ETCO2 >10)
o Cardiac monitor
Paramedic
o Needle decompression - for suspected tension pneumothorax
Contact Medical Control
59
Critical Care
& Paramedic Cardiac Arrest - Asystole / PEA Protocol III. O
Approved: 10/30/13
Effective: 4/01/14Medical Control Options:
o Epinephrine 1:10,000 1 mg IV/IO
o Fluid challenge
o Naloxone (Narcan) 2.0 mg IV/IO/IN
o Dextrose (D50) 25gm IV/IO bolus (if blood glucose ≤ 60 mg/dl)
o Sodium bicarbonate 1 mEq/kg IV/IO o Sodium bicarbonate 1 mEq/kg IV/IO
o Calcium chloride 1 gm IV/IO
o Glucagon 1mg IV/IO
o Needle decompression - for suspected tension pneumothorax
o Termination of resuscitation.
Any of the above orders may be repeated as per Physician's discretion
NOTE: CPR should not be paused for procedures or to administer medications.
Continue CPR while defibrillator charges. If possible - rotate chest compressors q 2 min.
All medications should be followed by a normal saline flush.
Consider & treat underlying causes if possible:
Hypoxia, Hypovolemia, Hypothermia, Hyper / Hypokalemia, Hydrogen Ion (acidosis)
Trauma, Tension pneumothorax, Tamponade, Toxin/Overdose, Thrombosis/Embolus 60
Critical Care
& Paramedic Post Resuscitation / Return of circulation (ROSC) Protocol III. P
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management including waveform capnography (EtCO2 35-45)
o If hypoperfusion persists - see Hypoperfusion /shock protocol
o Treat other medical/trauma conditions as appropriate
Maintain a waveform capnography value of 35 - 45 mmHg o Maintain a waveform capnography value of 35 - 45 mmHg
o Perform 12-lead ECG - evaluate for STEMI criteria
o If patient is Comatose/Unresponsive initiate hypothermic procedures (if available)
� Use ≥ 18g device (IV/IO)
� Start rapid infusion of ice cold (4 Celsius) normal saline via IV/IO
to a total of 30ml/kg (max total = 2 liters) (use pressure infusion sleeve)
o Contact medical control for transport to nearest STEMI / Hypothermia
capable hospital.
61
Critical Care
& Paramedic Post Resuscitation / Return of circulation (ROSC) Protocol III. P
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Hospital diversion
o Dopamine drip 5-20 mcg/kg/min IV/IO o Dopamine drip 5-20 mcg/kg/min IV/IO
o Norepinephrine (Levophed) (2-4 mcg/min- initial dose) IV/IO (max 30 mcg/min) - large vein if possible
o Midazolam (Versed) 1-5 mg IV/IO - for shivering
o Diazepam (Valium) 5 mg IV/IO
o Fentanyl 1mcg/kg IV/IO (max 100 mcg)
62
Protocol III. P – Updates
Standing Orders
Rapid infusion ice cold Normal Saline (4 degree Celsius) 30ml/kg
Medical Control OptionsMedical Control Options
Fentanyl 1mcg/kg IV/IO
Norepinephrine 2- 4 mcg/min IV/IO
Dopamine Drip 5-20mcg/kg/min IV/IO
Diazepam 5 mg IV/IO
Midazolam 1-5 mg IV/IO
63
Critical Care
& Paramedic Wide Complex Tachycardia - with Pulse Protocol III. Q
Approved: 10/30/13
Effective: 4/01/14
treat only if symptomatic Standing Orders:
o Airway management
o Vascular access
o Cardiac monitor / 12 lead ECG o Cardiac monitor / 12 lead ECG
(Paramedic)
o Synchronized cardioversion 50-360 j - if unstable (consider procedural sedation)
o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 min.
o Fluid challenge - as appropriate
64
Critical Care
& Paramedic Wide Complex Tachycardia - with Pulse Protocol III. Q
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 min..
o Magnesium sulfate 1-2 gm IV/IO - over 10 min o Magnesium sulfate 1-2 gm IV/IO - over 10 min
o Synchronized cardioversion 50-360 j - (consider procedural sedation)
o Fluid challenge
o Sodium bicarbonate 1 mEq/kg IV/IO
o Calcium chloride 1 gm IV/IO
65
Protocol III. Q – Updates
Standing OrdersDelete Lidocaine
Paramedic OnlySynchronized cardioversion 50-360 joulesSynchronized cardioversion 50-360 joules
Amiodarone 150mg in 100ml D5W IV/IO
Medical Control Options
Amiodarone 150mg in 100ml D5W IV/IO
Sodium Bicarbonate 1mEq/kg IV/IO
Calcium Chloride 1 gm IV/IO
66
Critical Care
& Paramedic Narrow Complex Tachycardia Protocol III. R
Approved: 10/30/13
Effective: 4/01/14
treat only if symptomatic Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
o Cardiac monitor / 12 lead ECG as appropriate o Cardiac monitor / 12 lead ECG as appropriate
o Valsalva maneuvers (such as bearing down) while preparing for other treatments
(Paramedic)
o Synchronized cardioversion 50-360 j - if unstable (consider procedural sedation)
o Adenosine 6mg IV/IO push - (20 ml flush) - if conscious & alert
o Adenosine 12mg IV/IO push - (20 ml flush) - second dose
o For stable A-fib / A-flutter - contact medical control
67
Critical Care
& Paramedic Narrow Complex Tachycardia Protocol III. R
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Valsalva maneuver
o Adenosine 6mg IV/IO push - (20 ml flush)
o Adenosine 12mg IV/IO push - (20 ml flush) - second dose o Adenosine 12mg IV/IO push - (20 ml flush) - second dose
o Synchronized cardioversion 50-360 j (consider procedural sedation)
o Fluid challenge
o Amiodarone 150 mg (in 100ml D5W) IV/IO - over 10 minutes.
o Diltiazem (Cardizem) 0.25 mg/kg slow IV (over 2 minutes) - (for A-fib / A-flutter)
68
Protocol III. R – Updates
Medical Control Options
Amiodarone 150 mg in 100 ml D5W over 10 min IV/IOAmiodarone 150 mg in 100 ml D5W over 10 min IV/IO
Diltiazem 0.25mg/kg slow IV/IO for A Fib/A Flutter
69
Class
Calcium Channel Blocker
Pharmacokinetics
Onset: 3 minutes
Half-life: 3-8 Hours
Diltiazem (Cardizem)
Half-life: 3-8 Hours
Dose / Route
Diltiazem (Cardizem) For patients in A Fib & A Flutter 0.25mg/kg IV/IO
Slow over 2 minutes
Protocols Adult - III.R, Pedi - NONE
70
Critical Care
& Paramedic Symptomatic Bradycardia Protocol III. S
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
o Cardiac monitor / 12 lead ECG as appropriate
o Atropine 0.5 mg IV/IO IF - second degree (type II) or third degree block, start pacing
o Transcutaneous pacing - (start at 60 PPM) - (consider procedural sedation III.F)
o Atropine 0.5-1.0 mg IV/IO - Repeat q 5 min x 2 if needed
o Fluid challenge - if hypotensive
71
Critical Care
& Paramedic Symptomatic Bradycardia Protocol III. S
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Atropine 0.5-1.0 mg IV/IO
o Fluid challenge - if hypotensive
o Dopamine drip 5-20 mcg/kg/min IV/IO o Dopamine drip 5-20 mcg/kg/min IV/IO
o Epinephrine drip 2-10 mcg/min IV/IO
o Calcium chloride 1 gm IV/IO
o Sodium bicarbonate 1 mEq/kg IV/IO
o Transcutaneous pacing - (start at 60 PPM) - (consider procedural sedation III.F)
o Hospital diversion - if STEMI
72
Protocol III. S – Updates
Standing Orders
Atropine Sulfate 0.5mg IV/IO if 2nd (Type2) or 3rd degree Heart Block
begin pacingbegin pacing
Repeat 0.5 mg to 1mg every 5 minutes X2 if needed
Transcutaneous Pacing ( start at 60 BPM)
Medical Control Options
Calcium Chloride 1gm IV/IO
Sodium Bicarbonate 1 mEq/kg IV/IO
73
Critical Care
& Paramedic Altered Mental Status Protocol III. T
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
Cardiac monitor as appropriate o Cardiac monitor as appropriate
o Naloxone (Narcan) 0.4 mg - 2.0 mg (titrated) IV/IO/IM/IN - if signs/history of narcotic use with respiratory depression. (give prior to dextrose if OD is suspected) May repeat x 2
o Assess blood glucose - treat if ≤ 60 mg/dl
o Oral glucose, juice, etc. - if patient is alert enough to swallow with intact gag reflex
o Dextrose (D50) 25 gm IV/IO
o Glucagon 1 mg IM (if no IV access)
74
Critical Care
& Paramedic Altered Mental Status Protocol III. T
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Dextrose (D50) 25 gm IV/IO
o Naloxone (Narcan) 0.4 - 2.0mg - IV/IO/IM/IN
o Glucagon 1 mg IM o Glucagon 1 mg IM
75
Protocol III. T – Updates
Standing Orders
Access Glucose level treat if < 60 mg/dl
Naloxone 0.04 mg to 2mg (titrated) IV/IO/IM/IN (if history of narcotics
use with respiratory depression present) may repeat 2X
Administer prior to dextrose if opioid is suspected
Oral glucose if patient able to swallow Glucose < 60 mg/dl OR
D 50 – 25 gm IV/IO
76
Critical Care
& Paramedic Seizures / Status Epilepticus Protocol III. U
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
o Cardiac monitor as appropriate
o Assess blood glucose - treat if ≤ 60 mg/dl
o Dextrose (D50) 25 gm IV/IO
o Glucagon 1 mg IM (if no IV access)
o Diazepam (Valium) 5 mg IV/IO/IM/PR
or o Midazolam (Versed) 1-5 mg IV/IO/IM/IN
or Lorazepam (Ativan) 2-4 mg IV/IO/IM
77
Critical Care
& Paramedic Seizures / Status Epilepticus Protocol III. U
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Diazepam (Valium) 5 mg IV/IO/IM/PR o Diazepam (Valium) 5 mg IV/IO/IM/PR
o Midazolam (Versed) 1-5 mg IV/IO/IM/IN
o Lorazepam (Ativan) 2-4 mg IV/IO/IM
o Dextrose (D50) 25 gm IV/IO
o Glucagon 1 mg IM (if no IV access)
o Magnesium sulfate 2 gm IV/IO (over 10 minutes) - if eclampsia
78
Protocol III. U – Updates
Standing Orders
Access blood glucose treat if <60mg/dl
Dextrose (D50) 25 gm IV/IODextrose (D50) 25 gm IV/IO
Glucagon 1mg IM (if no IV access)
Diazepam 5 mg IV/IO/IM/PR
Midazolam 1-5 mg IV/IO/IM/IN
Lorazapam 2-4mg IV/IO/IM
79
Protocol III. U – Updates (continued)
Medical Control Options
Diazepam (Valium) 5 mg IV/IO/IM/PR
Midazolam (Versed) 1-5 mg IV/IO/IM/IN
Lorazepam (Ativan) 2-4 mg IV/IO/IM
Dextrose (D50) 25 gm IV/IO
Glucagon 1 mg IM (if no IV access)
Magnesium sulfate 2 gm IV/IO (over 10 minutes) – if eclampsia
80
Critical Care
& Paramedic Stroke / Transient Ischemic Attack Protocol III. V
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Airway management - including waveform capnography
o Vascular access as appropriate
o Cardiac monitor as appropriate
Assess blood glucose - treat if ≤ 60 mg/dl o Assess blood glucose - treat if ≤ 60 mg/dl
o Dextrose (D50) 25 gm IV/IO
o Glucagon 1 mg IM (if no IV access)
o Cincinnati stroke score or other stroke symptom assessment
o Obtain the "time of onset" of symptoms
o Transport to a "stroke center" hospital with notification
81
Critical Care
& Paramedic Stroke / Transient Ischemic Attack Protocol III. V
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Dextrose (D50) 25 gm IV/IO
o Glucagon 1 mg IM (if no IV access)
o Hospital diversion / stroke team activation o Hospital diversion / stroke team activation
82
Protocol III. V – Updates
Standing OrdersAccess Blood Glucose treat if < 60 mg/dl
Dextrose (D50) 25 gm IV/IO
Glucagon 1mg IM (if no IV access)Glucagon 1mg IM (if no IV access)
Obtain Cincinnati Stroke Scale / Obtain time of onset of symptoms
Transport to Stroke Center with notification
Medical Control OptionsDextrose (D50) 25 gm IV/IO
Glucagon 1mg IM (if no IV access)
Hospital diversion / Stroke team activation
83
Critical Care
& Paramedic Behavioral Emergency/Agitation Protocol III. W
Approved: 10/30/13
Effective: 4/01/14
Contact medical control if unable to treat
Standing Orders:
o Airway management
o Vascular access o Vascular access
o Cardiac monitor
o Additional assistance / restraints as needed * (Check circulation frequently / document application time if restraints are used)
o Transport to appropriate hospital - (prior notification if possible)
84
Critical Care
& Paramedic Behavioral Emergency/Agitation Protocol III. W
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Diazepam (Valium) 2-10 mg IV/IO/IM
o Midazolam (Versed) 1-5 mg IV/IO/IM/IN o Midazolam (Versed) 1-5 mg IV/IO/IM/IN
o Lorazepam (Ativan) 1-2 mg IV/IO/IM/IN
o Haloperidol (Haldol) 2-5 mg IM
* NOTE: In order to protect the patient's airway, consider placing patient in a
lateral recumbent position.
NO restrained patient shall be transported prone.
85
Protocol III. W – Updates
Standing Orders
Airway/Cardiac Monitor/Vascular Access
Additional assistance/ Restraints as required
Transport to appropriate hospital
Medical Control Options
Diazepam (Valium) 2-10 mg IV/IO/IM
Midazolam (Versed) 1-5 mg IV/IO/IM/IN
Lorazepam (Ativan) 1-2 mg IV/IO/IM/IN
Haloperidol (Haldol) 2-5 mg IM
86
Class
Antipsychotic and neuroleptic
Pharmacokinetics
Onset: Within minutes
Peak effect : 20 minutes IM
Haloperidol (Haldol)
Peak effect : 20 minutes IM
Duration: 2-6 hours
Dose / Route
Haloperidol (Haldol) 2 - 5mg IM
Protocols Adult - III.W, Pedi - NONE
87
Critical Care
& Paramedic Poisoning / OD / Toxic Exposure Protocol III. X
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
oIf external contamination - Patient must be decontaminated prior to transport
oAirway management - including waveform capnography
oVascular access as appropriate
oCardiac monitor as appropriate
oAssess blood glucose - treat if ≤ 60 mg/dl
oNaloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory depression.
If (opiates suspected) May repeat x 2
oOral glucose, juice, etc - if patient can swallow (intact gag reflex)
oDextrose (D50) 25 gm IV/IO
oGlucagon 1 mg IM (if no IV access)
88
Critical Care
& Paramedic Poisoning / OD / Toxic Exposure Protocol III. X
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
Cocaine, amphetamines, sympathomimetics, or ETOH withdrawal
oMidazolam (Versed) 1- 5 mg IV/IO/IM/IN
oDiazepam (Valium) 2-10 mg IV/IO
oLorazepam (Ativan) 1- 2 mg IV/IO/IM
Organophosphates, nerve agents
oAtropine 2 mg IV/IM (or autoinjector) (repeat as needed)
oPralidoxime (2PAM) 600 mg autoinjector IM (max 3 autoinjector)
oDiazepam (Valium) 2-10 mg IV/IO/PR (max total dose 20 mg)
Opiates
oNaloxone (Narcan) 0.4- 2.0 mg IV/IO/IM/IN
Tricyclic antidepressant ( w/ QRS > 10 m/sec)
oSodium Bicarbonate 1 mEq/kg IV/IO89
Critical Care
& Paramedic Poisoning / OD / Toxic Exposure Protocol III. X
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:Calcium channel blocker
o Calcium chloride 1gm IV/IO
Beta blocker
o Glucagon 1-2 mg IV/IO
Eye InjuryEye Injury
o Tetracaine eye drops - 2 drops in affected eye(s) before irrigation
Cyanide (including smoke inhalation)
o Obtain blood samples prior to medication administration (a red & lime green tube)
o Hydroxocobalamin 5g IV (over 10 min.) * needs dedicated IV
o Start a second I.V. line
o Sodium Thiosulfate 25% sol. 12.5g IV/IO (50ml NS - over 10 min.) *
o Dopamine drip 5-20 mcg/ kg /min IV/IO
90
Protocol III X – Updates
Standing Orders
Access Blood Glucose treat if < 60 mg/dl
Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory Naloxone (Narcan) 0.4 - 2.0 mg (titrated) IV/IO/IM/IN - If respiratory
depression. If (opiates suspected) May repeat x 2
Administer oral glucose if patient can swallow
Dextrose (D50) 25 gm IV/IO
Glucagon 1mg IM (if no IV access)
Medical Control Options
REFER TO PROTOCOL FOR PARTICULAR SUBSTANCE OVERDOSE
91
Class
Topical Anesthetic
Pharmacokinetics
Onset: Immediate
Duration: 15-30 minutes
Tetracaine
Duration: 15-30 minutes
Dose / Route
Tetracaine Hydrochloride 0.5% solution 2 drops in effected eye before irrigation
Protocols Adult – III.X, Pedi – None
92
Critical Care
& Paramedic Obstetric / Pregnancy Related Protocol III. Y
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o BLS childbirth management
o Airway management - including capnography - Oxygen 100% via NRB
o Vascular access ( ≥ 18g device)
o Contact medical control for diversion to "obstetric" receiving hospital.
o Rapid transport - Do not delay on scene o Rapid transport - Do not delay on scene
Postpartum hemorrhage
o IV Bolus - 1 liter Normal saline
o Massage fundus firmly & consider allowing infant to nurse
Placenta previa or Placenta abruption
o IV bolus - 1 liter Normal saline - if hypotensive
Eclampsia (Seizures) or
Pre-eclampsia (SBP ≥ 160 / DBP ≥ 110 and/or severe headache, visual disturbances,)
(acute pulmonary edema, upper abdominal tenderness)
o Transport carefully - with lights dimmed.
o Contact Medical control for Magnesium sulfate or Diazepam order. 93
Critical Care
& Paramedic Obstetric / Pregnancy Related Protocol III. Y
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Magnesium sulfate 2gm (in100ml NS) - IV/IO (over 10 minutes) - for seizures
o Diazepam (Valium) 5 mg IV/ IM - for refractory seizures
o Fluid challenge - hypotension / bleeding
o Hospital diversion to "obstetric" receiving hospital
94
Protocol III. Y – Updates
Standing Orders
Consider diversion to “Obstetric” receiving hospital
If Postpartum Hemorrhage- 1 liter Normal Saline bolus
massage fundus, consider allowing infant to nurse
If placenta previa or abruption – 1 liter Normal Saline bolus if hypotensive
If eclampsia or Pre-eclampsia – Contact medical control for Diazepam or
Magnesium Sulfate, transport with lights dimmed
Medical Control Options
Magnesium Sulfate 2gm (in 100 ml NS) IV/IO over 10 minutes for seizures
Diazepam 5mg IV/IM for refractory seizures95
Nassau Regional Emergency Medical Services
Advanced Life Support
2014
Advanced Life Support
Pediatric Protocol Manual
96
PEDIATRIC ADVANCED LIFE SUPPORT PROTOCOLS
TABLE OF CONTENTS
Approved Effective
Newborn Resuscitation P 1 10/30/13 4/01/14
Respiratory Arrest P 2 10/30/13 4/01/14
Obstructed Airway P 3 10/30/13 4/01/14
Respiratory Distress / Failure (Croup/Epiglottitis) P 4 10/30/13 4/01/14
Non-Traumatic Cardiac Arrest P 5 10/30/13 4/01/14Non-Traumatic Cardiac Arrest P 5 10/30/13 4/01/14
Asthma/Wheezing P 6 10/30/13 4/01/14
Anaphylactic Reaction P 7 10/30/13 4/01/14
Altered Mental Status P 8 10/30/13 4/01/14
Status Eilepticus P 9 10/30/13 4/01/14
Decompensated Shock P 10 10/30/13 4/01/14
Traumatic Cardiac Arrest P 11 10/30/13 4/01/14
For Nassau County protocols, pediatric patients are as defined by the AHA, children
without secondary signs of puberty.
A "length/weight based" dosing device should be used on all pediatric patients to
assure the correct administration of medications.
97
Pediatric ALS Protocols NEWBORN RESUSCITATION Protocol P1Approved: 10/30/13
Effective: 4/01/14
Suction immediately after birth ONLY if there is an obvious obstruction to
spontaneous breathing or positive-pressure ventilation is necessary.
Standing Orders
o BLS Newborn Resuscitation procedures.
If newborn is depressed and meconium staining is present, delay drying and stimulation. o If newborn is depressed and meconium staining is present, delay drying and stimulation.
Suction airway before taking other resuscitative measures.
o Begin Newborn Resuscitation procedures only after the airway has been cleared of thick
meconium, as follows:
• Perform endotracheal intubation and directly suction the endotracheal tube via a
meconium aspirator/adapter while slowly withdrawing the endotracheal tube.
Note: Do not exceed 100-mmHg suction vacuum
• Repeat this procedure until little or no meconium is acquired or until the heart rate
indicates resuscitation must begin immediately.
• Do not replace the endotracheal tube once the airway has been cleared of thick
meconium unless the newborn remains limp, apneic, or pulseless.
98
Pediatric ALS Protocols NEWBORN RESUSCITATION Protocol P1Approved: 10/30/13
Effective: 4/01/14
For all newborns requiring resuscitation once BLS Newborn Resuscitation procedures
have begun:
During transport, or if transport is delayed:
Standing Orders (continued)
During transport, or if transport is delayed:
o If the newborn appears to be in respiratory distress and the heart rate is below 120 BPM,
administer oxygen in as high a concentration as possible.
o If the newborn appears to be in respiratory distress and the heart rate is below 100 BPM,
ventilate via BVM or mouth-to-mask with oxygen attached.
o If the newborn appears to be in respiratory distress and the heart rate is below 60 BPM,
Perform Endotracheal Intubation, Ventilate via BVM or mouth to mask, begin CPR,
administer:
Epinephrine 1:10,000 0.01 mg/kg via IV/IO
99
Pediatric ALS Protocols NEWBORN RESUSCITATION Protocol P1Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS
o Repeat Epinephrine every 3-5 minutes
o Endotracheal Intubation o
o Epinephrine 1:1000 0.1 mg/kg via Endotracheal tube
o Check for Blood Glucose - if < 60 mg/dl - Dextrose D10 IV / IO - (0.5 gm/kg)
o IV / IO infusion of Normal Saline (0.9% NaCl) 10 ml/kg.
Reassess & document after each bolus. Attempt IV or IO only once each.
100
Protocol P1 – Updates
Medical Control Options
• Check for Blood Glucose - if < 60 mg/dl - Dextrose D10 IV / IO - (0.5 gm/kg)
101
Pediatric ALS Protocols PEDIATRIC RESPIRATORY ARREST Protocol P2
Approved: 10/30/13
Effective: 4/01/14
For pediatric patients in actual or impending respiratory arrest, or who are unconscious and cannot
be adequately ventilated:
Standing Orders
o Open airway and begin ventilation as per BLS Pediatric Respiratory Distress/Failure
procedures. If narcotic overdose is suspected, refer AMS protocol (P8) procedures. If narcotic overdose is suspected, refer AMS protocol (P8)
o If an obstructed airway is suspected, refer obstructed airway protocol. (P3)
o Perform endotracheal intubation if BLS measures are not adequate.
Consider a supraglottic airway
o I.V. of Normal Saline (0.9% NaCl) KVO or a saline lock
Paramedic
During transport or if transport is delayed
o Administer Naloxone,
Patients ≥ 2 years old - titrate in increments of 0.1mg/kg- until effective (max 2 mg)
Patients < 2 years old - titrate to (max 1 mg)
102
Pediatric ALS Protocols PEDIATRIC RESPIRATORY ARREST Protocol P2
Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS
o IO infusion of Normal Saline (0.9% NaCl).
o Naloxone IV/ IO / ET / IN / IM as directed.
(No more than 2 attempts at vascular access) (No more than 2 attempts at vascular access)
Paramedic - If a tension pneumothorax is suspected consider orders to perform needle
decompression, using an 18-20 gauge catheter
103
Protocol P2 – Updates
Medical Control Options
• Paramedic Standing Orders
• Administer Naloxone• Administer Naloxone
• Pt greater than 2 y/o- titrate in increments of 0.1
mg/kg until effective- Maximum dose 2 mg
• Pt less than 2 y/o – titrate to max 1 mg
• Medical Control Options
• Naloxone IV / IO / ET / IN / IM as directed
No more than 2 attempts at vascular access104
Pediatric ALS Protocols PEDIATRIC OBSTRUCTED AIRWAY Protocol P3Approved: 10/30/13
Effective: 4/01/14
For pediatric patients who are unconscious or present with signs & symptoms of inadequate air
exchange:
Standing Orders
o Begin BLS Pediatric Obstructed Airway procedures.
o Perform direct laryngoscopy - attempt to remove the foreign body with appropriate size
Magill Forceps.
NOTE:
IF AN ENLARGED EPIGLOTTIS IS VISUALIZED - DO NOT ATTEMPT
ENDOTRACHEAL INTUBATION. USE BAG-VALVE-MASK (w/ pop-off disabled)
o Perform endotracheal intubation, if BLS measures are not adequate.
Consider a supraglottic airway
105
Pediatric ALS Protocols PEDIATRIC OBSTRUCTED AIRWAY Protocol P3Approved: 10/30/13
Effective: 4/01/14
Paramedic
If unable to ventilate despite confirmed intubation by direct visualization:
� Note the endotracheal tube depth
� Deflate cuff (if cuffed tube is used)
� Advance tube to its deepest depth - and return to original depth
MEDICAL CONTROL OPTIONS
Paramedic - If a tension pneumothorax is suspected consider orders to perform needle
decompression, using an 18-20 gauge catheter
� Advance tube to its deepest depth - and return to original depth
� Re-inflate tube cuff and attempt ventilation
� If unable to ventilate effectively - immediately initiate transport
106
Protocol P3 – Updates
• Paramedic
• If unable to ventilate despite a CONFIRMED tube
placement by direct visualization
• Note the ET tube depth• Note the ET tube depth
• Deflate cuff (if cuff tube is used)
• Advance tube to its deepest depth- and return
to original depth
• Re-inflate cuff and attempt visualization
• If unable to ventilate effectively- immediate
initiate transport107
Protocol P3 – Updates
Medical Control Options
Paramedic- If a tension pneumothorax is suspected consider
orders to perform needle decompression, using an 18-20 gauge
catheter
108
Pediatric ALS Protocols PEDIATRIC RESPIRATORY DISTRESS or Suspected Croup / Epiglottitis
Protocol P4
Approved: 10/30/13
Effective: 4/01/14
Standing Orders
•Begin BLS Pediatric Respiratory Distress / Failure procedures.
•If child is alert and oriented, transport in position of comfort with parent.
Offer cool mist 100% Oxygen if child will allow.
•If child presents with signs & symptoms of inadequate air exchange, refer to protocol (P3)•If child presents with signs & symptoms of inadequate air exchange, refer to protocol (P3)
________________________________________________________________________________________________________________
NOTE: DO NOT ATTEMPT ENDOTRACHEAL INTUBATION. USE BAG-VALVE-MASK
109
Pediatric ALS Protocols PEDIATRIC RESPIRATORY DISTRESS or Suspected
Croup / EpiglottitisProtocol P4
Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS
Racemic Epinephrine, 0.05 mg/kg in 3cc 0.9% saline (Max. 5 ml) via Nebulizer
(if unavailable, Epinephrine may be used at the same nebulizer dose)
Consider Endotracheal Intubation in acute epiglottitis with an ET tube one mm
smaller than calculated.
Dexamethasone (Decadron) 0.6 mg/kg IV / IO
Methylprednisolone (Solu-Medrol) 2 mg/kg IV / IO (max 60 mg)
Paramedic - If child is in respiratory arrest, perform needle cricothyrotomy.
110
Protocol P4 – Updates
Medical Control Options
• Racemic Epinephrine, 0.05mg/kg in 3cc 0.9% saline (Max 5 ml) via nebulizer• Racemic Epinephrine, 0.05mg/kg in 3cc 0.9% saline (Max 5 ml) via nebulizer
(if unavailable, Epinephrine may be used at the same nebulizer dose)
• Consider ET in acute epiglottis with an ET tune one mm smaller than calculated
• Methylprednisolone ( Solu-Medrol) 2 mg/kg IV/IO (Max 60 mg)
• Dexamethasone (Decadron) 0.6 mg/kg IV / IO
111
Indications
Used to treat croup (laryngotracheobronchitis)
Interactions
Cardiac stimulation, vasodilation in skeletal muscle
Racemic Epinephrine (Vaponefrin, microNefrin)
Pharmacokinetics
Onset: 3-5 minutes
Duration: 1-3 hours
Dose / Route
Racemic Epinephrine 0.05mg/kg in 3 ml 0.9% Normal Saline via NebulizerMaximum 5 ml
Note: if unavailable, Epinephrine may be used at the same nebulizer dose
Protocols Adult - NONE Pedi – P4 112
Pediatric ALS Protocols NON–TRAUMATIC CARDIAC ARREST Protocol P5Approved: 10/30/13
Effective: 4/01/14Standing Orders
o Begin BLS Pediatric Cardiac Arrest procedures. Initiate CPR
Perform endotracheal intubation, if BLS airway measures are not adequate.
o Cardiac Monitoring.
• If in ventricular fibrillation or pulseless ventricular tachycardia, immediately defibrillate
at 2 joules/kg. Resume CPR immediately. - (2 min.) at 2 joules/kg. Resume CPR immediately. - (2 min.)
• If still in ventricular fibrillation or pulseless ventricular tachycardia, immediately repeat
defibrillation at 4 joules/kg. Resume CPR immediately - (2 min.)
• Epinephrine 1:10,000 0.01 mg/kg via IV or IO (Repeat every 3-5 minutes)
– OR Epinephrine 1:1,000 0.1 mg/kg via ET (only if no IV/IO) (Repeat every 3-5 minutes)
• If still in ventricular fibrillation or pulseless ventricular tachycardia, immediately repeat
defibrillation at 4 joules/kg. Resume CPR immediately - (2 min.)
o Begin transport
o IV or IO infusion of Normal Saline (0.9% NaCl) KVO.
o Contact Medical Control for additional medication orders. 113
Pediatric ALS Protocols NON–TRAUMATIC CARDIAC ARREST Protocol P5Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
• Increase energy settings up to 10 joules / Kg
• Amiodarone 5mg/kg IV/ IO if V-Tach or V-Fib (max. 300mg)
OR OR
• Lidocaine 1 mg/kg rapid IV/IO push if Amiodarone is not available.
• Dextrose D10 IV / IO - (0.5 gm/kg)
• Sodium Bicarbonate 1 mEq/Kg IV/IO/saline lock.
• Magnesium Sulfate 25-50 mg/kg (max. 2g) - for Torsades
114
Protocol P5 – Updates
Medical Control Options
• Increase energy setting up to 10 joules/kg
• Amiodarone 5mg/kg IV / IO if V-Tach or V- Fib (max 300 mg)• Amiodarone 5mg/kg IV / IO if V-Tach or V- Fib (max 300 mg)
orLidocaine 1mg/kg rapid IV / IO push if Amiodarone is not available
• Dextrose D10 IV / IO - (0.5 gm/kg)
• Sodium Bicarbonate 1mEq/Kg IV / IO / saline lock
• Magnesium Sulfate 25-50 mg/kg (max 2 g) for Torsades
115
ClassElectrolyte
Pharmacokinetics
Onset: Immediate IV/IO
3-4 Hours IM
Magnesium Sulfate
3-4 Hours IM
Duration: 30-60 minutes IV
Dose / Route
Magnesium Sulfate 25-50 mg/kg (max 2 g) for Torsades de Pontes
Protocols Adult - III.N, III.Q, III.U, Pedi – P-5
116
Pediatric ALS Protocols PEDIATRIC ASTHMA/WHEEZING Protocol P6Approved: 10/30/13
Effective: 4/01/14
For pediatric patients with acute asthma and/or active wheezing:
Standing Orders
o Begin BLS Pediatric Respiratory Distress/Failure procedures.
o Administer Albuterol Sulfate 0.083% -one unit dose of 3 ml - via nebulizer. o Administer Albuterol Sulfate 0.083% -one unit dose of 3 ml - via nebulizer.
patients < 6 months - ½ unit dose
If no response, 2nd unit dose to follow immediately.
If still no response, contact medical control immediately.
o Administer Ipratropium Bromide 0.02% (one unit dose of 2.5 ml for children ≥ 6 years)
(1/2 unit dose of 2.5 ml for children under 6), via nebulizer in conjunction with each
Albuterol Sulfate dose.
Patients ≥ 1 year, with severe respiratory distress, respiratory failure, and/or decreased breath sounds
o Epinephrine 1:1000 0.01 mg/kg IM (max. 0.3 mg)
o Intubation
o Consider IV/IO and rapid transport - if Patient unstable. 117
Pediatric ALS Protocols PEDIATRIC ASTHMA/WHEEZING Protocol P6Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
o IV infusion of Normal Saline (0.9% NaCl) KVO, IV/ IO
o Repeat Albuterol Sulfate via nebulizer.
o Repeat Ipratropium Bromide 0.02% by nebulizer.
o Repeat Epinephrine 1:1,000 0.01 mg/kg IM (max 0.3 mg)
o Methylprednisolone (Solu-Medrol) 2 mg/kg IV/IO (max 60 mg)
118
Protocol P6 – Updates
Standing Orders
• Administer Albuterol Sulfate 0.083% (one unit dose of 3ml) via nebulizer
If patient > 6 months ½ dose of medication
• If no response, 2nd unit dose to follow immediately
• Administer Ipratropium Bromide 0.02% (one unit dose of 2.5 ml) for children > 6
years or ½ dose of 2.5 ml for children under 6, via nebulizer in conjunction with each
Albuterol Sulfate
• Patients > 1 year with severe respiratory distress, respiratory failure and or
decreased breath sounds
• Epinephrine 1:1000 0.01mg/kg IM (max 0.3 mg)
• Consider intubation
• Consider IV / IO and rapid transport- if patient unstable119
Protocol P6 – Updates
Medical Control Options
• IV infusion of Normal Saline ( 0.9% NaCl) KVO, IV /IO
• Repeat Albuterol Sulfate • Repeat Albuterol Sulfate
• Repeat Ipratropium Bromide 0.02% via nebulizer
• Repeat Epinephrine 1:1000 0.01mg/kg IM ( max 0.3mg)
• Methylprednisolone ( SoluMedrol) 2mg/kg IV / IO ( max 60 mg )
120
Pediatric ALS Protocols PEDIATRIC ANAPHYLACTIC REACTION Protocol P7
Approved: 10/30/13
Effective: 4/01/14
Standing Orders
o Begin BLS Anaphylactic Reaction procedures.
o Epinephrine 1:1000 0.01 mg/kg IM (max. 0.3 mg)
or or o Epinephrine Autoinjector JR. 0.15 mg IM
o Administer Albuterol Sulfate 0.083% one unit dose of 3 ml - via nebulizer. - if wheezing
patients < 6 months - ½ unit dose
If patient develops signs of respiratory failure or airway obstruction:
o Endotracheal intubation
o Initiate rapid transport.
121
Pediatric ALS Protocols PEDIATRIC ANAPHYLACTIC REACTION Protocol P7
Approved: 10/30/13
Effective: 4/01/14
Standing Orders (continued)
Paramedic
o Diphenhydramine 1mg/kg IV/ IO / IM
During transport, or if transport is delayed:
o IV infusion of Normal Saline (0.9% NaCl) via a large bore IV (18-22 gauge) to keep the
vein open, or a saline lock.
o IF PATIENT IS IN ANAPHYLACTIC SHOCK and IV cannot be established,
IO infusion of Normal Saline (0.9% NaCl) at KVO rate.
122
Pediatric ALS Protocols PEDIATRIC ANAPHYLACTIC REACTION Protocol P7
Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
o Repeat any of the above standing orders.
o Begin rapid IV or IO infusion of Normal Saline (0.9% NaCl), 20 ml/kg.
Repeat as necessary. Repeat as necessary.
o Methylprednisolone (Solu-Medrol) 2 mg/kg IV/IO (max 60 mg)
123
Protocol P7 – Updates
Standing Orders
• Removed administering Diphenhydramine from EMT-CC Standing Orders
• Begin BLS Anaphylactic reaction procedures• Begin BLS Anaphylactic reaction procedures
• Administer Epinephrine 1:1000 0.01 mg/kg IM (Max 0.3mg)
OR
• Epinephrine Autoinjector JR> 0.15mg Deep IM injection
• Albuterol Sulfate 0.083Z% one unit dose of 3 ml for patients >6 months or
½ unit dose for patients < 6 months (IF WHEEZING)
• If patient develops signs of respiratory failure or airway obstruction
• Endotracheal intubation, Initiate rapid transport
124
Protocol P7 – Updates
Standing Orders
• Paramedic- Diphenhydramine 1mg/kg IV / IO / IM
During transport or if transport delayedDuring transport or if transport delayed
• IV infusion of Normal Saline via large bore (18-22 gauge) to KVO or a
saline lock
• If patient in Anaphylactic Shock and no IV established administer IO
infusion of Normal Saline at KVO rate
125
Protocol P7 – Updates
Medical Control Options
• Repeat any standing orders
• Begin rapid IV or IO infusion of Normal Saline at 20 ml/kg • Begin rapid IV or IO infusion of Normal Saline at 20 ml/kg
( repeat as necessary)
• Methylprednisolone ( Solu-Medrol) 2 mg/kg IV / IO ( Max 60 mg)
126
Pediatric ALS Protocols PEDIATRIC ALTERED MENTAL STATUS Protocol P8Approved: 10/30/13
Effective: 4/01/14
For pediatric patients in coma, with evolving neurological deficit, or with altered mental status of
unknown etiology:
NOTE: MAINTENANCE OF NORMAL RESPIRATORY AND CIRCULATORY
FUNCTION IS ALWAYS THE FIRST PRIORITY. PATIENTS WITH ALTERED
MENTAL STATUS DUE TO RESPIRATORY FAILURE OR ARREST,
OBSTRUCTED AIRWAY, SHOCK, TRAUMA, NEAR DROWNING OR OTHER OBSTRUCTED AIRWAY, SHOCK, TRAUMA, NEAR DROWNING OR OTHER
ANOXIC INJURY SHOULD BE TREATED UNDER OTHER PROTOCOLS.
Standing Orders
o Assess respiratory and circulatory status.
o Begin BLS Altered Mental Status procedures.
o IV of Normal Saline (0.9% NaCl) KVO, or a saline lock. Attempt IV only once.
Perform a glucometer test for blood sugar level. If less than 60 mg/dL administer dextrose
or glucagon and continue to monitor as needed after administration.
o Dextrose D10 IV / IO - (0.5 gm/kg)
OR
o Glucagon 0.1 mg/kg IM (if no IV established). 127
Pediatric ALS Protocols PEDIATRIC ALTERED MENTAL STATUS Protocol P8Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
o Repeat any of the above orders.
o IO infusion of Normal Saline (0.9% NaCl).
o Naloxone 0.1mg/kg IV / IO / IM / IN - if there is no change in mental status
o Transport to a Pediatric specialty receiving facility
128
Protocol P8 – Updates
Medical Control Options
• Administer 0.1mg/kg Naloxone IV/IO/IM/IN if no
change in mental statuschange in mental status
• Transport to a pediatric specialty receiving facility
129
Pediatric ALS Protocols PEDIATRIC STATUS EPILEPTICUS Protocol P9Approved: 10/30/13
Effective: 4/01/14
For pediatric patients in Status Epilepticus:
Standing Orders
o Begin BLS Seizures procedure - cardiac monitor, pulse oximetry, waveform capnography.
Perform a glucometer test for blood sugar level. If ≤ 60 mg/dL: Perform a glucometer test for blood sugar level. If ≤ 60 mg/dL:
o IV / IO infusion of Normal Saline (0.9% NaCl) KVO
o Dextrose D10 IV / IO - (0.5 gm/kg)
OR
o Glucagon 0.1 mg/kg IM (if no IV established).
Paramedic
If patient is still seizing or blood sugar is normal:
o Midazolam 0.2 mg/kg IM / IN (max. 5 mg) Note: IN route is preferred
If seizures persist - contact Medical control of options.
130
Pediatric ALS Protocols PEDIATRIC STATUS EPILEPTICUS Protocol P9Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
o IO infusion of Normal Saline (0.9% NaCl).
o Midazolam 0.2 mg/kg IM / IN (max. 5 mg) - Note: IN route is preferred
o Lorazepam 0.05 mg/kg IV/ IN/ IO (slowly over 2 minutes)
Repeat doses may be given if seizures persist
o Diazepam 0.1 mg/kg IV/ IO (slowly over 2 minutes)
Repeat doses may be given if seizures persist
If NO IV / IO:
o Repeat Midazolam 0.2 mg/kg IM / IN (max. 5 mg)
o Diazepam 0.1 mg/kg per rectum
NOTE: DO NOT ADMINISTER DIAZEPAM or MIDAZOLAM IF THE SEIZURES HAVE STOPPED.
FLUSH IV LINE BETWEEN GLUCOSE AND DIAZEPAM or MIDAZOLAM
131
Protocol P9 – Updates
Standing Orders• Begin BLS Seizure procedures
• Perform a glucometer for blood sugar. If <60 mg/dL start
• IV / IO infusion of normal saline KVO• IV / IO infusion of normal saline KVO
• Administer Dextrose D 10 IV / IO (0.5gm/kg)
ORGlucagon 0.1mg/kg IM (if no IV or IO established)
Paramedic Only
• If patient is still seizing or blood sugar is normal
Administer Midazolam 0.2 mg/kg IM / IN ( Max 5 mg ) IN preferred route
If seizure persists contact Medical Control for options 132
Protocol P9 – Updates
Medical Control Options
• IO infusion of Normal Saline
• Midazolam 0.2 mg/kg IM / IN (Max 5 mg) Note : IN preferred route
Paramedic ONLY
• Lorazepam 0.05 mg/kg IV / IN / IO (slowly over 2 minutes)• Lorazepam 0.05 mg/kg IV / IN / IO (slowly over 2 minutes)
Repeat doses may be given if seizure persist
• Diazepam 0.1mg/kg IV / IO ( slowly over 2 minutes )
Repeat doses may be given if seizure persist
IF NO IV / IO
Repeat Midazolam 0.2 mg/kg IM / IN ( Max 5 MG)
Diazepam 0.1 mg/kg per rectum
Do not administer Diazepam or Midazolam if the seizures have stopped
FLUSH IV line between Glucose and Diazepam or Midazolam133
Pediatric ALS Protocols PEDIATRIC DECOMPENSATED SHOCK Protocol P10Approved: 10/30/13
Effective: 4/01/14
Standing Orders
o Begin BLS Pediatric Shock procedures.
o If signs of hemorrhage or dehydration are not present, begin Cardiac Monitoring.
If adrenal cortical insufficiency (Addison's) / hyperplasia is confirmed *
o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg) o Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)
NOTE: FOR PATIENTS IN SUPRAVENTRICULAR TACHYCARDIA OR VENTRICULAR
TACHYCARDIA WITH A PULSE, AND WITH EVIDENCE OF LOW CARDIAC OUTPUT,
CONTACT MEDICAL CONTROL FOR OPTIONS.
During transport, or if transport is delayed:
o Begin rapid IV Bolus of Normal Saline (0.9% NaCl) 20 ml/kg, via a large-bore IV (18-22
gauge) or IO catheter. Attempt IV or IO only once each.
o If signs of hemorrhage or dehydration are present, and the patient remains in decompensated
shock, begin second large bore IV and repeat bolus up to an additional 20 ml/kg,
(total of 40 ml/kg), Attempt second IV only once.
134
Pediatric ALS Protocols PEDIATRIC DECOMPENSATED SHOCK Protocol P10Approved: 10/30/13
Effective: 4/01/14
MEDICAL CONTROL OPTIONS:
• Begin IO infusion
• Continue rapid IV or IO bolus of Normal Saline (0.9% NaCl) up to an additional 20 ml/kg
(total of 60 ml/kg).
• Hydrocortisone Sodium Succinate (Solu-Cortef) 2mg/kg IV/IO (max.100mg)
• If transport is delayed or extended, and the patient presents with:
1. Supraventricular tachycardia or ventricular tachycardia with a pulse, with evidence of low
cardiac output, perform synchronized cardioversion at 0.5-1 joules/kg, using pediatric pads. If
necessary, repeat at 1-2 joules/kg.
2. Supraventricular tachycardia with evidence of low cardiac output, if the Defibrillator is not able
to deliver a calculated dose, administer Adenosine 0.1 mg/kg, rapid IV or IO bolus (not to exceed 6
mg), followed immediately by 5-10 ml of Normal Saline (0.9% NaCl) flush. If necessary,
Adenosine may be repeated at 0.2 mg/kg, rapid IV or IO bolus (not to exceed 12 mg), followed
immediately by 5-10 ml Normal Saline (0.9% NaCl) flush.
135
Protocol P10 – Updates
Standing Orders
• Rapid IV / IO Bolus of Normal Saline @ 20 ml/kg may repeat if patient
remains in decompensated shock additional bolus @ 20 ml/kg (total 40
mg/kg
Medical Control Options• May continue additional rapid IV / IO bolus of Normal Saline 20 mg/kg
(total 60 mg/kg)
• Supraventricular Tachycardia or Ventricular Tachycardia with pulse and low
cardiac output perform synchronized cardioversion at 0.5 – 1 joules/kg
using pediatric pads. May repeat at 1-2 joules/kg
• If defibrillator is not able to deliver calculated dose- Administer Adenosine
0.1 mg/kg rapid IV / IO (not to exceed 6 mg) If necessary Adenosine may
be repeated at 0.2 mg/kg (not to exceed 12 mg).
All medications should be immediately followed by 5 – 10 ml Normal Saline 136
Pediatric ALS Protocols PEDIATRIC TRAUMATIC CARDIAC ARREST Protocol P11
Approved: 10/30/13
Effective: 4/01/14
Standing Orders:
o Initiate BLS stabilization procedures
o Perform ETI - if BLS measures not adequate (use caution with possible C-spine injury)
o Begin rapid transport
o Establish IV or IO access, administer bolus Normal Saline (0.9% NaCl) - 20 ml/kg
o Monitor ECG
o If continued signs of inadequate perfusion persist repeat a second IV bolus of 20 ml/kg (total of 40 ml/kg)
137
Pediatric ALS Protocols PEDIATRIC TRAUMATIC CARDIAC ARREST Protocol P11
Approved: 10/30/13
Effective: 4/01/14
Medical Control Options:
o Continue Normal Saline (0.9% NaCl) up to an additional 20 ml/kg (total of 60 ml/kg).
o Hospital Diversion
o Epinephrine 1:10,000 0.01 mg/kg IV/IO
Paramedic - If a tension pneumothorax is suspected consider orders to perform needle
decompression, using an 18-20 gauge catheter
138
Protocol P11 – Updates
Standing Orders• Establish IV / IO access administer bolus Normal Saline at 20ml/kg unless
ordered by Medical Control
• If signs of inadequate perfusion persist repeat second bolus at 20ml/kg
(40ml max total) (40ml max total)
Medical Control Options
• Continue Normal Saline IV / IO drip up to 60 ml/kg total
• Epinephrine 1:10,000 at 0.01 mg/kg
• Paramedic only- if tension pneumothorax is suspected consider orders to
perform a needle decompression with 18-20 gauge catheter
139
QUESTIONS ?QUESTIONS ?
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